Ethical Dilemma in Clinical Setting
Introduction
As a clinician, I am bound to face ethical dilemmas that conflict with my values and beliefs as I continue to execute my duties which include offering primary care to patients. The below is a discussion on an ethical dilemma and most specifically, informed consent and how this ethical behavior conflicted with my values. I cared and decided for a patient who was in a critical state when I found myself conflicting over whether to administer medication on trial on a patient whose Acute myelogenous leukemia cancer was at the (Myelomonocytic leukemia) M4 stage. The medical condition of this patient was not changing, the cancer had continued to grow regardless of many chemotherapy sessions. I administered a medication used on patients from a clinical trial that had saved a few patients and helped prolonged their life for a few years. I will utilize the theory of utilitarianism and deontology as well as the College of Nurses of Ontario (CNO) standards to discuss the dilemma presented by the tough decision I made. It is important to recognize that ethical dilemmas have stood as a challenge for clinicians who are used to evidence-based practices. It is the personal nature of the ethical decisions making process that presents the conflict. it is important to ensure the successful resolution of ethical dilemmas as this could interfere with the performance of clinicians and to avoid legal troubles and disciplinary actions that could arise from not maintain within the code of ethics.
My desire to buy this patient more time with her family outweighed my ethical obligations of informing this woman before putting her on the medication. I did not consider what she wanted at that time, all I wanted was to do my job and try to save her life. Having studied her medical history I knew that the new medication would buy her time. I did manage to buy the patient another extra two years considering that when her time ran out, she came back to the hospital and was admitted for a month before passing on. I was afraid of how the patient would react after learning that I had introduced her to new medication to save and prolong her life. She did react positively even after admitting to her my actions could have cost me my career had she disapproved of them.
A moral dilemma is an ethically challenging situation that presents an obvious ethical solution that conflicts with an individual’s beliefs and values (Sharma, 2011). When more than one ethical value applies to one specific situation a moral dilemma arises thus complicating the decision-making process (Paterick, et al., 2008). I felt a moral obligation to prolong the life of this patient. My desire to save the life of this woman conflicted with the obligation of informing her. This was a decision that could end my career or delay the death of a patient just a little longer. As an individual who got into the profession with a focus on saving as many lives as possible, letting this patient die without even trying would not be what I hoped to accomplish.
According to the College of Nurses of Ontario (CNO), ethics are important in a clinical setting, CNO acknowledges that these dilemmas are unavoidable as a result of the constant changes taking place in the healthcare industry. CNO has provided a guiding ethical framework that can help nurses and physicians prevent ethical dilemmas. To make decisions about ethical dilemmas health professionals need to be aware of their values (College of Nurses of Ontario, n.d). Professionals need to develop the ability to thoroughly think over a problem and be able to reach a sound decision. Client choice and consent means that the client plays a major part in refusing or accepting medical care. Patients should decide for themselves following informed consent. According to CNO, the decision of a patient or the decision made on behalf of the patient by a substitute decision-maker should be respected (College of Nurses of Ontario, n.d). Deciding to indulge the patient in medical care that they had not chosen was an ethically wrong decision. Moreover, the act of not involving a substitute decision-maker to decide for the patient was also unethical according to the rules established by the CNO no matter how ethical the actions seemed to me. Many ways can be used to work out an ethical dilemma.
CNO presents a framework and approach that can be used to resolve the moral dilemma of an ethical situation. The first approach presented by the CNO is to develop a plan that accounts for all of the factors in the ethical dilemma, this includes all the options and consequences of the various actions that can be taken (College of Nurses of Ontario, n.d). Developing a plan is a conscious decision that helps in shaping the decision one takes. After planning the next approach is deciding the best course of action. The third approach is consulting with others to see if they share the same opinion. Mostly, it is important to consult with an individual who differs with your decision. This gives rise to the need to further asses the situation.
Medical ethics has always been and will always remain an important part of moral philosophy that is responsible for dealing with conflicts that arise as a result of moral obligation to duty and the outcomes of these actions. The theory of utilitarianism argues that the outcomes justify the means, this theory has been contradicted by the deontological theory that argues that the result does not justify the uprightness of an action, it is the means used that determine how ethical a decision is (Amer, 2019). It is fairly common for decisions to be made by nurses and physicians based on what is in the best interest of the patient. The theory of utilitarianism is based on the good for the greatest number of people. An action of the greatest good is bound to produce good outcomes and as a result, the concept of consequentialism emerges (Stiggelbout et al., 2006). Consequentialism is based on the framework that the morality of an action depends on the outcomes produced by the action. However, these two works only when the prima facie obligations are not conflicting.
According to the theory of utilitarianism, several factors stand as relevant when making an ethical decision. To dissect the moral dilemma involved in making the decision it is important as a medical practitioner to consider what is your moral obligation to the patient (Laakasuo, et al., 2016). While applying this theory to resolve the moral dilemma raised by the issue of denying the patient consent and administering treatment, according to this theory my actions are justified since they were for the greater good, as a medical practitioner I had an obligation to at least try and save the life of the patient. The utilitarianism theory is based on trying to maximize the length and quality of life regardless of the means used. However, this theory is not the only theory that justifies actions based on saving lives, the distinguishing factor that sets this theory apart from the rest is that the morality of actions taken are right if they aim to maximize human welfare (Laakasuo, et al., 2016). John Mill a famous utilitarian believes that the action is right if they fulfill their purpose which is to bring happiness and positive outcomes. Scholars have concluded that no matter how appealing this theory is in resolving ethical dilemmas, it has its implications, Scholars have argued that it is important to consider and think carefully about other factors at play apart from happiness and prolonging life.
