3. Identify the ethical problem/consider a moral diagnosis.
4. Seek a resolution.
5. Work with others to determine a course of action.
The steps in the model outline a process, a way of making judgments about what should be done in a particular situation. Additional steps could be added, and much elaboration could be included within each step. But the basic framework is suffi cient to focus moral judgments and simple enough to recall and apply in actual clinical practice.
Application of the Model
The fi ve-step structure will be applied to Case 1-1 to illustrate the process of decision-making.
CASE 1-1 Reporting a Possibly Lethal Error: Who Needs to Know?
Roger Lucas, 70 years old, was admitted to the medical intensive care unit from the surgi-cal fl oor of the hospital with what appeared to be a pulmonary embolism. Mr. Lucas had fractured his femur in a fall at the nursing home where he is a patient and was awaiting surgery the next morning when he developed dyspnea, tachypnea, and tachycardia.
At almost the same moment that Mr. Lucas arrived in the ICU, another patient, Ronald London, was admitted in the next room under equally emergent conditions.
Mr. London was 60 years old and had a history of liver cirrhosis from alcohol abuse.
Mr. London had ruptured esophageal varices. Helen Fowler, Pharm.D., was the pharmacy supervisor for the evening shift for the six intensive care units in the hospital. She and two other pharmacists worked frantically to fi ll all the orders for intravenous drugs and parenteral solutions that came from the intensive care units.
Later, after the rush had subsided, Dr. Fowler decided to conduct rounds and learned that Mr. London had died. The code team was still picking up their equipment when Dr. Fowler got to the unit. “That’s a shame,” Dr. Fowler said to the nurse who was straightening up the room and conducting postmortem care so that Mr. London’s family could spend some time with him before his body was sent to the morgue.
Then Dr. Fowler noticed the label on the IV bag in the trash, the one that had held the IV the nurse had just removed from Mr. London’s arm. Dr. Fowler was shocked to see that the empty IV bag included heparin, not the octreotide he should have received.
A hemorrhaging patient should never receive heparin.
Without saying anything to the nurse, Dr. Fowler stepped next door to see what solution was hanging in Mr. Lucas’s room. Much to her dismay, Mr. Lucas was receiving octreotide when he should have been receiving heparin. And, the two names had been switched on the labels. In the rush and confusion surrounding the admissions and the critical nature of both patients, the IVs were inappropriately labeled. Apparently no one checked the bags for the name of the drug before hanging them since in each case the patient’s name and room number were correct.
A Model for Ethical Problem Solving 23
Commentary
This case is complex but reveals potential ethical concerns. As the pharmacist involved in the case, Dr. Fowler will need to decide what she needs to do and why.
The fi ve-step model can help Dr. Fowler work toward a justifi able resolution.
1. Respond to the Sense That Something Is Wrong
The fi rst step in the ethical decision-making process is to respond to the intuitive sense that something is wrong in a given situation. Unlike obvious signs and symp-toms, such as a rise in partial thromboplastin time or a drop in hemoglobin level, there are no objective signs that one is involved in an ethical problem. It is obvi-ous that urgent care areas, such as the emergency department and intensive care units, can be fraught with stress and emotion. Do these emotional signs indicate that an ethical problem is in progress? The answer, as is often the case in ethics, is yes and no. Just because people are emotionally upset with each other or under a lot of stress does not necessarily mean that an ethical problem is involved.
However, heightened emotional sensitivity—along with “. . . stress and tension intrapersonally or interpersonally; and ineffective communication patterns such as avoidance, nagging, or silence”2—is often a warning sign that one is involved in an ethical problem.
In Mr. London’s case, Dr. Fowler happened to notice the discarded IV bag that led to her discovery of a drug error that may or may not have contributed to Mr. London’s death. Dr. Fowler also experiences a sense of dread when she thinks about reporting the error to the intensivist in charge of both patients. She can certainly expect some type of negative reaction from Dr. Mann based on past interpersonal interactions. She may also feel guilty about the error that has occurred. She expresses “dismay” when she sees the wrong drug being adminis-tered in Mr. Lucas’ room. These negative emotions are indications that an ethical problem is present. This fi rst step in the decision-making process merely requires one to respond to the feeling that something is wrong. One should then move on to the next step.
CASE 1-1 Continued.
Dr. Fowler knew that the risk of mortality is high with patients who have ruptured esophageal varices, so the mix-up with the heparin may not have had anything to do with Mr. London’s death, but she knew that such a patient should not receive heparin.
Dr. Fowler believed the next step should be to stop the octreotide IV and notify the pharmacy to send up the right drug for Mr. Lucas. She thought she had to tell Dr. Janice Mann, the intensivist who was treating both patients, but dreaded doing so because Dr. Mann did not tolerate mistakes. But, Dr. Mann needed to know so that she could adjust Mr. Lucas’s treatment. Then there was the issue of Mr. London’s family. Dr. Fowler wasn’t as sure that they needed to be told about the error.
