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Introduction – Ethical Dilemmas

“What is usually the right thing to do?”

Consider the following four opinions:

“We cannot afford that much help.” …… v. …… “The more we give, the more we get”

“People should forgive people” …… v. …… “We can never forgive the Nazis”

Organ Transplantation: Ethical Dilemmas

The following is excerpted from a background paper prepared by the President’s Council on Bioethics in 2003:

Organ Transplantation: Ethical Dilemmas and Policy Choices

Since the first human kidney was transplanted in 1954, the nation has engaged in searching public discussions about the ethics of organ transplantation: about the human significance of removing organs from both living and cadaveric donors; about the criteria for determining when death occurs and thus when the decedent’s organs might be taken; about whose wishes should ultimately decide whether organs are used or not used; and about the ethics of different organ procurement and allocation laws.

The current organ policy is shaped largely by two important laws: The first is the Uniform Anatomical Gift Act of 1968, adopted in all fifty states, which granted individuals the right to decide before death whether they wished to donate their organs; the second is the Organ Transplantation Act of 1984, which aimed to encourage organ donation by establishing an organized organ matching and procurement network, while outlawing the buying and selling of human organs or the direct compensation of organ donors and their families. Taken together, these laws sought to reap the medical benefits of organ transplantation and to encourage individuals to become organ donors, while preserving certain ethical limits against treating the body as property and the newly dead as simply natural resources. It also sought to ensure, as much as possible given other inequities in the health-care system, that organs are allocated in an equitable way.

Whether this policy has been a great success or terrible failure – both medically and ethically – is a complex question. Many lives have been saved that would not have been otherwise, and yet waiting lists for organs continue to increase. Many individuals have given of themselves (literally) to save the life of another, and yet the unequivocal protection of those who are not-yet-dead (but would be useful if they were) has been called into question. The human body (dead or alive) has not been reduced to mere property, and yet the desperation of watching thousands of individuals die every year while waiting for organs has prompted a renewed debate about whether monetary incentives should be used in an effort to increase organ supply.

In the 107th Congress (2001 – 2002), a number of bills aimed at promoting organ donation and increasing organ supply were proposed. Some bills would have provided formal recognition of donors with commemorative medals. Other bills offered tax credits to individuals who donate organs (or credits to their surviving families) or reimbursement of the costs incurred by living donors. In addition, numerous books and articles have been written claiming that the current organ procurement system has been a failure, resulting in “prolonged suffering, declining health, and rising death rates,” and that the time has come to explore a market-based system to solve the organ supply problem. A new group – called LifeSharers – is attempting to develop a private network of organ giving and receiving, so that members have first priority on the organs of other members. And while the medical community generally supports the guiding principle of the current policy – that organ donation should be an act of giving, without monetary incentives of any kind – the American Society of Transplant Surgeons has endorsed the idea of a pilot program that would partially reimburse surviving families for the funeral expenses of individuals who allow their organs to be taken after death.

Source: https://bioethicsarchive.georgetown.edu/pcbe/background/org_transplant.html

1. How do you define a dilemma?

Since a dilemma deals with two possible rights, these two right choices must be clearly stated. Then the dilemma can move to a solution, where one of the rights is preferred over the other one.

Determine the two sides of the dilemma. (__v. __)  Write the dilemma as “a. one view” versus “b. another view.”

Analyzing dilemmas: Ethical dilemmas are termed in the form of  _____v. ______, such as Equality of workers v. Integrity of organization.  Many dilemmas are also written as dealing with :

1. Primacy of the interests of one party over the other (client or group)
2. Distribution in one way or other (merit or equal share)
3. Obligation of one to another (duty, custom, legal obligation)
4. Responsibility to client, colleague, profession, employer, society etc.

