Q. The doctor in–charge of admission to the Intensive Cardiac Care Unit (ICCU) has just learnt that a bed in the unit has fallen vacant. He has information of three cases waiting for admission.

• The Health Secretary of the State, who is also the executive head of the hospital.
• The Office Superintendent of the hospital, in-charge of the hospital administration.
• A known notorious character of the area.

If the doctor-in-charge of ICCU were to decide purely on administrative grounds, the Health Secretary would get preference since he is the Executive Head of the Department of Health including the hospital. The doctor-in-charge is his subordinate. If he decides in favor of the Secretary, denying admission to the other two, there can be no legal challenge to his decision. Is it ethical to give preference to a life-saving medical facility purely on administrative grounds? Is status-based preference proper in medical services?

Response:

This is a complex and thought-provoking scenario that touches on both ethical and practical considerations in medical triage. Here are some key points to consider:

Ethical Considerations

• Principle of Justice: Medical ethics emphasize fairness and equality. The principle of justice suggests that all patients should have equal access to medical care, regardless of their social status or position. Prioritizing patients based on their administrative roles rather than medical need could be seen as a violation of this principle.
• Medical Need and Urgency: Triage decisions should ideally be based on the severity of the patient's condition and the urgency of their need for medical intervention. This approach ensures that resources are used to save the most lives and provide care to those in critical need.
• Professional Integrity: Healthcare professionals have a duty to act in the best interests of their patients. Making decisions based on non-medical factors, such as administrative status, could undermine the trust in the healthcare system and the integrity of medical professionals.

Practical Considerations

• Administrative Pressure: In reality, doctors may face pressure from higher authorities to prioritize certain individuals. This can create a conflict between professional ethics and administrative directives.
• Legal Implications: While the scenario suggests there may be no legal challenge to prioritizing the Health Secretary, it raises questions about the potential for future legal or ethical scrutiny. Policies and guidelines should be in place to support fair and transparent decision-making processes.

Status-Based Preference in Medical Services

Status-based preference is generally considered improper in medical services. The primary goal of healthcare is to provide the best possible care to patients based on their medical needs. Introducing status-based preferences can lead to inequities and undermine the ethical foundation of medical practice.

Conclusion

While administrative considerations may sometimes influence decisions, it is crucial to uphold ethical principles and prioritize patients based on medical need and urgency. Developing clear guidelines and policies for triage can help ensure that decisions are made fairly and transparently, maintaining the integrity of the healthcare system.
 

Q. The doctor-in-charge wishes to be just and fair. For this he has to consider the respective rights, claims and needs of the three patients. Which one of these three attributes should he give preference to, to be fair and just?

Records reveal that:

• The Health Secretary seeks admission to ICCU as he is scheduled for angiography on the next morning.
• The Office Superintendent is presently being treated in the Cardiology Ward. He had been admitted for coronary artery blockage, and had some cardiac arrhythmia at that time. But, since no bed was available in ICCU at that time, he was managed in the ward. He is now stable. He has been advised shifting to the ICCU should the cardiac arrhythmia recur.
• The notorious character of the area has just been brought to the emergency with myocardial infarction and life-threatening cardiac arrhythmia. He needs immediate ICCU management.

Response:

In this scenario, the doctor-in-charge must balance ethical principles and practical considerations to make a fair and just decision. Here's an analysis based on the primary and secondary ethical principles:

Primary Ethical Principles

• Beneficence: The doctor should aim to do the most positive good. This means prioritizing the patient who would benefit the most from immediate intensive care.
• Non-maleficence: The decision should aim to do no harm or the least harm. This involves considering the potential harm to each patient if they are not admitted to the ICCU.

Secondary Ethical Principles

• Justice: This includes right-based, merit-based, and need-based considerations. The doctor should ensure fairness and equity in resource allocation.

Analysis of the Three Patients

• Health Secretary: Scheduled for angiography the next morning. While important, this procedure is planned and not an emergency. His condition does not appear to be immediately life-threatening.
• Office Superintendent: Currently stable in the Cardiology Ward. He has a prior claim but is not in immediate danger. He can be monitored and managed in the ward unless his condition worsens.
• Notorious Character: Presenting with myocardial infarction and life-threatening cardiac arrhythmia. This patient has the greatest medical need and requires immediate ICCU management to prevent imminent harm or death.

Conclusion: Based on the principles of beneficence and non-maleficence, the doctor should prioritize the patient with the greatest medical need, which in this case is the notorious character with myocardial infarction and life-threatening arrhythmia. This decision aligns with the ethical obligation to do the most good and prevent the most harm.
 

Q. The ethical doctor did admit the notorious character and personally suffered as the ego of the IAS Health Secretary was hurt. The secretary thought his urgency merited preference. The doctor learnt his lesson - to be pragmatic rather than ethical. Your comments?

Response:

This scenario highlights a significant ethical dilemma that many healthcare professionals face: the tension between doing what is ethically right and navigating the practical realities of hierarchical and administrative pressures.

Ethical Integrity vs. Pragmatism

• Ethical Integrity: The doctor acted in accordance with ethical principles, prioritizing the patient with the greatest medical need. This decision reflects a commitment to the core values of medical ethics, such as beneficence, non-maleficence, and justice.
• Pragmatism: The backlash from the Health Secretary underscores the challenges of maintaining ethical integrity in environments where administrative and political pressures are prevalent. The doctor's experience suggests that being pragmatic, or making decisions based on practical considerations rather than ethical ones, can sometimes seem necessary to avoid personal or professional repercussions.

Balancing Ethics and Pragmatism

• Support Systems: Healthcare institutions should provide robust support systems for doctors to make ethically sound decisions without fear of retribution. This includes clear policies, ethical guidelines, and backing from hospital administration.
• Education and Training: Continuous education on medical ethics and conflict resolution can empower healthcare professionals to navigate these dilemmas more effectively.
• Advocacy and Policy Change: Advocating for policy changes that protect healthcare professionals from undue pressure can help create an environment where ethical decision-making is the norm.

Reflection
While the doctor's experience is disheartening, it is crucial to remember that ethical decision-making is fundamental to the trust and integrity of the medical profession. Compromising on ethics for pragmatism can erode this trust and lead to long-term negative consequences for patient care and professional standards.

Moving Forward
Encouraging open dialogue about these challenges and fostering a culture that values ethical integrity can help mitigate such conflicts. It's important for healthcare professionals to support each other and advocate for environments where ethical decisions are respected and upheld.

• What are your thoughts on how healthcare professionals can better navigate these ethical and practical challenges?
• How can doctors balance administrative pressures and ethical obligations?
• What role should hospital leadership play in supporting ethical decision-making?
• Are there any success stories where ethics prevailed over pragmatism in healthcare settings?

Written By: Dr. Shri Gopal Kabra, MBBS, LLB, MSc, MS(Anatomy), MS(Surgery)
Ph no: 8003516198 email: [email protected]