As any physician or health care provider knows, moral dilemmas and competing ethical claims can occur even if a physician has cultivated a strong moral character and has a deep understanding of the ethical and moral foundations of medicine. A classic example is the Tarasoff case, in which patient confidentiality and the need to protect a third party from a credible threat of severe harm competed.
The Tarasoff Case
In 1968, a graduate student at UC Berkeley, Prosenjit Poddar, became romantically involved with another student, Tanya Tarasoff. After Ms. Tarasoff broke off the relationship, Mr. Poddar grew increasingly depressed, finally seeking psychological counselling at the university. Mr. Poddar told the psychologist that he planned to kill Ms. Tarasoff. The psychologist found the threat credible and notified campus police. The police briefly detained Mr. Poddar, but ultimately released him since he did not appear to pose an immediate threat, and he promised to stay away from Ms. Tarasoff. The psychologist, maintaining professional confidentiality, did not notify anyone else. Three months later, Mr. Poddar went to Ms. Tarasoff’s house to talk with her, but Ms. Tarasoff’s mother refused to allow it. Mr. Poddar returned later with a gun and a knife. He fatally stabbed Ms. Tarasoff when she tried to flee from the house.
A case was brought against the psychologist, the campus police, and UC Berkeley by the Tarasoff family. The court’s opinion was that the psychologist’s duty to protect Ms. Tarasoff from harm superseded his duty to maintain Mr. Poddar’s confidentiality.
Similar cases were debated during the AIDS epidemic in which a physician’s obligation to warn the potential sexual partners of individuals with HIV was questioned. Although these decisions are legal, they illustrate how moral dilemmas can occur when there are competing moral norms. In the Tarasoff case, the psychologist’s duty to protect someone from harm competed with his duty to maintain confidentiality. A process called balancing is one way to consider competing ethical claims.
Proposed by Beauchamp and Childress, balancing is a system for weighing competing ethical claims that can lead to moral dilemmas. The construct begins by considering the prima facie claim, that which is to be upheld, obeyed, or followed unless another claim is equally or more morally compelling. To use the Tarasoff case, patient confidentiality is a prima facie claim; it is the ethical norm that a physician holds what a patient tells us in confidence. That claim is followed unless there is an equally or more morally compelling claim, such as protection of another party from the credible threat of severe bodily harm.
Another case involving balancing is when a patient requests the physician to administer a treatment that the physician cannot morally administer. In these cases, the physician’s commitment to benefit and avoid harm to the patient typically takes precedence over the physician’s conscience, particularly in an emergency. For instance, a Jehovah’s Witness physician would not be ethically justified in refusing to give a medically indicated blood transfusion to a bleeding patient who would otherwise accept the transfusion. Situations where such conflicts could arise should be anticipated and an acceptable alternative plan formulated.
In order to avoid arbitrarily weighing one claim over another, Beauchamp and Childress go on to outline six conditions that must be met when infringing on a prima facie claim.
- Good reasons can be offered for acting on the overriding norm rather than on the infringed norm.
- The moral objective justifying the infringement has a realistic prospect of achievement.
- No morally preferable alternatives are available.
- The lowest level of infringement, commensurate with achieving the primary goal of action, has been selected.
- All negative effects of the infringement have been minimized.
- All affected parties have been treated impartially.
While balancing and prima facie claims present a system for considering competing ethical norms—such as patient confidentiality and the need to inform and protect—in other instances, the prima facie claim may not be clear; in fact, the claims may seem roughly equivalent. In these cases, such as when physician autonomy and patient autonomy have different claims, particularly in withdrawing or initiating a life-sustaining intervention, the system of balancing may not be satisfactory. In these cases, which are often very emotionally laden, it is important to get expert input in order to sort through the issues. Ethics committees and professionals skilled in negotiation, such as a hospital ombudsman, can be very helpful in resolving some of these conflicts. Sometimes, after all other avenues are exhausted, the only resort is to seek legal remedy and have the courts decide.
Dealing with Physician Personal and Moral Distress
The distress that stems from disagreements between the health care team and patients and their families can take a huge emotional toll on everyone involved. Physicians derive great meaning in their lives from having rewarding relationships with their patients and patients’ families. When those relationships become adversarial, particularly when everyone is emotionally invested in the patient, this can be a significant source of stress and anxiety for physicians. There may even be threats of legal action by patients or their families. Sometimes physicians will feel many different emotions, such as anger, fear, or sadness. It may also be hard to find a colleague who is comfortable talking about these feelings. For some, it can be difficult even to acknowledge the feelings. They can be confusing and difficult to sort out. A physician’s personal feelings can also affect how well she or he communicates with a patient or family. In these instances, it is important for physicians to care for themselves and the other members of the team. Employee assistance programs, physician health and wellness committees, spiritual advisors, and mental health professionals can all provide essential support.