The “OUGHT” versus the “IS” the sources used by doctors for decision making in medical quandaries

Abstract

Doctors make moral and ethical decisions every day in medical practice. These are decisions that require normatively reasoned deliberation to determine the ‘right’ action or what ‘ought’ to be done. Ethical theories, professional guidelines and law purportedly guide these decisions. In diverse, pluralistic, liberal democracies the application of ‘universal’ ethical principles is expected. This study sought to examine the normative sources that medical doctors refer to when confronted with moral and ethical quandaries in the clinical context. In Phase I, an analytical tool, the Ethics Tetrad, based on the Wesleyan Quadrilateral, was developed to facilitate the analysis of data collected from interviews obtained from doctors in Phase II. The data collected in Phase II was analysed according to the dilemmas, the resolutions, and the justifications. It was further analysed according to thematic content analysis. Finally, the normative sources were identified and discussed. The study concluded that doctors experience normative uncertainty and justify their decisions in resolving moral and ethical quandaries in medical practice on the basis of the “patient’s” best interest, and on the traditional values of the ‘Golden Rule’ and ‘first do no harm’. There was little reference to ethical theory, professional guidelines, or the law. The law was used defensively rather than normatively. There also appeared to be minimal awareness of the professional guidelines as provided by the HPCSA medical ethical guidance booklets. A consequence of normative uncertainty was moral distress; and this has implications for the practice of medicine. To ameliorate the moral distress experienced, regular debriefing and discussion groups, both inter and intra healthcare professionals, would help bring awareness and resolution of the problem. Finally, it was concluded that the teaching of ethics to medical doctors, should be specialised to a clinical ethics, rather than an umbrella bioethics. Further, a system needs to be implemented to ensure that doctors are adequately trained on the topics covered in the HPCSA guidance booklets and that this training should form part of the licensing standards that are required for doctors to practise medicine in South Africa. A mobile application of these guidance booklets would also provide easy access for reference when needed in ethical quandaries