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Ethics Question

Discussion in 'Topics in Healthcare' started by Redneck, Jul 17, 2006.

  1. I'm and MS0 so bare with me if there are some logisitical issues behind this scenario...

    Well, during the moments between waking up and actually rolling out of bed I had an interesting ethics question strike me. Let's say you are a pain doc and you are walking away from your clinic and *bam* your jumped. You now have the misfortune of a drug seeker holding you at gun point. The seeker then leads you back to your office and demands a fix (plus some to go). Let's assume, for arguments sake, the seeker wants you to inject him since he is suffering withdrawal symptoms. At this point you have the option to oblige his wishes to meet his drug habit with an immediate dosage OR you could sedate him OR you could overdose the guy.

    I'm curious what the ramifications are of these different pathways as a physician who is potentially at death's door...
     
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  3. Buckeye(OH)

    Buckeye(OH) 5K+ Member
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    They can have the damn drugs. Are you kidding me? Death or breaking the law in a circumstance like that to me, at least is a no-brainer, and not even an ethical question.

    It literally is, life or death.
     
  4. a_ditchdoc

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    He would look like a fish out of water when I got through pushing the drugs.... (aka: Guppy Sign)
     
  5. The ethical part is would you provide a safe dose, risk sedation, or push for an overdose? I'm wondering if you risk sedation and actually kill the person or simply aim to overdose the guy from the start how that would be viewed. As a physician are you supposed to uphold the do no harm even in a situation like this? Could you lose your license? Could you be arrested because you are a professional and should have had the knowledge to not overdose the guy? In short I believe the underlying issues are 1) Do you take that lethal step in good conscience 2) As a physician can you be held to different standard in a life threatening situation
     
  6. odrade1

    odrade1 UASOM alum
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    The ethical thing to do would probably be to save yourself while minimizing harms to the drug user. From your scenario it sounds like that would mean giving him a sedative or perhaps a mix of sedative and the drug he sought (assuming you knew there weren't harmful interactions between the two).

    This scenario is why my partner, a dentist, doesn't keep any pain medication at the office. It's less convienent for the patients, but far safer for both the patients and the clinic staff. (And your property insurance!) I don't know about MD clinics, but dental clinics are not infrequently broken into or robbed of pain medication.
     
  7. Buckeye(OH)

    Buckeye(OH) 5K+ Member
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    A better description of what I was thinking in my head but failed to say on paper.
     
  8. a_ditchdoc

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    If your life was at risk, I would not believe you would be held to the standards of medical practice as you are not providing "medical care" to this person and the physician-patient relationship does not exist. Regardless, it is possible to give this guy enough narcotics to render him unconscious, even breathless, disarm him, and then administer an antidote when he is no longer a threat. As a care provider, your safety comes first.

    You have posed an interesting question, but perhaps you left too many ways out. Suppose you only had lethal agents in your office and the guy said he would kill you unless you gave him something to make him high? Now that is a more difficult question...

    Again, I may be heartless and jaded, but if I thought he would really kill me, I would have to give him his eternal high and worry about feeling guilty later.
     
  9. odrade1

    odrade1 UASOM alum
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    Deliberately overdosing someone would be probably be construed as murder or voluntary manslaughter, unless you could show that there weren't other options available to you. Some states treat businesses like places of residence (which often have a different, more lax, set of standards for justifying use of lethal force). Sedating someone so that they are helpless, then killing them would also be murder, regardless of the fact that they threatened you, since you could merely sedate the individual then subdue him or call the police. In fact, that sounds less like self protection or voluntary manslaughter and more like premeditated murder.

    I would say that in this scenario your role as a physician is not your primary role. A physician, acting as a physician, when treating a patient, should act in the patient's best interests while minimizing harms to the patient. Some summarize this idea as the "first, do no harm" principle. Of course, we also allow live organ donation from non-sick individuals (think kidney and partial liver donation), which causes definite harms (without theraputic benefit) to the donors. So the "first, do no harm" priniciple isn't an iron-clad rule, but more of a heuristic. I would also say that the standard duties you have to patients don't apply in the same way to this situation, since the criminal is not your patient, and he is not seeking you out to be his physician or to provide care, but as a mere means to getting high.

    A second issue may arise once the criminal is incapacitated or medicated. If he enters distress, I believe you would be morally obligated to save him. Despite the fact that he didn't seek you out to be his caregiver, once he is before you, exhibiting signs that his life is in danger, you should help him (unless he brought a DNR form with him! :laugh: ) This is just a view on the moral responsibilities you may have--qua physican--in this strange situation.

    Will you lose your license? If you deliberately sedate someone only so that they are easier to kill, I would hope so. Such an action seems both perverse and unprofessional. If you accidentally kill him, maybe not: I know I sound a bit jaded here, but I bet it depends on the politics surrounding you and the case. The state board may need to set an example of you. If you merely incapacitate him (by sedation or giving the person a heavy dose of the narcotic they want, perhaps) then call the police, I can't imagine why either the courts or the medical board would punish you.

