Ethical Dilemma in Health and Social Care: A Case Study

This report discusses a case study on professional ethical dilemma in health and social care, focusing on the withdrawal of life support. It explores the ethical issues raised, identifies the stakeholders involved, and examines potential conflicts and points of agreement in ethical arguments.

SH5000 Assessment A

Ethical dilemma is an ethical issue that needs an individual to select from among two or
more morally acceptable options or between equally unacceptable courses of action such as one
choice can prevent selection of others. In simple word, ethical dilemma is a conflict between
what is righteous and what is profitable for the organisation. Conflicts takes place between
principles or values. For example, for any medical practitioner, there is an ethical dilemma
situation because according Mental Capacity Act, 2005; doctor must support patient to relive
him/her from painful life by assisting them to attempt death (Malek, Rahman and Hasan, 2018).
While medical order for life sustaining treatment stated that doctor should try to give such
treatment to the patient which can sustain their life for long time. In this report we will discuss
about professional ethical dilemma from health and social care with support of case study.
Further, the variety of stakeholders involved will also be discussed and conflicts in ethical
arguments will be discussed further. Lastly, the relevant laws and legislations will also be
discussed in detail in the report.
Overview of case study
The case study is based on ethical dilemma such as Katherine is an unmarried 40 year old
women who is suffering from Gullian- Barres syndrome, a painful neurological illness that
leaves her in paralysed situation for unpredictable length of time. However, lots of people have
recovered from the syndrome and lives their healthy life. Generally, Katherine has been
paralysed for 3 years and 10 months ago meanwhile period it was identified by doctor that she
was unlikely able to take breath and mover ever on her own again because her nerves and muscle
have damaged. But now she needs ventilator which help her breath (Golijanin, 2020). However,
her doctors have clearly mentioned to her and her parents in gentle manner. Last week, Mrs
Katherine requested to speak with doctor privately. She said to her that she does not want to live
anymore because she told her life held no value for herself if it meant being in continuous pain
and without the freedom to move or breath on her own. She told the doctor that she has discussed
with her family to remove ventilator and they have agreed on her wish. From the above case
study, it can be analysed that there is a big ethical dilemma for the doctor is to remove patient
from ventilator or not.
3

Identify the ethical issues the dilemma raises
In Katherine’s case study, ethical dilemma is that Katherine is forced to take certain
actions due to circumstances like she unable to take breath on her own, cannot move etc. She is
bearing lots of pain due to medication that’s why has desire to death. But it is moral duty of
Katherine’s doctor to make her understand that it is not good decision. This is because of the
grave consequences that are associated with her actions that will be harmful in the longer run.
But it is moral duty of the doctor to be fair to patients about their health issues (Je, Park and
Bang, 2020). Katherine was right that there is no meaning of life because she cannot take breath
on her own and have to stand high level pain. So, it is a right of patient that they can stop their
life if they do not have any wish to live more. Living in a free country with adequate laws and
regulations giving an individual right to take their own decisions automatically makes them
entitled to take any steps that they deem appropriate. While doctor also knew that Katherine
cannot live for long time and ventilator is the reason only which helps her breath (Kennedy and
et.al., 2009). According to Katherine situation, it is a moral duty of doctor to understand patient’s
situation and give her mercy death. Patients also have right to take own decisions. But according
to government norm’s doctors do not have any right to give mercy death to the patient. It is a
duty of doctor to stay live patient’s till then can’t (Ahenkan, Afari and Buabeng, 2018). Second,
patient’s also do not have right to stop their life expectancy. Thus, both situations are right own
their places. So, this situation is known as ethical dilemma.
This professional ethical dilemma raises various ethical issues for the doctor such as if
patient is too much requesting to doctor to stop her/his life then it is ethical duty of doctor to
support her and make her free from painful life. This is because they have moral responsibilities
towards the patients where it is their duty to take those decisions which focus on the wellbeing of
their patients. But ethical issue for the doctor is that code of ethics do not allow doctor to so
something like this. But to remove patient from ventilator is not allowed to the doctor because
this practice is opposing code of conduct (Miller and et.al., 2019). The reason behind is that, if a
patient is taking breath with the support of ventilator and it removes that means, it is too painful
death of patient. This type mercy death does not allow doctor to give the patient. In Katherine’s
case study it is a biggest ethical issue for the doctor. Another ethical issue is type of conversation
like want type communication has doctor with the patient for example Kathrine wanted to speak
with the doctor privately to share her feeling. It denotes that, there was good communication of
4

