Kuenzang¹

¹Faculty of Nursing and Public Health, Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Bhutan

Corresponding author: Kuenzang, Faculty of Nursing and Public Health, Thimphu, Bhutan.

Email: kuenzang@fnph.edu.bt

DOI: https://doi.org/10.47811/bsj.0026061006

Copyright © 2025 Bhutan Sorig Journal published by the Faculty of Traditional Medicine, Khesar Gyalpo University of Medical Sciences of Bhutan.

This is an open access article under the CC BY-NC-ND license.

ABSTRACT

Healthcare setups are becoming sophisticated and mechanical, often disregarding human, emotional, and socio-cultural perspectives. This leads to forms of ethical conflicts that may not result in making the right choices for the patient and family members. Bhutan is positioned in a unique socio-cultural context that has strong influence on the core principles of ethical medical practice. The core principles of ethics in medical practice are autonomy, beneficence, non-maleficence and justice. It is observed that a form of relational autonomy may be a dominant force where family members make choices on behalf of patients. The healthcare professionals may be nudging patients and family members towards certain healthcare choices. There are instances in which the treatment decisions made by the healthcare professional is seen as lacking beneficence by family members, while patients’ socio-cultural practices are seen as lacking beneficence by healthcare workers. While health policy and strategy aim at improving health equity, there are instances in clinical practice where distributive justice is breached. With attrition of healthcare workers, distributive justice has come into question as the healthcare workers remaining behind are faced with increasing work pressure, burnout and compassion fatigue. In end-of-life decision making, there are situations of intense conflict regarding resuscitation attempts and continuation of non-life-saving care processes. The medical curriculum for doctors, nurses and traditional medicine physicians includes ethics education as part of their training. This article provides a contextual set-up of how ethical principles intertwine with medical practice in Bhutan.

Key words:  Clinical Decision-Making; Ethical Dilemma; Health Communication; Humanities Education; Principle-Based Ethics; Professionalism

The principles of ethics are of paramount importance in medical practice and for all categories of healthcare professionals. The framework of ethical principles must guide the healthcare professionals at their workplace taking into account the socio-cultural and diverse perspectives of the patients [1]. The delivery of healthcare services has evolved from the traditional setup to a patient-centered approach and partnership-based concept [2]. Healthcare setups have become more complex and mechanical, often disregarding the human, emotional, and socio-cultural perspectives in daily medical practice [3]. In Bhutan, it is reported that health workers facechallenges in communicating patients’ health outcomes [4]. Besides the capability to speak the locallanguage, it is important to understand the foundationsrequired for conducting effective communications with patients and family members and to meet the needs of the situation. Some situations may involve explaining how to take a medication, while others may involve more difficult situations, such as breaking bad news. In such circumstances, the fundamental principles of autonomy, beneficence, non-maleficence and justice must be taken into consideration (Figure 1) [5]. This article presents a perspective on how these basic principles of medical ethics may be contextualized in the healthcare setup in Bhutan.

AUTONOMY AND HETERONOMY

Autonomy refers to an individual’s right to make choices or decisions regarding their healthcare-related matters. This includes the right to choose a treatment, refuse treatment, discontinue treatment, die with dignity, and know the truth about their medical condition [2]. Heteronomy, on the other hand, refers to external control over an individual’s will, or the need to adhere to the external legal concepts such as legal age requirement for a driving license. In Bhutan, we observe ‘relational autonomy’ when family members accompany patients to health facilities. For instance, a woman’s mother or a female family member accompanies her during institutional delivery. In such cases, healthcare decisions are made collaboratively by the patient and their family members [4]. At times, conflicts may arise, for example, in pain management when the decision for the level of analgesia is made primarily by medical professionals. This reflects a diminished autonomy of the patient [6]. In other circumstances, diminished autonomy occurs when patients are incapacitated and unable to make decision for themselves. Family members without legal representation may be compelled to make choices or give consent to treatments that may not necessarily align with patient’s best interest. Every patient has the right to ask questions about the care process, refuse or withdraw consent at any stage, express their thoughts freely, and make their choices regarding treatment. Medical professionals are obligated to provide complete and relevant information in simple, understandable, and preferably in native language when patients are required to make choices of treatment. However, it is often observed that the ‘nudge concept’ influences the consenting process. This happens when the healthcare worker emphasizes only the beneficial effects of an invasive procedure, perhaps by comparing a positive outcome in another patient who underwent the same medical intervention, rather than adequately informing the patient of the potential risks and harms [7]. Such undue influence and nudging a patient or family member towards a treatment choice compromises not only the patient’s autonomy but also their overall welfare [8].