    Personally, my own belief is that people who are willing to endanger or harm others for their own pleasure or benefit are not needed or welcome in society. His death would not diminish society in any appreciable way, by my lights. The morality of the situation is definitely made more complicated by the fact that you would be a physician. However, I think it may be difficult to argue that the criminal is your patient, so not all the same moral duties would apply. Secondly, the justifications for taking a life are usually quite few in number and strict in application. They also differ state to state. Thank god I live in Alabama, where if someone holds me up or threatens me with a weapon in my residence, car, or business, I can shoot them dead.
     
  10. QuikClot

    QuikClot Senior Member
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    Too much ER in this scenerio. I would never try to sedate a gun-wielding addict with an overdose. Who is the narcotics expert? They are. What are their tolerances? You have no idea. You plan to unobtrusively (i.e., single shot) giving a massive dose of something that will knock someone on their ass so fast that there is not a 1% chance they will realize what is happening and pull the trigger? There ain't no such animal. Give them the drugs. Let the cops be the cops.
     
  11. Sol Rosenberg

    Sol Rosenberg Long Live the New Flesh!
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    Pretty much agree with odrade1. I would give him whatever would sedate him quickest, and give him the maximum safe dosage (where I'll define safe dosage to mean < 50% chance of dying from the dose,) putting me at the least risk of harm. I don't think that giving him what he wants (i.e. safe dosage of the drug) is a realistic possibility, because how do I know that he won't kill me anyway after I give him what he wants?

    Oding with the intent to kill him is not only unethical, but like odrade1 said, likely illegal.

    If I give a strong, fast, sedative that the perp. happens to be allergic to and he has a violent, fatal, allergic reaction, I would still sleep with a clear conscience because those are the risks that you take when you hold someone at gunpoint.
     
  12. odrade1

    odrade1 UASOM alum
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    If you read the situation in the way quick-clot did, you are adding two new facts:
    a) you aren't able to construct a cocktail that would incapacitate him
    b) you have reason to believe that you could not determine the dosage for a single-substance overdose would reliably impair or incapacitate the criminal

    Since I don't believe it is reasonable to assume that the criminal *won't* harm you once he has what he wants, It would be worth it to give him a lethal or near-lethal overdose. Presumably, even if it is difficult to reliably dose him for the purposes of mere safe incapacitation, it would be easy enough to squirt him full of so much dope that you could be sure that he would either be (dangerously) knocked out/comatose or dead.

    If we adopt quick-clot's assumptions, and you also had reason to believe he wouldn't hurt you once he got his fix, the best thing would be to let him go.
     
  13. QuikClot

    QuikClot Senior Member
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    My "assumptions" are a realistic observation of the facts of medicine, based on personal experience with dozens of addicts. The unrealistic assumption here is that you can concoct an instantly incapacitating drug cocktail on a habitual drug user (or anyone else, for that matter). It was not premised by the OP that one could do this, therefore I am not adding new facts, but rather extrapolating from the facts given -- much as you do when you "add" the possibility that the robber will harm you after they have what they want.

    It would not be "easy" to "to squirt him full of so much dope that you could be sure that he would either be (dangerously) knocked out/comatose or dead." What drug are you going to use? What dose? MS, Dilauded, Methadone -- nothing works fast enough. If they ask for their drug of choice, are you going to try and fool them and give them something else?

    What is your experience with drug addicts? With armed robbers? On what do base your belief that someone who held you up for drugs would shoot you once you had the drugs?
     
  14. QuikClot

    QuikClot Senior Member
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    I might add that I would certainly have no problem, in principle, with incapacitating or killing someone commiting armed robbery. Legally, that is textbook self-defence, and it seems morally unobjectionable. This particular scernerio, in addition to being rather improbable, is one in which, as in most robberies, the smart thing to do is give it up. In all likeihood, the police will have the guy in an hour anyway. In principle, either course in moral; but in this specific example, "counterattacking" with a delibrate overdose would be dangerous and stupid.
     
  15. nicholonious

    nicholonious Street Performer
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    You know there's more options than just the three you described. You could not do anything at all and let him shoot himself up. You have no part in whatever "act" is done. No harm on your part.

    If this really happened to me, and I was a pain management physician, then damn, the man with the gun can do whatever he wants.
     
  16. SanDiegoSOD

    SanDiegoSOD Milk was a bad choice
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    If, in this unlikely situation, I *had* to push the drugs or the guy would shoot me, then I would push enough to kill a large rhino. Then I would restrain him, and then try to revive him. Why?
    1. The guy is obviously not your average druggie, I'm not going to risk pushing an unusually large dose that still (shockingly!) doesnt take him out and then have him go nuts and shoot me. I've seen alcoholics carry on normal conversations while they have 0.40 BACs; who knows what dose a morphine junky can handle?
    2. Few DAs would risk prosecuting this case, and no jury in the world would convict me for manslaughter in this situation.
    3. Damn the medical boards, this is your life at stake.

