Ethics Rounds



  • Every month or so, the students and interns in Internal Medicine and its subspecialties attend “ethics rounds” where a recent case is discussed. This is spearheaded by a couple of university/hospital ethicists who are typically consulted on these kinds of issues.

    Our case (more-or-less): a 25 year old IV drug user comes to the hospitals with signs and symptoms of endocarditis (an infection of the heart - in this case by S Aureus). He has had endocarditis 2 times before as a result of his habit requiring replacement of one of his heart valve both times. He had shot up 2 days prior to admission to the hospital, and it is thought once while in hospital as well.
    He is likely to require a new heart valve. What do you do?

    (keep in mind:

    1. In Canada ALL healthcare is provided by the taxpayer,
    2. The 4 pillars of medical ethics - Autonomy (the rights of the patient to act in their own interest/disinterest), Nonmaleficience (the most important - goes with “primum non nocere” - first do no harm), Beneficence (do good) and Justice (applying resources. This is a tricky concept - do you go with “the greatest good for the greatest number of people” or application of the most resources for those who need them the most?).
      I’ll tell you what we’d decided in a week or so if this forum is still running.


  • I would say:
    Here, we have these 4 pillars:
    You can act after your interest. Your choice is to join a program to get and stay clean and gt a new valve, or stay a junkie.

    Explain him that he suffers of two diseases and that helping him in one but not the other won’t do much good.



  • Damn, F_alk! 😮
    You freaking wrote what I thought as I read c_c_'s post. :-?
    This is frightening! I must be developing personal logical morality.
    Ee-yuck!
    Wait a minute…I think I forgot to take my meds this morning.
    No, my little SAT. MORN. slot in my weekly pillbox is MT. Jeez, morals & logic!?!
    I need some duct tape for my head. If my head explodes the doctors will have all the pieces. :roll: 😉

    No, really it’s 😎 .



  • I´m not sure I see the ethics dilemma.

    He gets the new heart valve and is offered drug-rehab. If he wants the heart valve, that is.

    What does the Canadian medical system have to do with the problem anyway? If the tax-payers pay for medical treatment, then ALL citizens have the right to treatment. If it´s privately paid or by insurance, then ALL citizens whose paperwork is in order get the valve (correct me on this last one, those of you who live the US).

    Is the ethics dilemma wether or not to give him the valve? How is that your dilemma as a doctor? The politicians (or maybe the hospital administrators) have made the rules. It´s THEIR dilemma. It´s YOUR operation. That´s how I see it anyway.

    I see a parallel to my experience as a doctor in Denmark: A drunk comes into the hospital to receive treatment for his alcohol-abuse. He is admitted although the previous 20 times he has been admitted, he has left the morning after, without sticking around to talk to the “alcohol-unit” (as we call them). He is admitted because you cannot turn down a person in need - even though you know in your heart that what he really wants is just a warm bed to sleep in. Ethical dilemma? No, but annoying as h…



  • m_00,
    I understand. Used to work in a drug rehab/psych hospital where we had the same thing happen every cold/snowy spell and a few rainy spells, too. One homeless guy would come in for detox wearing nice clothes(dirty), wore $400[cost 15 years ago]cowboy boots(with ‘the good pair’ in his duffle), and two large boxes of his possessions. He’d crash and the first nice day he was out the door.

    I say “No way, hoser!”



  • @morten200:

    I´m not sure I see the ethics dilemma.

    He gets the new heart valve and is offered drug-rehab. If he wants the heart valve, that is.

    What does the Canadian medical system have to do with the problem anyway? If the tax-payers pay for medical treatment, then ALL citizens have the right to treatment. If it´s privately paid or by insurance, then ALL citizens whose paperwork is in order get the valve (correct me on this last one, those of you who live the US).

    i was just setting up the scenario and giving our friends south of the border, many of whom are not/under insured, a heads up as to the picture.

    Is the ethics dilemma wether or not to give him the valve? How is that your dilemma as a doctor? The politicians (or maybe the hospital administrators) have made the rules. It´s THEIR dilemma. It´s YOUR operation. That´s how I see it anyway.

    The dilemma is how to best deal with this situation. In a system with increasingly limited resources - is it ethical to give one person 3-4 heart valves instead of giving 3-4 people heart valves? Cardiac surgery waiting lists in my city grow up to 6 months long.

    I see a parallel to my experience as a doctor in Denmark: A drunk comes into the hospital to receive treatment for his alcohol-abuse. He is admitted although the previous 20 times he has been admitted, he has left the morning after, without sticking around to talk to the “alcohol-unit” (as we call them). He is admitted because you cannot turn down a person in need - even though you know in your heart that what he really wants is just a warm bed to sleep in. Ethical dilemma? No, but annoying as h…

    Ahhh yes, but this is a “Several hundred dollar” night stay as opposed to a multiple thousand dollar valve surgery in a system that is considered to already be lacking sustainability by people commissioned to study the Canadian health care system (Romanow and Kirby Reports).
    Also we are not doctors yet, however in our final stages of training, so what is important for us is how to approach these problems - particularly in the event that some of us opt for an M.P.H.
    I appreciate your input as a physician in a similarily socialized healthcare venue tho’.



  • I think that in following the nonmaleficience principle you would have to give the great number of people the operation, seeing as it would do the least harm. If you give one person the operation five times while potentially letting 4 other people die of this problem, I would see it as doing more harm than if 5 people were given the operation with one dying later becuase his lifestyle required him to need the surgery again. Of course it’s never this simple, but if it were then this is what I would do.



  • Now that you say: Give one person 4-5 heart valves or 4-5 people one heart valve, it puts a whole new perspective on things. It´s never that black/white (and I know you didn´t mean to make it sound so), but obviously saving 4-5 people is better than saving one person 4-5 times.
    Hm, well it´s obvious to me …… I think



  • then ALL citizens whose paperwork is in order get the valve (correct me on this last one, those of you who live the US).

    The insurance company also has to cover that particular procedure. 😞


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