Taking the oath is as easy as lip service, carrying it out is the hard part of the job. The crux of the Hippocratic Oath, to “do no harm” is indeed easier said than done. Medical problems are often nuanced, involve many parties and also, often incur hefty costs. In a world that is getting increasingly complex, due in part to advancements in technology, these ethical dilemmas remind healthcare providers just how difficult it is to be in the healthcare industry.

1. Defensive medicine

Defensive medicine is not an ethical dilemma faced by most, but it is what gives rise to court cases that call into question the necessity of a doctor’s actions. It is where a non-integral test or treatment is recommended to the patient as a means of protecting the physician from potential legal claims. 

These tests or treatments, of course, incur costs that are unnecessary and may be completely non-beneficial to the patient, making them a waste of time or even adding risks in critical cases. At the end of the day, it all boils down to the controversial question of what is priority – saving a patient or a doctor’s career.

2. The placebo effect

Perhaps the most age-old of ethical dilemmas in medicine, the placebo is the provision of a fake treatment to patients. While it used to be seen as ineffective treatment that lowers the quality of healthcare, recent research has shown that it has its merits in improving the mental state of patients.

A survey of 10,000 healthcare practitioners showed that only 58.3% expressed that they would never prescribe a placebo. While advocates argue that placebos do make patients “feel better”, they do indeed beg the question of morality, given that patients are paying but actually receive no treatment at all.

3. “Breaking the news”

For doctors and nurses that work in departments and areas such as the Intensive Care Unit (ICU), Oncology and Surgery, the weight of bearing and breaking “the news”, that is, an often unfortunate outcome or finding, is a heavy one.

Complications arise when multiple parties, such as the patient’s family, are involved. What happens when one half of a couple has contracted HIV? Should risk communication extend to the family if it is against the patient’s wishes? Breaking the news is never easy, and with so many considerations involved, it is undoubtedly one of the toughest decisions to make in the medical world.

4. Physician-assisted death

Physician-assisted death is certainly the most controversial of ethical issues in modern medicine. It involves processes such as assisted suicide and passive euthanasia. When family members deem life-prolonging or palliative care to be futile, they may request for doctors to step in.

Sometimes, patients make the decision themselves as well. While euthanasia is illegal in Malaysia and Singapore, in the latter a process called the Advance Medical Directive (AMD), refusing extraordinary but futile life-prolonging procedures, stands. The ethical question is then often of ‘who gives one the right to die?’ and at what stage and in what capacity one has the right to make that decision.

5. Accepting gifts

Post-treatment, patients and family members often present healthcare practitioners with gifts to show their gratitude. The Singapore Medical Council’s Ethical Code and Ethical Guidelines states that gifts may be accepted, but never solicited, and that they should only be of a personal, and never commercial, nature.

Critics, however, feel that gifts cheapen the medical practice and may render recipients to become driven only by them which may influence their judgement. While big ticket items may do so, cards and notes certainly would not, and patients should not shy away from giving gratitude where it is due.

6. Treating disadvantaged patients

Should doctors treat patients that are unable to pay for their services? Much like in the field of Law, the concept of “pro bono healthcare” is often debated. In countries such as Singapore, however, policies such as Medifund act as a safety net for those unable to pay off medical debts within their own means. The CHAS scheme also helps soften the financial impact of healthcare for the less privileged. Yet, these policies should not be taken for granted, as one would never know when the decision to refuse treating a non-paying patient would need to be made.

7. Organ buying

The black market of organ buying in Singapore was brought to light due to a fiasco in 2008 involving a high-profile businessman. While the Human Organ Transplant Act (HOTA) has been expanded to include Muslims and had its age limit changed, it does not mean that the prospect of organ buying is wiped out completely. Where ethics is involved, it concerns the dichotomy of waiting to obtain the organ legally, which may worsen the patient’s condition; and obtaining the organ through illegal means, which presumably would be beneficial for the patient.

8. Telemedicine

In a world that is incrementally being improved by technology, the birth of telemedicine is one that physicians of history could only have dreamed of. It comprises the use of telecommunication to treat illnesses, in the form of apps such as Healint that provide advice to cope with migraines; and Artificial Intelligence (AI) such as Babylon, a self-touting “online health doctor”.

Allowing patients to input medical conditions themselves and consequentially provide remedies for self-treatment is an impressive way to make healthcare more efficient, yet the authenticity and accuracy of data and discretion is still one that cannot be ensured.

Should healthcare become completely AI-based one day, where will doctors stand? Can telemedicine ever completely replace medical practitioners? While this is still a grey area, in time to come it will surely see fruition, and till then, practitioners will have to decide if technology really is the key to good healthcare. MIMS

Read more:
Ethical controversies in today’s medical research
SMC's ethical codes and guidelines: Doctor-patient communication is key
Placebo or nocebo: The importance of doctor-patient conversations 
Is medical malpractice on the rise?