2. Gather Information
There is an old saw in ethics: “Good ethics begins with good facts.” Clearly, to make an informed decision, one must have the facts. To organize the numerous facts in the situation in which Dr. Fowler is involved, one can classify them into clinical and situational information.
Clinical information deals with the relevant clinical data in the case in question.
The following types of clinical questions are relevant when reviewing a case: What is the medical status of the patient or patients involved in the situation? Medical his-tory? Diagnosis? Prognosis? What drugs are involved, and what are their actions, side effects, etc.? What is the patient’s probable life expectancy and general condition if treatment is given? What is the patient’s probable life expectancy and general condi-tion if treatment is not given?
In Mr. London’s case, the clinical information appeared to be unambiguous. His illness was acute and life-threatening. If not treated immediately with appropriate drug therapy and other life-saving measures, Mr. London would certainly die from hemorrhage and shock. Even if the treatment was effective in managing the bleeding, it would not resolve the underlying problem of cirrhosis. Additionally, the chance that treatment would be effective was small given the underlying condition. The adminis-tration of heparin to a patient who is already hemorrhaging would increase the risk of bleeding, but it may not have hastened Mr. London’s death. As much as possible, it is important to clarify the relevant clinical information in the case before moving on to a more in-depth analysis of the moral relevance of these facts.
Situational information includes data regarding the values and perspectives of the principals involved; their authority; verbal and nonverbal communication, including language barriers; cultural and religious factors; setting and time constraints; and the relationships of those immediately involved in the case. In other words, even if the clinical “facts” of a case remain constant, changes in the situational or contextual fac-tors, such as the values of a key principal in the case, could change the ethical focus or intensify the ethical confl ict. Of all the situational data mentioned, the most important is the identifi cation and understanding of the value judgments involved in a case. An extensive discussion of value judgments is in Chapter 2.
The main players in this case are the two patients, any family involved, Dr. Fowler, Dr. Mann, the pharmacist(s) who prepared the drugs, and members of the nursing staff responsible for hanging the IV medications. All the individuals involved in the case possess values about many things, including values about health, honesty, profes-sional competence, and loyalty, to name a few. We know specifi cally that Dr. Mann
“. . . did not tolerate mistakes.” What does this mean in practical terms? Do individu-als who make mistakes lose their jobs? The case individu-also includes a situational factor that impinges on the case—urgency and time constraints. Two emergencies occurred almost simultaneously. If the two admissions to the intensive care unit had been spaced further apart, it is possible that the error would not have happened. We know that responsibility for the error-free care of Mr. London and Mr. Lucas rested with various members of the health care team. Each member’s responsibilities are distinct yet overlap. As part of the information-gathering step it is important to sort out the
A Model for Ethical Problem Solving 25
various responsibilities, not for placing blame but for identifying moral accountability.
For example, Dr. Fowler may not be the one who mislabeled the IV bags, but as evening supervisor she has overarching responsibility for all medications that leave the pharmacy. Second, she is the one who discovered the error. Knowledge of the error carries its own responsibility. These are only some of the facts affecting ethical decision-making in this case. Once all the facts are outlined, they can be examined to see whether the situation has the characteristics of an ethical problem.
3. Identify the Ethical Problem/Moral Diagnosis
As has been noted in the introduction, ethics deals with a wide range of imperatives and obligations regarding human dignity and conduct. The distinct characteristics of moral evaluation, also mentioned in the introduction, apply to this third step of the fi ve-step model, that is, they must be ultimate, possess universality, and treat the good of everyone alike. Ethical principles are relevant sources of ethical guidance and can serve as guidelines to identify the types of ethical problems involved in a case. The values, rights, duties, or principles that are in confl ict should be identifi ed. The ethical principles most often involved in complex cases, such as Dr. Fowler’s situation, are (1) patient and health professional autonomy, (2) benefi cence and nonmalefi cence, and (3) justice.
In this volume, veracity, fi delity, and avoidance of killing are treated as possible principles as well. Separate chapters presented in Part II develop each of these principles.
At a minimum the principles in confl ict in this case are nonmalefi cence and veracity. Clearly an error has occurred. In the case of Mr. London, the degree of harm caused by the error is still in question. Even an autopsy might not be able to deter-mine whether the error contributed to his death. All we know for certain is that the error deprived him of drug therapy that could have provided benefi t. The error may have caused harm to Mr. Lucas as well. He too was deprived, at least for a while, of a treatment that could have helped him. Thus, harms have occurred that, at this point, are unknown to key players in the case. Nonmalefi cence suggests that Dr. Fowler has a duty to protect the pharmacist involved from having to endure the unjustifi ed wrath of Dr. Mann but also to prevent further harm to Mr. Lucas by making sure he begins to receive the right drug. Nonmalefi cence would also suggest a duty to initiate procedures to make sure this kind of error does not occur again.
