Ethical dilemmas in day to day General Medical Practice

Ethical dilemmas in day to day General Medical Practice
Ethics is about judgment, which is rarely black and white. 

 DM2  accucheck reading  High,  signs of dehydration did not take meds did not check sugars   > 2 years
She has a  son with type 1  DM2 who is more important to her than own health?
refuses to go to ER/

 a truck driver  comes  with  SOB  DOE
x-ray chest  done in  er  shows  pleural effusion and  cardiomegaly  Ct scan  shows  unilateral effusion  nodules and  pulmonary consolidation
 pt referred to oncology and  cardiology
 refuses to go  2 months later comes for a DOT  physical and a DOT clearance form when the  situation is explained and explained why I will not sign the form he becomes  irate and walks out saying I will go to a  different doctor?

Scenario 2

You are due to do a bronchoscopy/gastroscopy/cardiac catheter list tomorrow and your father has been rushed into a hospital in another city with bowel obstruction. He is going to have emergency surgery and your mother would like you to be with her during this difficult time. What do you do?

This scenario occurs regularly. As doctors we owe a duty of care to our patients but we also have personal responsibilities to our families. In this scenario there is clearly a conflict between the two. However, patients must be able to trust doctors with their lives and wellbeing and to know that the doctor’s primary concern is to them. In essence the GMC says you must make the care of your patient your first concern.3

You would betray your patients if you cancelled the list at short notice, and you would be breaking the GMC code. You cannot walk away from your responsibility and turn your back on your patients. You should try to arrange with a colleague of equal training and experience to do your list. You should not expose your patients to a higher risk than normal by asking an inexperienced colleague to substitute for you. If you are unable to get a substitute or locum at short notice then you have little alternative but to do the list yourself. You should remember you also have a duty to ensure that you are capable of doing your job without jeopardizing patient care. The GMC says you must act quickly to protect patients from risk if you have good reason to believe that you may not be fit to practice. Thus, if you are so upset by your family circumstances you should declare yourself unfit to practice. ( This the kind of double meaning unrealistic diplomatic bullshit which absolutely does not give the medical practitioner any real help to solve the  on the ground problem..Another  useless advice 

Scenario 5

You admit a barrister after a sudden collapse where an eye witness observes him to have a grand mal fit. After full investigations are negative you discharge him. He tells you that he is due in court the next day in Liverpool. You have advised him not to drive but you are convinced that he will. What do you do?

The GMC advice is:

“Disclosure of personal information without consent may be justified where failure to do so may expose the patient or others to risk or death or serious harm. Where third parties are exposed to a risk so serious that it outweighs the patient’s privacy interest, you should seek consent to disclosure where practicable. If it is not practicable, you should disclose information promptly to an appropriate person or authority. You should generally inform the patient before disclosing the information”.6

The GMC gives specific advice for the patient who continues to drive despite medical advice not to do so. If you think the patient may be a danger to himself or others when driving and you cannot persuade him to stop driving or to inform the Driver and Vehicle Licensing Agency himself, then you should disclose the information to a medical adviser at the agency. You should let him know of your decision.7 As always in these situations make sure that you fully document any and all discussions in the medical notes as a contemporaneous record

This is the most hilarious situation of all 

what happens if he confronts you in the parking lot or slashes your tires or follows you to your home and when you are not there , invades your home and rapes , kills your wife and  kids ?

However, there is some evidence that GPs have practised implicit personal rationing, at least in the area of referrals, for example, by referring fewer elderly, unemployed and single persons for expensive procedures such as renal transplants or coronary artery surgery (18,19).