doctor with the Katherine so, it can possible that doctor become emotional and accepts Katherine
wish. Emotional factor can also consider into ethical issue which can affect doctor to take right
decision. Another is that Katherine discussed with her family that she does not want to live
anymore because she was too much in pain, that’s ‘why her family were agreed with her decision
(Bringedal and et.al., 2018). This situation can also affect doctor’s psychology like according to
people, doctors are considered life giver not snatcher. For instance, doctor become agree to fulfil
wish of Katherine as per her statement like her family has accepted her wish. But it can also
possible like her family is not agree to give Katherine painful death. Psychological factor is
another ethical issue that also rises in ethical dilemma for doctor. Thus, there are different ethical
issues such as psychological, emotional, code of conducts that raises at different situations which
can affect doctor’s decision-making process (Ahenkan, Afari and Buabeng, 2018).
Identification of the different stakeholders
Various stakeholders are involved in this ethical dilemma that Katherine is going through
and they all have different roles, viewpoints, impact of the decision, and perspectives in terms of
the decision of withdrawal of the life support/ ventilation. In terms of the patient itself, the
ethical decision that has to be taken is discontinuation of the life support and the Katherine has
made up her mind after a careful analysis of the disadvantages and situation she wis facing and
will continue to face in the possible future, this was decided soon after she was clearly yet gently
told by her doctor regarding the permanency of her Gullian- Barres syndrome, a painful
neurological illness that leaves her in paralysed situation (Mueller and et.al., 2010). The major
reasons why the decision is right in terms of the patient is because she is suffering from
unimaginable pain and hopelessness, which cannot be countered by any other physical or
emotional support, as not being able to move and breath for unknown duration of time is quite
painful for the patient. This action can also be justified by utilitarianism ethical theory which is
based on the ability of an individual to predict or evaluate the possible consequences of any
action. Thus an individual may perform any action which can benefit the other people regardless
of law or personal opinion (Brightonand et.al., 2019). Hence even if decision to withdraw the life
support system may not be a preferred choice of the doctors or family members but they tend to
agree so that patient can get relief from endless suffering and pain. Also, as per the medical
outcomes, the period of uncertainty which was keeping her motivated to keep living has
5

suddenly come to halt as soon as she came o know regrading the permanency of her situation.
Therefore, it can be justified by this situation the factors that were involved in the decision-
making process by Katherine, also the patient has a complete legal right to withdraw from any
treatment (Kennedy and et.al., 2009).
In terms of Carers, they have the view that the decision-making process should undertake
some more time and consultation and a detailed analysis has to be done before taking any
decision about the patient. The carers and doctors might also feel that the patient might be
reacting too quickly to the situation and may need more time in order to think more hopefully
and should also occur regarding this with other family members. There is a high possibility that
the sudden shock of the terminal illness may have led the patient in taking the wrong decision in
haste. It is also possible that the patient may be suffering from depression due to the condition
and other psychological factors must me involved, therefore as per the doctors and carers
perspective, the decision should be re analysed and needs some more time, A few more sittings
with the psychotherapist could also help Ms Katherine in thinking more effectively and
rationally, rather than on emotional basis. On moral grounds it is required because
psychotherapist will help reasons and emotional support to take rational and logical decisions
instead of making quick decisions on the basis of momentary pain. It may also smoothen or heal
quick recovery of the patient. The legality and ethics are also involved in the decision where the
patient’s request has to be clear, in written guidance such as symptom control, and the doctors
need to understand the difference between withdrawal and assisted suicide as the latter is illegal
in the United Kingdom (Dreyer and et.al., 2012). However, it is the carers duty to agree to what
the patient is saying despite of the consequence, as the patient has told that she has taken her
family’s approval regarding the same and is agreed to finally terminate the ventilation. From
ethical grounds also carers must pay attention to the needs and thinking of the patient they are
serving. Because if carer will not listen to the patient then they may fail to provide adequate care
and services. When it comes to family members, they are a major stakeholder in terms of the
decision that has been taken by Katherine. However, the decisions and discussion regarding this
must have to be taken in a timely manner and in the state of full capacity of the patient. Before
finalising any decision, the doctor has to talk with the patient, the family members and other
experts as well as legal advice and lead the decision with an overall sense of responsibility or
causation.
6

