How physicians face ethical difficulties: a qualitative analysis

Abstract

Background: Physicians face ethical difficulties daily, yet they seek ethics consultation infrequently. To date, no systematic data have been collected on the strategies they use to resolve such difficulties when they do so without the help of ethics consultation. Thus, our understanding of ethical decision making in day to day medical practice is poor. We report findings from the qualitative analysis of 310 ethically difficult situations described to us by physicians who encountered them in their practice. When facing such situations, the physicians sought to avoid conflict, obtain assistance, and protect the integrity of their conscience and reputation, as well as the integrity of the group of people who participated in the decisions. These goals could conflict with each other, or with ethical goals, in problematic ways. Being aware of these potentially conflicting goals may help physicians to resolve ethical difficulties more effectively. This awareness should also contribute to informing the practice of ethics consultation. Objective: To identify strategies used by physicians in dealing with ethical difficulties in their practice. Design, setting, and participants: National survey of internists, oncologists, and intensive care specialists by computer assisted telephone interviews (n = 344, response rate = 64%). As part of this survey, we asked physicians to tell us about a recent ethical dilemma they had encountered in their medical practice.Transcripts of their open-ended responses were analysed using coding and analytical elements of the grounded theory approach. Main measurements: Strategies and approaches reported by respondents as part of their account of a recent ethical difficulty they had encountered in their practice. Results: When faced with ethical difficulties, the physicians avoided conflict and looked for assistance, which contributed to protecting, or attempting to protect, the integrity of their conscience and reputation, as well as the integrity of the group of people who participated in the decisions. These efforts sometimes reinforced ethical goals, such as following patients' wishes or their best interests, but they sometimes competed with them. The goals of avoiding conflict, obtaining assistance, and protecting the respondent's integrity and that of the group of decision makers could also compete with each other. Conclusion: In resolving ethical difficulties in medical practice, internists entertained competing goals that they did not always successfully achieve. Additionally, the means employed were not always the most likely to achieve those aims. Understanding these aspects of ethical decision making in medical practice is important both for physicians themselves as they struggle with ethical difficulties and for the ethics consultants who wish to help them in this process.

The Ethics of Chronic Dialysis for the Older Patient

“…In our current system, inexorable momentum toward seeking care that extends life is the norm (46,47). Physicians have even reported agreeing with families against a patient's expressed wishes when the family member's goals are more aggressive than those of the patient (48,49). This can be viewed as a failure to respect patient autonomy, or even maleficence if the treatment burden is significant.…”

Dialysis in the Frail Elderly — A Current Ethical Problem, an Impending Ethical Crisis

“…34,35 Physicians have reported giving preference to the wishes of family members over the patient's stated wishes both for competent 35,36 and incompetent patients, 34 thus not respecting patients' autonomy despite explicitly stated wishes. 35,37 Moreover, nephrologists feel ill prepared for these discussions.…”

GPs’ approaches to documenting stigmatising information: a qualitative study

“…Yet, documenting sensitive or stigmatising information can compete with the goal of respecting patients' rights and maintaining confidentiality, leading to an ethical dilemma for providers. [1][2][3] Patients with potentially stigmatising conditions are often concerned that documented information could be used against them, do not want to share the information with family members, and regard the sharing of information between medical providers without prior consent as a breach of confidentiality. [3][4][5][6][7][8] Yet, lack of relevant information in the medical record may interfere with continuity of care and, as a result, reduce quality of care over time.…”

“…11,12 For patients with mental illness, GPs are often the first contact 13 and can play a pivotal role in managing their care. 14 Although there is much research about how GPs should manage mental health (MH) conditions 15,16 and ethically challenging situations in a manner that protects patient confidentiality, 2,17 there is little research on how GPs actually document stigmatising information.…”