Medical Ethics for Physicians __________________________________________________________________
thinks would benefit the patient. When principles conflict, such as those in the example statement above, a choice must be made about which principle should be honored. • Sort the issues by differentiating the facts from values and policy issues. Although these three matters often become confused, they need to be identified, particularly when the decision is an ethical one. So, ask the following questions: what are the facts, values, and policy concerns, and what appropriate ethical principles are involved for society, for you, and for the involved parties in the ethical dilemma? • Solve the problem by creating several choices of action. This is vital to the decision-making process and to the patient’s sense of controlling his or her life. When faced with a difficult dilemma, individuals often see only two courses of action that can be taken. These may relate to choosing an intervention, dealing with family and friends, or exploring available resources. It is good to brainstorm about all the possible actions that could be taken (even if some have been informally excluded). This process gives everyone a chance to think through the possibilities and to make clear arguments for and against the various alternatives. It also helps to discourage any possible polarization of the parties involved. Ethical decision making is not easy, but many problems can be solved with creativity and thought. This involves the following: - Gather as many creative solutions as possible by brainstorming before evaluating suggestions (your own or others). - Evaluate the suggested solutions until you come up with the most usable ones. Identify the ethical and political consequences of these solutions. Remember that you cannot turn your ethical decision into action if you are not realistic regarding the constraints of institutions and political systems. - Identify the best solution. Whenever possible, arrive at your decision by consensus so that others will support the action. If there are no workable solutions, be prepared to say so and explain why. If ethics cannot be implemented because of politics, this should be discussed. If there are no answers because the ethical dilemma is unsolvable, the appropriate people also must be informed. Finally, the patient and/or family should be involved in making the decision, and it is imperative to implement their choice. • Initiate and act because ethics without action is just talk. In order to act, make sure that you communicate what must be done. Share your individual or group decision with the appropriate parties and seek their cooperation. Implement the decision. • Evaluate and reflect, as perfect ethical decisions are
seldom possible. However, healthcare professionals can learn from past decisions and try to make them better in the future, particularly when they lead to policy making. To do this: - Review the ramifications of the decision. - Review the process of making the decision. For example, ask yourself if you would do it in the same way the next time and if the appropriate people were involved. - Ask whether the decision should become policy or if more cases and data are needed before that step should occur. - Learn from successes and errors. - Be prepared to review the decision at a later time if the facts or issues change. PHYSICIAN-ASSISTED SUICIDE Many physicians have known an old, wise, and respected clinical colleague who told of helping patients with terminal cancer in intractable pain “go more easily (and quickly) with a bit of extra morphine sulfate.” Of course, this action was performed quietly, with permission from the patient and/or his or her family (not written) and the tacit understanding of the nursing staff. This is in contradistinction to the retired pathologist Dr. Jack Kevorkian, who flagrantly performed an assisted suicide on a patient with national television coverage in 1998. He was subsequently convicted of second-degree murder for the act and sentenced to 10 to 25 years in prison. In October 2002, the U.S. Supreme Court rejected his appeal to overturn the verdict. As will be discussed, in 1997 the Court had previously decided that there is no constitutional right to physician-assisted suicide. The physician-assisted suicide debate, like the abortion issue, is many sided, with differing opinions from members of all religious and cultural groups. What is somewhat unusual is that the subject has appeared on the ballots in some states to allow the voting public to cast an opinion. However, as noted, the judiciary’s opinion in the matter often leads to the final decision. There are two court cases that are of major importance in this matter; they are the cases of Dennis Vacco v. Timothy Quill, MD, et al. in New York and the State of Washington v. Glucksberg. On June 26, 1997 the U.S. Supreme Court decided these two cases, reversing the landmark court of appeals decisions that had invalidated laws in New York and Washington that criminalize physician-assisted suicide [24]. In March 1996, the Ninth Circuit Court of Appeals had concluded in Compassion in Dying v. State of Washington (now titled State of Washington v. Glucksberg) that there is
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