The Ethical Dilemmas Among Medical Practitioners

The stance of making an urgent decision or choosing a specific plan of action from limited options upon the thoughts of ethical principles is a challenge experienced mostly by healthcare professionals in carrying out their practices. Notwithstanding this, for a medical practitioner to make a specific decision from two options implies forgoing the other option hence, a transgression of medical ethics or a violation of code of conducts governing medical practice (Larew et al, 2006).

Ethical dilemmas are difficult to resolve especially when a medical practitioner is torn between choosing what is right and in the best interest for a patient. Riddick (2003) notes that what may be right may not always be in the best interest for the patient. For instance, in situations of life and death, contemplating on whether saving the patient’s life is the right thing to do or allowing the patient to die when staying alive will only cause more harm is difficult to solve (Caplan, 2014). Therefore, the medical practitioner in fixing the dilemma in terms of the decision to make to will have to consider factors such as social beliefs, or religious beliefs of the patient, the patients family's choice, codes of the medical profession, etc (William, 2015). As such Gardiner (2003), posits that the choice to withdraw or withhold treatment is not solely made by the medical practitioner but with a combination of several factors which revolves around picking the best approach which will also be the right decision. Ethical dilemmas must thus be carefully and radically analysed (Beauchamp and Childress, 2001).

A major ethical dilemma which medical practitioners face is on the issue of blood transfusion and religious beliefs. A case was experienced when a Jehovah witness lady (Mabel) who was 8 months pregnant got involved in a ghastly accident and was rushed to a hospital. Mabel had lost a lot of blood, the best option to save her life as prescribed by her physicians was to administer a blood transfusion and carry out a caesarean section to save her unborn baby. Mabel, however, would not have both as they were against her religious belief, according to the Jehovah Witness Code of Conduct their members are prevented from having blood transfusion or caesarean section as they both contradict the Bible in the biblical scriptures Gen 9:36 and Revelations 1:5 (Watchtower Bible and Tract Society, 2004). For Mabel to have a blood transfusion or caesarean section would render her an infidel and condemn to eternal damnation. The physicians were thus torn between making the best decision i.e. overriding Mabel's belief by administering the blood transfusion and caesarean section which would save both her and her baby's life or make the right decision by upholding Mabel's belief. Hence, a formidable dilemma to the medical practitioner to fix.

The rise of blood transfusion-related dilemmas had grown in the UK to about 17,000 in 2015 (Wisnewski, 2015). This dilemma involves deliberations either to forgo life-sustaining treatments or take compulsory and necessary actions which can only be understood by analysing the ethical principles of autonomy, beneficence, non-maleficence, Unitarianism, and deontology. This is thus the aim of this study. This study further answers questions as to how can the application of ethical principles provide comprehension to Mabel’s case, where the ethical principles conflicts, and why blood transfusion was pertinent to Mabel's emergency situation. To address these questions the Volbrecht's framework for analysis was utilised, this theory centres on virtue ethics and was the prominent theory employed prior to and after the 17th century. The theory revolves around 'familial and cultural histories, religious traditions norms and values and acknowledges the community’s ability to identify, interpret, prioritize and adjust to moral consideration within a particular context' (Volbrecht, 2002:6). Virtue ethics focuses on what is considered morally right from the patient’s perspective and respect for the patient’s autonomy.

Autonomy is the patients right to accept or refuse a treatment or allowing the patient to have a decision regarding his/her health (Jonsen, 1998). According to Lynch (2001), autonomy that is expressed through informed consent is a fundamental principle of bioethics. This principle of autonomy is enshrined in numerous medical laws and codes. For instance, the Council of Europe's Convention on human rights and Biomedicine (Article 5, states that 'an intervention in the health field may only be carried out after the person concerned has given free and informed consent to it)

In the UK, the principle to autonomy or self-determination is also contained in the Bill of Rights (1997) which acknowledges that health care providers have the responsibility to give patients accurate information and patients must consent to their treatment. Also, the Code of Medical ethics (Article 35) notes that a physician may not undertake diagnostic or therapeutic actions without obtaining the explicit and informed consent of the patient. Applying this to Mabel's case, she had the right to refuse blood transfusion or Caesarean section based on her religious beliefs (Gillion, 2000). Religious beliefs according to Miramoto (2000) stands as a major factor that shapes a person’s perspective of life especially relating to medicine, hence the physicians adhering to Mabel’s decision to abstain from blood transfusion would be a respect to her autonomy and self-determination of which many laws and codes confirm.

The contextual component of this case revolves around the patient’s religious belief. For Mabel blood transfusion was not an option, as she would rather die than survive with the guilt of disobeying Jehovah and being condemned for eternity. According to William (2015), medical practitioners are to extract from the ethical principles of autonomy to reflect upon and understand the patient's point of view and honour their wishes. Still on respecting the patients autonomy, it is stated in the BMA (2001) code that 'medical practitioners should provide services with respect to human dignity and the uniqueness of the client, unhindered by considerations of economic or social status, personal attributes or the nature of the health problem (BMA, 2001,p 1).

