Ethical Dilemmas and Research
The practice of medicine, especially research, continuously confronts the doctor with ethical dilemmas, where many conflicting alternatives force physicians to make value judgments choosing a path that based on medical indications will lead to respect the patients’ preferences in their environment and also respect.
In the practice of medicine it common to find patients whose alternative of diagnosis and/or treatment or even research, present an ethical dilemma.
In this report, we propose a simple classification of the dilemmas related to clinical research and practice.
Clinical: It is a term used in the doctor-patient encounter when a physician is caring for an individual patient. Such patient care is the essence of a physician’s work, as are the relationships with family, other health professionals and medical institutions, including insurance companies, given the economic, administrative and legal influence, play an important role in the patient environment for decisions making.
Investigation: Dilemmas in research have emerged and continue to emerge as science advances and appearance of new scientific and technological inventions. The discoveries of DNA, antibodies, in vitro fertilization, transplantation techniques, etc. continue to present medical dilemmas in the research process in patients.
Types of Dilemmas
1. Case analysis or closed case dilemma.
2. Solution cases or open cases dilemma.
3. Hypothetical cases dilemma.
4. Real Dilemma.
5. Complete dilemma.
6. Incomplete dilemma.
Conclusion: Ethical dilemmas are an inevitable feature of life. They are also an inescapable part of medicine because ethical dilemmas force us to make a choice between damages and results.
Keywords: Bioethics; Behavioral Medicine; Community medicine; Medical Ethics; Research Ethics / Informed Consent; Academic Medicine
The practice of medicine, and especially research, continuously confronts the doctor with ethical dilemmas, where many conflicting alternatives force physicians to make value judgments choosing a path that based on medical indications will lead to respect the patients’ preferences in their environment and also respect them.
Medical ethics is a method for making decisions that involve some difficulty. Make some decision forces the physician to give up the other alternatives, committing to a certain option towards which should direct its efforts and resources. Decisions in the clinical setting are the most difficult to make, because when all alternatives seem bad decisions, the doctor may be inclined to decide to do something that is morally wrong. However, he/she must make a decision and in many cases the risks are great and the consequences are difficult to predict and accept.
In the practice of medicine it common to find patients whose alternative of diagnosis and/or treatment or even research, present an ethical dilemma. Therefore, physicians have a responsibility to make a responsible decision that is consistent with patient’ preferences and frequently to assess and challenge the decisions proposed by others [1]. This implies that each clinical case must be analyzed methodically so that the result is the integration of medical indications and they are in harmony with the preferences and quality of life of patients in their social, economic, religious, administrative and legal context.
The word dilemma comes from the Latin dilemma which means “two premises.” In a dilemma are two proposals against disjunctively, that by denying or granting one of them indicate what is intended to test [2]. The dilemma is that either alternatives proposals are not completely acceptable or both are equally acceptable. By choosing one of the two alternatives, the person is not entirely satisfied with the decision; being a particular circumstance where any decision making to avoid evil, generates other ills, becoming an incognito in the field of ethics.
An ethical dilemma is when it occurs in a situation where the moral precepts or ethical obligation of similar obligatoriness are in conflict and is necessary to determine which should be selected [3].
The discipline that proposes a method to respond to moral dilemmas has its origins in the early doctors and predates the transformation of scientific medicine in the modern sense. It is called bioethics, since Van Rensselaer Potter published a book with the same name in 1971 [4].
In this report, we propose a simple classification of the dilemmas related to clinical research and practice [5].
Clinical.-It is a term used in the doctor-patient encounter when a physician is caring for an individual patient. Such patient care is the essence of a physician’s work, as are the relationships with family, other health professionals and medical institutions, including insurance companies, given the economic, administrative and legal influence, play an important role in the patient environment for decisions making [6].
Investigation.- Dilemmas in research have emerged and continue to emerge as science advances and appearance of new scientific and technological inventions. The discoveries of DNA, antibodies, in vitro fertilization, transplantation techniques, etc. continue to present medical dilemmas in the research process in patients.
