How to identify facts and values in a situation
The scene starts in the hospital parking lot. There is an accident between two ambulances. One of the patients being transported died of cardiac arrest and the paramedics traveling in the vehicle have suffered serious injuries - emergency attention is organized during which time a series of ethical issues can be identified.
Bringing these issues to the forefront makes it possible to unfold a method of deliberation in bioethics, thus transforming the passage into an exercise on the treatment of human differences in the field of health.
1. Conflicts of interests
One of the paramedics, who is badly injured, receives immediate attention from Dr. Bailey, the hospital’s Chief Resident. She is an experienced doctor and tries to approach him in order to stabilize his condition, but he acts with self-sufficiency and refuses her help saying that his spine is all right and that the damage is intestinal. Dr. Bailey accepts the spontaneous diagnosis from her colleague and allows him to sit up on his own. The first ethical question arises: Is there a conflict of interest due to his double condition of being a patient as well as a paramedic? Should the doctor have accepted the paramedic’s self-diagnosis, or should she have followed medical protocol?
2. Loyalty to individual patient
In this case upholding the wishes of this individual patient would not really affect the physical health/life of the patient, and so should his demands be met as part of the physician’s duty to the individual patient? Is the physician always duty bound to the individual patient? Should a physician always put the interests of the patient first, or are there circumstances that would allow for other ethical considerations to be applied?
3. Autonomy of the patient
The paramedic can make autonomous decisions about his health condition, even though in this case the demands of the patient seem to be unreasonable. Is it always the physician’s ethical duty to take the autonomous decision of the patient into consideration? Are there cases where the patient’s autonomy is not an ethical priority?
4. Gender bias
Once on the stretcher in the ER, Dr. Bailey tries again to approach her patient to check his injuries, but the man holds his lower stomach, refuses assistance and requests to be attended to by a male doctor. A second ethical question arises: Does the patient have a right to choose the gender of the physician that is to assist him? Up to this point we, as spectators, have no idea what the patient’s reasoning is all about. We can imagine castration, a birthmark on the genitals, a malformation… in other words, something that for reasons of modesty he wishes to hide from a woman. Should a request such as this be considered reasonable? Is it part of the patient’s right to privacy? Is this request pertinent in face of the urgency and gravity of the case?
5. Racism / Antisemitism
Dr. Bailey finds the request odd, however, she accepts the patient’s insistent demands and decides to look for a male colleague. A second doctor comes, another African American like herself, who approaches the patient to assist him. As soon as the patient sees him, he again refuses to be attended, arguing that he again wants a “different” doctor. At this point, both professionals realize that what the patient is actually asking for is a white doctor.
Racism and antisemitism are unfortunately found in epidemic proportions today in society and in medicine. Can this be approached as a case of racism, antisemitism? Is racism, as are other biases in medical care, acceptable today? Is it ethically acceptable to meet the requests of the racist or antisemitic patient? Would the patient’s request be pertinent in terms of the urgency of the situation?
6. Abuse of authority
Dr. Bailey finally accepts the patient’s request and goes in search of a doctor who is not Black. Given the state of emergency that the hospital is in, there are not many doctors available. She then resorts to Dr. Hahn, Head of Cardiothoracic Surgery, and asks her if she can let her have Dr. Yang, a doctor of Asian origin who had just been assigned to a surgical intervention that would be professionally important to further her career. Dr. Yang does not agree with the decision and protests bitterly but finally submits to the will of the Chief Resident. Another ethical question follows: is Dr. Bailey’s decision to divert a professional resource in order to attend the emergency under these particular conditions legitimate? Does this represent an abuse of authority, or is it perhaps a case of unreasonable demand?
7. Hierarchy and moral courage
Hierarchy is integral to the practice of medicine. In this case the head of Cardiothoracic Surgery is the senior physician in charge and Dr. Yang has no ability to resist. The questions arise as to whether hierarchy is always acceptable in medical practice, and when is it acceptable for a junior physician to summon moral courage and to resist an order given from above even when it goes against his or her principles?
8. Ideology
When finally the doctor of Asian origin manages to effectively assist the patient, the reason for his previous behavior is revealed –he has an enormous swastika tattooed on his stomach. This was the reason why he did not want to be attended by the African American doctors. This poses a new ethical question, one that has to do with ideology. Does a patient have the right to profess certain ideas and not be attended by somebody who he or she supposes holds an ideology totally opposed to that of his own? And reciprocally, does a doctor have the right to deny assistance to a patient when the doctor abhors the patient’s ideology which is opposed to his or her traditions and personal history? –Dr Yang makes a reference to her stepfather’s parents who had died in Auschwitz. Does the fact that such ideology conflicts with elemental human principles add anything substantial to the situation? [1]
9. Moral distress
This case is also about moral distress of the personnel involved. In this case does the moral distress caused to Dr. Yang warrant her being taken off the case? Or should she overcome her personal moral distress and consider only the ethical principle of placing the patient’s interests first? When is it ethically appropriate to consider the moral distress of the caregiver?
10. Informed consent
Finally a diagnosis is established, surgery is indicated and the patient has to sign informed consent for the procedure. The patient then demands the presence of a white doctor in the operating-room, for fear that his life might be at risk if he is operated on by professionals opposed to his National Socialist ideology. Again, is this demand pertinent or is it excessive in relation to valid ethical principles?
11. Conflict of interests
Being as it is no longer a matter of an emergency situation (in which the doctor would be obliged to treat the patient), but rather a programmed surgical procedure, does the doctor have the right to refuse to operate on the patient? Even more importantly, should the doctor abstain from performing the procedure, given the strong discrepancy between her ideological beliefs and those of her patient? Is there a true conflict of interest due to their ideological differences?
12. Right to privacy
Finally, Dr. Bailey performs the surgical intervention with Dr. Yang assisting in the presence of a white doctor. Once the operation is performed, at the moment of suturing, the doctor alters the tattoo, stating aesthetical reasons for doing so. She then turns to the assisting white doctor in search of approval. He gives his approval. Is this conduct in accordance with the prevailing norm of medical ethics or is it a case of abuse and interference of the patient’s right to privacy?
13. Abuse of power?
After the surgery, the patient is visited by the white doctor who had attended the operation. The patient complains about the disfigurement of his tattoo and blames this on the operating doctor whom he accuses of ill will. Contrary to the patient’s expectations, the doctor proceeds to let the patient know about his own ideological convictions, opposed to Nazism, telling him that if he had died in the operation, “the world would have been better off without him”. Is this comment pertinent and appropriate for a doctor to say to a patient? Should a doctor transmit their ideological convictions to their patients? Could this be a case of abuse of power, given the asymmetrical nature of their relationship?
NOTE
[1] A variant of this theme is found in the Italian film "Non odiare", by Mauro Mancini, 2020, in which a surgeon of Jewish origin must face a similar dilemma. The film tells the story of Simone Segre (played by Alessandro Gassmann), a surgeon from a Jewish family who grew up with a father who survived the Holocaust, who finds himself rescuing a man who is the victim of a road accident on the street and discover that the wounded man has a swastika tattooed on his chest. "This scene is inspired by an event that really happened in Germany, when a doctor of Jewish origin refused to operate on a patient who had a Nazi tattoo,” says Mauro Mancini, director of Non odiare. “I wanted to force the doctor’s ethical dilemma, cornering him in a condition of choice of life or death”.
FORUM
Film:Grey's Anatomy
Original Title:Grey's Anatomy
Director: Michael Grossman
Year: 2007
Country: Estados Unidos
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