The family members should also have full information regarding the medical conditions
and any potential improvements that might happen or any present medical advances, along with
various other alternatives that might be present in order to improve or stabilise the condition of
the patient. The discussion that the family members have should be with the doctor and carers,
healthcare professionals and the patient thoroughly after considering all options and the intensity
of the present situation. The communication needs to be honest and open and all family members
need to express their views and emotions regarding the end of the palliative care and withdrawal.
In such cases the family members also need to go through and study the similar conditions and
experiences of people who have had earlier gone through this process. Apart from them the other
stakeholders that are involved ae the pressure groups such as NHS support federation, People
health movement and Socialists Health association who have the right to seek changes in the
existing laws and rules in the UK (Lyu and Zhang, 2018). After witnessing the condition of
Katherine and her strong and logical consent to remove treatments, it is evident that the UK
needs laws and clarity in terms of ethical issues for doctors in assisted suicide. Although there
have been many legislations for legalising physician assisted suicide or passive euthanasia in the
UK, with many reforms being rejected.
Potential conflicts and points of agreement in terms of ethical arguments
In terms of withdrawal of ventilation as per the consent of the patient, the society and
medical facilities have to understand, that mere recognition and acceptance that human life has a
natural end and that it does not have to be preserved just because a treatment to sustain the body
exists. The major point of agreement in the ethical dilemma is the moral principle of virtue the
act and the trait of the person taking the decision has to be seen (Hernández-Marrero, Fradique,
and Pereira, 2019). Katherine is a strong and intelligent woman who has analysed all her options
and the focus should be on the motive of the agent. There are various uncertainties in life and
people have to come to terms with it, and also the fact that death itself is not disturbing unlike the
way or events that led up to it. Katherine is merely saving herself from her own pain and
ambiguous life. She might consider the removal of ventilation that is NIV ad TV to be a good
death rather than being in pain and suffering for the rest of the days and dying in painful way
anyhow in later stage due to the higher rate of the progression or advanced stage of the disease
(Tripodoro, Rabec and De Vito, 2019). Apart from that the ethical principle of autonomy can be
7

seen as the central aspect in this decision-making process which argues that people have a right
to make their own judgements and also act upon them. Therefore, a healthcare professional and
medical system is obliged to respect the autonomous choice of the patient. However, it can be
moted that there are potential conflicts with this argument as it may conflict will other ethical
principles like non-maleficence and beneficence. The professional has a responsibility of not
causing any harm and to do the good job role. A healthcare personnel is thereby obligated to
respect the autonomous decisions about not only the manner in which patients choose to live
lives but also the manner in which they want to terminate it. There end of life decisions have
always been debated and deem to be highly controversial. But due to the rise of organised
religion the laws associated with end of life through assistance of physicians such as assisted
suicide has always been rejected. The argument against this belief is that god has only given the
life and can take it away. But the society is also becoming increasingly secular and no universal
laws govern any view regarding this issue. The argument can be summarised into the end-of-life
choices as the recognition that not all patients can be healed and it is impossible to relieve al the
suffering (Weiner, Brunkhorst and Lantos, 2016). This aspect should be recognised and
understood by doctors, carers and other healthcare professionals who should be able to recognise
all the compassionate and sensitive management of death can be considered merely a single
aspect regarding end-of-life choices. The dialogue should be between the patient that is receiving
the administration and treatment and the one administering it and the fact that the provision of
healthcare does extend up to all the phases that the patient undergoes, including the death. But
the legalisation of termination of life wilfully needs to be debated more and made lawful at least
in the cases of incurable and terminal diseases. The doctors should understand that they need to
administer the will of their patient to remove the ventilation support in lieu of the autonomy and
informed consent (Crimi and et.al., 2019).
Ways in which cultural dimensions influence response of people to the ethical dilemma
Ethical dilemmas exist in the healthcare from administration of certain medications and
allocation of resources to ending the medical palliative care due to end of life choices. There are
various cultural factors that directly impact the way a person thinks and behaves regarding the
ethical dilemmas in context of difference in sex, gender, religion, ethnicity, values and beliefs.
Katherine is a female, is unmarried which may represent a factor of loneliness or no dependents
8

that might have influenced her decision. In regards to religious beliefs, it is possible that she does
not have any orthodox or strict organised religion-based beliefs that does not agree with ending
one’s own life. From the ethical dilemma to even taking in medications and other forms of care
are affected by religious beliefs as any people refuse to take certain medical interventions.
Cultural influences also tend to trigger moral distress in many aspects and can be a major
dimension in decision-making process (Phelps and et.al., 2017).
Consideration of relevant codes of professional conduct
In context to UK, the ethical decision of withdrawal of the ventilation of Ms Katherine
can be challenging as it requires proper assessment of the terminal illness, legalities, moral
considerations, consent of the patient and the family etc (NHS UK, 2020). There are certain rules
and professional conduct and laws regarding how and why to perform a particular action. As per
the association of Palliative medicine position statement, there are legal and ethical aspects for
caring for patients that suffer from Gullian-Barres syndrome which is a rare yet severe condition
that is a neurological onset of immune system attack which damages the nerve function and leads
to paralysis. Ms Katherine has now been advised a terminal illness where she will not be able to
move or breath, leading her to make a decision on withdrawal of ventilation support. As per the
UK law, the decisions regarding refusal of treatment has to be respected and adhered to even if
the consequences of the refusal lead to the death of the patient. When it comes down to assistive
ventilation, either delivered via tracheal tube or done invasively, or non-invasively through mask
and other equipment is considered a medical treatment. A patient has the right to be either
assisted with it or refuse to bused it (Gleeson and Johnson, 2017). In cases like Katherine where
the patients consider the burden of medical administration outweighing the benefits, a separate
law regarding is available as a decision for foreshortening their lives through either self-neglect
or suicide. It has been clearly mentioned that withdrawing of the medical treatment which the
patient does not want anymore, and which is deemed to be life threatening, is not considered
assisted suicide, and is therefore legal in the UK. Apart the legal aspects, the moral stakes are
extremely high in such cases and tends to be influenced by beliefs, ethics, values and leads to
misunderstandings and tough decision-making (Messer and et.al., 2020). To counter the moral
obligations, the UK medical conducts ates that before committing the process of withdrawal,
certain standards have to be followed which involves sharing and communication of onto,
9

