Ms Bigelow, a dental hygienist, identifies progressive periodontal disease in a

patient at a periodic recall visit. Despite Mr. Chafin's (the patient) best efforts
the periodontal condition is progressing with notably deeper pocket depth
this appointment than 6 months ago. She has documented in the dental
record the deepening pockets, the exudate and bleeding on probing, and the
radiographically observable bone loss among all the posterior teeth. Ms.
Bigelow thinks Mr. Chafin should be referred the local periodontist, as her
employer, Dr. Johnson, a general practitioner, only treats mild periodontal
problems requiring root planing and curettage.

When she informs Dr. Johnson of her findings and recommendation, he

dismisses her with a wave of his hand, and enters the operatory where Mr.
Chafin is seated. He probes among a few anterior teeth, and dismisses Mr.
Johnson in a cordial manner, reconfirming to him the importance of
returning again in 6 months for another "cleaning."
Ms. Bigelow is distressed by her employer's cavalier attitude regarding
Mr. Chafin's serious periodontal disease. She is confident that it is imperative
that he receive substantive and definitive periodontal treatment or he will
lose his teeth to the condition.

What should she do?

ETHICAL THINGKING &

PROBLEM SOLVING
drg. ELASTRIA WIDITA, M.Sc.

ETHICAL DECISION MAKING

1. Clearly State The Problem

2. Get The Facts

3. Consider The Fundamental Ethical Principles
4. Consider How The Problem Would Look From
Another Perspective Or Using Another Theory
5. Identify Ethical Conflicts
6. Consider The Law
7. Making The Ethical Decision

Clearly State The Problem

Consider the problem within its context and
attempt to distinguish between ethical problem
and other medical, social, cultural, linguistic, &
legal issues
Explore of the meaning of value-laden terms, ex
futility, quality of life

Get The Facts

Find out as much as you can history,
examinations, relevant investigation
Take the time
Listen patients narrative
Understand their personal & cultural biography
Are they necessary facts that you do not have? If
so, search for them

Consider The Fundamental Ethical

Principles

Autonomy
Beneficence
Non-maleficence
Justice

Confidentiality
Veracity

: what is the patient approach to the problem?

: what benefit can be obtained for the patient?
: what are the risks and how they can be avoided?
: how are the interest of different parties to be
balanced?
: what information is private and does confidentiality
need to be limited or breached?
: has the patient and the family honestly informed & is
there any reason why the patient cann`t know the
truth?

Consider How The Problem Would Look From

Another Perspective Or Using Another Theory
Who are the relevant stakeholders?
What is their interest?
What do they have to lose?
How salient are they interest?
How powerful are they?
How legitimate are they?
How urgent are they?
How woul d the problem look like from alternative ethical
positions?
consequentialist, right based, virtue based, feminist,
communitarian, care based

Identify Ethical Conflicts

Explain why the conflicts occur
How they may be resolved?

Consider The Law

Identify relevant legal concepts & law how they might
guide manaagement
Examine relationship between the clinical-ethical decision
making & the law

Making The Ethical Decision

1. Identify ethically viable options
2. Make the decision & justify for it specifying how
guiding principles were balanced & why
3. Take the responsibility for the decisions
4. Communicate the decision & assist relevant stekeholder
determine an action plan
5. Document the decision
6. Evaluate the decision

JD was an 82-year old man who lived in a nursing home and had
CASE
STUDY
several strokes. He was aphasic and
altough he
appeared to
understand some of what was said to him, the extent of his
understanding was never certain.
He was paralysed down one side & spent much of his day in a large
chair in front of the tv at the nursing home. He had two children
who visited him infrequently.
The
question
arose
whether
he should
restrained
During
the winter
time,asJDtooften
developed
chest infections
that in
order to continue
with
the infussion
or should allowed to
usually
responded
to oral antibiotics.
dieofdehydration,
& be
infection.
During one
these infectionsmalnutrition
he appeared to
more unwell than
usual began spitting all his medications out, as well as spitting out
all food and fluid. He became quite dehydrated, and was
transferred to the local hospital. An IV infussion was commenced,
but he kept pulling it out and seemed much more settled when it
was removed.

ETHICAL PROBLEM
Apakah suatu keputusan yg ETIS jika kita menyetujuinya untuk
menghentikan makan & minum?
1. He was aphasic and altough he appeared to understand
some of what was said to him, the extent of his
understanding was never certain.
2. Mentally incompetent

Can we ethically refrain from providing food & fluid to a mentally

incompetent individual who appears to have quality poor of
life but will need to be restrained by force to feed him?

Facts..?
Literature
1. Man mouth would dry & become ceked or coated with thick
material. His lips would become parcehd &
crack.(Aronheim & Gasner 1990) dehydration
depression, dysphagia, headaches, nause, vomiting.
2. If people are fully hydrated just before they die their
bladders fill causing either incontinence or distressing
restlessness nuissance of needles & tube that make a
cudle almost impossible (Lamerton 1991)

Narasi dr riwayat penyakit

Bigrafi personal & kebudayaanya

Ethical Principles.?
Autonomy
: pasien punya pandangan sendiri u/ atas
berbagai aspek perawatan pemahaman dr perjalanan
penyakit.
Kasus JD, mentally incompetent
Keterlibatan keluarga, teman terdekat well understand
Beneficence & Non-maleficence : intellectual & emotional
efficient & efffective communications skills
Best for him TO DIE OR BEING FORCED TO LIVE?
Justice
: resource allocation & cost of patient`s care

Ethical Conflicts..?
Beneficence & Non-maleficence
We wish to help him but unsure if our help will
actually harm him

Require
Specification (meaning & scope)
Balancing (reasons or justifications)
Keseimbangan dr prinsip etika, hak, tdk berdasarkan moral sj,
tp kekuatan dr argumen, konteks klinis, & perspektif moral

Clinical decission?
Information
Sensitive manner
Systematic manner
Ethical judgment
Communicated & documented
assist the relevant stake holder action plan
development of way
1. Negotiation
2. Compromise
3. Mediation
4. Plan review

Clinical ethics services

Increase the quality of care
Reduce litigation
Facilitate the fair distribution of limited resources
Ensure public confidence in medical institutions