Prioritizing Principles

The Bioethical Dilemma

In the abstract, bioethical principles often appear simple; however, in practice, applying bioethical principles may be confusing. When two or more seemingly equivalent principles or values seem to compel different actions, a bioethical dilemma exists. This situation is often described as being "damned if you do and damned if you don’t," where any potential action appears, on first reflection, to be an option between two seemingly equivalent goods or evils.


In the following example, taken from Ethics in Emergency Medicine, the physician can be said to be on the horns (two prickly but seemingly equal choices) of a dilemma. Although there seem to be only two options for action, they involve several conflicting bioethical principles.

Case

A 60-year-old man stabbed himself in the abdomen because of intractable pain from terminal pancreatic cancer, unrelieved by any medical therapy. Paramedics brought him in after a well-meaning friend, who happened to be in the house when the event occurred, called them. Although he is obviously going to exsanguinate if not given aggressive care, neither the patient, who is still alert and oriented, nor his wife, who is present, want him to be given any treatment other than pain control. A review of his chart confirms that his physicians are at a loss as to how to alleviate his pain and that he is expected to die within the next several weeks.

Emergency physicians respect their patients’ autonomy, but generally question patients’ decision-making capacity if they have attempted suicide. This patient’s actions seem to raise the question of whether in fact he has a right or an ability to be autonomous. This physician also believes strongly in beneficence: helping those in need, relieving pain, and saving lives when possible. Beneficence suggests alternative courses of action palliative care or aggressive therapeutic intervention. Merely using analgesics and other comfort measures will abet a suicide, yet nonmaleficence suggests that initiating aggressive medical and surgical interventions will prolong and make more painful a dying process that the physician’s colleagues have found to be unresponsive even to palliative treatment. He or she also knows that he or she faces possible professional sanctions if he or she does not intervene and is personally struggling over the issue of so-called rational suicide.

Which value(s) take precedence in this instance patient autonomy, beneficence, nonmaleficence, or personal safety? Three of the four principles point in a single direction, but beneficence may suggest several conflicting actions. As in this case, bioethics considers problems that are neither black nor white only gray.

The first question the physician should ask is whether he or she has had this or a similar ethical dilemma before. If so, how was that resolved or how should it have been resolved? The question of "how should it have been resolved?" suggests that he or she may have later discussed it with colleagues, read more about this type of dilemma, or discussed it as a retrospective case review with the institution’s bioethics committee. Even if a similar ethical situation has been encountered before is this case similar enough to apply the action from the last situation? If so, the physician should then proceed.

Let us assume, however, that this is the first time the physician has encountered this type of dilemma. The next question is whether there is a way clinically to buy time so that the physician has time to think through this case more thoroughly, consult with colleagues, or obtain a bioethics consultation (may be available in some institutions). In that case, the physician should try to determine a course of action that falls within the "ethically reasonable" spectrum. It may not be the action taken after further reflection, consultation, or reading, but if, as in this case, he or she must act immediately, he or she needs to have some guidelines.

The physician then decides on a course of action and tries to apply the three tests: the impartiality test, the universalizability test, and the interpersonal justifiability test. For example, if the physician decides only to make the patient comfortable and let him succumb to his injury, he or she should ask herself the three questions:
1. Would I be willing to have my physician act in this manner if I were in this patient’s place? (Impartiality Test)
2. Would I be comfortable if all clinicians with my background and in these same circumstances act as I am proposing to do? (Universalizability Test)
3. Am I ready to state openly to my peers, superiors, or to the public my reasons that I acted as I propose to do? (Interpersonal Justifiability Test)
If all these answers are affirmative, then the action is most probably within the range of ethical acceptability and the clinician can proceed. If not, he or she should choose another option and go through the process again.