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Five Principles Help Resolve Ethical Dilemmas in Care

Five Principles Help Resolve Ethical Dilemmas in Care

SEATTLE--Physicians and nurses frequently confront ethical dilemmas in caring for cancer patients, and these must be resolved on an individual basis, through established principles, Tom McCormick, DMin, senior lecturer in medical ethics, University of Washington, told the Association of Pediatric Oncology Nurses. "I don't think we'll ever see the day," he said, "when we can put all of the alternatives into a computer, press a button, and ask the computer to come up with a decision."

Dr. McCormick outlined five principles to guide the health care provider in making ethical decisions: (1) Respect the autonomy of the patient and the family; (2) balance the benefits with the burdens of therapy; (3) attempt to do no harm while providing benefit to the patient; (4) seek justice such that those who are poorly educated or do not have access to health care insurance are not deprived of the resources of the health care community; and (5) maintain integrity and veracity in the professional relationship.

Because even health care professionals are influenced by personal biases and value judgments, the last principle is especially important, Dr. McCormick said. For example, personal bias might drive a health-care provider to push for intensive therapeutic interventions, when considerations of quality of life or helping the patient to achieve a "good death" might be more appropriate.

The nursing staff are often the first to become aware of this shift in what is truly in the best interest of the patient. "The cure orientation of the medical staff and the care orientation of the nursing staff will sometimes come into conflict," he said. It is therefore important that institutions have mechanisms, such as ethics conferences or care plan discussions, to resolve these conflicts, and that nurses be included in these discussions.

Ethical dilemmas may arise from a conflict between the health care professional's moral duty to provide the greatest benefit for the patient (the principle of beneficence), and the need to respect the patient's own informed choice regarding treatment (patient autonomy).

"The right to consent to treatment also encompasses the right to refuse treatment," Dr. McCormick said. "We often discover that patients have goals and values that differ from the traditional goals of health care."

Issues in Pediatric Oncology

In pediatric oncology, decisions regarding the best interest of the patient are further complicated by the inability of children to make informed decisions.

At times, the desire of the parents to prolong the life of their child may be so overwhelming that the quality of the child's life is ignored, even when there is little hope for a cure. Dr. McCormick recommended the development of age-appropriate consent forms so that children might truly take an active role in their own care.

Finally, Dr. McCormick outlined a formal framework of questions designed to make the process of resolving ethical dilemmas in patient care an easier one, or to justify one choice over another.

Questions to Consider in Resolving Ethical Dilemmas in Medicine

  • What are the indications for medical intervention in this case?
  • Is any therapy likely to be efficacious? Is therapy likely to be futile?
  • What are the risks?
  • What course of care is likely to provide the greatest benefit and the least burden?
  • What are the preferences of the patient, or surrogate, in light of these alternatives?
  • How do quality of life issues figure in the decision-making process?
  • What are the needs of the patient's family and caretakers?
  • How do cost factors influence treatment decisions?
  • Is there a scarcity factor that may overshadow other considerations?
  • What institutional factors are shaping the decision process?

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