    Did I mention how silly this exercise is? :D
     
  17. QuikClot

    QuikClot Senior Member
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    Exactly. But there are two further problems: a) Even a massive dose takes time to work, and it takes only a fraction of a second for the addict to realize he's been had and pull the trigger, and, even more to the point; b) IV narcotics don't come packaged in doses large enough to kill a large rhino. They are typically dispensed in single syringes of, say, 10mg Dilauded. So what are you going to do? Pretend that they're 1mg syringes and push ten of them? That won't make the guy with the gun suspicious. Bear in mind that a system-abusing narcotics addict has probably seen a syringe of Dilauded before.
     
  18. odrade1

    odrade1 UASOM alum
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    Cool your jets. No need to be defensive.

    I was partaking in what I thought to be an interesting (but not emotional) intellectual thought experiment. You should realize that the spirit of this discussion (until your comment) was one in which people seemed to be merely exploring the ideas surrounding the OP. The term "assumptions" is not perjorative in a philosophical discussion, as you seem to believe. If you actually think about what my post said, you will see that I wasn't arguing against you anyway.

    I may be just an MS0/MS1, but you don't have to be an MD to know that lay people (even regular users) can shoot up too big of a dose and hurt or kill themselves. You claim that this is actually difficult to do. I am not so sure; as I said, once you aren't worrying about getting the dose right (for saftey reasons), it can't be that hard to kill or nearly kill someone if you give them what seems to be a ridiculous amount of dope. And the effects don't have to be instantaneous; the crook will surely be enjoying his high for the first bit anyway. Drug-using lay people mistep in this way every day & end up dead.

    The *real* discussion here isn't about what dosage one should use, which is merely a technical consideration about practical application. So we should stop fretting about them. The *real* discussion here is the philosophical one about the ethics behind the situation painted by the OP. Whether or not the discussants could (in the real world) accurately pull off a proper chemical incapacitation of a jonesing robber is moot.
     
  19. SanDiegoSOD

    SanDiegoSOD Milk was a bad choice
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    In that case, I jam the syrninge through his temple - game over. :D
     
  20. nicholonious

    nicholonious Street Performer
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    You know there was a recent news article on a physician who was giving out painkillers to addicts and caught for 17 different accounts of doing so. The state suspended his licence. Four died under his care in relation to his overprescribing. Slap on the wrist if you ask me.
     
  21. eternalrage

    eternalrage Even Kal has bad days...
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    For people who are trained in martial arts, if they are attacked, held up, whatever, and they do something, anything, that gets the attacker killed, they are responsible via something called "premeditative action." Meaning they have been trained in combat prior to the confrontation, and although they may not have had control over the situation, they did have control over ourselves.

    So similarly, since you would be a trained doctor, with the knowledge beforehand of proper dosage limits, you could be held responsible. Now given the debate thats been going on in this thread about state law, precedent, whatever - the only consistent thing we know is that lawyers are sharks. If the family of the attacker gets a good one it wouldn't be too hard for them to spin the whole thing out of context given all the ethical dilemmas and grey areas. Of course, you yourself could get a good lawyer and watch them duke it out.

    From an ethical point of view, I think it really does depend on your perspective. You as a doctor shouldn't do anything to endanger anyone, to take your given knowledge that was meant to save lives and then twist it to kill someone is a complete perversion. You as a person however have a right to your life, to your freedom of choice, yada yada yada. You have a duty to your fellow man - by just giving him what he wants you endanger other lives (what if he gets high and kills someone else?) but then again this guy IS one of your fellow man and has his own rights (despite the fact that he has thrown some of them away) - to be tried in a court of law, right to good health, etc etc. I suppose ethically, in terms of right or wrong, you have to find which way your scales tip and hopefully you will be able to sleep at night after making your decision.
     
  22. QuikClot

    QuikClot Senior Member
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    You were not using the term correctly, whether or not you were using it in a perjorative sense. As I pointed out. My post was not written either in a defensive spirit, nor an "emotional" one. Perhaps you are projecting?

    Nothing "only" about that, but listen to the people who have been there.

    The difference is that an addict taking street drugs has no idea of the concentration of his drug or what it was cut with, unless he or she prepared it from scratch. This is why herion overdoses come in runs; one "bad batch" nails a bunch of customers.

    Narcotics in a medical setting are delivered so as to minimize the possibility of an overdose or the theft of drugs by providers; therefore they are dispensed in moderate amounts via single-use syringes at fixed (and low) concentrations. So no, it is not easy to give a ridiculous amount of dope without its being apparent to the subject. The whole system is designed to make that difficult, for safety reasons.

    You want to bet your life? People don't like to be double-crossed. They have been through this experience hundreds of times and they know what it is supposed to feel like. A shot of dope does not immediately take away one's ability to think and function, and it certainally doesn't take away one's ability to get angry. Last Wenesday I spent the better part of an hour being yelled at by an addict who had had 120mg of Methadone a couple hours before.

    Now who's being defensive? Never mind. Killing the addict with a syringe to the temple; I'm going with that.
     

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