Male physicians’ narratives about being in ethically difficult care situations in paediatrics
Introduction
Paediatrics is a field where the use of medical technology has revolutionised practice. It has made treatment more successful, but has also created new and ethically difficult care situations, which exert heavy professional and personal pressure on the physicians in charge of the treatment decisions. Physicians have the legal and professional responsibility for all activities relating to patients in various institutions within health care. It is they who have to make decisions and the ultimate choices between several difficult alternative courses of action. It is believed that the responsibility of the physicians often leads to their giving priority to action ethics perspective stressing justice (Cooper, 1991; Udén, Norberg, Lindseth, & Marhaug, 1992; Norberg & Udén, 1995).
The basic question in action ethical reasoning is: What should be done and why? The aim of this reasoning is to explain choices of actions when the people involved seem uncertain, and to give a well-founded answer to the question of what should be done (Lindseth, 1992). Ethical problems can be analysed as a conflict between general ethical principles (Beauchamp & Childress, 1994). Reasons for the choice of action can be given in a deontological (ethics of principles, ethics of duty), casuistic (situation-oriented) or teleological (utilitarian, goal-oriented) form (Lindseth, 1992).
Gilligan (1982) claims that males and females both narrate and solve ethical problems differently. According to her men, more frequently than women, reason about ethical matters in a principled way, while women are more often concerned with relations. Gilligan's approach has been described as: “…men, more often than women, conceive of morality as substantively constituted by obligations, rights, and duties, and as procedurally constituted by the demands of fairness and impartiality; while women, more often than men, see moral requirements as emerging from the particular needs of others in the context of particular relationships” (Flanagan, 1991). Stemming from Gilligan's ‘two voices’ typology the terms “justice” and “care” are often used to describe these two types of ethical responses (Puka, 1991; Udén et al., 1992). These two types of ethical responses may also be understood from an action ethics perspective and a relation ethics perspective (Lindseth, Marhaug, Norberg, & Udén 1994).
The basic question in relation ethical reasoning is: How can I meet adequately the challenges that confront me in the relationships in which I am involved in this situation? The aim of relation ethical reasoning is to help us to see and understand how we are challenged as human beings in situations and in our relations in life. Relation ethical reasoning answers such questions as: What makes a good physician? Am I a good physician? (Lindseth, 1992). The qualities that make a person a good physician are not only individual traits but they are also borne by the relationship (MacIntyre, 1985).
According to these terms used in ethical reasoning, one may wonder whether male physicians are describing the ethical problems they face from an action ethics perspective or whether they are more concerned with a relation ethics perspective or with both perspectives.
It has been shown empirically that professionals of different gender narrate care situations in different ways (Ford & Lowery, 1986). However, there are also studies which question this (Udén, Norberg, & Norberg, 1995). A Swedish study found that physicians in intensive care were concerned about relationship problems as well as problems related to the choice of action. Too much treatment was identified as the most common ethical problem for the physicians (Söderberg & Norberg, 1993). It has also been shown that professionals at different levels of expertise narrate care situations in different ways (Corley & Seling, 1992).
Many studies have been performed within paediatrics that describe various ethical problems: Prenatal problems concerning foetus diagnostics, genetic investigations and aspects of in vitro fertilisation are focused on (Lindemann & Finne, 1988). Research in small children who cannot give their informed consent to participation and other ethical issues related to research involving children are described and discussed (Ramsey, 1976; Lee, 1991). There are several studies about the ethical problems connected with the treatment of specific groups of patients, for example abused children (Harris, 1985; Kinard, 1985) and organ transplantation in children (Bell, 1986; Moskop, 1987). Ethical dilemmas concerning the treatment of extremely premature infants are often in focus (Saugstad, 1988; Markestad, 1991; Hansen & Finne, 1995). However, few empirical studies have been found that disclose how physicians actually think about and how they experience being in ethically difficult situations in their care of children (Holm, 1997).
This study is part of a comprehensive investigation of ethical reasoning among male and female physicians and nurses. In a previous paper we have described female physicians’ narratives about being in ethically difficult care situations in paediatrics (Sørlie, Lindseth, Udén, & Norberg, 2000).
In that paper about female physicians we found that all the interviewees were relationally as well as action oriented in their ethical reasoning, although the relational dimension was dominant. The ethical problems from the action ethics perspective were related to overtreatment, withholding and withdrawing treatment. From the relational ethics perspective, almost all the interviewees reasoned on ethical problems in their relation to the patients’ parents, to physicians and to nurses. The less experienced female physicians seemed uncertain while conveying an air of certainty, whilst the more experienced female physicians disclosed their professional experience and their personal experience of care giving, and seemed to allow themselves to feel uncertain in their certainty. The experienced female physicians realised that they had to deal with insoluble problems. They had to deal with severely ill children without knowing, neither generally or in every specific case, if they could be saved or not. Their experience had taught them to accept doubt and uncertainty. All the female physicians emphasised the need for and importance of support and ethical discussion among colleagues.
The aim of this study was to elucidate male physicians’ experience of being in ethically difficult care situations in paediatrics.
Section snippets
Participants
Seventeen male physicians working on various wards within paediatric clinics in two University hospitals in Norway participated in the study. They were aged from 34 to 61 years (median=46), had worked in the paediatric clinics from 1 month to 30 years (median=16) and in health care from 5 to 35 years (median =20). The physicians had been trained in a 6-year programme at university level and 12 of them had 4–7 years of specialist training in paediatrics. They were divided into two groups: the 11
Results
The repeated reading of the individual interview texts revealed that all the male interviewees reasoned along two different ethical tracks. Overtreatment, withholding and withdrawing treatment were the main ethical problems from an action ethics perspective. Problems in a relation ethics perspective concerned situations involving children, their parents, nurses, colleagues and journalists. The experienced and less experienced male physicians’ narratives were quite similar concerning what the
Comprehensive whole and reflection
The practice of paediatrics may be seen as making a moral commitment in which complex medical, but it also raises relational, spiritual and emotional questions (Lantos, 1997). The interviews analysed in this study confirm this complex picture. They reveal that the traditional picture of medicine as an enterprise in which biomedical data are competently dealt with and in which professional distance to a problem the ideal, is insufficient (Hunter, 1991; Duff, 1987).
Although they have had very
Acknowledgements
The authors are grateful to the participants in the study. This project was supported by the Faculty of Medicine at University of Tromsø, NORWAY.
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