Topic : Case studies draw an ethical

challenges encountered by
physicians in everyday practice

Name : Manish Das

Registration No : 11811480

Submitted To : Ms Bhanu Sharma

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Abstract
It is not possible, and perhaps not even desirable to construct a code of ethics that covers all
eventualities, and yet we are swamped with ethical problems and decisions every day in general
practice. In my experience, most doctors are predominantly ethical people, and hold the interests of
their patients as the prime reason for their existence. In the final instance, it is our own conscience
that will dictate our behaviour, and it is the opinion of our peers that will guide us in difficulty. This
poses more questions than it does answers, but we must continue in our tradition of service, practising
only to the highest standards of ethical behaviour.

Introduction
The public holds physicians to a moral standard for their work that often exceeds legal requirements.
Physicians—whose life-and-death decision-making profession exposes them to enormous risks—must
also distinguish between the legal and the ethical in their practice. As we have seen in recent years,
some physicians are willing to challenge the law on certain issues because they believe the law is
immoral. This article should help clinicians be more ethically aware in their treatment of their patients.

Case Study
Case #1: A 34-year-old female has been under your care for the last 10 years. For the last three years,
she has been fighting metastatic breast cancer. Despite her being on chemotherapy and hormonal
therapy, recent scans indicate that the cancer has spread to her liver. She now asks you whether
anything else can be done. You think about the possibility of further therapy with a bone morrow
transplant but quickly realize that her HMO will not cover experimental therapies. Furthermore, you
know that the chances of success with that therapy are marginal. Do you tell her about this option? Or,
do you simply reassure her that every reasonable option has been tried?

Case #2: A 42-year-old male comes into your office complaining of no urine output for the last 24
hours. Three days ago, he was in your office with a muscle strain in his shoulder. At that time, you gave
him an injectible non-steroidal medication. The blood work that you obtained in the office reveals
creatinine levels of 3.4, and you suspect interstitial nephritis caused by the non-steroidal medication.
Do you now tell him that the deterioration in his kidney function might be due to the medication that
you prescribed several days before? Or, realizing that this may be self-limited, do you simply advise
him to come in for follow-up lab tests in hopes that this will resolve without causing further problems?

While the above cases are straightforward and unlikely to cause a major moral dilemma for most
physicians, they do illustrate that physicians daily confront ethical issues. The principles that apply to
straightforward cases will also help the physician address more complex ones.

A final case illustrates that an ethical dilemma may occur not with the physician but with the patient.
For that reason, physicians also need to be adept at counseling and advising their patients who face
their own ethical dilemmas.

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Case #3: A 49-year-old Caucasian male presents to your office with penile discharge. A slide made of
the discharge confirms that he has a chlamydia infection. You counsel him that he should inform his
wife, as she may also need treatment. He confides in you that he has not had relations with his wife in
several months but has been seeing a friend from work. He asks that you not tell his wife, who is also a
patient in your practice and who is scheduled for an appointment in two weeks. What are your
obligations to this man and his wife, both of whom are your patients? What counsel would you give to
help him make the right decision in this dilemma?

As you read these cases typical of situations that confront the primary care physician, what mental
steps did you take? What kind of reasoning did you employ to work through the issues? Did you start
with the facts and details of the cases and then work toward a solution based on your general
understanding of the moral atmosphere of our culture? Were you concerned more with the
consequences than with the nature of the action itself? If so, you employed the kind of moral
reasoning we call casuistry and may have employed a utilitarian method in your approach. Casuistry is
an inductive approach that starts from the concrete facts of a case in the context of the moral rules
people ordinarily use to make ethical decisions. It is not reasoning from general norms to particular
cases. Using this approach, you would carefully weigh whether informing the female in case #1 about a
bone marrow transplant would be appropriate given the facts of her case, her current feelings about
her treatment, and the quality she wanted to have in the life remaining to her. There might be reason
not to tell her about the bone marrow transplant option, although, even if it was hopelessly beyond
her financial reach, we suspect that most physicians would mention it. Or, the physician might consider
advocating on behalf of the patient with her insurance company, pressuring it to support this protocol.

Because medicine often deals with people in extremis, or at least with people in pain and fearful about
their health, every practicing primary care physician is familiar with the ethical challenges inherent in
these cases. They are woven into the fabric of medicine so completely that it is difficult—if not
impossible—to make any decisions or recommendations about patient care that do not have ethical
implications. For that reason, it is helpful for physicians to familiarize themselves with how current
medical-ethical thinking affects the challenges they face every day. While there are a number of
principles that are important to medical ethics, most modern ethicists recognize that at least these
four basic principles in medical-ethical reasoning form the basis for most of their work. They have been
employed in one form or another since the time of the Greeks.

The Four Principles

1. Beneficence. Beneficence may be understood as that principle which impels the physician to "seek
the patient’s good," to put the patient’s welfare above all that would compete with that welfare in the
physician’s eyes, most especially the physician’s own good. Financial concerns, time constraints,
managed care, government DRGs—nothing can trump the importance of the patient’s welfare. In the
fee-for-service system, one could afford to seek the patient’s good without fear of being challenged, if
"good" is taken to mean do everything possible for the patient. If a physician had the slightest doubt
about a diagnosis, more tests could easily be ordered. No one would challenge a physician decision
regarding diagnosis or treatment. Today, one must "do good" in a way that does not unduly waste
resources. Now, clinical quality indicators and standards of care are invoked by medical institutions as
well as HMOs to somewhat regulate the doctor’s decisions about diagnosis and treatment. Recently,

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several celebrated cases in which HMOs refused to pay for either a lengthened hospital stay (obstetrics
case) or for certain kinds of treatment modalities have been reviewed by the courts, thus reining in
what some regard as excessive interference in medical treatment and patient care.

