Medical ethical dilemmas

Medical ethical dilemmas

This Sunday session at Euroanaesthesia addressed common ethical dilemmas within the clinical work setting. Two expert speakers provided insights into how to perceive the dilemma, how to deal with it and which resolving strategies could be approached.

In the first talk, Dr Hartmut Buerkle, MD Professor in Anesthesiology and Intensive Care Medicine at University Hospital Freiburg, Germany, addressed the often controversial issue of ‘do not resuscitate’ (DNR).

In November 2017 a letter to the editor (NEJM 2017; 377:2192-2193) —with the title “An Unconscious Patient with a DNR Tattoo”, authored by Holt and colleagues —described the very stressful situation of treating an unconscious person, whose presumed code-status preference led him to tattoo “Do Not Resuscitate” on his chest.

While this patient was treated initially with all possible medical care options, his condition still deteriorated. The DNR tattoo on his chest became an issue of greater discussion, which eventually resulted in a DNR advance directive and the patient died.

This case was covered widely by the media worldwide, and also prompted a discussion in national and international academic societies about the will of patients, the legality of tattoos, possible regretted decisions (the patient’s state of mind) at the time a tattoo was inked and, most prominent, about medical ethical issues.

“The foremost questions are within the controversy about formal versus non formal declaration of the individual´s will,” explains Professor Buerkle. “Legal and ethical issues about non-standardised advanced directives from tattoos will become more prominent in our therapeutic scenarios as tattoos become more prevalent in society.”

He added: “Advance directives have been standardised for good reasons, legally and ethically. Non-standardised advance directives are in this regard very problematic. Intuitively the moral weight will mostly favour acute care, since witholding lifesaving therapies may end with non-reversible status or death. Featuring the discussion about the DNR tattoo, one must also discuss the value and the conflicts of medical tattoos overall. Anaesthesiology and critical care medicine often encounter unconscious patients, who may benefit from a broader consent and comprehension about the patient´s tattoo – more than just the picture itself.”

In the second talk, Dr Paul McConnell of the Royal Alexandra Hospital in Paisley, Scotland, addressed an extremely emotive topic: suicide.

“Attempts at suicide can take many forms from overdoses to violent acts. When these patients present to us, we make an assumption; that they have acted without thought or lack the capacity to know what they have done and treat them regardless,” explained Dr McConnell. “The more violent the injuries, the more we are hardwired to attempt to save their lives, no matter the cost. But if we pause and think of what are actually trying to accomplish, we must ask ourselves: am I doing the right thing?”

His lecture explored many of the challenges that bubble under the surface of these difficult cases. “Can a person of sound mind commit suicide? Can (and should) I treat someone who has done so, if it is against their wishes? If my patient lacks capacity, I must act in their ‘best interests’, but what are those? Is life always the answer and what if that life will now be worse than the one which prompted their suicide attempt?”