Everyday use and abuse of bioethics

By Dr Mark Bernstein

That bioethics should become a routine part of the thinking and vocabulary of healthcare workers seems, on the surface, to be a good thing. On the downside, however, those who have a working knowledge of the issues and jargon can use bioethical principles to justify almost any course of action. Let me illustrate with two recent examples from my experience.

THE RIGHT PRIORITIES
A young woman dying of primary brain cancer was brought to the ER by her husband; he was apparently unable to cope with managing her needs at home anymore. There were no more therapeutic options available to prolong and/or improve the quality of her life because of the nature of the recurrence of her tumour. She required admission on compassionate grounds for terminal/palliative care and her family physician did not have admitting privileges at the local hospital. I was not her original surgeon but, being on call, was consulted by the ER physician. I felt the patient should be admitted but not to Neurosurgery. My suggested hierarchy of responsibility for admitting her was the Neuro-oncology service (covered on the weekends by Neurology), then the Palliative Care service and then maybe General Internal Medicine. Nobody wished to admit the patient and even the Nurse Administrator on call got involved and called me.

I stood my ground using prioritization of resources allocation as my "ace in the hole." I had already had to turn away a few referrals of neurosurgical cases from peripheral hospitals over the weekend because of lack of availability of beds. I stated emphatically that it would be unethical and an abdication of my responsibility to the million patients in my hospital's regional catchment area to fill my beds with patients not requiring neurosurgical intervention. I honestly believed this but also realized that a primary responsibility was due the young woman in the emergency room and that it might well fall to me. Finally, after some animated discussions, the Neurology staff agreed to admit the patient on behalf of Neuro-oncology but ironically the patient was bed-spaced into the last available neurosurgical ward bed.

TRANSPLANT RESPONSIBILITY
During the same weekend on call, a previously healthy 55-year-old woman presented with a severe sudden headache to a rural hospital where she quickly sank into a deep coma. A CT showed a large cerebellar hemorrhage. I was able to accept her for assessment and upon arrival she had no brainstem reflexes and had a Glasgow Coma Score of 4. She was not brain dead but her prognosis for recovery was so grave that surgical intervention was felt to be pointless and was not recommended to the patient's family. After some consultation among themselves they accepted this, acknowledging that "mother always said she never wanted to live as a vegetable."

While transfer back to the rural hospital was being arranged, the Charge Nurse in the ER asked the Neurosurgery team why the patient was not being kept at the tertiary hospital as she would most certainly be a potential organ donor when she inevitably progressed to a state of brain death. My residents and I discussed this and recognized that the downside of this was that she would occupy the last intensive care unit (ICU) bed blocking its availability for patients who truly needed it for therapeutic intervention and monitoring. Also, keeping her here would create a large amount of work for the team, mainly the Neurosurgery residents, who already are extremely busy while on call. I informed the Nurse that it would be unethical to discuss organ donation with the family prior to the patient being brain dead, which I honestly believe, and also that it would be in the patient's family's best interest to have her close to home in her town for her last hours or days on this planet. But I also realized I was abdicating a responsibility to a long list of patients waiting patiently for a cadaveric organ transplant.

THE "RIGHT THING?"
In these two everyday examples from a neurosurgeon's experience, was a morally acceptable and even preferable course of action pursued? Or was there an abdication of responsibility to patient(s) which was justified to others and himself in the guise of good ethics? Did knowledge of the issues and "lingo" provide an excuse for not doing the "right thing," even though the right thing is often not clear or obvious?

At the root of the problem I am trying to highlight is that there is indeed often no definitive right or wrong answer in many bioethical issues. Look, for example, to the very high-profile issue of euthanasia for terminally ill suffering patients, exemplified by the Canadian case 10 years ago of Sue Rodriguez. The Supreme Court ruled five judges to four against allowing Ms Rodriguez to have a physician-assisted suicide and it is still illegal in Canada. I suspect that if one canvassed every licensed physician in Canada on this issue, the vote would be something like 51% in one direction and 49% in the other. A lot of individuals' decisions might be based on religious beliefs, cultural and ethnic roots, and upbringing. These same values might well colour their decision on more mundane cases like the examples presented above.

With so much ambiguity and difficulty in even thinking one knows the right thing to do, there may be ample opportunity for abuse of arguments based in ethics in deciding on the course of action in individual cases, especially when there is secondary gain for the personnel involved. It is good and important for the whole team to be virtuous and/or at least attend to bioethical principles when making decisions in health care but it is also too easy to obscure self-interest and/or other interests in the discourse of doing what ethics dictates.

Dr Mark Bernstein, MHSc, FRCSC is a member of our editorial board.