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
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
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
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