Ethical dilemmas arise in healthcare every day; they can even occur multiple times within the span of a few hours. As a bioethics student and a fellow healthcare worker, some days I find myself taking stock of ethical challenges throughout the entirety of my shift. Many of these challenges are the same old issues I faced 12 years ago when I was first hired at the hospital. In other words, sometimes it can feel like things will never change. Common ethical concerns that emerge include miscommunications and mistreatment between staff, poor communication that can lead to upset or difficult patients, injustices towards patients from inexperienced students or busy residents, lack of compassion and empathy from caretakers towards patients, inconsistencies and illogical types of decision making, and mismanagement at various levels, to name only a few. In highlighting these concerns, it is important to note that excellent care occurs every single day within Nova Scotia Health Authority by dedicated and skilled individuals who are doing their best to manage patients within the confines of a public system; however, there are simply many areas in which we can all improve.
More ubiquitous ethical issues in medicine (i.e. those that are most familiar to us) tend to take the form of larger social and legal debates. Consider pro-life/pro-choice advocates, motions to legalize euthanasia or what is now medical assistance in dying (MAiD) in Canada, or presumed consent for organ donation in Nova Scotia. Aside from these prominent public concerns (many of which have been born out of advancements in medical technology) I want to discuss the more pervasive ethical dilemmas in healthcare, those that are smaller, more frequent, and are the cause of moral distress. Take for instance the following examples: How do you safely discharge your homeless patient back onto the street? How do you explain to a patient who has been waiting two weeks for emergency surgery that they haven’t been prioritized yet? How do you reconcile the fact that because the nursing unit is short-staffed tonight, you’ll have to ignore one of your patients for a short while in order to triage tasks? How do you confront a surgeon who has broken the sterile field during surgery, but who is known to lose their temper? How do you convince your post-op craniectomy patient that it’s safer to wear a protective helmet when mobilizing, but they refuse? What if you just caught a medical error, no harm came to your patient, but you’re unsure if you should disclose the mistake anyway? These are the types of issues that confront providers on a daily basis and can be the source of disagreement amongst the interdisciplinary team, and can require moral courage to confront.
Barbara Carper, author of Fundamental Patterns of Knowing in Nursing, writes that “every solution to an existing problem raises new and unsolved questions”. She reminds us that we are never finished analyzing new ways to approach our problems, because “all knowledge is subject to change and revision”. It is important to remember that as much as we like to think we are dealing with facts, our value judgments (i.e., our perceptions on the rightness or wrongness of someone or something) often shape our decision making. Value judgments are unique to individuals and may seem like immovable objects, yet if we take the time to examine the reasons behind our judgements, we can sometimes come to new and enlightening conclusions. Substitute decision makers often have to imagine alternative viewpoints when taking into consideration the needs and desires of others. When it becomes difficult to make what we think is a ‘correct’ decision, we may deem it necessary to become intimately familiar with moral theories and their knowledge of what is thought to be good, what ought to be desired, or what is considered right. When trying to solve ethical dilemmas there is a strong urge to find both the “right” answer, and to come up with a replicable solution to the problem at hand. Since if we are not able to ground our decisions in concrete and universally applicable ways, then what guides our moral compass? Unfortunately, our past choices may not be applicable in future situations because the details of a case do matter.
Moral particularism holds that no one moral theory applies in all cases, instead, we must take into consideration the actual details of a situation in order to best determine right action. Moral principles do provide us with general guidelines, but they do not give us concrete answers. The principles of biomedical ethics are best used to describe the majority of our shared values in the face of certain dilemmas, but they are not cookie cutters and will still need to be critically engaged in each specific situation. So, how would knowing the details of a case help us make better decisions? Consider the example that Kant believed lying is always morally wrong, no matter the situation. This is an abstract moral ideal, whereby we lose track of the specifics of daily human life. Can you think of an example where lying might be morally justified? A classic counter example that has been used to challenge Kant’s argument about lying poses the following dilemma: if Nazis come to your door and ask if you are harboring Jews, is it morally wrong to lie to them? Compared to only being told “it’s wrong to lie”, once we know the details of a case, our perspective on lying is subject to change. The natural instinct might now be to say that it’s okay to lie in this case, because we are aware of the exact stakes of the game. We may not be entirely certain of which universal forces might judge our moral indiscretion (i.e. our lie), but we are certain that if we tell the truth people will die.
We face conflict in ethical decision making because we all have slightly different world-views and everyone who comes to the table has a particular set of values. I think it’s okay to have different perspectives, as long as those perspectives are put into context in each medical situation. Many providers are advocates of MAiD services, whereas others choose not to participate in this practice. What is important is that despite contentious objection patient needs are still met and services continue to be provided without compromising the integrity of providers. The “patient-centered care” movement was an attempt to shift the emphasis away from paternalistic physicians who felt academic knowledge was the cornerstone of good decision making, and towards patient values and personal choices. Today, most decisions are made to reflect the desires of patients, whatever those choices may be. The next step is to better understand how patient-centered care can allow providers to give what we might call integrity-based care, or care that does not compromise their own values or wellbeing. Interdisciplinary teams working in areas like Critical Care (i.e., ICU) are dealt the difficult task of trying to decipher the needs and values of their intubated (i.e., silent) and sedated (i.e., incompetent) patients. They also have to face the varying opinions of their colleagues who may or may not agree with the proposed care plan. The trick is reconciling multiple world-views, conflicting values, and the needs of unique persons. I will engage more with this topic next time.