Your Most Challenging Ethical Dilemmas: Medscape UK Survey

Tim Locke

Disclosures

May 27, 2020

Yesterday we published part 2 of our Medscape UK Ethics Report looking at money, romance, and patients. Last week part 1 looked at COVID-19, life, death, and pain.

For the survey we also asked what have been your most challenging ethical dilemmas and why? The responses were received before the impact of COVID-19 hit our work and home lives.

Today we're able to share many of these. Some relate to personal experiences, others are reported as being common for certain specialties.

NHS Frustrations and Burnout

"Treating patients who continue to engage in violent and abusive behaviour whilst in hospital."

"Changing treatment for patients based solely on finance."

Clinical Dilemmas 

"Patient refusing to accept that a treatment will be more harmful than good but still wishes to proceed with high risks of recurrence or the symptoms getting worse after treatment."

"Treating a patient in vegetative state and severe head injury. Family wanted all treatment and were unrealistic but it was futile. Had to go to courts for declaratory order for DNR and to withdraw treatment and give palliative care."

"Giving ECT compulsorily (under the Mental Health Act) to an intelligent patient with clearly expressed refusal of it."

"Reversing gender surgery."

"Resuscitation of babies at the age of viability, particularly babies born between 22+0 - 22+6 weeks of gestation." 

"Are patients fit enough for operation?"

Ethical Dilemmas 

"Turning off life support on a severely brain injured child."

"A baby born with syphilis but mum didn’t want to let dad know the actual cause of illness in baby as she had sex outside her marriage."

"Stopping lifesaving intervention in a patient who was still quite well, at his request."

"Writing a private prescription for a relative."

Racism, Religious, and Cultural Issues

"Should I treat someone with a swastika tattoo? (I am Jewish)."

"Dealing with a racist doctor who had to treat an ethnic minority patient."

The issues over the beliefs of Jehovah's witnesses were fairly common: "18 year old who was a Jehovah's witness who died as his parent argued over a blood transfusion." 

"Facilitating patients' perceived need for abortion and dissociating my own views."

"Culture and religious belief against correct treatment."

Sleepless Nights

"How to explain to patient and family how I nearly killed him on the operating table."

"Decision to discharge a patient who later took their life.”

"Apologising to a patient when I had made a surgical site error."

"Aggressive & uncooperative patients."

Ethical Issues in Specialties

We also asked about the most common ethical issues in different specialties. Here are some of them:

Anaesthetics

"When a surgeon doesn't have the moral fibre to tell a patient that surgery may be futile, usually in a very frail patient, and rely on us to make the decision - rather than sharing such a decision."

"Whether to cancel patients' operations because the theatre list is overrunning (usually because some manager has overbooked). Balancing overworking staff (and impacting on families and children and such) vs effect on patient."

"Working out what's in the patient's best interests when the patient is unable to comprehend or discuss the issues."

"Whether to carry out a necessary but unconsented procedure while a patient is unconscious."

"Children with multiple comorbidities given surgical procedures due to insistence by parents and paediatricians.

"Anaesthetising high risk patients rather than refusing to."

"Should we perform major surgery on very frail patients when we expect poor outcome but patients insist on having surgery?"

Cardiology

"End stage heart failure patients and decision to withdraw treatment."

"Discussing patients' lifestyle issues with their relatives. Decisions [to] discontinue treatments in very ill patients. Referring to tertiary centres of patients who are perceived to be frail."

"Driving issues."

Critical Care and Emergency Medicine

"When to treat, when not too."

"Admission to critical care facility of multiple comorbid patients with multi-organ failure who have small chance of recovery but very little or no chance of returning to previous activities."

"EOL and treatment limitation."

"Colleagues bullying."

General Practice

"Receiving gifts from patients, drug reps."

"Whether to discuss - or not - a patient's issues with their spouse/next of kin - specifically with a view to helping the patient."

"Over treating elderly patients at the behest of relatives [to ease their consciences?]"

"Prescribing drugs which people might sell."

"Euthanasia."

"Patients asking for long-term sick certification in order to claim state benefits when I am not in agreement about the degree of perceived incapacity."

"'My partner can’t know I have HIV. Don’t put that in my notes - it’ll affect my insurance'. 'Don’t call it asthma otherwise I won’t be able to join the Air Force', 'Please don’t say I can’t drive any more. I only go to the shops and back - there’s no other way'. 'Don’t tell him I said so but my husband drinks and drives'."

"Giving antidepressants to teens and young people, knowing the evidence is that they don’t work any better than placebo but having no placebo option and no CAMHS available."

Neurology and Neurological Surgery

"End of life and cessation of treatment issues."

"Life prolonging therapy in untreatable degenerative neurological disease."

"Surgical treatment of intracranial bleed in the very elderly."

"Withdrawal of life support. Possible child abuse."

"Patients requesting non-proven treatments for terminal condition. Issues around escalation of treatment (especially tracheostomy)."

"End of life care. Resuscitation. Life-prolonging drugs for life-limiting conditions. Surgical operations with no proper indication."

"Offering/not offering treatment."

"When patient who is under care of one of my colleagues asks me to accept him under my care, this happens very frequently and is very embarrassing for all parties, doctors and patients."

Oncology & Haematology

"Capacity for decision making."

"Questions of assisted suicide."

"End of life care. Decisions on whether or not patients are well enough for treatments."

"Patients with mental health issues or severe learning disabilities who require intensive cancer treatment."

"Escalation of care. DNA CPR. Allocation of clinical trial spaces. Whether it is right to offer 8th line treatment or phase 1 clinical trial or whether patients feel they then have to take this option so as not to be seen to 'give up'."

"Chemotherapy in the elderly; end of life situations; blood transfusions in patients who for religious reasons refuse blood and blood products."

"Patient refusing treatment."

"Families wishing to withhold significant diagnoses from their older loved ones. However, we have a duty of candour."

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