How to navigate complex ethical dilemmas

By Vanessa Pigrum*
Monday, 17 June, 2019

How to navigate complex ethical dilemmas

When our care system is in crisis, how do hospitals decide how to distribute scarce resources? We address the ethical dilemmas facing health practitioners.

The recent crisis in Queensland’s hospital system shines a light on the complex challenges practitioners and administrators grapple with every day.

Hospitals were faced with multiple public health events, a glitch-ridden system upgrade, and a bed shortage that led to emergency departments dealing with a flood of people seeking help and waiting days for admission. Experts warned that the situation was heading to a point where lives were at risk.

This confluence of events shows what happens when an already strained system is placed under acute pressure — and the decisions made in hospitals become even more consequential than usual.

You can’t magic extra beds and more staff out of thin air. Increased investment can help address the problem in the long term, but provides no immediate relief for frontline workers battling to deliver an essential public service. It forces healthcare professionals and administrators to undertake the difficult moral calculus of deciding how to distribute a scarce resource.

How should hospitals tackle this impossible task? There is no shortage of operational rules, codes and procedures to follow, but they may not always have the answer we need. The starting point may be ‘do no harm’, but what if helping one person means leaving another to suffer? When there is no perfect outcome, what ethical frameworks might inform our decision-making?

The utilitarian approach: Do the most good

Utilitarianism says the goal should be to produce the greatest good for the greatest number. According to Peter Singer, this can be understood as an ethical requirement to do the most we can to reduce avoidable pain and suffering.

At first glance, this is how our public hospital system works: patients are triaged based on need and treated in order of severity. But it’s not as simple as just treating as many patients as possible.

Philosophers like John Stuart Mill argued that the goal is to maximise outcomes for the community at large — not just the individual presenting to emergency. This can ask for cold, dispassionate number crunching: is it right to treat a small number of car crash victims with potentially fatal injuries before containing a contagious disease that may affect the lives of thousands? Such a binary may be hypothetical, but utilitarianism demands consideration of uncomfortable questions that are all too familiar in health budgets: should funds go to acute care or prevention?

Justice as fairness: Prioritise the disadvantaged

In contrast to utilitarians, egalitarians like John Rawls ask that we place fairness at the heart of everything we do. A just society is one where everyone, regardless of race, gender, culture or class, has equal opportunity to participate in the system and enjoy equal access to essential public goods like health care.

For Rawls, institutions have a moral obligation to address inequality through their procedures and processes. This means devoting extra resources to the most disadvantaged people in society. By prioritising access to the most vulnerable, hospitals would arguably be delivering care to those who it will benefit most. It’s a high moral bar to shoot for, but one that needs to be considered if our public health system is to be truly fair.

Virtue ethics: What is the good we are seeking?

In the opening of his cornerstone work, the Nicomachean Ethics, Aristotle cautions that the study of ethics isn’t an exact science. His point is that it’s impossible for any list of rules to dictate the ‘right’ thing to do in every situation. Instead, he proposes we focus on identifying the larger good that we are trying to achieve. Keeping that goal clearly in view helps us to determine the right course of action in difference circumstances. Our decisions must be guided by virtues like courage, kindness, generosity and moderation, and also need continual reappraisal in light of our growing understanding and experience — what Aristotle calls practical wisdom.

For those on the frontlines, these aren’t hypothetical thought experiments. Who to treat and where to allocate funds are daily challenges with genuine consequences. Health care is riddled with wicked problems, yet decisions have to be made. Reflecting on the ethical frameworks that underpin those determinations can help us to make better, more considered judgements.

*Vanessa Pigrum is the CEO of the not-for-profit Cranlana Centre for Ethical Leadership that helps executives develop their skills in critical reasoning and ethical decision-making.

Top image credit: ©

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