ETHICAL DILEMMAS IN MEDICINE: AN ANTHROPOLOGICAL PERSPECTIVE (INTENSIVE CARE NURSERY, HEMODIALYSIS)

This is an anthropological study of ethical dilemma situations in contemporary American medicine. The medical setting is of special importance for studying ethical dilemmas because of its increasing complexity, its technological achievements and limitations, and its intense human encounters. Too often complex dilemma situations are reduced to single issues. The objective of this study was to understand and characterize ethical dilemma situations as they occurred in the clinical setting from the perspectives of the staff, patients and families involved in them. Participant-observation fieldwork and interviewing were carried out on an intensive care nursery and an adult hemodialysis unit in a medical center hospital. Data were collected and analyzed using a grounded theory approach and a research guide inspired by the work of Arthur Kleinman. Twenty-one cases were examined in detail, 15 from the nursery and six from the dialysis unit. From the participants' viewpoint, an ethical dilemma was (1) a specific situation characterized by uncertainty, (2) involving normative and existential issues, (3) interpersonal and/or intrapersonal conflict about how to handle these issues, and (4) the need to make an action decision regarding them. This is a broader definition than is usually found in discussions of ethical dilemmas. It specifically includes concerns about staff-patient-family problems. In the clinical setting action was needed to resolve the dilemmas, and these concerns could influence the action that was taken. The participants identified 26 dilemmas in the 21 cases that could be classified broadly under three types: how far to go in using medical technology (16 cases), family problems (6 cases), and intra-staff conflict about patient care (4 cases). Analysis revealed five significant features of the ethical dilemma situations in these cases. They were unpredictable and had to be dealt with after they had developed. They were felt to be "long and draining" regardless of how long they lasted. They were shaped by the clinical context in which they occurred: the structure of pediatric medicine could lead to different dilemma experiences than those found in adult medicine. They involved problems in decision making and communication. They both reflected and were influenced by values and social factors in the larger society. The study identified characteristics of ethical dilemma situations that contributed to the difficulty of their resolution in ways not generally recognized in medical practice. It also points to the need for a broader view of ethical dilemmas than has been traditional among ethicists.