2. Non-maleficence. Non-maleficence or "do no harm" is the second principle. This principle recognizes
that when a patient places her very life in the physician’s hands, she has the right to expect that the
physician will not harm her, and that any risks associated with treatment will be reasonable ones in
relationship to the desired outcome. This is also the principle used to support the view that under no
circumstances may a physician assist a patient who wishes to die. Physicians may withhold or withdraw
treatment; they may even prescribe pain-controlling drug therapies that can shorten life. Such
practices fulfill the "do no harm" criterion.

3. Patient autonomy. Patient autonomy is the next principle. This means that we must give the
competent patient or her designated surrogate final decision-making authority over what will or will
not be done to and for her by the physician. That is, no one can ever be forced to accept treatment she
does not want, even if it is in her best interest. In the history of medicine, the importance of this
principle is a rather late arrival. For several centuries, a heavy-handed paternalism operated in medical
culture. Patients could be treated against their will if the physician deemed it appropriate. Some will
argue that our anti-paternalism is a uniquely American—or Western—principle given our highly
individualistic democratic culture. Other parts of the world (Africa, for example) may not find this
principle as compelling in their tribal or communal cultures. Because of our emphasis on autonomy,
we have found it more difficult to deal with mentally ill people who refuse help and at the same time
are not ill enough to be declared incompetent.

4. Justice. Justice is the fourth principle. It is concerned about the fair distribution of health care
resources when it is impossible for everyone to have everything "possible." It is the principle that
compels moral beings to be concerned about the tens of millions of Americans without health care
coverage, with the fact that prenatal care among poor women is considerably below the national
average, and with the fact that in some circumstances (e.g., a major earthquake or flood), resources
may need to be "triaged" between those who need immediate care to survive, those who cannot
survive, and those whose needs are real but not life-threatening. In other words, it is the principle that
prevents us from neglecting the powerless and poor and from wasting resources.

Other Ethical Issues

"Assisted Death" or what used to be called "Physician Assisted Suicide" (an inflammatory and
prejudicial phrase in the opinion of many; hence, the change) will be with us for some time to
come.There are two primary reasons patients may ask for help in dying. The first is that in a very few
instances, the physical pain cannot be relieved. In such a case, what is to be done? Some suggest that
the patient "bear" the suffering bravely. Others believe that is cruel treatment. They assume that a
"dignified" death is one made as tranquil as possible. A second, more widespread reason that people
want help in dying is that they do not want to die a lingering death with the indignities associated with
incontinence, memory loss, and dependence on family and health care workers. In their view, mercy
and compassion require that we do all we can for people (or even animals) who are in suffering
(physical, emotional, and spiritual) as they await their deaths.The recent Supreme Court decision has

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made it clear that terminally ill patients do not have a "constitutional right" to assistance in suicide. On
the other hand, the same decision also made it clear that it is not "unconstitutional" for states to have
legislation permitting it. One may expect that this dilemma in bioethics and the law will undergo
intense debate in the coming years.

Conclusion
An urgent need exists for both national and international strategies to retain a qualified workforce.
Healthcare institutions should consider the range of ethical problems that physicians encounter in
their work and how it impacts their level of stress and their ability to do good for their patients. Ethics
support, including ethics committees, bioethicists are all needed to mitigate the loss of providers that
regrettably might occur due to these ethical challenges.

The principles discussed above provide guidance to the practicing medical professional. They will help
keep a physician from getting stuck in an ethical quagmire, with this caveat: Ethical principles are no
substitute for the virtuous physician. Physicians may do the right thing for the wrong reason. When
students begin their careers in medicine, we as a profession must model those virtues which are to
govern the way a physician practices regardless of the restraints, legal system, or an ethics committee.
If physicians foster a genuine respect for persons, especially the most disadvantaged members of
society, if they manifest an interest in the patient as a person and not just as a diseased body, many
modern healthcare dilemmas could be avoided. Further, because we live in a pluralistic society
comprised of a bewildering plethora of cultures, religions, and value systems, the practice of quality
medicine requires us to discuss seriously with our patients what their values and beliefs are. Even now,
a program to teach spirituality and values in medical school is being funded by the Templeton
Foundation. Because we can no longer treat every patient with a similar disease in the same way or
assume we know what is best for each patient, it is imperative that physicians have a basic
understanding of ethical principles and ethical reasoning and be able to articulate a justification for
their actions in reference to a moral framework. The years of physicians "knowing what’s best" are
over. We can only claim to know what is "best" in treating disease, not what is best in treating the
patient as a person. We can only know what is best in concert with our patients and their families and
in cooperation with the society at large.

References
1. Cases in Medical Ethics by Markkula center https://www.scu.edu/ethics/focus-
areas/bioethics/resources/cases-in-medical-ethics-student-led-discussions/
2. Primary Care Medicine and Some Medical/Ethical Issues by Relias Media
https://www.reliasmedia.com/articles/35186-primary-care-medicine-and-some-medical-
ethical-issues