An ethical dilemma is any circumstance in which direct moral values are put in conflict in deciding which path of action is correct or incorrect (Pozgar, 2011). Ethical decision-making procedures, however, provide a useful framework in which to understand the conflicts, evaluate the alternatives and decide on the best course of action to take in the specific situation confronting the decision maker. Indeed, while employing a method of ethical decision-making to an ethical dilemma may not provide all the answers but it should help clarify the issues enough so that a means of resolution will be obvious or easier to see.
Gather the facts needed to identify the problem
The first step in the ethical decision making process would be to gather all the facts needed to analyze the situation. In this case, the relevant facts to consider are: (1) a 96-year old, terminally ill patient who is admitted into the intensive care unit (ICU) physically exhibits common characteristics of one suffering from liver cancer, except he is also confused and disoriented; (2) his daughter, who is an independent naturopathic physician, insists on treating her father and that her treatments are lifesaving; (3) she begins administering “unknown substances” down her father’s nasogastric (NG) tube; (4) the patient (her father) is clearly in pain after receiving the treatments from his daughter and (5) the medical staff is concerned that the daughter’s treatments are hastening the patient’s death rather than curing his illness.
Determine the nature and dimensions of the ethical dilemma
Once all the facts are gathered, the next step is to determine the various dimensions of the ethical dilemma. One way to help make this determination is to consider the four core ethical principles of autonomy, beneficence, non-malfeasance and justice.
Autonomy looks to guarantee that the patient has the freedom and knowledge to make their own choices about their care and which treatments they may allow or refuse (Forester-Miller & Rubenstein, 1992). In this case, there is no question that the patient has the right to decide what treatments he wants and who will administer them but there is a question of whether he can make these decisions knowingly and voluntarily. As the facts state, when he was admitted he was “confused and disoriented” so it is not at all clear whether he could understand how his decisions on treatment might harm himself and so consideration needs to be given on whether to allow him that autonomy.
Beneficence requires that every measure taken on behalf of the patient is done to make available the best possible result (Forester-Miller & Rubenstein, 1992). In this case, neither the daughter nor the medical staff seem to be acting for the benefit of the patient. On the one hand, the content and methods of the daughter’s treatments are clearly causing pain to her father. On the other hand, the inactivity of the medical staff in administering a treatment plan of their own is similarly and clearly not in the best interests of the patient.
The principle of non-malfeasance requires that caregivers avoid causing the patient harm (Pozgar, 2011). In this case, both the daughter and the medical staff are causing the patient harm. The daughter is putting her father’s well-being into question by putting “unknown” substances into his feeding tube even after she sees that it is causing him pain. The medical staff, in turn, is not following through with their oath to “do no harm” by simply doing nothing and allowing the daughter to administer substances that, “smell like feces and look like tar.”
Finally, the principle of justice holds that consideration must be given to the finite nature of available resources for care; how those resources are distributed and the decision making process in deciding who receive what treatment (Kichener, 1984). In this case, the principle focuses on the finite resources of the ICU and whether or not the patient is a suitable candidate for admission or whether there are alternatives within the hospital that are as good if not better for his treatment.
Determine the Issues
Application of the four core ethical principles not only helps to clarify the ethical dilemma(s) of the case but also helps to determine the ethical issues that will need to be resolved. The first issue concerns the ability of the patient to make his own decisions about treatment and about his treatment provider. His confusion suggests he currently does not have the mental facility to make such an important decision on his own. Secondly, the medical staff should be concerned about the medical credentials of the daughter and what her ultimate purpose is in wanting to treat her father. They know that she is a naturopathic physician but they don’t seem to know where she was trained; how long she worked as a naturopathic physician, where she works and if she has treated her father before. They also can see that her administration of treatments is not working which should suggest to them that she does not know what she is doing. Moreover, if they feel she is trying to hasten his death then clearly there is a problem in the relationship between her and her father which should cause them to act rather than stand on the sidelines. Finally, there is the question of whether or not the patient should have been admitted into ICU at all, being that he has been diagnosed with terminal liver cancer. While it is clear that the patient is in need of serious care and just as deserving of it as any other patient, but since the goal of the ICU is to make sure a patient’s health is stabilized as much as possible before making other plans to be moved to another unit perhaps there is another alternative, such as long-term healthcare unit, that is just as effective for a terminally ill patient.
Determine Possible Courses of Action
At the end of the day, there is no perfect answer to an ethical dilemma. However, the ethical decision making process provides a guide to analyze, evaluate and determine the best possible road forward. In this case, the medical staff should not allow any harm to be done to the patient. Accordingly, they should either stop the daughter from administering mysterious substances into her father’s feeding tube or first make a determination of what the substances are, what factors they are thought to cure and whether they have any harmful side effects. Secondly, the patient should be given the opportunity to rest and clear his mind. If he can come around, he should then be given the chance to decide about his own treatments. If it is determined that he can’t make these decisions, then a discussion needs to be had among the medical staff and the daughter on what treatments are in his best interests. Indeed, if the medical staff is concerned that the daughter might be trying to hasten her father’s death, then they consider having a surrogate or representative assigned on his behalf. The daughter does not need to be the one making decisions on her father’s behalf but rather it should be a collective decision that includes the medical staff’s input.
References
Foreester-Miller, H. & Rubenstein, R.L. (1992). Group Counseling: Ethics and Professional Issues. In D. Capuzzi & D.R. Gross (eds.) Introductions to Group Counseling (307-323). Denver, CO: Love Publishing Co.
Kitchener, K.S. (1984). Intuition, critical evaluation and ethical principles: the foundation for ethical decisions in counseling psychology. Counseling Psychologist, 12 (3), 43-55.
Pozgar, G.C. (2011). Legal Aspects of Healthcare Administration (11th ed.). Sudbury, MA: Jones and Bartlett Publishers.
