Healthcare provider and patient / client: Situations in which fulfilling your ethical duties may not be obvious.

Thanks in large part to the invitation of the fantastic Doctor Zen, I had the honor last week of attending PACE’s 3rd Annual Biomedical Ethics Conference. The conference brought together an eclectic mix of bioethically minded people: nurses, counselors, physicians, physician assistants, lawyers, philosophers, scientists, students, professors, and those working “around the world”. *

Like good conferences do, this one left my head full of issues that I still grapple with. So, as bloggers sometimes do, I’m going to outline one of these issues and invite you to tackle that as well.

One question that kept coming back was what exactly it means for a healthcare provider (broadly defined) to perform their duties towards their patient / client.

Of course, those in the ballroom could spell out the standard ethical principles that should guide their decision-making – respect for people (which includes respect for patient-client autonomy), beneficence, non-maleficence, justice. – but sometimes these principles seem to pull in different directions, which means what to do when the rubber hits the road isn’t always obvious.

For example:

1. In some states, healthcare professionals are “mandatory whistleblowers” ​​of domestic violence – that is, if they come across a patient who they have reason to believe is being abused. domestic, they are required by law to report it to the authorities. However, sometimes the introduction of the case into the justice system triggers retaliatory violence against the victim by the perpetrator. In addition, as a result of the report, the victim may be less willing (or able) to seek further medical attention. Is the best way to do your duty to your patient always to report? Or are there cases where these obligations are best met by not reporting (and if so, what are the foreseeable costs of such an action plan – for that patient, the health care provider, others? patients, the community at large)?

2. A patient with a terminal illness may think that the best way for their doctor to respect their independence would be to help them end their life. However, physician-assisted suicide is generally interpreted to be clearly contrary to the requirements of non-maleficence (“do no harm”) and beneficence. In most of the United States, it is also illegal. Can a doctor refuse to provide the patient in this situation with the help he is seeking without being paternalistic? ** Is it fair that the doctor’s discussion with the patient here touches on personal values ​​that he might not be fair to the patient to ask the doctor to compromise? Are there any foreseeable consequences of what to the patient looks like a personal choice that could impact the doctor’s relationship with other patients, with his professional community, or with the wider community?

3. In Texas, the law currently requires that patients wishing to have an abortion must first have a transvaginal ultrasound. In other words, the law requires the health care provider to subject the patient to a medically unnecessary invasive procedure. The alternative is for the patient to carry an unwanted pregnancy to term. Both choices, arguably, subject the patient to violence.

Does a health care provider who tries to meet their obligations to their patient have an obligation to break the law? If this is a bad law – here, a law whose requirements prevent a health care provider from fulfilling their duties to patients – should health care providers put their own skin in? the game to change it?

Here’s what I’ve already written on how to challenge bad rules ethically:

If you are part of a professional community, you are expected to abide by the rules set by the committees and institutions governing your professional community.

If you think these aren’t good rules, of course one of the things you should do as a member of this professional community is advocate for them to be changed. However, in the meantime, making an exception to the rules that govern other members of your professional community is pretty much the classic definition of an ethical violation.

The bottom line here is to slyly break a bad rule (maybe even by pretending to follow it) rather than standing up and explicitly arguing against the bad rule – not just when it applies to you, but when it does. applies to anyone else in your professional community – is wrong. It does nothing to overturn the wrong rule, it involves you in deception and it puts your interests first over those of others.

The particular situation here is a delicate one, however, given that, as I understand it, Texas law is a rule imposed on medical professionals by lawmakers, and not a rule that the medical professional community created and implementation itself to better help them fulfill their duties to their patients. Indeed, it seems pretty clear that lawmakers were willing to sacrifice absolutely central duties in the doctor-patient relationship when they enacted this law.

Further, I think the way forward is complicated by concerns about how to ensure that patients receive care that is helpful and not harmful. If doctors in Texas who opposed the mandatory transvaginal ultrasound requirement filled prisons to protest the law, who leaves to provide ethical care to outsiders seeking abortions? Is this a place where the professional community as a whole should push back against the law rather than having individual members of that community push back?

* * * * *

If these examples have some commonality, one of them is that what the law requires (or what the law allows) does not seem to correspond perfectly to what our ethics require. This perhaps reflects the difficulty in ensuring that laws capture the delicate balance that ethical action towards its patients / clients demands of healthcare professionals. Or, perhaps it is a testament to the fact that lawmakers are not always focused on creating an environment in which healthcare providers can meet their ethical obligations to their patients / clients (perhaps even in disagreement with professional communities on the nature of these ethical obligations).

What does this mismatch mean for what patients / clients can legitimately expect from their healthcare providers? Or for what healthcare providers can realistically deliver to their patients / clients?

What if you were a health care provider in any of these situations, what would you do?

_____

* It can be argued, however, that universities and their inhabitants are also in the world. We share the same space-time fabric as all of you.

** Note that paternalism is probably justified in a number of circumstances. However, when talking about a sane patient, perhaps paternalism shouldn’t be the doctor’s go-to position.