Aug 2, 2008

World - The Minefield of medical morals

Hardly a week goes by without a medical ethics dilemma appearing in the news.
Occasionally, on the screen or in print, a "medical ethicist" makes an appearance.
But what do we actually do?
Consider the following case:
18-year old Susan wants to donate one of her kidneys to her father John. Without the transplant, John will soon die. He has end-stage kidney disease and the waiting list is several years long. His wife died from cancer two years ago.
When performing routine blood tests, the medical team unexpectedly discovers that John is not in fact Susan's biological father. Thankfully, the two are still a match, but should the clinicians disclose the non-paternity to Susan and her father, or should they keep it quiet and perform the transplant?
When I asked this question to several hundred doctors, patients and members of the public in Oxford, the results were consistent across each group: about two-thirds of respondents said the clinicians should withhold the information, while the remaining third believed the patients should be told.
In North America, many hospitals employ medical ethicists.
Faced with the case of Susan and her father, the doctor would contact the on-call ethicist for a consultation.
The ethicist would help the medical team identify the key ethical and legal issues.
He or she would clarify the facts of the case, look at similar past cases, find relevant guidelines, apply ethical principles, and help the clinicians make a morally robust decision.
When a similar case arose in Canada, the ethicist recommended telling the patients.
The daughter and father were shocked, but grateful to have been told.
The transplant went ahead as planned.
Lower UK profile
In the UK, there are no full-time hospital ethicists.
The medical team might decide on their own, seek legal advice, or bring the case to a clinical ethics committee, if the hospital has one.
Although not all medical ethicists are alike, most divide their time between teaching ethics to doctors, nurses, and medical students, writing articles in academic journals, and sitting on committees which review hospital cases and applications for medical research.
The more outspoken ethicists may also do some media work.
About once a week, I speak to journalists about topical issues in medical ethics.
For instance: "Dr Sokol, what do you think about the case of Ashley X, the disabled girl whose parents stunted her growth to care for her more easily?"
Or: "What are your thoughts on Ms A, the teenage girl who told her doctor that she was abused by her father but begged the doctor to keep her secret?"
Or: "Should the parents of this severely disabled baby be allowed to insist on life-sustaining treatment, even if doctors think it's futile?"
As we often only get one side of the story (for example, the parents' views but not the clinicians', who are instructed not to comment), I try to give a useful but cautious analysis.
Just as doctors don't like to give medical advice without a proper examination of the patient, medical ethicists are reluctant to give their detailed opinions without a thorough examination of the facts.
Common cases
The cases that hit the headlines are dramatic, but relatively rare.
The vast majority of clinicians will not face life-or-death decisions about separating conjoined twins or giving high doses of oestrogen to stop the growth of a disabled child.
The common ethical cases are more mundane.
What should a GP do when confronted by a patient who asks for a sick certificate but who probably isn't sick?
Should a junior doctor tell a patient that he has never performed a procedure before?
When you spend your days thinking about such cases, it can sometimes be difficult to remember that the dilemmas are not mere intellectual exercises, but events affecting real individuals.
By focusing so much on analysis and argument, on trying to make our reasoning as sharp as the surgeon's scalpel, we can forget the human and emotional dimensions.
Problem solving
William Osler, the famous Canadian doctor, said doctors should have a cool head and a kind heart.
The same is true of medical ethicists.
One thing that probably all medical ethicists share is the enjoyment of problem-solving.
Contrary to what some people think (that ethicists do not experience any moral dilemmas since they know instantly what is right and wrong), my initial reaction to a case is occasionally "I have no idea what to recommend".
Most of the time, I enjoy the process of resolution: finding out the pertinent facts of the case, identifying the available options, weighing up their pros and cons, and arriving at the most ethical and practical solution.
At school, I was torn between the humanities and the sciences.
One day, I saw the late professor Jean Bernard, a French haematologist and bioethicist, interviewed on television.
He told the story of a hard-working farmer in a developing country who needed to sell his kidney to feed his family.
I remember thinking: "How tragic and fascinating!"
Medical ethics, which combines philosophy and medicine, was a perfect compromise between the humanities and the sciences.
With the growing need for ethical reflection in medicine (partly as a result of technological developments), there are more and more courses in the UK for clinicians and non-clinicians interested in the subject.
The future
Medical ethics is still an emerging field.
In a few years time, several hospitals in the UK may have medical ethicists to help health professionals deal with ethical problems, draft hospital policy, and provide ethics training.
A few have already hired very part-time ethicists.
Even in the absence of hospital ethicists, however, if you're a patient or a relative struggling with a medical ethics issue, you may wish to contact the hospital's clinical ethics committee.
Some committees are happy to consider cases brought by patients.
They may not always resolve the problem, but they will help you think through it.
• Dr Daniel Sokol is a medical ethicist at St George's, University of London, and Director of Imperial College's Applied Clinical Ethics (ACE) course.

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