BENEFICENCE TOWARD INDIVIDUALS AND SOCIETY

The principle of beneficence refers to the responsibility of medical professionals to act in ways that promote patient’s welfare and safeguard individuals from harm [9]. For instance, consider endotracheal intubation, an invasive procedure performed during severe respiratory distress or cardiac arrest. Endotracheal intubation carries risks such as hemodynamic alterations, airway injury, laryngospasm, bronchospasm, and increased risk of intracranial bleeding [10]. Notwithstanding these risks, the medical professional’s decision to perform the procedure in such a circumstance is driven by the intention to maintain patent airway by placing the tube correctly and provide the lifesaving benefit.

The principle of beneficence extends beyond simply ‘doing no harm’ (non-maleficence). It represents a moral drive grounded in the virtues of compassion and kindness. However, this principle may be tested to its limit in certain situations. For example, if a patient refuses to allow a male medical professional to perform manual removal of a retained placenta due to socio-cultural considerations, the healthcare worker, despite having good intentions, is unable to fully exercise beneficence.

Beneficence towards society aims at achieving the ‘maximum good or happiness for the maximum people’ while concurrently minimizing harm. At times, this broader approach may require prioritizing the welfare of society over the individual rights or requirement of the minority [11]. A prime example of beneficence of the society at large is Bhutan’s national immunization policy. This routine immunization program for children provides extensive public health benefits, greater good/happiness for the Bhutanese population, and maximizes the welfare of individual patients by preventing the transmission of infectious diseases [12].

NON-MALEFICENCE

The principle of non-maleficence is a duty to ‘do no harm’ by the medical professionals. Healthcare providers must carefully assess the benefits and risk of all treatments offered to patients. Some medical interventions may cause undue burden to the patient and family members including out-of-pocket financial expenditures [9,13]. To avoid unintended harms, hospitals implement standard procedures and protocols. For instance, prescribers are encouraged to follow good prescribing practices while nurses are required to identify the right patient, the right drug and right dose before administration of medication.

In Bhutan, cultural and traditional beliefs influence practices that may breach the principle of non-maleficence. It is reported that “[at] times, the patient’s family does not allow the nurses or doctors to inject or give medication unless the [religious] ceremony is over”[14]. Such practices have direct influence on patient outcomes. The principle of non-maleficence requires the medical professional to protect the patient’s welfare and to ensure patient safety [13]. However, healthcare professionals must find ways to balance these conflicting factors with patient safety, taking rational and legally informed steps to minimize harm.

JUSTICE

The principle of justice refers to fairness in rights and laws, equal opportunities and benefits, and the equitable distribution of both benefits and risks, ensuring healthcare resources are available, accessible, and affordable to all. This includes the allocation of resources including material (such as medical equipment, drugs and non-drugs), manpower (medical professional), and financial resources. However in practice, these resources are often unequally distributed, both within countries and globally [6].