Some cases may be also deal with:

• Permanency v. physical safety
• Best interest of client v. obligation to do no harm (or v. rights of others, benefits, etc)
• Quality of life v. prolonging of life
• Client self-determination v. obligation to prevent harm
• Right to confidentiality v. autonomy
• Effectiveness of service v. client privacy

2. What values are at stake?

Explore the relevant values in the authorities literature of the case. Individuals may validate their basic ethical values from such sources as laws, social science research, and religious texts such as the Bible.

Some of the issues concerning values are: 

1. The right or wrong of an action.
2. The acceptance, reputation or embarrassment of an action.
3. Qualification and disqualification of a person, with reasons.
4. Virtues such as integrity, love,  forgiveness, respect, purity, trust, sanctity of life.

3. What principles are at stake?

Select the relevant principles that apply to the case and explain the reasoning process that you used to arrive at a tentative solution. Some of the terms presented in the dilemma definitions in Section 1. also suggest principles that may be at stake.

Some relevant principle may be:

1. Protection of life etc.
2. Conflict avoidance
3. Greatest good of group, etc.
4. Truth telling
5. Acceptance of Biblical/religious command
6. Accountability

4. What personal issues are at stake?

Consider what personal issues of people or populations may effect the outcome of the case to such an extend that a particular ethical position is required. Reconsider your tentative solution in light of the personal issues involved and suggest a final solution.

In some cases, the loyalty for one group takes precedence over the loyalty to another group. Some groups include the:

1. Victim
2. Family
3. Employer
4. Profession
5. Community

5. How will you deal with these 10 cases?

Use each of the above four steps to analyze the following cases, describe your reasoning, and reach a solution. For an example of using a case worksheet, see sections 4.7-4.8 of the Ethical Choices course.

Case Worksheet

Cases to Analyze for Practice

5.0 Two orphans

Two sisters, Ann (age 6) and Bev (14), who live in foster care must leave the place. They have very different problems, Ann is physically handicapped, Bev is mentally handicapped. Should the sisters be placed together or separately? (Case 1.2)

5.1 Wanting to die

Mrs. Klimov (age 33) wants to stop her difficult cancer treatment and wants to die. She has a ten-year old son, who can be taken care of by her mother. Her mother says she is too young to die and considers it suicide. She was named her daughter’s Advance Directive (medical decision maker) and refuses to let her daughter stop the treatment. (Case 1.3)

5.2 Adoption

Mary (age 15) was adapted 12 years ago and now wants to know who her birth-parents are. The records are sealed. Her adopted parents do not want her to meet her extremely poor birth-parents for they feel that it will upset her too much and that she may want to leave them.  (Case 1.7)

5.3 Computer Records

To be more efficient, Pastor Jones places his confidential home visitation records on his officer computer. That will make record-keeping easier and he could visit more homes. While at present he is the only one with access to that computer, it would be easy for anyone to access the information when he is not in the office, that is usually unlocked. It could compromise the records. (Case 3.2)

5.4 Cultural Differences

Mr. Kim has immigrated from Korea some 3 years ago and joins the Washington Writer’s Society. He speaks and writes very good English but has many problems adopting to the rules of the Society, which seem very strange to him. All his practices are acceptable in Korea, but not in Washington. The Society is considering if it can keep Mr. Kim as member because his presence disrupts the Society. (Case 3.3)

5.5 Organizational Mission

Joe, age 25, comes to a social worker at JKM, an organization that serves and supports homosexuals. He requests help in becoming heterosexual. JKM does not have a program for that and does not advocate sexual-orientation changes. (Case 3.4)

5.6 Suicide

Bill, age 45, has been abused as a child and has recently lost his wife. He is very depressed and visits his only friend, a male nurse. He threatens suicide. His friend things that he will get over it and tries to motivate him to living. He could also commit him to a clinic for treatment.  Next day Bill commits suicide. (Case 4.1)

5.7 Family

Henry, age 95, is keen of mind but feeble, lives alone and wants to stay living alone. He sometimes falls, but has not injured himself seriously. His daughter is concerned and wants him to come live with her. He refuses to move. (Case 4.4)

