Navigating Ethical Issues in Medical Practice

Unfortunately, many are misinformed by inaccurate or inadequate medical information obtained through “research” – usually from the internet. Media reports cause them to distrust the profession and the system; patients demand instant solutions, can’t accept uncertainty of medical outcomes, see death as a failure and have become litigious. Compounding all these are the technological developments that enable irreversibly failed body systems to be supported for prolonged periods.

The medical system by design has resource limitations to help control runaway costs; yet it is required to deliver services that result in high patient satisfaction, substantial cost recovery and even generate some profit. Doctors (and other healthcare professionals) have limited cultural competence and skills in complex communications. Often, they are in a transactional doctor-patient relationship based on commercial values, consumerdriven practices and technology-driven considerations. They may be paid on the basis of fee for service, in which service is usually quantified by numbers and rewarded. The doctor thus often experiences moral distress and conflicts of interests – he has to weigh personal rewards against his patient’s best interests.

ETHICAL ISSUES

A review of criminal court convictions, civil court findings of liability and Medical Disciplinary Tribunal findings of professional misconduct will give an idea of the extreme ethical violations that have occurred. Studying the reports of the Singapore Medical Council for the last decade reveals no major change in the nature and incidence of violations. Though reassuring, it is obvious that this is only the tip of the iceberg.

Categorisation of scholarly work in ethics produced here in the past decade reveals that about a third pertained to ethical issues originating from the clinical medical specialties (dramatic ethics); another third rose from everyday ethics; the remainder pertained to research ethics and ethics education. The phase covering the end of life was the setting for most of the scholarly inquiry.

Experience gained through the deliberations of the Clinical Bioethics Committee at the National University Hospital over the past decade also reveals that most referrals pertained to issues related to the medical care rendered to patients

nearing and at the end of life and who had lost decisionmaking capacity

With this background, the following can be expected to be the more common ethical issues that the medical practitioner and the team in an acute hospital setting will need to identify, address and resolve.

These include confidentiality breaches, conflicts of interest, disagreements between different stakeholders, decision-making, failure to set goals of care, gifts, insistence on non-clinically indicated interventions, the inadequately-insured patient, non-disclosure, remote consultations, over-servicing and the unavailability of doctors for consultations. In an academic medical centre like ours, there are additional unique issues – requests to use non-licensed investigational drugs, fragmented care from multiple subspecialists, vigorous measures to prevent death and a general ignorance or reluctance to consider the cost of “doing everything possible”. The majority of these issues unfortunately occur during everyday doctorpatient encounters and are often not even recognised and hence rarely reported. When clinicians gloss over these ethical issues routinely, the consequences accumulate, the practice ethos changes and then manifests as dramatic ethical issues. How may these be prevented or minimised, and when necessary be addressed and resolved?

PERSONAL COMMITMENT TO PROFESSIONALISM

An abiding personal commitment to professionalism in the face of persistent threats is a fundamental. Given that the usual locale for contact between patient and doctor is a private setting and hence not readily observable by colleagues and supervisors, we will not know how good our “bedside manners” are, or how professional we were in that encounter. The temptation to compromise is intense when the perceived reward is irresistible. The large daily number of such encounters is sufficiently high to subtly shape and mould us, both positively and negatively. By the time a negative attitude or behaviour attracts attention, it may have become too ingrained within and difficult to change.

The responsibility and duty thus falls on self. Regular self-reflection and mindfulness accompanied by intensive strengthening of our knowledge base is known to be very essential.

Some questions that can guide our reflections on a consultation are: Does the patient feel comfortable with me? Are my interpersonal skills so developed that they allow patients to express themselves and be comfortable with me? Is ethics part of my analysis of the encountered clinical situation? Does my view of my patient’s decision provide a generous understanding of their values? Am I treating like cases alike? Are individuals with different social and cultural backgrounds equally able to express themselves?

BUILDING CULTURAL COMPETENCE

The second proactive measure would be to build our own cultural competence. So often, we focus only on the disease, the symptom, the sign and the results of investigations, such that we fail to appreciate who deep down is the person we are trying to care for. There are the usual descriptors, e.g. “Indian married female, aged 35” or “a 85 year old with severe dementia and activities of daily living (ADL) dependant”. Are these enough? The team needs to spend more time with patients, taking time to befriend them, understand their world view and perspective of their illness, understand their system of beliefs, explore their values and preferences, reconcile the two and through interviewing family members, establish the authenticity of their statements. This background knowledge enables rich and fruitful discussions that contribute so much to customising care, especially towards the end of life.

STRENGTHENING COMMUNICATION SKILLS

When our patients’ illnesses deteriorate, the need to communicate with them and family members acutely develops; often the situation is also characterised by a loss of the patient’s decision-making capacity. In such a charged state, family members can be expected to be emotionally overwhelmed and respond in a highly defensive mode comprising shock, denial and anger, taking a variable period of time to reach acceptance. The situation calls for a specialised type of interviewing, in which the emotional barriers can be identified and addressed in the light of relevant ethical obligations and

values. Such interviewing skills need to be deliberately developed.

HELPING CARE PROVIDERS IN A TEAM TO COME TOGETHER

Many patients have multiple co-morbidities, each managed by a sub-specialist. It is not uncommon for subspecialists to focus on the specific pathology they have the expertise in and offer intervention and prognosis without taking into effect the other morbidities, prognoses and previously stated values and preferences. The value conflicts which then arise in team members provokes in them emotional reactions. Studies show that when adequately coached and supported, the team as a group will

move through the following five phases: (i) expression of feelings of frustration, (ii) sharing disempowerment and helplessness, (iii) the revelation of the value conflict, (iv) enhancing realistic expectations and (v) seeing opportunities to change the situation instead of seeing only obstacles resolved2. This allows them to move from an individual interpretation of the situation to an open communication phase, resulting in the original value conflict being revealed and resolved. Team leaders need to possess these coaching and support skills so as to keep their teams functional. When such team-related conflicts are not resolved, patients and relatives receive mixed and often opposite messages; they too will slip

into a defensive mode, communication will break down and a simple ethical issue becomes a dramatic ethical dilemma.

CONCLUSION

Medical professionals and teams are high-capacity units with intense internal motivations to do the right thing, for the right reason and to do it well. At times they need a little nudge, some guidance and, maybe an occasional prod. With these in place, they can be depended on to overcome ethical issues in the same way that their predecessors have done in the past.

REFERENCE

1. Joseph R. A clinical view of Western or Eastern principles in a global ethics. Asian Bioethics Review, 2011, 3:313.
2. Grönlund CF, Dahlqvist V, Zingmark K, Sandlund M, Söderberg A. Managing Ethical difficulties in Healthcare: Communicating in Inter-Professional Clinical Ethics Support Sessions. HEC Forum. 2016 May 5 (E pub ahead of print).