Hospitals in Bhutan are facing shortage of trained and experienced medical professionals due to high attrition rates [15]. As a result, the remaining medical professionals experience immense work pressure with frequent concerns raised over the quality of healthcare [16]. According to media reports, “[people] are more conscious about their health and they want more and better services, whereas the system and health care are not equipped with adequate human resources to give that expected services to people. Even though the health care is free, the government has to pay for it. There are issues of inadequate resources, medicines going out of stock, and the recruitment policies restricting the number of human resources.” [14]. In such circumstances, there is a need of equitable re-distribution of workforce and resources, ensuring that high-volume departments, such as the Emergency Room, have an adequate number of nurses and doctors. The consequences of violation of distributive justice includes a vicious cycle of negative impact, such as burn out, compassion fatigue, poor performance, and ultimately poor patient outcome.

The Royal Government of Bhutan has consistently prioritized equitable access to healthcare, providing essential services, vaccines, and immunization programs free of charge to all eligible residents [12]. The three referral hospitals are spread in geographically strategic locations to cater to needs of the population. However, instances of violations of distributive justice still occur. According to the concept of the essential medicines list, required medications should be continuously available at all the hospitals all the time. In practice, when one hospital runs out of medicines, it is often supplied from the stock of another hospital, inadvertently creating shortages elsewhere. Addressing such challenges requires coordinated mechanisms to ensure uninterrupted availability of medicines and minimize inconveniences caused by stock-outs.

SITUATIONS OF CONFLICTS AND ETHICAL DILEMMAS

Medical professionals, patients, and families often face numerous ethical dilemmas regarding endof- life for incapacitated individuals. For instance, healthcare providers strive to respect a patient’s autonomy in end-of-life decisions. Nonetheless, this decision-making process often involves disagreements with family members based on cultural or religious beliefs. While the value of peaceful dying process is recognized in Bhutan [17], the family’s perspectives, possibly framed under the context of beneficence, contradict the individual’s choice, generating a conflict with their autonomy. In response, medical professionals sometimes adopt a paternalistic approach, creating decisions aimed at avoiding harm (non-maleficence).

Even when a patient expresses a wish for a Do-Not-Attempt-Resuscitation (DNAR) order, these preferences are often incompletely documented or lack supporting legal documents such as Advance Directives [18]. An Advance Directive is an important legal document framed to protect a patient’s healthcare wishes if they become incapacitated and unable to make clinical decisions. While many countries use legal document such as Advance Directives and DNAR orders to guide these choices, Bhutan currently lacks legal documents in this area.

Another ethical conflict arises concerning the continuation of medical care in situations where it may not lead to patient’s survival [17]. This raises the queries: Is it fair to allocate critical care resources that are limited to a patient with poor prognosis when the same resources could be better utilized for another patient with a greater chance of recovery?

BRIDGING THEORY AND PRACTICE: ETHICS IN ACTION

The Faculty of Nursing and Public Health at the Khesar Gyalpo University of Medical Sciences of Bhutan has introduced “Law and Ethics in Nursing” into its curriculum. After completing clinical rotations, students engage in critical reflection on the ethical principles that guide decision making in patient care [19]. Similarly, the Faculties of Postgraduate and Undergraduate Medicine provide dedicated learning sessions on ethics in medical practice. The Faculty of Traditional Medicine has contextualized teaching of ethical principles based on values derived from Buddhist philosophy. These integrated teaching and learning methods create a comprehensive learning environment to adopt intrinsic and extrinsic values to navigate the complexities of ethical conflicts in medical practice.

CONCLUSION

Autonomy, beneficence, non-maleficence and justice constitute the four fundamental principles for ethical practice in healthcare settings. In Bhutan, socio-cultural practices exert a strong influence on healthcare decision-making and patient care, which can sometimes create conflicts with these ethical principles. Healthcare workers often have to navigate delicate paths in creating the right situational environment for the delivery of healthcare services without the breach of ethical principles. Students in Bhutan are provided with a unique learning environment that allows them to adopt and integrate these principles into their learning and future practice.

Declarations

Ethics approval and consent to participate.

Not applicable

Consent for publication

Not applicable

Competing interests

The authors declare no competing interests.

There was no funding for this article.

All public sources of data have been cited in this article.

investigation, resources, writing – original draft, writing – review and editing: K

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