Doctors’ Dilemmas - How would you cope?

With resources running low, the doctors in Dangerous Visions – Culture have to choose between which patients can receive care. In real life, doctors face lots of moral dilemmas in their work: we’ve pulled out five such scenarios for you to test yourself. How would you fare in these ethically-testing questions? Click the arrows to find the possible answers...

Giving placebos to patients when the real medication is unaffordable...

You can only afford one set of antibiotics, but two patients suffering from the same disease. One is a child and the other is a single mother. Do you give one the drugs and try and explain to the other one that you cannot afford the required medication, or do you give the other a placebo to give them hope?

Giving the patients the truth of the situation is the tougher option, but it's is the path most doctors would take (58.3% from a Medscape poll). It falls in line with the views of Schopenhauer and Nietzsche that hope is not enough to deal with the demands of human existence. In fact, in Nietzsche’s telling of Pandora’s Box he described hope as “the worst of all evils because it prolongs the torments of man.” While you are upsetting the patient, you are not extending their misery but pretending that they are getting better. It also means that you are accurately keeping the patient informed of what is happening to them and enabling them to make decisions in the future in the knowledge that they can trust you.

René Descartes said that “hope is a weaker form of confidence,” and you might feel that you are giving your patient the ability to go on. However, you are undermining your patient’s ability to give informed consent. A patient can only be said to give informed consent if they are fully aware of all the facts about what is being performed to them. By giving them a placebo and actively deceiving the patient, they are in a position where they cannot be said to give informed consent. While you are giving them hope, as Descartes said, you are undermining their confidence in you in the long term as well as not really addressing the underlying situation.

Reporting an impaired colleague

A colleague is suffering from very occasional and incredibly brief seizures. They come to see you in a professional capacity, but you can see how this would affect their work. Do you break doctor-patient confidentiality or do you keep it, even if there is a chance it might endanger their patients in the future?

This scenario is a play on the “Trolley Problem”, which is: would you kill one to save many? Fortunately in this version, you don’t have to kill the one person! As Star Trek's space philosopher, Science Officer Spock once asserted: “The needs of the many outweigh the needs of the few.” Care of patients trumps confidentiality and you would be endangering more patients if you didn’t report it. You would need to report them to their superior or possibly to the medical board. Many doctors say that in this scenario it’s best to talk to the colleague and convince them to come forward themselves.

On the surface, this might feel like the correct course of action. Doctor-patient confidentiality is designed to protect the patient from numerous risks including public shaming and losing control of what happens with their body. However, in this particular circumstance, your inaction in speaking up will result in damage in the future. You would be applying the doctrine of the “Double Effect”. This is where one distinguishes between harm that is intended and harm that you can foresee. While you aren’t causing harm, you can see that your decision could potential damage future patients of your colleague. In allowing this to happen, you would be partially responsible for any of that harm.

Exaggerating illness to get treatment required.

One of your patients is exhibiting signs of a disease, however they are in the early stages and the hospital refuses to pay for the treatment. You, on the other hand, believe that the patient needs treatment now. Do you exaggerate the severity of their condition so that they can get treatment or do you go along with the hospital’s decision, even though you disagree with it?

A contentious issue in the world of bioethics (ethics relating to medical and biological research). Some doctors see this as a moral imperative. Nicolas Tavaglione and Dr. Samia A. Hurst, both of the Institute for Biomedical Ethics at Geneva University Medical School in Switzerland, have said that telling the truth in such a situation would be “honouring an ideal principle in a non-ideal world.”

You are putting practicalities first and holding yourself up to the highest ideal of never lying, even if it puts a patient in a difficult position.

While exaggerating to save one patient might be tempting, it does come with the risk of becoming a self-sustaining problem. You start lying more and more – the hospital has to increase its administration costs to compensate with the higher number of successful claims which in turn uses a higher percentage of your budget, so there’s less money and the cycle starts over.

Technically an act of fraud, doctors in the United States have said that it’s sometimes the only way to explain conditions to those who, while less medically qualified, control the money flow.

Condemning someone to a terminal illness by stopping treatment and reallocating the money to a case where the patient might make a full recovery...

There are two patients, but again, there’s only enough room in the budget for a single course of treatment. You’ve got one elderly patient, who is suffering from a terminal disease. They want to die but the treatment will keep them alive with a severely reduced, but not debilitating, quality of life. On the other hand, you have another patient who is young and critically ill. With the right treatment they will recover and lead a full and happy life. Do you cancel the treatment to the person who wants to die, effectively helping them commit suicide or carry on the course?

If you remove the funding, then you commit an act of passive euthanasia, where through inaction or ending of an action you help end someone’s life. Even though you are acting in accordance with the patient’s wishes, you are technically breaking the law. The ethical debate on euthanasia has been going on for centuries – even Plato has written on it (he wasn’t in favour) – and the issue gets complicated by religious doctrines. If you were to subscribe to Bernard Gert’s “Beneficence Theory” – to minimize the causes of harm or evil, not to promote good – then you would take this path. The elder person who wants to die views their disease as a source of pain and the younger person who will make a full recovery would also have their pain removed. Whether or not you believe that is a justification for euthanasia or not falls entirely to you.

The trickier course of action, particularly when you apply the Utilitarian theory of “do the most amount of good for the biggest number of people”. In extending the elderly patient's life, even at a reduced quality of living, you would be seen as doing a good act. However, you could be seen to be doing the greatest volume of good deeds but complying with the elderly patient’s wish to die and restoring the younger patient to full health. This is complicated by two elements: first, having taken the Hippocratic Oath, you have a duty to help a patient who has a chance to recover, even if it is not to perfect health; second, you are going against the patient’s autonomy, and you are complying with the law of the land. Your view on the law might vary
– you might even think it is wrong – but as it stands, breaking it would result in severe consequences for you personally.

An ill homeless man who refuses treatment...

This scenario was first proposed in a New York Magazine article and starts with a homeless man who comes into hospital clearly suffering from multiple chronic diseases, including psychiatric disorders. After consulting a psychiatrist, the man is declared unable to make decisions for himself. He continues to refuse treatment and assaults the nurses by throwing bodily fluids at them. Do you send the patient back out on to the street or do you treat him against his will?

According to the doctors interviewed for the New York Magazine, this would be in violation of the Hippocratic Oath. As the patient is suffering from chronic conditions, if you were to refuse treatment you would be condemning him to death. While the autonomy of patients has to be respected, when they are deemed to be psychiatrically incapable, then doctors can act against patients' wishes as long as they gain the relevant permissions. The assaults on the staff are clearly unacceptable, but since this patient is suffering from psychiatric complications, provisions must be made.

As the patient suffers from psychiatric disorders, he is unable to give informed consent. While continuing to suffer from such a condition, a patient will never be able to consent. In order to acquire it, you would have to apply to the medical board as well as the individual’s family if you can get in touch with them. Once granted, you can proceed, with a doctor acting as a surrogate in the decision-making process. The issue here is one of autonomy, and since the patient is unable to supply that, you have go elsewhere to find it.

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