Ethical Decision-Making in Clinical Nutritional Practice

François P. R. de Villiers

.

DOI: 10.4236/fns.2011.26089                

Abstract

Ethics requires a critical evaluation of assumptions and arguments about norms and values; what should be done and what should not. Practitioners should practice ethically, and the professions should be at the forefront of applied ethics. There are four principles, patient autonomy, beneficence, non-maleficence and justice, which are guides to ethical day-to-day practice. Patient autonomy: Autonomy means self-rule by persons of their thoughts and actions. Patient autonomy requires the practitioner to realise that patients have the right to be involved in decision-making on their own behalf. Beneficence refers to the duty of the practitioner to do the best for the patient. The benefits of breast-feeding are many, and the eventual outcome on health enormous. Nevertheless, health-care workers are diffident in promoting breast-feeding, and readily accept excuses for not breast-feeding, contrary to the principle of beneficence. Non-maleficence refers to the duty of the practitioner not to do harm; it requires the practitioner to withhold harmful therapies; Vitamin E, for example, has been proven to be ineffective as an antioxidant in humans, and large doses have been proven to increase mortality. Yet these are the doses available in supermarkets and “Health shops”. Nutritionists should actively advise against harmful “dietary supplementation”. Distributive justice requires every patient to have an equal opportunity to obtain appropriate therapy. There are relatively few nutritionists and dieticians in South Africa, and indeed in the entire African continent, but proportionately even fewer in the areas of greatest need. A case illustrates the application of these ethical principles to show how they can be applied to our daily practice. Using these four principles is a practical approach to solving ethical dilemmas.

