Chapter: Introduction

                                           Section 1. Case Presentation    

What is this all about?   Well, to begin, please consider these three cases in Medical Ethics.

1. Whistle Blowing

  • Dr. D: surgeon
  • Dr. A: anesthesiologist
  • Nurse N: scrub Nurse in OR

Dr. D is about to perform a surgery-an appendectomy. It is 3pm Dr. A and nurse N both observes Dr. D with slurred speech and detects alcohol on his breath. Dr. D prepares for the surgery. The patient is anesthetized. Dr. D. is handed the scalpel and drops it then fumbles to pick it up again. Dr. A asks, "Are you alright?" Dr. D answers, "Of courses I am!"  "Let's get this done."

Dr. A:  "Doctor, perhaps we could postpone this?"

Dr. D: " No, I'm perfectly all right."

Nurse N: "I'm not so sure."

D: " Who are you to tell me what to do?"

Should A and N continue to assist D in the surgical procedure? Should they physically restrain D? Should this event be reported? If so, by whom and to whom? What should be done then?

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2. Truth Telling

80 year old female B has cancer of the uterus-metastasized- and through the pancreas and liver

She asks her physician A "Just what are my chances?"

The doctor wonders what exactly to tell her: should the physician report the exact findings of the various tests and their meaning in terms of the prognosis in the clearest manner possible or should the physician present a less negative report in a compassionate manner even though the report will not be as accurate or as truthful as it otherwise might be?

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3. Letting Die

A 45 year old female with ALS. Diagnosed three years earlier she has endured continual loss of control over her muscles and deteriorated considerably. She is immobilized and has experienced several respiratory failures and now asks her doctor to leave her alone. The next time she experiences respiratory arrest she wishes to be left alone to die. Should the doctor grant her request? Follow her instructions?

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These cases present us with interesting questions. These question are of a moral nature. They are presenting us with the issue of what is the "right" thing to do. This is the stuff of morality. The principles upon which morality rests are the stuff of Ethics. To examine these cases and think about them and arrive at some decision as to what is the morally correct course of action involves thinking about and using concepts and principles that are what ethics is all about.  Deliberating about such cases would involve applying general principles of ethics to a particular area of human life or social institution known as medicine and involves both medical research and care. The analysis of such cases and the consideration of and application of such ethical principles to such cases and situations constitutes a branch of Applied Philosophy known as Medical or Biomedical Ethics.

A student once posed this question about such cases and the study of Medical Ethics.

It is all well and good to talk about what is the ethical thing for nurses to do when presented with moral dilemmas. It is easy to say on paper or through the computer the the nurse should have done x, y, and z, but not a and b. But in real life how practical is this? Ideally nurses and other health care providers should be looking out for the best interests of the recipient of care and should go to all means to protect the recipient of care. But again how practical is it? How many nurses are willing to stand up for their beliefs to the point that it may cost them their job and possibly their license?

This question goes to the heart of what this text is about. It is a question that assumes that  there is a contrast or even a conflict between what is practical and what is theoretical or ideal. Well, there are philosophers who deny that distinction and others who caution us that we make it at our own peril.

It is my hope that, at least by the end of reading this textbook or taking a course, those who do so will be thinking at a deeper and richer level which demonstrates considerations for factors, values and perspectives that indicate an educated person. Here is what that means. The question presents the situation of a person having to decide between thinking about and acting in an ethical or ideal fashion versus a practical manner. Well, there is really no such distinction. Many people may begin the study of ethics with the ability and perhaps the practice of thinking that way but hopefully we learn through the readings and exercises in this text that there are actions humans take that can be the result of deliberate thinking about alternatives and making decisions based on an awareness and sensitivity to ethical principles and human values enunciated through human actions.  . Now the study of ethics and applied ethics, such as Medical Ethics, will present a number of concepts from philosophy, sociology and psychology that a person should be applying in thinking about ethical matters and moral dilemmas.

Here is more concrete detail:

If a nurse, physician, EMT, or any health care provider (HCP) is in a situation where they have an idea about what would be the ethical thing or the correct moral behavior and yet they are faced with what some would call the  "practical" consequences that are unpleasant, it is suggested that the HCP's will go with what is in their best interest rather than in the interest of someone else or even the ideal of upholding some value or ethical ideal. Well, reflection upon ethical principles and applying them here to such a scenario might bring the realization that one is not leaving the domain of ethics at all. When HCP's decide to look out after their own interests, protecting their jobs, licenses, etc.. they are applying an ethical principle and it is most likely to be the one that has become known as Egoism.

What a person who studies ethics would be really facing is the challenge of moving beyond Egoism to some other foundation for moral decision making and even perhaps for the foundation of a moral order for society. This textbook and most courses on ethics and applied ethics will present the problems with Egoism and will present how many situations in Medicine and research are born out of those who make decisions based upon the use of the principle of Egoism.  A very important issue involves the decision of a person to become or remain an Egoist  rather than to use another basic principle for morality such as might be found in any of the following theories of the Good: the Utilitarian or Kantian or Natural Law Theory or even the Theory of Justice as Fairness developed by the American, John Rawls.

Yes, sometimes acting out of principles other than EGOISM might involve personal jeopardy or sacrifice but that is more often what being ethical involves than just protecting oneís own interests.

People who read a textbook such as this do so presumably because they want to learn about ethics in the context of medical research and practice and health care. Why do they want to know this? My thought is that most would actually want to make better decisions when faced with moral dilemmas. Well, there is the basic choice that such a person will need to confront and to make and it is this: be an Egoist or something else!

I present this material so that people can learn about ethical thinking and hopefully make decisions employing principles that will make for a better world for us all. If people do not know about the principles how can they ever use them?

I think that it is a good thing to have laws and traffic regulations even though we know that some people will break them. In time maybe fewer people break them. Letís hope so and work toward that end.

In moral decision-making I think that it is good to have principles and to offer alternatives to relativism and egoism. In time maybe fewer people will accept and act on relativism and egoism. Letís hope so and work toward that end.

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© Copyright Philip A. Pecorino 2002. All Rights reserved.

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