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Chapter 4
Thursday 17 May 2012
An ethical dilemma is a conict between two or more value - or virtue driven interests.
You have to identify the parties in the conict, what their interests are, and what virtues and values underlie those interests. There follows Raes list of elements for making moral decisions:
Thursday 17 May 2012
7. Make a decision
Ethical decisions rarely have pain-free solutions - it might be you have to choose the solution with the least number of problems / painful consequences. Even when making a good decision you might still lose sleep over it!
- she lives with her son and his wife - the family appear happy - the son has taken responsibility for her as her husband has died - the son translates for her with almost all information needing translating - the son does not want her to know anything more than the bare minimum about the treatment as he fears she will give up on life and resign herself to dying - the son is strongly motivated by cultural and family values
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- The patient does not know her full diagnosis or the full eects of the chemotherapy - she knows she is sick and treatment will make her feel sick to her stomach as well as losing her hair You are the doctor - what would you do? Follow the familys wishes (based on their culture)? Decide the patient needs to know what is happening - tell her even if it increases her fear (and alienates you from the family)
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1. Gather the facts - go back over the information given and write down all the facts. 2. Determine ethical issues patient autonomy, including giving consent for treatment versus what a caring family think is best for the patient. In such a situation nurses are bound by what the doctor decides - yet still they have to solve the problem of obedience to the doctor with the patients integrity in being able to give informed consent.
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3. Determine what values / principles have a bearing on the case - the right of the patient to give informed consent chemotherapy is a very invasive treatment. This is recognised by law, the person has a right to control what happens to their body. Such dignity comes from being made in the image of God.
- the obligation of the medical team to act in the patients best interest. They should do good for the patient whenever they can - to act with compassion (the family will also claim to be acting in compassion)
- respect for the familys wishes and culture. Humility is the virtue which says the doctors must realise not all they think is best. How heavily do they respect family / cultural values? The family may think they are taking some of the burden for their mother by making the decisions and not telling her everything - this caring is highly valued by them - also the law regarding informed consent must be applied, and nursing stas obedience to doctors
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4. List the alternatives - attempt to convince the family of the seriousness of the treatment and why she needs to know - call an ethics committee conference to discus the case and try to convince the family to tell her These two options should be discussed prior to any further treatment. - override the familys wishes and tell the patient of her condition and the treatment
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- continue to follow the familys wishes, the son continues to translate and she knows nothing more - wait for the patient to ask questions about treatment and then encourage her to ask very direct questions of her family and doctor (another translator is required here) - bring in another translator and ask the woman if she wants to know the details of all that is happening - likely to cause cultural oense to the son
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5. Compare the alternatives with the virtues / principles - initially try to pursue all possibilities of talking with the family and the doctors trying to get them to disclose the information themselves - if above is unsuccessful you can either withhold or disclose information to the patient - use another translator and tell the patient (or ask if she wants to know full details of what is going on - this alternative respects her autonomy)
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- she can make it clear at this time she wants her son to make the decisions for her - this would satisfy most important principles / virtues - if she chooses to know then it is her who is challenging the culture, yet she retains her dignity and has full information - if nurses are unhappy with what is happening the most viable option is probably for them to be requested to be removed from the case
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6. Consider the consequences If you disclose the information directly possible consequences include; - family feel alienated, cultural values have been violated - family may take patient to another hospital - patient may give up - patient might be happy they are nally being told the truth
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If you continue withholding information possible consequences include; - patient continues to be fearful and anxious about the treatment - patient nds out somehow and trust is compromised - family are happy cultural values are being respected
If you ask the patient if she wants to know through another translator, possible consequences include; - family are unhappy at disrespect for their cultural values - patient gets to speak for herself and make own decisions - she can choose to let her son continue making the decisions, both law and culture are satised here - patient will be relieved as she knows her wishes have been respected
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7. Make a decision - we have had to think through our ideas of respect for family and culture - how far should we go in respecting this cultural approach, is the patients best interest compromised, is her dignity as an individual respected? Rae suggests, Here it seems the alternative that involves asking the patient if she wants to know the details of her situation satises most of the virtues and values at stake and produces the best balance of consequences too.
Thursday 17 May 2012