The deontological ethics theory of morality argues that the morality of an action lies on whether it is right or wrong rather than on the consequences of the action. The approach used by this theory bases right and wrong on the adherence to set obligations and duties (Mandal, et al., 2016). If the deontological theory is used to judge my moral dilemma, my actions would have been considered unethical regardless that my actions helped in prolonging the life of the patient. The means used to get these results are more important than the consequences of the action while using this theoretical approach. These two ethics theories used to judge the morality of an action are different from each other, the means of judging the morality of an action depends on different factors in each theory. Despite this, these two theories present frameworks that are very useful in judging and resolving many moral and ethical dilemmas taking place in a clinical setting. A balance between these two that is not likely to be achieved would go a long way in establishing harmony in medical practice (Mandal et al., 2016).
At the moment of making my decision, I justified my actions using the utilitarianism theory, my actions were for a greater good and my intentions were based on saving and prolonging her life. This way my actions are ethically right since I achieved the desired results of prolonging her life. Only the consequences of my actions mattered. CNO (n.d) outlines that in cases where one has a conflicting moral dilemma one should consult with other practitioners who do not share the same opinion as them. At this moment I did not do any consultation.
Moral residue is regarded as the distress that occurs when an individual knows which action is ethically right but fails to implement that action. Research conducted on the issue of moral residue has concluded that moral residue has dire implications on the professional and personal progress of the practitioner (Hardingham, 2004). Moral residue is as a result of regrets and moral distress. The issue of moral residue revolves around an ethical debate. Ethical discussions are vital in a healthcare institution, engagement in these debates means that ethical conflicts are resolved and healthcare providers are listened to. However, the presence of moral distress signals that ethical dilemmas are not being addressed. In my situation I did not experience moral residue for various reasons to include that I made the decision I thought was ethical, therefore I could not regret never making that decision.
Moral distress develops as a result of medical practitioners having their opinions and moral judgments being ignored. The continued understanding that one’s opinion is not acknowledged brings about moral residue (Epstein, et al., 2010). Moral residue occurs after many occurrences of moral distress. Another reason I could not have suffered from moral residue is that my moral judgment was not ignored and I did not experience the repeated situation of moral distress. The level of moral residue rises each time the healthcare practitioner experiences moral distress. Consequences of moral distress and moral residue include losing the ability to make decisions ethically during challenging situations, these healthcare providers start distancing themselves from situations that require moral sensitivity (Epstein, et al., 2009). The last and most severe consequence of moral residue is burnouts that make these professionals want to leave their jobs.
It is important to address the issue of moral distress and moral residue before it causes greater damage. A few approaches to include speaking up, building support networks and focusing on changing the work environment are just a few. Shifting one’s focus from an individual patient to a general work environment, this way the healthcare provider will be able to understand that it is the system that needs to change (Epstein, et al., 2010). Lastly, it is important to participate in moral distress education. Attending forums and seminars that focus on discussing moral distress and moral residue is important in understanding how to deal with the problem. To curb cases of moral distress and moral residue, most healthcare institutions have implemented hospital-wide moral distress consult services that help in addressing moral distress cases as they arise.
I believe that if I were to be presented with an ethical dilemma similar to the one, I faced I would not do things differently. It is my belief that saving lives is the main reason I choose a career in medicine. I believe that saving the life of a patient should be the number one priority. The situation taught me that I will always choose what I believe is right over what others believe is right and am willing to save and prolong life when I can. The only thing I would change in such a scenario would be to consult with other healthcare professionals that do not share my opinions not to change the way I would do things but to understand how their perspective is different from mine.
Inconclusion, ethical dilemmas, and moral conflicts are regular occurrences in the lives of healthcare providers. Various ethic theories present frameworks and approaches that can be used to resolve moral conflicts and dilemmas. CNO has also established guidelines that can be used to resolve moral dilemmas. Moral residue is as a result of the distress caused by not taking and action one viewed as ethical. The morality and ethical uprightness of an action depend on the method that has been used to evaluate it.
References
Amer, A. B. (2019). Understanding the Ethical Theories in Medical Practice. Open Journal of Nursing, 9(02), 188.
College of Nurses of Ontario (n.d). Practice Standard Ethics. Retrieved from; https://www.cno.org/globalassets/docs/prac/41034_ethics.pdf
Epstein, E. G., & Hamric, A. B. (2009). Moral distress, moral residue, and the crescendo effect. The Journal of clinical ethics, 20(4), 330-342.
Epstein, R. J., & Rubinfeld, D. L. (2010). Understanding UPP. The BE Journal of Theoretical Economics, 10(1).
Hardingham, L. B. (2004). Integrity and moral residue: nurses as participants in a moral community. Nursing Philosophy, 5(2), 127-134.
Laakasuo, M., & Sundvall, J. (2016). Are utilitarian/deontological preferences unidimensional? Frontiers in psychology, 7, 1228.
Mandal, J., Ponnambath, D. K., & Parija, S. C. (2016). Utilitarian and deontological ethics in medicine. Tropical parasitology, 6(1), 5.
Paterick, T. J., Carson, G. V., Allen, M. C., & Paterick, T. E. (2008, March). Medical informed consent: general considerations for physicians. In Mayo Clinic Proceedings (Vol. 83, No. 3, pp. 313-319). Elsevier.
Sharma, A. (2011). Ethical and Moral Aspects of Informed Consent: General Considerations. Journal of Research in Medical Education & Ethics, 1(1), 11-14.
Stiggelbout, A. M., Elstein, A. S., Molewijk, B., Otten, W., & Kievit, J. (2006). Clinical ethical dilemmas: convergent and divergent views of two scholarly communities. Journal of medical ethics, 32(7), 381-388.