5.8 Rape Report

Jane, age 16, was raped by a neighbor and comes to tell her teacher she trusts. She asks the teacher not to tell anyone about that. The teacher feels that reporting it to the police and the investigation may be worse than the rape itself. Reporting may also place Jane’s life in danger.  (Case 4.9)

5.9 Tasha’s Baby

Tasha, age 23, is single and 3 month pregnant. She uses drugs that endanger her fetus. Her mother tries to persuade her to give up drugs. She refuses. She also refuses to go see a doctor for she feels that the doctor will make her feel bad about her drug-use. (Case 5.3)

The above cases were adapted from Juliet Cassuto Rothman’s From the Front Lines: Case Studies in Social Work Ethics, Allyn and Bacon, 1997.

Ethical Dilemmas in Practice

Please read the following excerpted articles from professional journals relating to ethical dilemmas in clinical and health care settings.

Ethical Dilemmas in Clinical Practice

Further Reading
Values at the Bedside: A Survey of European Physicians Regarding Ethical Dilemmas in Clinical Practice

      Further study details as provided by National Institutes of Health Clinical Center (CC):

 

Study Start Date: August 2002
Description:

Ethics support services are being developed in many European countries, but the evidence base concerning the types of ethical dilemmas faced by physicians in these countries is small. The ways in which physicians respond to ethically difficult situations and the types of ethical support they would consider useful in such cases are also largely unexplored. In this study, we aim to explore the experience of physicians regarding ethical issues at the bedside in Italy, Norway, Switzerland, the UK, and the US. These are countries with very different cultural contexts, where ethics support services are in various stages of development. A better understanding of the ethical difficulties encountered by physicians in these different settings and the ways in which they respond to them would be useful locally to assist the development of support services. It would also permit intercultural comparison of the practical answers given to difficult questions for which there cannot be said that there is one right answer.

One of the ethical dilemmas faced by physicians at the bedside is the allocation of scarce resources. This is of particular interest, as it has implications that go beyond the physician-patient encounter. The choices made by physicians in situations of scarce resources not only reflect their values, but also the constraints they must work with. Knowing more about the role of those factors could be an important contribution to an evidence base for health policy.

This is an exploratory cross-sectional self-administered mailed survey of physicians in primary care in Italy, Switzerland, and the UK. The part of the survey instrument exploring physicians’ experience and attitudes regarding resource allocation at the bedside will also be conducted in the U.S. The questionnaire will address the type and frequency of ethical dilemmas faced by physicians, how they approach such dilemmas, the type of ethical support they would find useful in such situations, as well as their attitudes and practices in situations of scarce resources. Data will be analyzed using descriptive statistics, factorial analysis of variance to determine factors associated with the type and frequency of ethical difficulties encountered, and logistic regression to determine factors associated with reported rationing behavior and with perception of the equity of the health care system. Independent variables used in the analysis of the last two points will also include health care systems’ characteristics collected from the literature. Participants will be selected on the basis of national listings. To ensure sufficient exposure to direct clinical practice, inclusion criteria will include direct patient care for at least a year and at least 20% of the participants’ time.

http://clinicaltrials.gov/ct2/show/NCT00352573

 Ethical Dilemmas in the Health Care System

Living with conflicts-ethical dilemmas and moral distress in the health care system.

Kälvemark S, Höglund AT, Hansson MG, Westerholm P, Arnetz B.

