Damned if you Do, Damned if you Don't
Wherein we look at how to tell if you are in a true moral dilemma whilst engaging in only mild profanity
Photo by Jan Canty on Unsplash
In Practical Bioethics, I define a moral dilemma as having three necessary characteristics:
There are at least two options we can take
All of the options have moral cost
Doing nothing causes one of the options to occur anyway.
My students will probably tell you I drill this into them like some maniacal dentist. Asking over and over what is the “Damned if you do, and damned if you don’t” question or pressing them to tell me why this or that option violates this or that moral value.
Knowing when you are in a moral dilemma is really important in healthcare. If all the options don’t suck (morally speaking) then it’s not a dilemma. And the dilemma is the dark, chocolatey, center where the interesting and difficult lies waiting.
Practical Bioethics is full of really tough dilemmas. One of my favorites is actually a true story. A 48 year old man who has been on a ventilator for over 10 years. He can’t breathe unaided. He has a close call with dying when his breathing machine (ventilator) malfunctions. Now he’s ready to end his life by having his ventilator turned off. I sum up the dilemma.
If the staff comply with the request, they may harm some- one unnecessarily. But if the staff refuse to honor the request, they violate the patient’s freedom to refuse treatment.
Medical staff extubate (remove a ventilator) patients so they can die all the time. But this patient doesn’t fit the picture of a terminal patient. He does have a disease that would make him terminal except for the ventilator. Paralysis of the diaphragm is treatable with a ventilator, so it feels like something wrong. Hastening his death.
At the same time, the strongest right a patient has is to stop treatment or refuse treatment. His ventilator is treatment. Being on one for 10 years is no picnic. I’ve heard it described as “shredding the lungs” If we don’t comply with his request, aren’t we also doing something wrong?
I push my students to articulate the dilemma in a sentence like this: If we do (action), we violate (value), but if we don’t do (action), we violate (other value).
Damned if you do, Damned if you don’t.
Usually students want to find a morally neutral loophole. They’ll astutely point out, that this may be someone who is scared and depressed and we shouldn’t immediately comply with his request. Often they will suggest a psych consult.
They want more information.
Fair enough, but what if (I press) he continues to make this request after a good ole psych consult. Maybe its a few weeks? A few months? Maybe he tries to do it himself and someone kindly calls 911 and he’s back here again?
Moral dilemmas cannot be resolved with more medical information. That’s what makes them moral dilemmas.
We can use fancy moral terms but the simple question is which value is more important: The staff’s moral intuitions about a good death or the patient’s freedom to refuse treatment?
Ultimately the goal is to come up with a resolution that we can look ourselves in the mirror and live with.
Notice I said, “resolution” not “answer” or “solution” because it’s rare that I’ve left a ethics committee thinking, “Goodness, that was the only solution, no doubt about it.” There’s almost always some sliver of regret our committee couldn’t find an option that doesn’t violate any moral principles.
In PB, I offer three goals for any ethical decision we can live with:
Clear : Everyone involved - patients , family members , and providers - can understand not only what decision was made but also why it was made.
Coherent : a decision that is consistent with other, similar ethical decisions.
Justified : all those involved will be able to point to reasons that the decision makers used to make the decision , and whether they agree with the decision or not , any reasonable person would agree it was a reasonable decision.
I would love to hear what you would decide if you were asked to help with the extubating? Assume our patient can’t extubate himself (tracheostomies can be tricky) and he really doesn’t want to. What if you were a family member and your asked to talk him out of it?
Next substack we’ll look at the steps of solving a moral dilemma or what I call the 5 Ds (describe, dilemma, discern, decide, and defend).