Also at stake is the principle of veracity, the moral notion that one is obligated to speak truthfully, especially when one’s role in the situation makes it ethically impos-sible to keep silent. As far as we know to this point, only Dr. Fowler knows about the error. As soon as she calls attention to the error by stopping the octreotide IV and ordering the correct medication from the pharmacy, others will become aware of the error too. She believes she is obligated to tell the truth to Dr. Mann so that she can adjust Mr. Lucas’s treatment. But there are others involved in the case who have a claim on knowing the truth, the other members of the health care team, such as the nurses and pharmacists, as well as Mr. London’s family.
Dr. Fowler seems to feel quite certain that she has a duty to inform Dr. Mann but isn’t as clear about her obligation to Mr. London’s family. One could propose arguments for either telling or withholding the truth from the family. The harm to
Mr. London has already occurred and is irreversible. The principle of nonmalefi -cence, or of doing no harm, could lead Dr. Fowler to be concerned about caus-ing unnecessary psychological stress on his family. Traditionally, the Hippocratic ethic permits, or even requires, health professionals to remain silent whenever information would be needlessly disturbing to patients or families. On the other hand, the family could benefi t from knowing what happened. They could pursue legal action that would benefi t them fi nancially and may help them gain closure over the incident. Benefi cence involves balancing the burdens and the benefi ts of an action, an analysis that can be extremely diffi cult.
The ethical principle of fi delity requires that people act out of loyalty to those with whom they stand in a special relationship, such as between health provider and patient. The requirements of fi delity when a provider interacts with family members are more complex, but a case could be made that, in this situation, Dr. Fowler owes it to Mr. London’s family to let them know truthfully what happened. At this point, exploring various courses of action requires both determining which principles are involved and what their implications are. At that point, we can move to the fourth step in solving the problem at hand.
4. Seek a Resolution
Proposing more than one course of action and examining the ethical justifi cation of vari-ous actions is, indeed, the working phase of decision-making. Many people try to avoid this step and, at the same time, to reduce the stress of the situation by settling for the fi rst option that comes to mind or for what initially appears to be the safe choice.
Several courses of action are open to Dr. Fowler: (1) She could fully share infor-mation about the error with all those involved; (2) she could tell Dr. Mann about the error and other internal entities in the hospital but not inform Mr. London’s family or Mr. Lucas’s family; (3) she could keep the knowledge to herself and not tell anyone and try to correct the error without being caught or just let the wrong drug continue to infuse into Mr. Lucas; or (4) she could wait to tell Dr. Mann about the error with Mr. Lucas’s medication until she can determine if it is having any side effects. These actions actually fall into the categories of telling, not telling, or waiting to tell, the last being a version of not telling. Because the error affected two patients, the range of possible actions doubles.
To determine which options are morally justifi able, one must project the prob-able consequences of each action and the underlying intention of the action as well as whether there are moral duties that prevail independent of the consequences.
This process involves the application of the ethical principles presented earlier and the ethical theories described below. By following this process, one can reject some options immediately because they would result in harm or would confl ict with another basic ethical principle.
Choosing the fi rst option would be in compliance with deontological (or duty-based) ethical theories, which assert that the rightness of an act can be judged insofar as it fulfi lls some principle of duty, in this case particularly the duty of veracity. This option would be compatible with the respect, dignity, and equality that all human
A Model for Ethical Problem Solving 27
beings deserve. Telling the physician fulfi lls the principle of veracity vis-à-vis the physi-cian but leaves open what that principle requires with regard to the family. The duty-based principles of veracity and fi delity require showing respect for others, especially when some special relation exists. Not telling the family members does not respect the dignity of the family members. The third option of withholding the truth about the error and not doing anything else would be hard to justify from the perspective of these duty-based principles. Furthermore, not telling and trying to correct the error without telling anyone about it is fraught with problems, not the least of which is the great possibility of getting caught in the act of a cover-up. The credibility of not only Dr. Fowler but of the entire pharmacy would be at stake should that happen. The fourth option delays the truth but holds open the possibility that it will be disclosed at a later time. This option seems to be based on the assumption that disclosure is warranted only if the consequences require it. This brings us to consideration of the consequence-oriented principles—benefi cence and nonmalefi cence.
Two major versions of consequence-oriented ethics were presented in the intro-duction: utilitarianism and Hippocratic ethics. Hippocratic ethics would focus on the prin-ciples of benefi cence and nonmalefi cence, but only insofar as the action has an impact on the patient. Mr. London is dead; he cannot be affected one way or the other. Mr. Lucas, conversely, is very likely to be affected. At least he needs to begin immediately receiving the right medication, but that may not require disclosure of the error. Then, too, disclo-sure may be distressing to him. A good case can be made that the error should be kept between Dr. Fowler and those who need to know in order to correct it.
Utilitarianism differs from Hippocratic ethics by not focusing on the principles of
Utilitarianism differs from Hippocratic ethics by not focusing on the principles of