Ethical Dilemmas in Practice
Resources
Mr. Kgomotso Kubisa
BA (Hons), MSc, MIHM.
• Medical Ethics, 2nd Edition, C. M Francis
Learning objectives
At the end of the unit, the learner will be able to
understand the following
• Apply critical analytical skills to analyze case
studies presented.
Case Study 1
The Case of MR Cain
Mr Cain aged 68, had been detained in a secure mental hospital for 30 years as paranoid
schizophrenic patient. His delusions included the belief that his doctors were torturers whilst he
himself was a world famous specialist in the treatment of diseased limbs. When his own foot
became infected he therefore hid his condition from medical personnel until it had actually
became gangrenous. His doctors believed that unless his foot was amputated, he stood an 80 to
85% chance of dying.
Mr Cain however, refused to consent to the amputation, saying that he would rather die intact
than survive with one foot. He sought reassurance from the hospital that his foot would not be
amputated without his consent if he slipped into a comma. The health authority in charge of the
hospital refused to give an undertaking not to amputate his foot without consent. Mr C then
sought a high court order to prevent amputation if he became unconscious.
Do you think Mr Cain was right to refuse consent to treatment? Support your argument clearly
showing all ethical issues or dilemmas at play.
Case study 2
The New Boyfriend
Grace is a home-based nurse who travels the long distance from Maun to Shakawe
once a month to check on a number of patients who are unable to make the journey to
Maun to be seen at the clinic. One of these patients is an elderly woman who is dying
of metastatic breast cancer. The patient’s primary caregiver is her eldest daughter who
lives with her mother and her own two small children. On one visit, the daughter
introduces Grace to her new boyfriend, a guide who recently moved from Maun to
work at Xaro Lodge. Grace recognizes the man as a patient from the ARV clinic in
town where she previously worked, and wonders if he has disclosed his status to the
young woman.
When Grace is given an opportunity to speak to the boyfriend on his own, she reminds
him that they have met previously at the ARV clinic. The boyfriend tells Grace
emphatically that she must be confusing him with someone else, as he has never been
to that clinic nor would he have any reason to be there as he is HIV-negative. Grace
does not think this is the case, but decides to let the matter go.
Case Study 2
The New Boyfriend continued
Two months later, during her regular visit, the daughter tells Grace that she is expecting
another baby. While Botswana has a comprehensive national program that tests
expectant mothers for HIV as part of routine antenatal care, Grace knows that it is
likely that this young woman will have her baby at home tended to by a traditional
birth attendant from the area.
Activity
Should Grace share her concerns about the boyfriend’s possible HIV status with the
daughter? Should she confirm her suspicions by asking one of her friends at the ARV
clinic to look up the man’s treatment records? She could easily do this and no one
would ever know. Does Grace have any obligation to the daughter and her unborn child
with regard to the possible transmission of HIV and the prevention of AIDS? After all,
the daughter is not her patient.
What are the ethical issues? What other options does Grace have?
Case Study 3
The risk of harm to others
A community health nurse is conducting home visits as part of follow-up to care
that patients have received at the Infectious Disease Care Clinic at Princess Marina
Hospital. In one home, it becomes clear that her patient, a young woman who is
not responding well to the normal anti-retroviral treatment program and is
bedridden, has not told her family that she is HIV-positive. The young woman’s
mother and elder sister are the primary caregivers of the patient in the home.
Unaware of their relative’s status, they are not following any of the safety
precautions that would protect them from becoming infected themselves as a result
of exposure to the patient’s bodily fluids.
What are the ethical issues? What should she do?
Case Study 4
Sero-discordant couples
• A community health nurse in Maun has been making home-care visits to an HIV-positive
man who has been in extremely poor condition for the past year. His mother, who lives
with him and has been seeing to his care, is aware of his status. The man’s wife, who is an
employee of the immigration service and currently working at the Tlokweng border
crossing, is not.
• Now that he has begun to regain his strength under a proper regimen of diet and anti-
retroviral therapy, the man has told the nurse that he will be ready to resume conjugal
relations with his wife, who is HIV-negative when she next returns home. The mother has
told the nurse that she cannot tell the wife about her husband’s status.
• The nurse, who understands from her training that she must protect the man’s right to
confidentiality, is nonetheless deeply concerned that the wife will be exposed to the risk of
infection unless she is aware of her husband’s status and takes precautions to protect
herself from infection.
• What are the ethical issues? What should the nurse do?
