Prevalent ethical dilemmas in practice today—as told by doctors

In the evolving field of healthcare, doctors face new ethical dilemmas on a regular basis. As issues surface, physicians must keep up with the most relevant and ethical navigational methods to best serve their patients.

To better understand the most prevalent ethical dilemmas facing clinicians in medicine today, MDLinx interviewed three established healthcare experts to discuss topics like COVID vaccination status, death with dignity, and medical boundary-setting—all of which have actionable roadmaps to follow.

• The first expert is Jesse Ehrenfeld, MD, who serves on the Executive Committee of the Board of Trustees of the American Medical Association. At the Medical College of Wisconsin, Ehrenfeld holds the titles of senior associate dean and tenured professor of anesthesiology, as well as director of Advancing a Healthier Wisconsin Endowment. At Vanderbilt University School of Medicine, Ehrenfeld is a professor of anesthesiology and health policy.

• Barron Lerner, MD, PhD, is the director of the bioethics curriculum within undergraduate medical education at the New York University Grossman School of Medicine. At NYU Langone Health, Lerner is also a professor in the departments of medicine and population health.

• Arthur Caplan, PhD, serves the New York University Grossman School of Medicine as the Drs. William F. and Virginia Connolly Mitty Professor and founding head of the Division of Medical Ethics.

COVID-19

COVID came up quickly with Ehrenfeld when asked about his experiences with prevalent ethical issues faced by doctors.

“It’s hard to have a conversation about ethical challenges and not talk about COVID, because so much of the stress and challenges I face every week are around prioritization of resources,” Ehrenfeld said. 

Resource allocation during pandemic

As an anesthesiologist, Ehrenfeld encounters resource allocation issues regularly. He has participated in difficult conversations with patients who need a specific treatment, but can’t get it because of COVID’s toll on hospital resources. 

“I can’t tell you how heartbreaking it is—and has been—to tell a patient with cancer that they can’t have their tumor removed,” Ehrenfeld said when asked about the scarcity of resources. “I’ve had to do that.”

Ehrenfeld stressed the importance of total transparency in conversations with patients about possible treatments amid the pandemic. He also highlighted the ethics surrounding resource allocation to vaccinated and unvaccinated patients, specifically regarding the Pfizer antiviral pill.

COVID vaccination

When the medication hit the markets, unvaccinated patients at higher risk of COVID complications had greatest access. 

“That was, I think, a really hard pill to swallow for a lot of physicians and folks in the healthcare community,” Ehrenfeld said. 

But he emphasized that doing so was the most ethically sound decision, despite the hard feelings it may have caused.

When asked if it was ethical for doctors to deny care to the unvaccinated, Ehrenfeld’s response was swift: 

“The answer is no.”

Ehrenfeld, who advocates for LGBTQ+ patients seeking healthcare in sometimes discriminatory medical spaces, argued the importance of standing by the medical code of ethics and treating patients regardless of the identities they hold, or their decision to remain unvaccinated.

Lerner echoed this sentiment. 

“There are many, many examples of patients doing things that are not in the best interest of their health—smoking, intravenous drug use—we don’t turn those people away,” said Lerner. “You get into a dangerous situation when you make value judgements about what people should and shouldn’t do, and then decide whether or not to treat them.”

Death with dignity

Another aspect of healthcare riddled with ethical dilemmas is death with dignity—a topic with which Lerner has extensive experience.

“It is a perennial problem and challenge,” Lerner said. “How do you treat people with severe disease in a way that tries to help them as much as possible, but also keep in perspective the fact that some of them aren’t going to do well?”

While current medical ethics may lack clear answers to such big questions, legislation in recent decades have changed the field. In New York, for example, pending legislation would legalize physician-aid dying.

However, just because a service is legal doesn’t mean doctors are willing to provide it.

In states where physician-aid dying is legal, Lerner feels that doctors don’t need to participate in it if they are uncomfortable doing so. In such cases, Lerner encourages doctors to direct patients to other resources—such as organizations and other physicians who are well-versed in the practice—for more suitable care.

Lerner’s stance on death with dignity centers the patient’s wishes instead of the doctor’s personal beliefs. 

“I’m a big proponent of: If it’s out there, even if I’m not comfortable with it, I think my patients deserve to know about what’s out there and what the options are,” Lerner said.

Communicating personal values

Caplan agreed, saying that it’s crucial for doctors to “make their values clear at the start of a relationship when possible.” He also encouraged physicians to facilitate honest communication with patients to avoid unnecessary ethical dilemmas. 

“Be truthful and provide all options including those with which they may not agree that are legal, standard of care,” Caplan advised. “Set terms and boundaries for care.”

Sources

1. Caplan, A. Personal interview. 2022.

2. Ehrenfeld, J. Personal interview. 2022.

3. Huecker MR, Shreffler J. Ethical issues in academic medicine. StatPearls. 2022.

4. Lerner, B. Personal interview. 2022.