Although you will always be in a position to discuss ethical dilemmas with tutors or senior colleagues, learning to identify and make reasonable decisions in the face of an ethical dilemma is a critical component of medical professionalism. Here we outline a proven step by step approach which you can take.
Where ethical dilemmas arise in medicine, practical solutions have to be found. Over a number of years the BMA’s ethics department has developed its own methodology, which is designed to help you analyse and resolve ethical problems.
Step one: recognise the situation as one that raises an ethical dilemma
Identifying that a problem has an ethical dimension is not always as easy as it sounds. While in extreme cases, such as a request by an otherwise healthy person for life-sustaining treatment to be removed, ethical issues are clearly present, these situations are unusual.
Some ethical problems however are more frequent, for example:
- Is it acceptable for me to respond to a relative’s request for information?
- Should I request that a teenage girl’s mother permits me to speak with her daughter in confidence?
- Can I agree to a request from a patient to withhold information from an insurance report?
These more day-to-day questions all have an ethical dimension – none of them, that is, can be reduced entirely to their clinical aspects. Ethical problems emerge where values, principles or moral imperatives come into conflict. All of the examples highlighted above involve conflicting imperatives or obligations and all of them are ethical dilemmas.
Step two: break the dilemma into its component parts
Having recognised the existence of an ethical problem, a critical next step involves clearing away irrelevant information and identifying the ethically significant aspects of the problem.
- identifying and describing as accurately as possible the question that we are seeking to answer
- identifying relevant principles.
When various different rights and interests compete, it may still be clear which should take preference. When child protection concerns arise for example, parents’ preferences will often take second place to the interests of the child.
Step three: seek additional information, including the patient’s viewpoint
Before going on to analyse the dilemma, a vital next step is to identify the relevant facts. In relation to a young person, for example, it will ordinarily be necessary to identify whether he or she is sufficiently mature to make a decision. If not, it will be necessary to identify someone with parental responsibility to make the decision.
As part of the information gathering process, the patient’s views should be sought wherever possible, even where he or she may be thought to lack the capacity to make relevant decisions.
Step four: identify any relevant law or professional guidance
Over the years a great deal of legal and professional guidance has been developed to assist doctors in managing many of the ethical dilemmas they confront.
When faced with an ethical dilemma, a solution can often be found by referring to guidance from:
- the GMC
- the BMA
- other medical bodies
- various legal sources such as statute and legal codes of practice.
In this way, practical ways forward can be found in relation to many ethical problems.
Step five: subject the dilemma to critical analysis
The majority of ethical dilemmas that you encounter on a day-to-day basis can be addressed using existing guidance. Others can be more complex and may require more careful balancing of relevant factors, including any principles highlighted by guidance, patient views and the opinions of colleagues. If in doubt, always ask for help.
Relevant factors will also include the nature and strength of the obligations involved and to whom they are owed, as well as potential harms and benefits arising from different options. Unless in an emergency, it is at this point that more searching critical analysis of relevant aspects of the dilemma can be required.
With an elderly confused patient who has concerned relatives who are involved in her care, doctors may, for example, be concerned to balance a respect for the patient’s choice with a concern for her welfare, recognising the strong obligation to respect the decisions of a competent patient.
Advice can also be requested from us, the GMC or medical defence bodies. Increasing numbers of hospitals have access to the services of a clinical ethics committee (CEC) and it can be extremely helpful to refer problems to the committee for consideration.
Step six: be able to justify the decision with sound arguments
Medical students, like doctors, are not expected to be philosophers, and many decisions have to be made under pressure of time and in the face of imperfect information. In these circumstances, you are not expected to be omniscient but to act reasonably and to be able to justify both clinically and ethically the decisions you make.
You will not be expected to try and resolve ethical dilemmas single-handed. Nevertheless, it is good practice to get into the habit, where confronted with ethical dilemmas, of recording any discussions with the patient or colleagues in medical notes as well as indicating any guidance notes consulted. Where advice has been sought from professional or medico-legal bodies, this should also be recorded in the notes. In this way the reasoning behind decisions can be given.