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Ms Bigelow, a dental hygienist, identifies progressive
periodontal disease in a patient at a periodic recall visit.
Despite Mr. Chafin's (the patient) best efforts the periodontal
condition is progressing with notably deeper pocket depth this
appointment than 6 months ago. She has documented in the dental
record the deepening pockets, the exudate and bleeding on probing,
and the radiographically observable bone loss among all the
posterior teeth. Ms. Bigelow thinks Mr. Chafin should be referred
the local periodontist, as her employer, Dr. Johnson, a general
practitioner, only treats mild periodontal problems requiring root
planing and curettage.
When she informs Dr. Johnson of her findings and recommendation,
he dismisses her with a wave of his hand, and enters the operatory
where Mr. Chafin is seated. He probes among a few anterior teeth,
and dismisses Mr. Johnson in a cordial manner, reconfirming to him
the importance of returning again in 6 months for another
"cleaning."
Ms. Bigelow is distressed by her employer's cavalier attitude
regarding Mr. Chafin's serious periodontal disease. She is
confident that it is imperative that he receive substantive and
definitive periodontal treatment or he will lose his teeth to the
condition.
What should she do?
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ETHICAL THINGKING &
PROBLEM SOLVING
drg. ELASTRIA WIDITA, M.Sc.
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ETHICAL DECISION MAKING
1. Clearly State The Problem
2. Get The Facts
3. Consider The Fundamental Ethical Principles
4. Consider How The Problem Would Look From Another Perspective
Or Using Another Theory
5. Identify Ethical Conflicts
6. Consider The Law
7. Making The Ethical Decision
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Consider the problem within its context and
attempt to distinguish between ethical problem
and other medical, social, cultural, linguistic, &
legal issues
Explore of the meaning of value-laden terms, ex
futility, quality of life
Clearly State The Problem
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Find out as much as you can history,
examinations, relevant investigation
Take the time
Listen patients narrative
Understand their personal & cultural biography
Are they necessary facts that you do not have? If
so, search for them
Get The Facts
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Autonomy : what is the patient approach to the problem?
Beneficence : what benefit can be obtained for the patient?
Non-maleficence : what are the risks and how they can be
avoided?
Justice : how are the interest of different parties to be
balanced?
Confidentiality : what information is private and does
confidentiality
need to be limited or breached?
Veracity : has the patient and the family honestly informed
& is
there any reason why the patient cann`t know the
truth?
Consider The Fundamental Ethical
Principles
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Who are the relevant stakeholders?
What is their interest?
What do they have to lose?
How salient are they interest?
How powerful are they?
How legitimate are they?
How urgent are they?
How woul d the problem look like from alternative ethical
positions?
consequentialist, right based, virtue based, feminist,
communitarian, care based
Consider How The Problem Would Look From
Another Perspective Or Using Another Theory
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Explain why the conflicts occur
How they may be resolved?
Identify Ethical Conflicts
Identify relevant legal concepts & law how they might guide
manaagement
Examine relationship between the clinical-ethical decision
making & the law
Consider The Law
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1. Identify ethically viable options
2. Make the decision & justify for it specifying how
guiding principles were balanced & why
3. Take the responsibility for the decisions
4. Communicate the decision & assist relevant
stekeholder
determine an action plan
5. Document the decision
6. Evaluate the decision
Making The Ethical Decision
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JD was an 82-year old man who lived in a nursing home and
had
several strokes. He was aphasic and altough he appeared to
understand some of what was said to him, the extent of his
understanding was never certain.
He was paralysed down one side & spent much of his day in a
large
chair in front of the tv at the nursing home. He had two
children
who visited him infrequently.
During the winter time, JD often developed chest infections
that
usually responded to oral antibiotics.
During one of these infections he appeared to be more unwell
than
usual began spitting all his medications out, as well as
spitting out
all food and fluid. He became quite dehydrated, and was
transferred to the local hospital. An IV infussion was
commenced,
but he kept pulling it out and seemed much more settled when
it
was removed.
CASE STUDY
The question arose as to whether he should restrained in order
to continue with the infussion or should allowed to
die dehydration, malnutrition & infection.
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Apakah suatu keputusan yg ETIS jika kita menyetujuinya untuk
menghentikan makan & minum?
1. He was aphasic and altough he appeared to understand
some of what was said to him, the extent of his
understanding was never certain.
2. Mentally incompetent
Can we ethically refrain from providing food & fluid to a
mentally
incompetent individual who appears to have quality poor of
life but will need to be restrained by force to feed him?
ETHICAL PROBLEM
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Literature
1. Man mouth would dry & become ceked or coated with thick
material. His lips would become parcehd & crack.(Aronheim &
Gasner 1990) dehydrationdepression, dysphagia, headaches, nause,
vomiting.
2. If people are fully hydrated just before they die their
bladders fill causing either incontinence or distressing
restlessness nuissance of needles & tube that make a cudle
almost impossible (Lamerton 1991)
Facts..?
Narasi dr riwayat penyakit
Bigrafi personal & kebudayaanya
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Autonomy : pasien punya pandangan sendiri u/ atas
berbagai aspek perawatan pemahaman dr perjalanan
penyakit.
Kasus JD, mentally incompetent
Keterlibatan keluarga, teman terdekat well understand
Beneficence & Non-maleficence : intellectual &
emotional
efficient & efffective communications skills
Best for him TO DIE OR BEING FORCED TO LIVE?
Justice : resource allocation & cost of patient`s care
Ethical Principles.?
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Beneficence & Non-maleficence
Ethical Conflicts..?
Require
Specification (meaning & scope)
Balancing (reasons or justifications)
We wish to help him but unsure if our help will
actually harm him
Keseimbangan dr prinsip etika, hak, tdk berdasarkan moral
sj,
tp kekuatan dr argumen, konteks klinis, & perspektif
moral
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Information
Sensitive manner
Systematic manner
Ethical judgment
Communicated & documented
assist the relevant stake holder action plan
development of way
1. Negotiation
2. Compromise
3. Mediation
4. Plan review
Clinical decission?
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Increase the quality of care
Reduce litigation
Facilitate the fair distribution of limited resources
Ensure public confidence in medical institutions
Clinical ethics services