Ms Bigelow, a dental hygienist, identifies progressive periodontal disease in a patient at a periodic recall visit. Despite Mr. Chafin's (the patient) best efforts the periodontal condition is progressing with notably deeper pocket depth this appointment than 6 months ago. She has documented in the dental record the deepening pockets, the exudate and bleeding on probing, and the radiographically observable bone loss among all the posterior teeth. Ms. Bigelow thinks Mr. Chafin should be referred the local periodontist, as her employer, Dr. Johnson, a general practitioner, only treats mild periodontal problems requiring root planing and curettage.

When she informs Dr. Johnson of her findings and recommendation, he dismisses her with a wave of his hand, and enters the operatory where Mr. Chafin is seated. He probes among a few anterior teeth, and dismisses Mr. Johnson in a cordial manner, reconfirming to him the importance of returning again in 6 months for another "cleaning."

Ms. Bigelow is distressed by her employer's cavalier attitude regarding Mr. Chafin's serious periodontal disease. She is confident that it is imperative that he receive substantive and definitive periodontal treatment or he will lose his teeth to the condition.

What should she do?

ETHICAL THINGKING &

PROBLEM SOLVING

drg. ELASTRIA WIDITA, M.Sc.

ETHICAL DECISION MAKING

1. Clearly State The Problem

2. Get The Facts

3. Consider The Fundamental Ethical Principles

4. Consider How The Problem Would Look From Another Perspective Or Using Another Theory

5. Identify Ethical Conflicts

6. Consider The Law

7. Making The Ethical Decision

Consider the problem within its context and

attempt to distinguish between ethical problem

and other medical, social, cultural, linguistic, &

legal issues

Explore of the meaning of value-laden terms, ex

futility, quality of life

Clearly State The Problem

Find out as much as you can history,

examinations, relevant investigation

Take the time

Listen patients narrative

Understand their personal & cultural biography

Are they necessary facts that you do not have? If

so, search for them

Get The Facts

Autonomy : what is the patient approach to the problem?

Beneficence : what benefit can be obtained for the patient?

Non-maleficence : what are the risks and how they can be avoided?

Justice : how are the interest of different parties to be

balanced?

Confidentiality : what information is private and does confidentiality

need to be limited or breached?

Veracity : has the patient and the family honestly informed & is

there any reason why the patient cann`t know the

truth?

Consider The Fundamental Ethical

Principles

Who are the relevant stakeholders?

What is their interest?

What do they have to lose?

How salient are they interest?

How powerful are they?

How legitimate are they?

How urgent are they?

How woul d the problem look like from alternative ethical positions?

consequentialist, right based, virtue based, feminist, communitarian, care based

Consider How The Problem Would Look From

Another Perspective Or Using Another Theory

Explain why the conflicts occur

How they may be resolved?

Identify Ethical Conflicts

Identify relevant legal concepts & law how they might guide manaagement

Examine relationship between the clinical-ethical decision making & the law

Consider The Law

1. Identify ethically viable options

2. Make the decision & justify for it specifying how

guiding principles were balanced & why

3. Take the responsibility for the decisions

4. Communicate the decision & assist relevant stekeholder

determine an action plan

5. Document the decision

6. Evaluate the decision

Making The Ethical Decision

JD was an 82-year old man who lived in a nursing home and had

several strokes. He was aphasic and altough he appeared to

understand some of what was said to him, the extent of his

understanding was never certain.

He was paralysed down one side & spent much of his day in a large

chair in front of the tv at the nursing home. He had two children

who visited him infrequently.

During the winter time, JD often developed chest infections that

usually responded to oral antibiotics.

During one of these infections he appeared to be more unwell than

usual began spitting all his medications out, as well as spitting out

all food and fluid. He became quite dehydrated, and was

transferred to the local hospital. An IV infussion was commenced,

but he kept pulling it out and seemed much more settled when it

was removed.

CASE STUDY

The question arose as to whether he should restrained in order to continue with the infussion or should allowed to

die dehydration, malnutrition & infection.

Apakah suatu keputusan yg ETIS jika kita menyetujuinya untuk

menghentikan makan & minum?

1. He was aphasic and altough he appeared to understand

some of what was said to him, the extent of his

understanding was never certain.

2. Mentally incompetent

Can we ethically refrain from providing food & fluid to a mentally

incompetent individual who appears to have quality poor of

life but will need to be restrained by force to feed him?

ETHICAL PROBLEM

Literature

1. Man mouth would dry & become ceked or coated with thick material. His lips would become parcehd & crack.(Aronheim & Gasner 1990) dehydrationdepression, dysphagia, headaches, nause, vomiting.

2. If people are fully hydrated just before they die their bladders fill causing either incontinence or distressing restlessness nuissance of needles & tube that make a cudle almost impossible (Lamerton 1991)

Facts..?

Narasi dr riwayat penyakit

Bigrafi personal & kebudayaanya

Autonomy : pasien punya pandangan sendiri u/ atas

berbagai aspek perawatan pemahaman dr perjalanan

penyakit.

Kasus JD, mentally incompetent

Keterlibatan keluarga, teman terdekat well understand

Beneficence & Non-maleficence : intellectual & emotional

efficient & efffective communications skills

Best for him TO DIE OR BEING FORCED TO LIVE?

Justice : resource allocation & cost of patient`s care

Ethical Principles.?

Beneficence & Non-maleficence

Ethical Conflicts..?

Require

Specification (meaning & scope)

Balancing (reasons or justifications)

We wish to help him but unsure if our help will

actually harm him

Keseimbangan dr prinsip etika, hak, tdk berdasarkan moral sj,

tp kekuatan dr argumen, konteks klinis, & perspektif moral

Information

Sensitive manner

Systematic manner

Ethical judgment

Communicated & documented

assist the relevant stake holder action plan

development of way

1. Negotiation

2. Compromise

3. Mediation

4. Plan review

Clinical decission?

Increase the quality of care

Reduce litigation

Facilitate the fair distribution of limited resources

Ensure public confidence in medical institutions

Clinical ethics services