When I was a new clinician in the early 1990s, I worked in a hospital setting and was very interested in the care of individuals who had swallowing problems. I was fortunate to be in a great setting during my clinical fellowship year and learned a great deal about the clinical techniques, management, and approaches for diet recommendations and swallowing programs for patients. However, I struggled with the challenges of how to manage when a person who was demonstrating aspiration or risk for aspiration would refuse a recommendation for a diet modification or for an alternative nutrition and hydration approach – even if just for a temporary period of time to help them get over their illness. Those were the kinds of things that we had not delved into enough in my graduate program at the time. These are things that we all learn when we get out into the professional setting.
I would like to talk about approaches that are helpful for cases that we struggle with, and discuss a paradigm or way of looking at a particular question. Then you can apply it to the next question that comes up, to determine if this case is similar or different from the one that you just dealt with. What was your approach or the collective approach in that situation, and can you apply it to this case? If not, what is different and what else can you think about?
Ethics – Overview and Definitions
Ethical Dilemmas
What is ethics and what is an ethical dilemma? One of the first and most important things that we need to do is to figure out how to define what an ethical dilemma is, versus what a clinical dilemma is. What is a clinical question or dilemma? Those are the challenges we are faced with in terms of the patient’s diagnosis and prognosis; their cultural backgrounds, belief systems, cognitive abilities, etc., that help us to choose a clinical approach and clinical recommendations for patients. An ethical dilemma is choosing between two or more options; sometimes they can be two good options, but more often, they are two bad options. However, we are thinking about the good approach, and what is the right approach, for a patient.
There is an excellent book on clinical ethics written by the late John Fletcher, Introduction to Clinical Ethics (1997). He says, “Hegel, in his short essay on logic, reasoned that the headachy business of choosing between one good and another, or obversely between one evil and another, is true tragedy, whereas the simplistic collision of good and evil - black and white - is only melodrama.” These are the types of challenges that we deal with in our clinical care where there is not one right answer. There is not one right approach to the situation.
Very often, when people approach an ethical dilemma and they think that they may want to involve consultation with an ethics advisory committee, they believe that the ethics committee will tell them what the right approach is; or perhaps they believe that the committee will come in and tell a member of the team that they are taking the wrong approach in that situation. In fact, to do a true ethics analysis is to identify the range of ethically acceptable options in terms of what is good for the patient, based on our current cultural values and norms.
