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Medical conflict and other ethical dilemmas

Conflict between patients or families and doctors about medical treatment decisions was ranked as the top ethical challenge facing health care today by a panel of 12 bioethics specialists, in a study published in BMC Medical Ethics.

The panel was asked to compile a top 10 list of health-related ethical challenges based on their clinical experiences. Panel members then ranked  and scored out of ten each challenge in order of importance. Individual scores were summed up to create the total score for each challenge with a maximum possible score fof 120 or a particular challenge. The results of the top 10 list are listed below:

  1. Disagreement between patients/families and health care professionals about treatment decisions (113 points)
  2. Waiting lists (102 points)
  3. Access to health care resources for the elderly, chronically ill and mentally ill (89 points)
  4. Shortage of family physicians or primary care teams (82 points)
  5. Medical error (76 points)
  6. Palliative treatment (56 points)
  7. Achieving informed consent (43 points)
  8. Ethical issues pertaining to subject participation in research (40 points)
  9. Substitute decision-making (38 points)
  10. Ethics of surgical innovation (21 points)

The issue of medical conflict is rarely covered in the media, but it constitutes a major moral dilemma. In contrast to the much publicized Terri Schiavo case, where her immediate family members feuded about whether to remove her feeding tube, most cases of medical conflict occur in private. "In a paediatric setting, these disagreements usually occur between the health care team and the parents," says Dr. Christine Harrison, Director of Bioethics at The Hospital for Sick Children.

In common end-of-life scenarios, families may want everything done to prolong their loved one's life, while the medical team may feel that aggressive treatment is tantamount to torture. "Sometimes, the more the health care team raises the issue, the angrier and more entrenched in their position the parents become. This can go on for months, with the team feeling they are causing suffering to the child and the parents feeling unsupported and judged," says Dr. Harrison.

Families are guided by a protective instinct, hope, and sometimes deeply held religious beliefs, and may feel that the medical team is being insensitive. Families may even accuse the physician of wanting to withdraw services to save money.

Disagreements between patients/families and health care professionals can occur in any health care context: family medicine, paediatrics, general internal medicine, surgery, palliative care, etc. Medical disagreements can be as serious as an end-of-life conflict, or as mundane as a family physician refusing to give in to a patient's request for antibiotics.

It is surprising, then, that the issue of medical conflict has not received much attention. To help address this top ethical dilemma and bring it to the forefront, the panel has proposed the following suggestions:

  • Education: health care professionals should be provided with training in the negotiation and mediation skills needed to address serious disagreements. The key is to try to understand the patient's perspective.
  • Creation of policies for health care institutions: mechanisms to resolve disagreements between the health care team and patients or their substitute decision-makers need to be put into place and made consistent.
  • Examination of the patient's perspective: quality research is needed, focusing on the perspectives of patients toward disagreements over treatment decisions.
  • Reports to the public: the public needs to be kept informed of research and attempts to address the challenge of medical disputes.

Investigators felt that the second, third, and fourth ranked ethical challenges - waiting lists for treatment, limited access to care for the elderly, chronically ill and mentally ill, and the shortage of family physicians - were particular to Canada because of its Medicare system. However, medical conflicts and the other ethical challenges rounding out the top 10 list were considered universal:

  • Medical errors: the prevalence of medical errors raises questions regarding if, when and how to disclose these errors to patients and families.
  • Palliative care: pain treatment can potentially hasten death of the patient. This has contributed to widespread undertreatment of pain.
  • Achieving informed consent: many patients do not or cannot read consent forms and thus give improperly informed consent.
  • Involvement in research: ethical considerations include obtaining informed consent, balancing the benefits and risks of research, and issues around patient privacy.
  • Substitute decision-making: when a patient is incapable of making health care decisions, a substitute decision-maker is assigned. Often, substitute decision-makers struggle with making life-altering decisions for their loved one, especially if the patient has not provided guidance about his wishes.
  • Surgical innovation: it is sometimes difficult to decide when a surgical innovation becomes an experiment requiring research ethics approval.

Breslin JM, MacRae SK, Bell J, Singer PA for the Universityof Toronto Joint Centre for Bioethics Clinical Ethics Group. Top 10 health care ethics challenges facing the public: views of Toronto bioethicists. BMC Medical Ethics. 2005;6:5. Available from: