Q&A: Trust, shared decision-making crucial when facing ethical dilemmas in medicine

Key takeaways:

• To address ethical dilemmas, allergists/immunologists must have an understanding of medical ethics, Timothy M. Buckey, MD, MBE, said.
• Trust is a key component of the patient-physician relationship.

Although allergists/immunologists frequently encounter ethical dilemmas in their daily clinical practice, medical ethics has not previously been a focus of research and training in their specialty, Timothy M. Buckey, MD, MBE, told Healio.

Buckey, assistant professor of clinical medicine in the division of pulmonary, allergy and critical care at Perelman School of Medicine at the University of Pennsylvania and attending physician at the Hospital of the University of Pennsylvania and the Children’s Hospital of Philadelphia, and colleague Kathleen E. Sullivan, MD, PhD, chief of the division of allergy and immunology at the Children’s Hospital of Philadelphia, discuss a case study involving an ethical dilemma that allergists/immunologists may encounter in practice in an editorial titled, “Navigating the ethical implications of immunoglobulin replacement therapy during pregnancy,” published in Annals of Allergy, Asthma & Immunology.

In this case, a woman with common variable immunodeficiency (CVID) declined receipt of immunoglobulin replacement therapy (IgRT) during pregnancy, and Buckey and Sullivan weighed in on the ethical implications of this decision and how physicians can navigate such a situation.

Healio spoke with Buckey on the specifics of the case study, the clinical importance of medical ethics, and how physicians can work together with patients to solve ethical dilemmas.

Healio: What inspired you and your colleague to write about this case?

Buckey: Allergists/immunologists frequently encounter ethical dilemmas in their daily clinical practice. These dilemmas arise from the diversity of patients and health conditions they treat. Yet, previously, medical ethics has not been a focus of research and training in our specialty. It is my goal to demonstrate the clinical relevance of medical ethics and provide education on this subject’s relevance for the practicing allergist/immunologist.

Healio: What are the challenges of treating CVID during pregnancy? What are the risks and benefits of continuing IgRT?

Buckey: CVID is a heterogenous disorder with different manifestations and complications. The disorder is commonly managed with IgRT, a form of passive immunity in which an individual receives antibody infusions. During pregnancy, IgRT dose requires adjustment. In addition to the benefit of providing immunity to the mother, IgRT also provides immunity to the fetus through the placental transfer of antibodies. Without IgRT, after delivery, the newborn would be at risk for severe, life-threatening infections while their immune system matures. With IgRT, there are potential risks of allergic reactions, irritation at the infusion site, headaches, among others, but these are often outweighed by the benefits of the provided immunity and reducing the risk for infection.

Healio: In the case study, you emphasize the importance of maintaining the patient-physician relationship. How can physicians not only maintain, but strengthen their relationship with patients when facing an ethical dilemma?

Buckey: Trust is essential in the patient-physician relationship. Trust is strengthened through active listening by the physician and engaging the patient to be a partner in the medical decision-making process. By seeking to understand a patient’s values and perspectives and incorporating these into the treatment plan, physicians can improve trust with their patients. Medicine should not be physicians making unilateral decisions, but a partnership between patients and their clinicians. To provide patient-centered care, it is important for physicians to offer patients opportunities to ask questions and provide their opinions during conversations. With a foundation of trust, patients and physicians can address ethical dilemmas together when they arise and further strengthen the patient-physician relationship.

Healio: You note that individuals must possess capacity to make autonomous decisions. If maternal capacity had not been assumed for this case study, how would the discussion have differed?

Buckey: If an individual does not possess capacity, then a surrogate decision-making would need to become involved. In this scenario, this would have been complex given the unique nature of the maternal-fetal relationship.

Healio: In addition to respecting patient autonomy, what other duties should allergists/immunologists fulfill when facing an ethical dilemma?

Buckey: The renowned ethicists, Tom L. Beauchamp and James F. Childress, enumerated four key principles of biomedical ethics. These are beneficence, nonmaleficence, autonomy and justice. Physicians should understand and respect these values during their interactions with patients. Obtaining informed consent (or assent in pediatrics), emphasizing trust and engaging in shared decision-making are also duties of physicians.

Healio: What advice would you give to a physician who is facing an ethical dilemma and is unsure of how to proceed?

Buckey: First, the physician should describe the ethical dilemma. This includes the clinical scenario, relevant individuals, management options and the pertinent ethical principles. Complex ethical dilemmas may not be solved in one session and it is possible the dilemma may need to be revisited on a later date. Ultimately, if the physician and patient cannot come to an agreement, engaging colleagues with ethics and/or mediation training may be beneficial.

If a reader is interested in learning more about facing ethical dilemmas, my colleagues and I developed and published a 10-step framework in an article titled “An Ethical Framework for Allergy and Immunology.”

HealioIn which scenarios would you recommend terminating the patient-physician relationship? What are considerations for doing so?

Buckey: There are scenarios in which a physician may need to terminate a relationship with a patient. These may occur if there is a breakdown in civility, understanding or trust between patient and clinician. If any of these occur, a physician may terminate the patient-physician relationship; however, the physician ought to transition the patient to a new clinician before ending the relationship. If this situation arises, the physician should consider engaging with legal counsel.

Healio: How did you resolve the ethical dilemma outlined in the case study?

Buckey: This case was adapted based on conversations with several patients. It was designed to be thought-provoking and incite discussion on one of many ethically complex dilemmas we face regularly. Regardless of the specific details of any singular case, I have found utilizing an ethical framework and engaging in honest, open dialogue with patients is the key to addressing dilemmas encountered in clinical practice.

HealioYou mention that there are other ethical dilemmas that can be encountered in allergy/asthma practice. What are some examples? Have you had experience with any of these?

Buckey: Due to the wide array of both allergic and immunologic conditions we treat, as well as the fact that we care for patients of all ages, allergists/immunologists regularly encounter ethical dilemmas. A few examples of dilemmas may include allergic reactions to foods and medications, consent for procedures, use of therapies that alter the immune system, genetic testing and bone marrow transplant.

As a physician who cares for both pediatric and adult patients, I have encountered many ethical dilemmas. When faced with these dilemmas, I utilize my clinical and ethics training to engage in shared decision-making with my patients so we can develop treatment strategies that are medically appropriate and align with the patient’s values and goals.

Additionally, as more is discovered about the immune system and medical genetics and with the development of novel medical therapies, new ethical dilemmas will continue to emerge. For this reason, an understanding of medical ethics is essential for allergists/immunologists.

Lastly, I would like to share my appreciation for my allergy/immunology colleagues. Although medical ethics has not previously been a focus of research and training in our specialty, I have been immensely grateful for their support and enthusiasm to continue to pursue my scholarly endeavors in medical ethics.

References:

• Buckey TM, et al. Ann Allergy Asthma Immunol. 2024;doi:10.1016/j.anai.2024.04.002.
• Buckey TM, et al. J Allergy Clin Immunol Pract. 2024;doi:10.1016/j.jaip.2024.02.018.

For more information:

Timothy M. Buckey, MD, MBE, can be reached at timothy.buckey@pennmedicine.upenn.edu; X (formerly Twitter): @TimothyBuckey.