Resolving an Ethical Dilemma in a Healthcare Context

The balance between right and wrong is complex to and is relative to the time, place, religion, and culture of the context of situations as well as of the protagonists. (Brown, Patankar, Treadwell, 2005) Nonetheless, basic invariant principle exist such as “You must not murder.” (Exodus 20:13)  In this particular example, the ethical dilemma takes place in the context of a rehabilitation center.  Mrs. Smith is a patient who is being treated for a stroke and a broken hip.  As the therapy is being applied for her condition, she feels that doctors, nurses, and her family should let her die because the rehabilitation process is very painful to her.  However, letting someone die is against the Hypocratic Oath that doctors have sworn to uphold

.  Additionally, physician-assisted suicide is not a legal option in our society.  Finally, her family understandably opposes her feelings since they want the best for her.  Besides, the doctors have told them that she will be fine.  In order to resolve the moral dilemma, the basic moral model of decision-making will be applied in this case.  This model was developed by Thiroux (1977) and Halloran (1982) further refined it.  A moral dilemma model specific to healthcare was designed by Uustal, which is appropriate to the presented scenario. (Uustal, 1995)

Method

The Model of Moral Dilemma in Healthcare (See Fig. 1.)

Subjects or Participants

1. Healthcare staff: doctors, nurses
2. Family: adult children and adult grandchildren
3. Subject: Jody Smith, a former nurse, retired, lives alone, limited income
4. Potential player: social worker

Procedure

Carefully summarize each step in the execution of solving the dilemma.  Explain the choices made at each step, decide which follow-up actions are needed, and indicate whether or not an ethic of care was considered in the decision-making.

Strategy

Massage the dilemma, outline the options, resolve the dilemma, act by applying the chosen option, look back, evaluate the entire process, including how each step as implemented.

Discussion

The purpose of this section is to use the model of ethical dilemma to solve the situation with Mrs. Smith.  The first step is to identify each participant and evaluate their contribution in the situation (massage the dilemma).

The patient and her family

The main issues with Jody Smith are that she is older, retired, living alone in a remote area with a limited income.  She has adult children and grandchildren.  She also used to be a nurse.  First, her former occupation implies that she has a very good knowledge of care giving issues.  Second, she is retired, implying that she may not have any hobbies or stimulating activities.  Third, she lives alone in a remote area and has adult children and grandchildren, implying that she has limited contacts with her children and/or other persons.

Fourth, she has a limited income, which may be a reason why she may not have the chance either to participate in stimulating activities, go on vacation or visit her family.  There is also no mention of a husband.  Either she was never married, got divorced, or became a widow.  Divorce or death may why she lives in a rural area.  Often when people are depressed, they isolate themselves, which is the opposite of what they should do.  She seems to have a large family with many grandchildren.  Do they have a close relationship?  Probably not if Jody Smith lives in a remote area.

The Healthcare staff

            The main role of doctors is to diagnose, treat, and rehabilitate a patient.  Nurses carry out care giving functions, applying the doctor’s orders for the patient but they also support the patients they care for by their daily visits and small talk or big talk! (Diers, 2004)  Doctors pledge the Hippocratic Oath that states that they would do everything in their power to save lives, not to harm anyone intentionally. (Hippocrates, 400 BCE)  They are also medical mediators between the patient and his or her family.

Based on Fig.1, the doctor must have a positive relationship with the patient, a character pre-disposed to work with the patient with the intent of caring for the whole person.  He also must be ready to deal not only with the patient but also with the family thereby concentrating on relationships.  In some cases, a doctor may have to put aside right or wrong principles in order to validate non-negotiable values for the sake of the patient or the family or both.  To solve a problem, he or she may have to raise questions to strategize a recovery option without burdening the patient.

