1. Choose a moral dilemma you faced in your personal or professional life. o I like to write from a point of a view of a doctor, practicing in India or may be Pakistan, who experiences an ethical...

An ethical dilemma case study
During my practice as a resident in the department of internal medicine, I happened to come across a patient who was in his end-stage kidney disease and was under dialysis. The patient was exhausted with dialysis as well as the medication. Henceforth, he expressed his thoughts of self-killing which arouse a situation of a medical dilemma in me. I had to
ainstorm and follow the ethical philosophies in solving the case.
Ethical dilemma in medical practice is routinely encountered, and this occurs especially with young budding doctors.[1] At times, patients and physicians are at crossroads where decision-making and choice become tough in terms of ethics. Certain clinical decisions might be difficult due to various reasons. It could be due to conflict or lack of evidence. The choices made might be full of uncertainty, for example, increasing life-span versus quality of life in a patient with end-stage diseases. The outcomes of such decisions may include a mix of pros and cons, though we know our values. Any decisions of such sort are described as ethical dilemmas. According to Ong et al, (2012) an ethical dilemma can be explained as a “situation where an individual has to make a tough choice between two extreme or different outcomes, either of which results in contravening a moral principle.”[2]
Medical ethics primarily involves recognition of morally right actions and resolution of any ethical dilemmas during decision-making by using moral principles in a specific medical case. Medical ethics has yielded into various
anches, aiming at good patient care. Furthermore, the author Nandi PL (2003) described clinical ethics as “a discipline which deals with identification, scrutiny and analysis, and problem-solving of moral issues that occur during medical care.” [3]
It is important for the healthcare workers to know the legal and ethical elements of modern medicine. Society has imposed specific laws that have to be implemented to regulate certain circumstances. Inability to comply with these laws may result in punishment from the court of law. A medical doctor should have a chance to familiarize with different ethical issues as a part of the medical cu
iculum and should be trained to face and solve ethical problems that are countered in day-to-day practice.[6]
Case scenario
A 75-year old male patient was admitted for the treatment of chronic kidney disease. He was admitted in the internal medicine ward under the supervision of a nephrologist. I was the duty doctor for that month, and I came across this patient during my regular rounds. After a couple of days, the patient asked me to spare some of my time as he wanted to talk to me in-person. The patient was seriously ill, debilitated, was on dialysis and medication. Though he was not told directly, he overheard about his end-stage illness when his relatives were discussing his problem. He knew that he hardly had 2-3 months to live, even after repeated dialysis and chemotherapy. He understood that any further medical or surgical therapy could not help him in that stage. He was entirely in depression due to his medical condition. On one on one interaction, the patient confided his thoughts of self-killing and about the failed attempt of suicide he made a couple of days back. He pleaded me not to disclose this to anyone, as he didn’t want his loved ones to mourn and retaliate on his decision.
The ethical dilemma in this case
I was taken aback, and I fell in a dilemma whether to disclose the matter to their relatives or not as this may lead to the
each of ethical principle autonomy as well as beneficence. The logical incompatibility of disclosing and not disclosing the matter has led to an ethical dilemma. By revealing the issue to the patient’s relatives or the senior nephrologist who is treating him, it could result in a
each of autonomy[7], as it can be disrespecting the patient’s will. If the patient’s decision was not disclosed, it could lead to the violation of beneficence. Also, non-disclosure may encourage the patient to continue with his thought of suicide which is an unethical thing for him to do, and hence it invokes
each of maleficence.[7]
Analysis of the ethical dilemma
In the present case scenario, the choice of keeping the patient’s secret of suicidal thoughts would ignore the potential suicide of the patient, and it may lead to self-harm behavior of the patient. In a
oader sense, the desire of the patient can be classified into ‘assisted dying.’[8] The dilemma about disclosing and non-disclosing arise a question about justice. When we
ing about different arguments to this context, the defenders of the choice of revealing the secret argue that if proper behavioral counseling is given to the patient, he could come out of his depression and live little longer with the help of treatment. While the opponents of the disclosure argue that the patient has a right to agree or disagree with the treatment and he has a right to live his life according to his will.
On application of Sandels’ philosophical methodology (2010) of ‘doing the right thing,’ to the present scenario, the question divides the old-school and modern political thoughts.[9] According to Aristotle, justice means giving an individual what is right. One needs to determine what qualities are right. In contrast, the modern philosophers argue that the rights defined by the principles of justice shouldn’t be based on one particular virtue, instead should respect the individual’s freedom to choose his way of a good life.[9] If the present case is closely analyzed, it is evident that the issue revolves around two ideas: respecting freedom and promoting welfare. Each of these ideas has its own take on justice.
Some of the debates reflect agreement with the choice of allowing individual’s freedom while some argue that promoting welfare by weighing the pros and cons is ideal. The right to suicide and the right to assistance in suicide, both, are the prerogative of every sane individual. Here, the patient expressed his views and asserted his liberty to withhold the treatment. However, according to the court of law, self-killing and assisted-killing in a mentally competent patient is a crime. It is highly important to judge whether this patient reserve the constitutional right to such practice. Also, any person who is knowingly involved in a suicide attempt is considered guilty.[10] The court of law is also interested in preventing suicide, preserving life, preventing undue influence, and protecting the profession’s integrity. This supports the idea of promoting welfare.
Sandelian argument reflects that whatever might be the outcome, it is essential to take the moral argument seriously to safeguard the legitimacy of the decision. As a law-abider, it is important to check if the right in question allows one to be a good citizen. Sandels’ philosophy of ‘doing the right thing’ abides by the political, legal, and ethical values. The reasoning in this particular philosophy is ends-focused as it connects the constitutional protection of practice and the emotional component of an individual.[9]
Back to the choices of promoting the welfare or respecting freedom, most of the theories support autonomy (respect for individual rights). However, these theories show disagreement among themselves about the importance of these rights. Justice, in most parts of the world, means respecting universal human rights. There are certain theories which co
elate justice with a good life. When these theories are to be assessed, it is essential to understand how philosophical arguments may proceed, especially in terms of political and moral philosophy. The moral difference lies in the intention of aiding a person make a right decision, rather than its effect on the victims.[9]
Both the theories are pretty conflicting, and hence one should explore the strengths and weakness of each and apply to the present scenario. In this case, I feel that the ancient principle by Aristotle on ‘doing the right thing’ for the patient is applicable. Also, as an abider of law, I prefer to maintain the integrity of the medical profession and hence, take the issue to my superior instead of letting the patient die by himself. In the process of respecting the patient’s decision, I also prefer to take some time, talk to the patient, and convince him about the pros of living a little longer and cons of self-killing. Enabling the patient for psychological and behavioural counselling may help in alleviating the patient’s mental condition. The principle of utilitarianism can be applied here. It focuses on determining right from wrong, by concentrating on the outcomes. Here, in this scenario, disclosing the secret might be wrong as it is considered a violation of the right to freedom and confidentiality. However, by letting others know about the patient’s decision can help in preventing him from committing suicide and living a little longer. This way, I feel I can still stand for justice.
Conclusion
I firmly believe that the patient’s decision should be disclosed and he should be given proper medical and behavioral therapy to alleviate his medical and mental condition, by following Sandels’ philosophy of ‘doing the right thing.’
References
1. Stiggelbout, A. M., et al. "Clinical ethical dilemmas: convergent and divergent views of two scholarly communities." Journal of medical ethics 32.7 (2006): 381-388.
1. Ong, W. Y., C. M. Yee, and A. Lee. "Ethical dilemmas in the care of cancer patients near the end of life." Singapore medical journal 53.1 (2012): 11-16.
1. Nandi, Panna L. "Ethical aspects of clinical practice." Archives of Surgery 135.1 (2000): 22-25.
1. Iyalomhe, G. B. "Medical ethics and ethical dilemmas." Niger J Med 18.1 (2009): 8-16.
1. Geppert, Cynthia MA, and Wayne N. Shelton. "A comparison of general medical and clinical ethics consultations: what can we learn from each other?." Mayo Clinic Proceedings. Vol. 87. No. 4. Elsevier, 2012.
1. Levin, Alex V. "Do I have an ethical dilemma?." Oman journal of ophthalmology 3.2 (2010): 49.
1. Jie, Lin. "The patient suicide attempt–An ethical dilemma case study." International Journal of Nursing Sciences 2.4 (2015): 408-413.
1. Josipović-Jelić, Željka, and Ivana Šoljan. "Clinical ethics dilemmas in theory and practice." Acta clinica Croatica 46.4 (2007): 325-330.
1. Sandel, Michael J. Justice: What's the right thing to do?. Macmillan, 2010.
1. Wash. Rev. Code Ann. § 9A.36.060(1) (West 1988); Compassion in Dying, 79 F.3d at 797.