The Dowd Model of Ethical Decision Making in Medical Imaging: Two Dilemma Scenarios
An ethical dilemma is raised in a situation where two "right" courses of action are found to be mutually exclusive of each other; that is, when doing one "right" thing necessarily leads to leaving the other "right" thing undone or even contravening this "right" and doing the opposite (Towsley-Cook & Young, 2007). A scenario in which an employee's rights must be weighed against those of the patient/consumer typifies this type of dilemma, and this is found in the current scenario: a medical imaging professional suspected of having alcohol problems comes to work with the smell of liquor on his breath and shows some trouble walking straight and enunciating clearly. After a confrontation by the supervisor, this employee refuses to take a blood test for drugs and alcohol. The dilemma exists in determining whether this is insubordination, or whether the test would violate the employee's privacy rights.
According to the Dowd model of ethical analysis, assessment is the first step (Towsley-Cook & Young, 2007; Wilson, 2010). The basic problem here is, of course, the possibility of impairment of the employee's ability due to his alcohol use; it is standard to expect employees in any and all industries to arrive for their work shifts sober and to remain so throughout the workday. For medical professionals of any sort as well as in certain other key occupations, there is an even greater responsibility for sobriety as the very lives of many individuals could depend on the lack of impairment in such professionals.
This leads directly to the second step of the Dowd model, isolation of the issue (Wilson, 2010). The danger to patients that the employee presents must be weighed against the danger to privacy rules and a fair and even-handed work environment that a drug-test-on-demand would entail. This issue is not, that is, whether or not it is ethically appropriate for the employee to show up to work intoxicated, but whether the ethical danger of administering a drug test outweighs the danger of either acting on unconfirmed suspicions or allowing the employee to continue working despite these unconfirmed suspicions.
Analyzing the data is the next step in the Dowd model, and it is here that things become slightly more complex (Wislon, 2010). Research has shown that among radiologic technicians specifically as well as amongst nursing staff generally, substance abuse problems are likely an issue for three to four percent of all professionals, with the rate of alcohol abuse higher than that of any other substance or substance class (Van Valkenberg et al., 1998). Such abuse, then, presents a serious risk to patients. It is impossible, however, to directly compare this data to the highly subjective and non-empirical data that can be derived from an examination of drug tests and privacy laws. One could perform such an analysis from an ultra-pragmatic utilitarian perspective, attempting to weigh the added costs in efficiency, turnover, and lower staff-patient ratios that are caused by drug tests and their results, but this ignores the imperative of nonmaleficence at work in the medical profession (Towsley-Cook & Young, 2007). Allowing impaired individuals to perform medical procedures cannot be compared to the right to privacy for these individuals in any direct way.
Developing a plan is the next step in ethical action according to the Dowd model, and this is actually relatively easy in light of the evidence and analysis described above (Wilson, 2010). As there can be no direct comparison between the two ethical rights in this dilemma, one of these rights must be selected wholesale over the other by determining which of the rights is more closely aligned with the imperatives of the community and individuals involved. Ethical decision only make sense in the context of specific communities and the application of specific values, and the medical community definitely defines these values in a clear-cut and unequivocal manner (Towsley-Cook & Young, 2007). Analyzing the values of the medical imaging community and applying them to the two rights in the dilemma is the proposed plan of action at this point.
Plan implementation comes next, and in this case it must first consist of identifying the core values of the medical community. Nonmaleficence towards the patient is the primary goal of all medical practitioners, and is even stated as such in the Hippocratic oath (Towsley-Cook & Young, 2007). The risk of doing harm exists, however, in most medical procedures, and therefore the imperative of nonmaleficence must be weighed against the priority of beneficence (Towsley-Cook & Young, 2007). In this case, there is a clear risk of causing harm by allowing the possibly inebriated employee to perform his duties, and the potential beneficence of allowing him to work despite refusing a drug test is decidedly minimal, especially in an organization with other people that can perform his tasks. As the patient must be the most respected and valued individual in the transaction, the decision here seems clear.
Analyzing the outcome of the plan, as is outlined in the final step of the Dowd model of ethical decision making, leads to the conclusion that the inebriated employee must not be allowed to perform his duties without first proving that he is not intoxicated through submitting to a drug and alcohol blood test. While there is certainly a right to privacy on the part of the employee, the right of the patients at the medical facility to receive the highest quality of care with the most reduced potential for harm possible is of paramount importance in the medical profession. The employee's right to privacy is outweighed by the patients' right to safety in this dilemma. The employee is still free to exercise his right to privacy by refusing to submit to the drug test, but he cannot be allowed to perform his duties while inebriated, and the circumstantial evidence that suggests this inebriation is definitely strong enough to request direct evidence via a blood test. His right to privacy in this matter ends when his private decisions begin to affect others; this is no longer a question of autonomy, but of the strident attempt at nonmaleficence that must be at the heart of all ethical decision making in the medical professions.
When there is a clear course of "right" and ethical action, but there are practical barriers that prevent the successful completion of this course of action and the ethical good at the end of it, there is said to exist a state of "ethical distress" (Towsley-Cook & Young, 2007). Such instances can be somewhat more complex than ethical dilemmas, where conflicts between two ethical imperatives exist, but they can be analyzed in largely the same manner. For example, a case in which a medical imaging individual has submitted to a random drug test at work and has been told that discharge proceedings are underway due to a positive result finds him or herself in a state of ethical distress when they have never used drugs or alcohol in their entire lives. The clear ethical objective is maintaining the employment position as well as having the positive result removed from the professional record, but this is far easier said than done. Applying the Dowd model allows for a clear course of action to be determined.
The Dowd model begins with an analysis of the issue (Wilson, 2010). In this case, this analysis is incredibly simple: the individual is about to lose their job, the ability to receive employment in the same career/profession, a great deal of social standing, and likely a great deal of faith in the justice of the world based on a false positive on a drug test. By agreeing to take a random drug test that was not necessarily mandatory (depending on the laws of the state in which the institution was located), this individual is now being punished for actions that they never took (Moeller et al., 2008). This situation is both ethically unfair and poses a massive practical risk to the individual accused of drug use.
Isolating the issue is the next step in the Dowd model, and in this case this allows for a clearing of a great deal of emotional and ethical clutter that exists in the situation (Wilson, 2010). There is not really a privacy issue at stake here, as the individual agreed to take the drug test in the first place and one could hardly assert feelings of an invasion of autonomy after the fact. What are at stake here are issues of veracity and justice -- the individual should ethically be treated as a non-drug-user, which is what in fact the person is, and in order to receive this just treatment they must prove the veracity of their non-drug-user status. The issue is the supervisor/manager's belief in the positive result, and not truly the result itself, that causes an ethical rather than a simply practical problem in this scenario.