1. Ethical dilemmas in treatment

2. Objectives Definition of Ethical dilemmas.
Examples of Ethical dilemmas regarding to healthcare /medical professionalism.
Health care decisions.
Decision-making capacity.
Elements of decisional capacity .

3. Ethical dilemmas
Is any situation in which guiding moral principles cannot determine which course of action is right or wrong.

4. “The biggest issue in medical ethics today is the growing occurrence of conflict between health care providers, their patients and families over treatment options”

5. Treatment Decisions
Preferences of current situation: The choices people make when they are faced with decisions about health and medical treatments.
Respect for autonomy: acknowledging the moral right of every individual to choose and follow his or her own plan of life and actions. Autonomy requires both freedom from controlling influences and the capacity for self determination.
Self-Advocacy: Does patient have capacity to advocate on their behalf?

6. Who decides?
Adult patient: able to understand treatment, risks, options and benefits.
Parents: legally authorized to consent for or refuse medical treatment. We assume that parents are best able to ascertain their child’s best interest.
Mature minor: “minors over 14 are presumed to have capacity to make medical decisions”- Cardwell v. Betchtol, 1987 New York.
Emancipated minor: married, in the armed services, bearing a child, graduated from high school, living apart from one’s parents or managing their own finances.
Guardian/ Power of attorney: court appointment due to diminished mental or physical or incapacitation.

7. Patient and Family Disagreement
Do they understand the treatment proposed?
Do they understand the risks and benefits?
Do they understand the consequences of refusing a treatment?
Are there religious or cultural reasons for refusal?
Are there financial concerns?

8. I ) Strategies to gain consensus
Verified understanding.
Ask what they think their life would be like with the proposed treatment?
Consider if finances are a barrier.
Do they expect their body to look different?
Do they think this will interfere with school or work?
Would they be willing to talk to someone who has experienced this treatment?
What do they perceive the impact on their relationships and family will be?
Are there ways to make the treatment compatible with religious or cultural beliefs.?

9. II) Resources Does patient has a similar treatment?
Connection to related associations like : Saudi heart association, Saudi Society of diseases and liver transplantation, Saudi Society of rheumatic diseases, Saudi Society of epilepsy etc.…
Financial counselor.
Social worker.
Psychologist.

10. Case Study
Ellen is a 32 old female who has had Ulcerative Colitis for 20 years. Recently married. No children. She is an attorney who typically works hours per week. She had 4 hospitalizations in the last 18 months. Treatments have included: Mesalamine Azathioprine Infliximab for 6 years course of prednisone in the last 2 years Her gastroenterologist recommends a colectomy. Her husband wants her to have the surgery right away, but Ellen refuses.

11. Possible Barriers? For Ellen: Concern over fertility. Body image.
Intimacy.
Loss of income during recovery.
Fear of unknown.

12. Possible Barriers? For her husband: Concern about cancer.
Difficulty seeing her sick.
Fear of her dying without surgery.
Caregiver fatigue.
Wanting a family.

13. POSSIBLE REASONS FOR ETHICAL DIELMMA :
The tension between and among ethical principles may create dilemmas for heath / medical care professionals when their obligations are in conflict. Ethical dilemmas usually occur in two types of situations; morally justified and unjustified. This makes it difficult for the individual to determine the appropriate course of action.

14. Health care decisions
Mrs. Klein is an 89-year- old woman admitted from home 5 days ago with cellulitis of the legs. Despite her discomfort, she has cooperated with her diagnostic workup and treatment and consented to all interventions related to the cellulitis. She was able to provide accurate information about her medical history, which was corroborated by her niece. According to both women, Mrs. Klein has been very healthy and self-sufficient all her life, a state she attributes largely to “keeping my distance from doctors and hospitals.” Her goal, expressed repeatedly since admission, is “to go home to my cats.”
Mrs. Klein’s admission blood tests revealed anemia that suggests slow internal bleeding. Despite repeated attempts to explain the dangers of unchecked bleeding and the importance of identifying the source, she has consistently refused consent for a GI series. When asked why she is opposed to a diagnostic work-up, she replies, “Darling, you look, you’ll find. No more tests or treatments. Just get me back on my feet so I can go home to my cats.” After several days, the attending physician requests a psychiatric consult to do a capacity assessment, suggesting that the patient is not capable of making decisions in her best interest and cannot be discharged under these circumstances. Why does no one question Mrs. Klein’s capacity to consent to treatment, only her capacity to refuse?

15. Case Explanation
Despite of Ethical principles of respect for patient autonomy, beneficence, and nonmaleficence normally require that decisions about care and treatment be made by the decisionally capable patient, following adequate discussion of the benefits, burdens, and risks of the therapeutic options. When the patient is not able to participate in this process, the responsibility for making care decisions must be assumed by others.
The quality of the decision-making process and the consent approval or refusal are dependent on the clarity of physician-patient communications; the patient’s understanding of the information presented; the physician’s attention to patient values and preferences; and the patient’s trust in the physician.

16. Decision-making in healthcare situations
Health care in general and bioethics deals with decisions that requires full attention to patient needs ,medicine’s capabilities and limitations.
These decisions should involve: personal ideas about life and death; the meaning of health, illness ,disability and importance of trust.
Decision makers includes: the patient him self, family members and care professionals to make an active discussion and influence patient’s assessment of information.

17. Decision-making capacity
Attempting to assess / evaluate the ability of the under focus patient to make a decision according to facts and available therapeutic options. Sharing of these information via open discussion with patient based on the respectable autonomy principle (personhood) regardless of their ability to make capable decisions and this surely includes comatose and newborn babies. In these cases, they cannot or to be expected to have autonomous decisions as autonomy needs maturity.
If a 5 year—old insists to not be vaccinated seriously, it means he will be vaccinated vigorously because we care about him and don’t want to be a victim of own-non- autonomous choice.
This assessment will define whether the patient can participate in care decisions and provide patient consent or refusal.

18. Elements of decisional capacity
Understanding and processing information about diagnosis , prognosis and treatment options.
Weighing the relative benefits, burden and risks of therapeutic options.
Applying set of values to analysis.
Arriving a final decision over time.
Communicating with the decision.