Arguments have been raised to override the patients’ autonomy in life-threatening situations such as the case study (Paul and Elder, 2006; Smith, 2003) this would be discussed later in the work. However, it has been discovered that on such rare scenarios where medical practitioners attempts to override patients’ autonomy and administer blood transfusion, such as in the case between (IWinois vs Brown, 1996), the Illinois Supreme Court upheld the decision of a mother to refuse blood transfusion for her and her foetus even though it was vital for her survival. This was based on the Patient's Bill of Rights which states that the healthcare providers' responsibility is to give patients accurate information and patients must consent to treatment (New York State Department of Health, 2008). This is consistent with other laws that create guidelines that assure healthcare quality and reaffirms the critical role that patients play in safeguarding their own health (Gardiner, 2003). Therefore, with respect to autonomy, health care practitioners are encouraged to respect the patient’s wishes and decisions despite their personal beliefs (Leonard and Plotnikoff, 2000).

On the Principle of Beneficence, it is explained by William (2015), that this principle involves medical practitioners acting in the best principle and what is best for the patient. Discovering what is in the best interest for the patient has always been difficult to ascertain especially in life-threatening situations (Macklin, 2003). In the case of Mabel what would be in her best interest? Uphold her religious belief or risk her and her baby's death? The two sides have been argued by scholars. Pasci (2008), notes that by adhering to Mabel's belief, her physician would be acting in her best interest and promoting her wellbeing, her wellbeing is not physiological but spiritually oriented,

According to Leonard & Plotnikoff (2000), Jehovah witness value spiritual things more and would risk their lives rather than living with the guilt of breaking a spiritual law, to Chua & Tarm (2006), administering a blood transfusion to Mabel would be detrimental in the long run as she risk the possibility of her friends and family finding out. This may result in her losing her acceptance from them, alienation from the church and causing psychological trauma which may lead to her deterioration of health. Elder (2000) however, is against this, to him the best interest would be to save Mabel's life by overriding her decision and administering blood transfusion as without blood transfusion she risks dying. He argued that according to the BMA (2001 Section 2.17), the Quality of Life which explains that in the making of decisions for the treatment of persons who are severely disabled by injury, the primary consideration should be what is best for the patient’s life. Thus, juxtaposing this with the principle of Beneficence it means the best interest would be to save Mabel's life. In the same vein, Smith (2003) argues that in scenarios like this, the doctors should consider her life first, since her circumstance is an issue of life or death, her situation is considered as legally enforceable and specific according to Bentham's tradition right (1816) which assigns the medical practitioner the role to defy inviolable rights to protect the wellbeing of the individual.

Paul and Elder (2006) also consented to this, to them it was not only medically right but also morally right to administer blood transfusion in order to save her life or conduct a caesarean section to save that of her baby. Rather than risking her life, it is best to save it. While in dealing with consequences from her faith she can change religious beliefs since there is a proliferation of religious groups and organisation, she can change from being a Jehovah witness to a religious group that is not against blood transfusion (Smith, 2003).

On the principle of non-maleficence, according to Iftach et al (2018), requires the physician to avoid harm wherever possible when treating the patient. Harm means there should be no deprivation, infliction of pain nor killing of the patient (Leathard and McLaren, 2007). The principle means that medical practitioners should always work for the benefit of the patient. According to Macklin (2003), withholding, a proven beneficial treatment is likely to produce harm. In the case of Mabel, what is more harm than death? Thus, refusing to administer blood transfusion can cause both her and her baby's death and this transgresses the principle. Gaylin et al. (1988), carefully notes that withdrawing or withholding treatment when it has the possibility of saving the patient means killing the patient. Thus, withholding blood transfusion and caesarean section which has the possibility of saving both Mabel’s and her baby’s life is in violation of the principle of non-maleficence.

Buka (2008) and Caplan (2014), disagree with the aforementioned, to them harm may not be physical, sometimes it may be psychological and the medical practitioner is obliged to not cause harm to the two. Their argument is that not administering some certain treatment relieves the patient of indignity, pain or prolonged suffering (Buka, 2008). Hence in Mabel's case not administering blood transfusion is adhering to the principle of non-maleficence as it will relieve her the pain and prolonged psychological trauma, feeling of guilt associated with transgression of religious laws. Upholding the religious belief of a patient to avoid a feeling of condemnation is classified as avoiding harm (Gillion, 2000).

