We all face difficult decisions and challenges, sometimes daily, in our lives. Doctors are no different, as they are further bound by the first code of the Hippocratic Oath – ‘First, do no harm’.

Whilst we have not had the resources to do any comprehensive survey of doctors in Jamaica, a 2016 survey of doctors in the United States found that they were challenged every day by patients, patients’ families, health administrators, health insurance payers, as well as people’s internal biases, differing cultural norms, and religious beliefs. It is reasonable therefore to expect that doctors in Jamaica would also have a wide array of stressors in their daily lives.

In the Medscape’s Physician Ethics Survey 2016, doctors were asked to describe the most difficult ethical challenges they face. Many doctors wrestled with similar challenges, such as whether to report their impaired colleagues, caring for patients who don’t try to help themselves or who don’t ‘deserve’ treatment, prescribing placebo-like treatments just to satisfy patients, and qualms about assisting patients to die.

REPORTING AN IMPAIRED DOCTOR

Whilst reporting an impaired colleague to the proper authorities would increase the chance of the doctor getting the help needed and would protect patients, doctors perceived that it could also cripple their colleague’s career, destroy friendships, and result in a professional backlash.

The cost of such reporting could also include jeopardising that doctor’s benefits for his family and him possibly losing his licence to practise medicine.

Some doctors informed that they confronted their colleague first, but it was a very unpleasant experience. In advising on the matter, the director of the Institute of Bioethics and Health Policy at the University of Miami stated that while finding the right answer regarding what to do was always easy, the actual ‘doing’ was quite hard. The matter required moral courage, as the doctor’s primary loyalty is to the patient, and so the idea that friendship or the doctor’s own self-interest took precedent would be very hard to defend.

PROVIDING CARE FOR ‘UNDESERVING’ PATIENTS

Patients who refuse to stop smoking, or to watch their diet, or to take their medication as directed, presented another daily challenge for most doctors. Particularly problematic was when the patient’s behaviour transitioned from being unhealthy to self-destructive while the medical resources required to treat them were particularly precious, such as in offering liver transplants to alcoholics. Some doctors were more challenged by those patients who wilfully harmed others, such as when they had to provide 100 per cent effort to treat a policeman’s killer.

One anaesthetist informed that a nurse at his hospital had been raped and strangled, and when her attacker was caught, he was brought to the operating room. The anaesthetist reported struggling in deciding how much anaesthesia to provide. Nevertheless, the ethical dictate is clear — so in administering anaesthesia to another prisoner who had thrown acid into the face of a young girl he had raped so she couldn’t identify him, the doctor must do the right thing and administer the same safe anaesthetic that he would to anyone.

UNDER-TREATING PAIN

In the USA, deaths from overdosing on prescription opioids (narcotics) have quadrupled since 1999, and doctors have been blamed for contributing to the epidemic. Yet, in their defence, doctors state that they are trying to alleviate suffering as more than 65 million Americans are estimated to be experiencing chronic pain.

The Centers for Disease Control and Prevention guidelines released last month indicated that non-opioid treatment is preferred for chronic pain unless the patient has active cancer, is in palliative care, or in end-of-life care.

Narcotics (for example morphine), therefore, may be prescribed for acute surgical pain, severe injury, and pain due to malignancies, but are not indicated for non-malignant, chronic pain. The solution therefore requires doctors to commit a significant amount of time to understanding the nature of each patient’s pain, working out a plan for pain management, and treating or referring the patient to specialists if necessary.

PHYSICIAN-ASSISTED DYING

In the USA, support for physician-assisted dying (doctors assisting terminally ill patients to die) is growing. More than one-half (57 per cent) of doctors surveyed believed that they should be allowed to help terminally ill patients end their lives. This has shown a marked increase above 2010, when only around one-quarter (28 per cent) of doctors then believed that assisted dying should be allowed for irremediable suffering.

However, defining the line between assisted dying and providing comfort through increasing anaesthesia, or denying physician-assisted suicide for a terminal patient in the intensive care unit (ICU), were particularly challenging. Interestingly, both doctors who had participated in assisted dying as well as those who had declined to assist still struggled with their decision.

At the centre of all these issues is the ethical dictate for doctors to do no harm. Is assisting a suffering terminally ill patient to die doing harm? Or by not seeking to relieve that severe pain and suffering, is harm being done? This issue requires a deep moral reflection on the nature of harm.

Derrick Aarons MD, PhD is a consultant bioethicist/family physician, a specialist in ethical issues in medicine, the life sciences and research, and is the ethicist at the Caribbean Public Health Agency – CARPHA. (The views expressed here are not written on behalf of CARPHA)