decision and planning of withdrawal, reasonable timeframes and validated request, informed
consent, supervision of higher authority, consultation with relatives and family and undertaking
the withdrawal procedure as per the conduct and symptom management (Gerdfaramarzi and
Bazmi, 2020).
10

References
Books and Journals
Ahenkan, A., Afari, M.B. and Buabeng, T., 2018. Ethical Dilemma of Health Professionals in
Ghana: Experiences of Doctors and Nurses at the Korle-Bu Teaching Hospital. African
Journal of Management Research, 25, pp.29-44.
Bringedal, B and et.al., 2018. Between professional values, social regulations and patient
preferences: medical doctors’ perceptions of ethical dilemmas. Journal of medical
ethics, 44(4), pp.239-243.
Crimi, C., and et.al., 2019. Long-term ventilation in neuromuscular patients: review of concerns,
beliefs, and ethical dilemmas. Respiration, 97(3), pp.185-196.
Dreyer, P.S., and et.al., 2012. Withdrawal of invasive home mechanical ventilation in patients
with advanced amyotrophic lateral sclerosis: ten years of Danish experience. Journal of
palliative medicine, 15(2), pp.205-209.
Gerdfaramarzi, M.S. and Bazmi, S., 2020. Neonatal end-of-life decisions and ethical
perspectives. Journal of Medical Ethics and History of Medicine, 13.
Gleeson, A. and Johnson, F., 2017. Withdrawal of invasive ventilation in a patient with motor
neurone disease and total locked-in syndrome. Practical Neurology, 17(5), pp.383-386.
Golijanin, I., 2020. Ethical and legal aspects of the right to die with dignity. Filozofija i
društvo, 31(3), pp.420-439.
Je, N.J., Park, M.R. and Bang, S.Y., 2020. Survey on Ethical Issues, Ethical Dilemma, and
Needs for Ethics Education in Healthcare Providers. Journal of Digital
Convergence, 18(10), pp.285-296.
Kennedy, S., and et.al., 2009. Key stakeholders' experiences and views of the NHS End of Life
Care Programme: findings from a national evaluation. Palliative Medicine, 23(4), pp.283-
294.
Lyu, C. and Zhang, L., 2018. Who decides in withdrawal of treatment in a critical care setting? A
case study on ethical dilemma. International journal of nursing sciences, 5(3), pp.310-
314.
Malek, M.M., Rahman, N.N.A. and Hasan, M.S., 2018. Do not resuscitate (DNR) order: Islamic
views. Al-Qanatir: International Journal of Islamic Studies, 9(1), pp.35-43.
Messer, B., and et.al., 2020. Requested withdrawal of mechanical ventilation in six patients with
motor neuron disease. BMJ supportive & palliative care, 10(1), pp.10-13.
Mueller, P.S., and et.al., 2010, September. Ethical analysis of withdrawing ventricular assist
device support. In Mayo Clinic Proceedings (Vol. 85, No. 9, pp. 791-797). Elsevier.
Phelps, K., and et.al., 2017. Withdrawal of ventilation at the patient's request in MND: a
retrospective exploration of the ethical and legal issues that have arisen for doctors in the
UK. BMJ supportive & palliative care, 7(2), pp.189-196.
Tripodoro, V.A., Rabec, C.A. and De Vito, E.L., 2019. Withdrawing noninvasive ventilation at
end-of-life care: is there a right time?. Current opinion in supportive and palliative
care, 13(4), pp.344-350.
Weiner, J., Brunkhorst, J. and Lantos, J.D., 2016. Ethical Issues in Assisted Ventilation of the
Neonate. Assisted Ventilation of the Neonate E-Book, p.36.
Online
Withdrawing treatment-End of life care, NHS UK, 2020. Available through:
<https://www.nhs.uk/conditions/end-of-life-care/withdrawing-treatment/>
11