Medical conflict: a top ethical dilemma

August 2005 - Conflict between patients or families and doctors about medical treatment decisions was ranked as the top ethical challenge facing health care today by a Toronto 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. Each panel member was then asked to rank each challenge in order of importance. For each panel member, the top-ranked challenge was assigned a score of 10; the second-ranked challenge a score of 9, and so on. Individual scores were summed up to create the total score for each challenge. The maximum possible score for a particular challenge was 120. The results of the top 10 list are listed below:

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.

	AGGRESSIVE Referring to a hostile or destructive person or behaviour.

	SURGERY The treatment of a disease or condition through an operation.

	PALLIATIVE CARE Supportive care that focuses on comfort, eliminating pain, and increasing quality of life. Palliative care may also attempt to reduce the seriousness of a disease or slow its progress rather than providing a cure.

	FAMILY PHYSICIAN A medical doctor with several years extra training in primary care. Family physicians provide care for the entire family and therefore is interested in all aspects of your family’s health.

	ANTIBIOTICS A medication that prevents or cures bacterial infection. An antibiotic interferes with the growth of bacteria.

	PREVALENCE The percentage (%) of a population that is affected with a particular disease or condition at a given time.