Dr Paulina Taboada
Profesor Centro de Bioetica
Pontificia Universidad Catolica de Chile
Alameda 340 Correo Central 1
Health care professionals frequently confront ethical dilemmas in the care of terminally ill patients. Some of them do not feel confident in dealing with these ethical dilemmas, especially if they did not get a formal ethical education during their training. They often distrust their skills for a systematic analysis of the conflicts in values that can arise in actual clinical decisions.
Appropriate knowledge of the basic ethical principles helps to analyze major dilemmas in the delivery of care to the terminally ill, such as issues related to communication, withholding or withdrawing treatments, hydration, nutrition or sedation, etc. In addition to their use in general discussions of specific issues, ethical analysis can be useful in reaching decisions in individual cases.
Bernard Lo operationally defined an ethical problem in clinical settings as a difficulty in the decision-making process with regard to an individual case, for the resolution of which one needs to refer to ethical principles that specify what should be done, in contradistinction to what can be (technically) done (Cf. Arch Intern Med 1981; 141: 1063 -1064).
In spite of some limitations of this definition, it has the merit of pointing out the fact that a clinician is confronted with an ethical problem when the question rises whether he should do something that could be actually done from a merely technical point of view. Another contribution of the definition is the reference to the key that would help in solving the dilemma: the referral to ethical principles or values. Nevertheless, precisely this point raises further questions to health care professionals, such as: Which are these ethical principles? How many are they? Are there ethical principles that might be accepted by people from different places, cultures or religious backgrounds? Is a rational analysis of ethical problems possible at all? Does this domain not rather belong to the realm of subjectivity?
In the context of these short lines, it is not possible to give a proper answer to the complex questions related to the objective or subjective character of ethics. Hence, without neglecting the importance of undertaking such an effort, I shall rather propose here a systematization of the ethical analysis of clinical cases that has proven to be helpful according to my experience with ethics consultations in the teaching hospital of the Pontifical Catholic University (Cf. Taboada, P: Ética Clínica: Principios básicos y modelo de análisis. Boletín Escuela de Medicina. 1998; 27, 1: 7 – 13).
Although I suggest to proceed in six different steps (Table 1), it might be good to state from the outset that I do not mean that these steps need to be applied in a rigid manner. They shall rather help as a reminder of the different types of information that should be always collected and revised when solving an ethical problem.
Define the specific ethical dilemma/s
A necessary (but not sufficient) condition to solve a problem (of any kind) is to adequately identify it. A clear identification of the problem means - among other things – that one is able to formulate the right question. In the case of ethical problems, this might not be always easy. It is therefore important to make an intentional effort to formulate the question as clearly as possible. At the same time, the question should be formulated in such a way that it can be answered (formulate an operational question, i.e., a question with which you can work).
Refer to the ethical principles involved
An ethical dilemma commonly rises when some values or principles seem to confront – or do actually confront - with each other, and one does not know for sure which one should have the priority. Hence, one has to make an effort to clearly identify the conflicting values: e.g., respect for life, non-maleficence, beneficence, confidentiality, respect for the patient’s autonomy, etc.
Collect and analyze ethically relevant clinical information.
There is always a corpus of clinical information that is usually relevant for the ethical analysis. I do not speak here about ethical information; I really mean technical or scientific information that has to be taken into account if one wants to perform an objectively founded ethics and not merely a theoretical discussion. For instance: the evidence-based certainty of the diagnosis and prognosis; the therapeutic options with their corresponding benefits, risks and burdens, etc. All this needs to be double-checked, because it is relevant to the ethical analysis.
Review alternative courses of action.
The idea of this step is not to review the therapeutic alternatives, but rather the alternatives with regard to the ethical question. For instance, if my question is whether it is ethically legitimate not to disclose the truth about the clinical situation to a patient at the family’s request, then the alternatives can be, for instance: 1. to follow the family’s request; 2. to disclose the truth against the family’s wishes; 3. to explore the patient’s preferences with regard to communication and decision-making; etc.
Suggest an ethical solution.
After having collected and analyzed all the information requested by the previous steps, one might be in a good position to answer the ethical dilemma, providing the corresponding foundations.
Consider the best way of implementing the suggested solution
For an action to be morally good not only the act itself (what I do) and the reason for doing it (why I do it) have to be good. Also, the way I do things is ethically relevant (how I do it). Thus, to solve an ethical dilemma means not only to suggest what ought to be done and the reasons for doing it. Also the practical way of implementing the proposed solution needs to be specified (for instance: who, how, where, when, etc.)
In my future monthly contributions to this newsletter I shall exemplify the practical application of the proposed tool to the analysis of some ethical dilemmas that are frequent in the care of terminally ill patients.
Dr. Paulina Taboada, MD, PhD
Palliative Care and Bioethics