The social worker

The social worker takes care of the social issues pertaining to the patient.  Does she have enough income, healthcare coverage, and access to other social services a visiting nurse when Jody returns home.  He or she may be a mediator with the family as to the kind of help would be needed on their part to help Jody recover. (Denhardt, 1988)

Outlining the options

The doctors think that Jody will recover rapidly and share their view with the family.  The option is form them to continue the present treatment or prescribe a new treatment taking into account Jody’s feelings about the treatment.  One important point that doctors may have overlooked is that Jody’s behavior might be due to depression, either an already set depression from retirement, limited income, and loneliness or a depression about her present condition, which may alter the perception of her recovery; feeling like dying is a symptom of severe depression.

 In addition, doctors should confer with the family and the patient together so that the patient is informed of their treatment options.  So, the doctors should treat a depressive state.  The family’s options are to support the doctors and their treatment decisions or request that they find another treatment that would be less painful to her.  In this process, the social worker may work with the family and doctors to facilitate in-home care or help with home care for the family taking Jody in to encourage her.  The bottom line is that Jody cannot be left to die.

Resolve the dilemma and act based on the options

            The doctors will not let Jody die.  They reevaluated the situation and her prognosis.  First, her prognosis remains (full recovery) and they assessed the type of therapy (aggressive versus light) she is getting, changing it since Jody complains that “it is very painful to her”, showing intent to help Jody by concentrating on their relationship with her, by communicating with her what they would like to do to help her while respecting how she feels.  Painful can refer to physical pain and/or mental pain.

  Therefore, they must also consider mental pain such as depression and treat it with medication as well as psychotherapy to locate the source of her depression, treating the whole person.  A light therapy will cause Jody to take longer to recover but doctors choose it because it will ‘benefit Jody’s pain.’  Further, the doctors recommend to the family that based on a light therapy as well as a depressive state, Jody should not be left in the Rehabilitation Center.

They suggest that one family member volunteers to take her in for a while until she fully recovers.  The social worker will take care of the details of getting a home care aid to help the family member care for Jody while making sure Jody’s income is maintained.  Figure 2 shows a pyramidal arrangement of the main decisions taken to solve the dilemma.  The pyramidal arrangement shows these decisions were all based on the previous ones and that the consequences followed as well from the bottom to the top.

The ethical part of the decision was based on the physician’s recognition that Jody’s behavior was caused by different factors: physical pain, mental depression, and loneliness.  Loneliness probably aggravated her mind frame.  To prevent her suicide, they needed to address all three factors by prescribing lighter therapy, addressing her physical pain, psychotherapy as well as anti-depressants, addressing her mental anguish, and the involvement of her family to prevent her lonely feelings while recovering. The last follow-up action was to get the social worker to help with home care and income.

Fig.1. The Doctor’s Point of View Based on the Key Features of the Healthcare Model of Moral Dilemma

Fig.2. The Evolution of the Actions Taken by Doctors while Following Uustal’s Model, from the Fundamental Decision to the Top with the Achieved Result.

References

Brown, JP, Patankar, MS, Treadwell, MD. (2005). Safety ethics: cases from aviation, healthcare, and occupational and environmental health. Ashgate Publishing.

Denhardt, KG. (1988). The ethics of public service: resolving dilemmas in public organizations. Preaeger/Greenwood, Wesport, Connecticut.

Diers, D. (2004).  Speaking of nursing: narratives of practice, research, policy, and the profession. Jones & Bartlett Publishers. Boston.

Halloran, M.C. (1982). Rational ethical judgments utilizing a decision-making tool. Heart and Lung, 11(6), 566-570.

Laureate Education, Inc., (2005). Ethical and legal issues in the changing healthcare system [Video recording]. (Available from Laureate Education, Inc. 12975 Coral Tree Place Los Angeles, CA 90066-7020).

New World Translation of the Holy Scriptures, Exodus 20:13. (1984). The Bible. New World Translation Committee: Brooklyn, New York.

Thiroux, J. (1977). Ethics: Theory and practice. Philadelphia:Macmillan.