Department of Public Health and Caring Sciences, Uppsala University, Uppsala Science Park, S-751 85, Uppsala, Sweden. sofia.kalvemark@apoteket.se

Abstract

During the last decade, the Swedish health care system has undergone fundamental changes. The changes have made health care more complex and ethics has increasingly become a required component of clinical practice. Considering this, it is not surprising that many health care professionals suffer from stress-related disorders. Stress due to ethical dilemmas is usually referred to as “moral distress”. The present article derives from Andrew Jameton’s development of the concept of moral distress and presents the results of a study that, using focus group method, identifies situations of ethical dilemmas and moral distress among health care providers of different categories. The study includes both hospital clinics and pharmacies. The results show that all categories of staff interviewed express experiences of moral distress; prior research has mostly focused on moral distress experienced by nurses. Second, it was made clear that moral distress does not occur only as a consequence of institutional constraints preventing the health care giver from acting on his/her moral considerations, which is the traditional definition of moral distress. There are situations when the staff members do follow their moral decisions, but in doing so they clash with, e.g. legal regulations. In these cases too, moral distress occurs. Hitherto research on moral distress has focused on the individual health care provider and her subjective moral convictions. Our results show that the study of moral distress must focus more on the context of the ethical dilemmas. Finally, the conclusion of the study is that the work organization must provide better support resources and structures to decrease moral distress. The results point to the need for further education in ethics and a forum for discussing ethically troubling situations experienced in the daily care practice for both hospital and pharmacy staff.

PMID: 14723903 [PubMed – indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/14723903

Practitioner’s Guide to Ethical Decision Making

ERIC_NO: ED413544, A Practitioner’s Guide to Ethical Decision Making. by Forester-Miller, Holly; Davis, Thomas E., 1995

ABSTRACT: Counselors must make sound ethical decisions but, often, determining the appropriate course to take when confronted with a difficult ethical dilemma can be a challenge. This guide assists counselors in ethical decision making; it is presented as a supplement, and is to be used in conjunction with, the American Counseling Association (ACA) Code of Ethics and Standards of Practice. This practitioner’s guide addresses principles that are globally valuable in ethical decision making and provides a model for professionals to utilize in their practice. It opens with a review of the five moral principles that are viewed by many as the cornerstone of ethical guidelines: autonomy, non-maleficence, beneficence, justice, and fidelity. These principles provide an absolute against which counselors can explore an ethical dilemma, thereby gaining a better understanding of conflicting issues. A sequential, seven-step, ethical, decision-making model is presented next and comprises the following: (1) identify the problem; (2) apply the ACA Code of Ethics; (3) determine the nature and dimensions of the dilemma; (4) generate potential courses of action; (5) consider the potential consequences of all options and then determine a course of action; (6) evaluate the selected course of action; (7) implement this action. www.eric.ed.gov

Resolving Ethical Dilemmas in the Workplace

ERIC_NO: ED334468, Resolving Ethical Dilemmas in the Workplace: A New Focus for Career Development. ERIC Digest No. 112., by Lankard, Bettina A., 1991

ABSTRACT: The diverse, multicultural population that constitutes today’s work force faces ethical dilemmas on the job that bring pressures to protect their own or their company’s interests, at the risk of losing their personal integrity. Employers and vocational and career development personnel are recognizing the need for decision-making and problem-solving skills that will facilitate negotiation and conflict resolution in the workplace. Conflicts arise between two or more personally held values, between personal values and those of another person or the organization, between principles and the need to achieve a desired outcome, and between two or more persons or groups to whom one has an obligation. The resolution of conflicts requires interpersonal and negotiation skills; the application of “employability skills” such as honesty, cooperation, and integrity; and the participation of all stakeholders in a situation. Ethics training should help employees (1) recognize which decisions involve ethics; (2) understand the values of all stakeholders; and (3) weigh the potential impact of various options on those values. As part of a career development curriculum, discussions and analyses of case studies, use of ethics committees and resource people, and training in critical thinking, conflict resolution, communication, group processes, and mediation skills can prepare students for the ethical dilemmas they may face in the workplace. www.cdc.gov/od/ethics .

Ethics Resources

• http://scholar.lib.vt.edu/ejournals/SPT/v8n1/devon.html 
• www.gutenberg.org/etext/15487
• www.law.manchester.ac.uk/research/centres/csep/

Ethics Library

Explore your concerns in ethics at three of the following sites:

Course Test