Keywords

Ethics, Patient Autonomy, Beneficence, Non-maleficence, Justic

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	J. P. de V. Van Niekerk, “HPCSA: A Mess in the Health Department’s Pocket,” South African Medical Journal, Vol. 99, No. 4, 2009, p. 203.
[2]	Anonymity, “The American Heritage Dictionary,” 4th Edition, Dell, New York, 2001.
[3]	T. Honderich, Ed., “The Oxford Companion to Philosophy (2nd Edition),” Oxford University Press, New York, 2005.
[4]	Anonymity, “Medical Dictionary Online,” 2009. http://www.online-medical-dictionary.org/accessed19Aug 2009
[5]	Anonymity, “Relationship of Law and Ethics,” 2009. http://www.britannica.com/accessed19Aug2009
[6]	T. L. Beauchamp and J. F. Childress, “Principles of Biomedical Ethics,” 5th Edition, Oxford University Press, New York, 2001.
[7]	R. Gillon, “Philosophical Medical Ethics,” Wiley, New York, 1992.
[8]	World Health Organization, “Infant and Young Child Feeding: Model Chapter for Textbooks for Medical Students and Allied Health Professionals,” WHO Press, Geneva, 2009.
[9]	World Health Organization/UNICEF, “Acceptable Medical Reasons for Use of Breast-Milk Substitutes,” WHO Press, Geneva, 2009.
[10]	E. Evenhouse and S. Reilly, “Improved Estimates of the Benefits of Breast-Feeding Using Sibling Comparisons to Reduce Selection Bias,” Health Services Research, Vol. 40, No. 6, 2005, pp. 1781-1789. doi:10.1111/j.1475-6773.2005.00453.x
[11]	M. Chung, G. Raman, T. Trikalinos, J. Lau and S. Ip, “Interventions in Primary Care to Promote Breast-Feeding: An Evidence Review for the US Preventive Services Task Force,” Annals of Internal Medicine, Vol. 149, No. 8, 2008, pp. 565-582.
[12]	M. M. Rovers, P. Glasziou and C. L. Appelman, “Antibiotics for Acute Otitis Media: A Meta-analysis with Individual Patient Data,” The Lancet, Vol. 368, No. 9645, 2006, pp. 1429-1435. doi:10.1016/S0140-6736(06)69606-2
[13]	US Preventive Services Task Force, “Primary Care Interventions to Promote Breast-Feeding: US Preventive Services Task Force Recommendation Statement,” Annals of Internal Medicine, Vol. 149, No. 8, 2008, pp. 560-564.
[14]	K. Hensley, E. J. Benaksas, R. Bolli, P. Comp, P. Grammas, L. Hamdheydari, S. Mou, Q. N. Pye, M. F. Stoddard, G. Wallis, K. S. Williamson, M. West, W. J. Wechter and R. A. Floyd, “New Perspectives on Vitamin E: γ-Tocopherol and Carboxyhydroxychroman Metabolites in Biology and Medicine,” Free Radical Biology and Medicine, Vol. 36, No. 1, 2004, pp. 1-15. doi:10.1016/j.freeradbiomed.2003.10.009
[15]	E. R. Miller, R. Pastor-Barriuso, D. Dalal, R. A. Riemersma, L. J. Appel and E. Guallar, “Meta-analysis: High- Dosage Vitamin E Supplementation May Increase All- Cause Mortality,” Annals of Internal Medicine, Vol. 142, No. 1, 2005, pp. 37-46.
[16]	R. S. Eidelman, D. Hollar, P. R. Hebert, G. A. Lamas and C. H. Hennekens, “Randomized Trials of Vitamin E in the Treatment and Prevention of Cardiovascular Disease,” Archives of Internal Medicine, Vol. 164, No. 14, 2004, pp. 1552-1556. doi:10.1001/archinte.164.14.1552
[17]	P. G. Shekelle, S. C. Morton and L. K. Jungvig, “Effect of Supplemental Vitamin E for the Prevention and Treatment of Cardiovascular Disease,” Journal of General Internal Medicine, Vol. 19, No. 4, 2004, pp. 380-389. doi:10.1111/j.1525-1497.2004.30090.x
[18]	D. P. Vivekananthan, M. S. Penn, S. K. Sapp, A. Hsu and E. J. Topol, “Use of Antioxidant Vitamins for the Prevention of Cardiovascular Disease: Meta-analysis of Randomized Trials,” The Lancet, Vol. 361, No. 9374, 2003, pp. 2017-2023. doi:10.1016/S0140-6736(03)13637-9
[19]	G. Bjelakovic, D. Nikolova and L. L. Gluud, “Mortality in Randomized Trials of Antioxidant Supplements for Primary and Secondary Prevention: Systematic Review and Meta-analysis,” Journal of the American Medical Association, Vol. 297, No. 8, 2007, pp. 842-857. doi:10.1001/jama.297.8.842
[20]	M. K. Horwitt, “Critique of the Requirement for Vitamin E,” American Journal of Clinical Nutrition, Vol. 73, No. 6, 2001, pp. 1003-1005.
[21]	P. Butow, R. Devine, M. Boyer, S. Pendlebury, M. Jackson and M. H. N. Tattersall, “Cancer Consultation Preparation Package: Changing Patients but Not Physicians is Not Enough,” Journal of Clinical Oncology, Vol. 22, No. 21, 2004, pp. 4401-4409. doi:10.1200/JCO.2004.66.155
[22]	M. Gattellari, K. J. Voigt, P. N. Butow and M. H. N. Tattersall, “When the Treatment Goal is Not Cure: Are Cancer Patients Equipped to Make Informed Decisions?” Journal of Clinical Oncology, Vol. 20, No. 2, 2002, pp. 503-513. doi:10.1200/JCO.20.2.503
[23]	P. Kinnersley, A. Edwards and K. Hood, “Interventions before Consultations to Help Patients Address Their Information Needs by Encouraging Question Asking: Systematic Review,” British Medical Journal, Vol. 337, No. 3, 2008, p. a485. doi:10.1136/bmj.a485
[24]	M. Levetown and the Committee on Bioethics, “Communicating with Children and Families: From Everyday Interactions to Skill in Conveying Distressing Information,” Pediatrics, Vol. 121, No. 5, 2008, pp. e1441-e1460. doi:10.1542/peds.2008-0565