Ethical Dilemmas

staircase.jpg
 
 

ReFLECT ON A TIME when…

You were faced with an ethical dilemma in medicine. How did it confirm and/or challenge your own morals and viewpoint? What thoughts and emotions did it insight? How did you respond? How do you wish you had responded? What internal and external conflicts were at play? What conflicts or differences of opinions arose? What factors informed those differences? What did you learn from the experience? How does this experience shape your current or future practice?

Related readings:

  • Fadiman, Anne. The Spirit Catches You And You Fall Down: A Hmong Child, Her American Doctors, And The Collision Of Two Cultures. New York : Noonday Press, 1998.

 
 

 
commonication.jpg

Author: Josh Caldwell, Harvard Medical School

Conformed Consent

As I stepped onto the L&D ward early in the morning, I was acutely aware of how conspicuous I was in my collared shirt, slightly damp with sweat, and pressed pants. I stepped up to the desk manned by two skeptical looking nurses in scrubs.  “Hi! I’m Josh, a medical student here for a clinical immersion this morning,” I said with a slightly supplicative tone.  I was ushered into a back office where I waited until a nurse poked her head in and tersely said, “Come with me.”

        The nurse steered me into a delivery suite, gestured me over to the corner in between the bedside and a bank of windows along the wall, and began loudly hammering her fist on the door of the bathroom.  “Ms. B!  Ms. B!  It’s time to come out of the bathroom.  You need to lie down now, Ms. B!” she loudly called against the shut door.  After a moment or two, a young woman was shepherded from the bathroom to the bed, one of the nurses hands urging her along at the small of her back and another steadying her at the shoulder.  As soon as the woman, whose brow was glistening with a sheen of sweat and whose face was contorted in obvious discomfort, was supine in the bed, the nurse turned to me and quickly related the patient’s relevant medical history. 

        Uncomfortable and a bit out of my depth, the only parts of the history that stuck in my mind were that she was a very recent arrival from Haiti with little or no prenatal care, no English proficiency, an “intriguing” possibility of Zika exposure, no support in the area, and no relationship with the father of the child. As the nurse began setting up an infusion of penicillin, because the young woman’s GBS cultures were not yet back from the lab, the woman squinted her eyes tightly shut and began screaming, “Jezi! Jezi! Maman!”  A translator, through an iPad mounted on a metal pole on wheels at the foot of the bed, said, “The patient is crying out for her mother and for Jesus.  I’m having a hard time understanding anything else the patient is saying.”  The nurse looked at the iPad and said loudly, “Tell her that an anesthesiologist is on the way and he’ll be doing an epidural.  She’ll feel much better soon.”

         Although seemingly little reassured, the woman’s pain subsided after a few moments and, when the anesthesiologist finally arrived with a little metal cart of supplies, was relaxed enough to follow the man’s instructions to, “Sit up, hang your feet off the edge of the bed, and do your best not to move.”  As the man donned a sterile set of gloves and moved to tape a sterile drape to the woman’s back, she began sobbing.  “She is saying ‘no, don’t do it,’” the translator said through the iPad.  The anesthesiologist and the nurse exchanged looks of frustration and incredulity, and the anesthesiologist turned to me, stripping off his sterile gloves, and said, “I’ve never had one refuse at this point!”  The patient, seemingly sensing the disappointment and irritation in the room blurted out, in English, “I’m just so scared!  Is this the thing that can make you not able to walk anymore?”

          The nurse quickly counseled the patient, through the iPad interpreter, that if she sent away the anesthesiologist now, he would be busy and she would just have to deal with the pain for as much as a few hours until he was able to come back.  Then, slowly and haltingly through the interpreter, the anesthesiologist gave the kind of risk and benefit analysis and description of the procedure that I had expected, at the outset of the procedure, to the patient.  The patient acquiesced and agreed to the epidural catheter, after the doctor agreed to show her the contents of the pre-packaged procedure tray.  After the line was placed, and the patient was comfortably lying back in her bed, the anesthesiologist cleaned up all of the plastic wrappers and trash and began to push his cart back out of the room. He stopped suddenly and turned back to the patient with a procedural consent form extended in his hand, blurting, “Oh, right! Can you sign this?”