In a further discussion, Rodrigo (2016), explains that in the case of not administering a blood transfusion to Mabel, a clear balance of autonomy and non-maleficence has been achieved. As to respect the patients right requires the physician to accede to the patient’s refusal of a blood transfusion. Going from the patient’s calculus value, the harm resulting from receiving a transfusion (denial of eternal salvation) is greater than the harm caused by refusing the transfusion (the end of mortal life on earth), arguably this is a rational calculation for anyone who believes in the spiritual world of the Jehovah Witness faith. If one thus has to choose between eternal salvation and few years of temporary mortal life the choice of eternal salvation is greater and hence more rational from the perspective of a Jehovah witness, hence refusal of a blood transfusion has a favourable benefit over harm (Miramoto, 2000).

Another way to analyse this dilemma would be to use the deontological approach, deontological ethics which is often referred to as duty-based ethics is concerned with what people do, i.e. their actions. It is noted that people haven the duty to do the right thing even if it produces more harm (or less good) or a bad result than do the wrong thing something is missing (Miller, 1996).

Using deontological principles especially as explained by Immanuel Kant (date), it is morally wrong to act in a way that treats people as mere means rather than ends to themselves (Mill, 1998). According to Kant (date), humans are made special by a distinctive set of principally psychological capacities which includes self-consciousness and rationality, a distinct capacity for personhood hence to undermine a person’s decision or belief would be going against moral doctrines. In relation to the case, according to Rich (2014), it would be wrong by the health care provider to undermine the rationality of Mabel by not respecting her decision to refuse blood transfusion based on her religious beliefs. Based on deontological principles is it best to respect her belief. Respect for her belief and principles flows from her status as a competent adult who is well informed of the options placed before her (Haryry, 2002).

In adhering to deontology, the doctors should comply with her expressed wishes even if the predicted outcomes are unfavourable or will lead to death based on the fact that she is a rational adult with intrinsic capacity to evaluate and know what is morally right and acceptable for herself. Just as Beauchamp and Childress (2001) argues that health care practice is governed by the patient’s right to his choice of treatment and respect for belief and morals. The BMA (2001) codes contain a statement that addresses respect for human dignity: 'Truth-telling and the process of reaching informed choice underlie the exercise of self-determination, which is basic to respect for person clients have the moral right to determine what will be done with their own person: to be given accurate information, and all the information necessary for making informed judgments: to be assisted with weighing the benefits and burdens of options in their treatment: to accept, refuse, or terminate treatment without coercion: and to be given necessary emotional support' (p. I)

From the principle of utilitarianism, it is believed that the moral standing of any action is dependent entirely on its consequences (Smith, 2003). The best action is that which maximizes utility, maximizing happiness and reducing pain and suffering Elder (2000). The worth of an action is therefore determined by its results. This means a form of consequentialism. For analysis in this context Mill (1998) opines that 'the morality of every action is judged by its intention', it will be proper to acknowledge what is morally right for the patient and best for her which is values that she expressed (Gillion, 2000). However, under the circumstances, her health risk might lead to miscarriage and the likelihood of her getting depressed about the loss of her child. From the utilitarian view, the young lady risks losing her life and that of her foetus if she doesn't get a blood transfusion. In this case, the doctors should consider her life first, since her circumstance is an issue of life or death, her situation is considered as legally enforceable and specific according to the Bentham's tradition right (1816) which assigns the law the role to defy inviolable rights to protect the wellbeing of the individual (Levy, 1999).

According to Paul and Elder (2006), the utilitarian approach is a clear method of determining the best possibilities for all involved. Which includes balancing pleasure over pain for everyone. Using their arguments, it is better to maximize equality between the lady and her foetus, in view of her severe pain, to proceed and perform a blood transfusion and emergency surgery. It is assumed that with the later, the patient after recovering will console and reconcile her moral stand with her predicament. The doctors thus have the moral right to override the lady's refusal to receive a blood transfusion (Asgay and Ramin, 2013).

Still using Paul and Elders (date) argument which supports the judgment to override the patient’s refusal to receive a blood transfusion. The principles of non-maleficence and beneficence is linked with utilitarianism. The principle of non-maleficence requires a doctor to avoid harm where possible, hence withholding a proven beneficial treatment would likely have the effect of producing harm. On the other hand, the principle of Beneficence which promotes the maximization of benefits and minimization of harm is useful in supporting the argument to override the patient's refusal to blood transfusion based on the premise that a blood transfusion would be more beneficial as her life could have been saved. However, as argued by Gillion (2000) and Rodrigo (2016), doctors may accept to forcefully administer blood transfusion on a dissenting patient to save his/her life. To the interest of such patient, this, may not always be the best interest to the patient, as overriding the decision of the patient may lead to far cases of depression resulting from the feeling of guilt by the patient, the situation may even go worse as she may be alienated from her church as going against the rules of her religion. Also, they may lose acceptance from her friends and family causing physiological trauma, which may lead to deterioration of her health. Thus, overriding a patient’s decision to refuse blood transfusion based on religious reasons may not be in their best interest.