All doctor-patient relationship has an ethical dimension, and each medical specialty, whether is in first, second or third level of care, has its own ethical dilemas [10].
Following Fernando Aguiar we canfirst say that there are two kinds of dilemas [11]:
1. The dilemmas whose decision is difficult.
2. The dilemmas whose decision is tragic.
Interestingly, these categories are not mutually exclusive, so that a single case can be difficult and tragic.
A dilemma is difficult when:
1. There is no right answer for the case.
2. The normative formulations are ambiguous and/or expressing concepts are vague, have open texture, etc.
3. The theory of ethics is incomplete or inconsistent.
4. There is no consensus on the resolution of the case in the medical community.
5. The case is not routine or a mechanical application of an ethical principle.
6. The case is not easy and is decidable only weighing the principles and arguments in conflict by no deductive arguments.
7. The case requires for its solution a principle-based reasoning.
8. The solution of the case necessarily involves a judgment about good and evil.
A dilemma is tragic when it has “ ... to do with matters of life and death (at least probabilistically) or less centrally, with other vital personal properties such as maternity, where political alternatives technically feasible have the effect (whether or not intended) to distribute these goods and these evils (or probability of occurrence) in different amounts and/or differently among individuals who receive them.” Interestingly, a tragic dilemma can be very easy to solve, without this means that the emotions the solution awaken are enjoyable.
For the medical professional learn to make decisions at being involved in a case that poses an ethical dilemma, Benitez Grande-Caballero proposes the following classification that complements Fernando Aguiar’s [12]:
It is when the protagonist of the story has already made a decision and implemented a behavior.
It consists that the participant physician makes value judgments on the solution of a problematic already solved. It offered the circumstances and the decisions making by the personsinvolved in order to give their opinions and own moral judgment about the dilemma in question. They are useful because they help to develop empathy and sensitivity to get on “someone else’s shoes.”
Consists in to raise the problem in an open way without presenting a concrete solution, limited to present the case and circumstances so that the professional participant is the one who makes the decision over the course of action more correct and treats it from his personal perspective based on his/her own moral judgments.
They are the problems or cases raised hypothetically with participants low viability of occurrence in the reality of everyday life; propose very general or abstract situations drawn from stories, novels, poems, media and the imagination of those who elaborates, and used as motivators to exercise analytical thinking, discursive logic, ethical and abstract philosophical reflections by the necessary lack of incarnation in real life.
They consist on the approach of conflict situations drawn from everyday life and its problems. By relying on real events, they are more motivating for students as they can to involve their experience next to the discursive logic for decision making. They are based on real events, close in time or space to people and are drawn from the various media, situations or historical events, situations or personal experiences, political and social, among others.
They are those who report widely different circumstances that influence the problem, so that, who is going to make a judgment has available the widest possible information which will help the decision making is the tightest to criterion.
By having all or almost all variables, moral judgment will be more reasoned and correct. This modality should be used at the beginning of working with dilemmas, being the easiest for participants unfamiliar with this type of activity.
They are those that do not provide complete information about the circumstances of the problem, merely putting it broadly, without details. Participants have to make a thoughtful effort to discern under what circumstances would make a decision in one way or another. The debate aims, in addition to seeking the solution, to investigate variables that would guide the choice. They should be used in students and professional staff who are familiar with the technique of the dilemmas.
Ethical dilemmas are an inevitable feature of life. They are also an inescapable part of medicine.13becauseethical dilemmas forceus to make a choice between damages and results; they can also be a source of anxiety. Any choice we make, is likely to leave us thinking: What if I had done differently?
They are as difficult as we think, but we are not powerless against ethical dilemmas. They are often a stimulus for finding practical answers to the welfare of patients. Learning to cope and live with the uncertainty associated with ethical dilemmas is a key part of professional development.
