One of our readers recently wrote a letter to me that I would like to share with you – and then, as always, share some reflections. This is the gist of his letter:

“Excuse me for preaching to the choir. As a formerly retired businessman I have experienced the struggle to remain ethical. The devolution of ethics in business is gradual. Most people do not enter into business with a Simon Legree mindset to pillage and loot their way to fortune. Instead this southward ethical journey, like most decisions in life, occurs in small or even tiny increments. This path starts from an increased use of fibs to an increasing size of fibs and onward to omission of relevant information and finally arriving at the world of lies.

“You so accurately write, ‘Look for moral paralysis on a personal level’. Yet the traits we extend into our business and social spheres derive from our personal ones. I’ve stumbled onto a useful rule for myself. I notice how someone deals with their loved ones and friends – especially in times of stress or trauma. More often than not, they will deal with the general world in a similar fashion, again in times of great stress!

“However, the most debilitating situation that I can perceive is when loving, caring, nurturing individuals find themselves in a medically compromising situation and cannot extricate themselves. To me this qualifies as a perversity and probably happens too often…”

Indeed! While answers are hard to find, I personally think that the most difficult decisions have to do with the problems that arise when “doing what is good and doing what is right conflict.” I remember to this day the first time I encountered one of these issues as a nursing student (back in the days when nursing students often ended up in charge of a patient care unit).

A 59-year-old woman was admitted with acute myeloid leukemia. Chemotherapy was still experimental, but the physicians decided that it offered her a chance for survival and them an opportunity to try a new drug. At that time, of course, the amount and frequency of the chemotherapeutic agent to be given was as experimental as the chemo itself. The patient’s husband was told it was experimental but it was her only chance – and the patient was not told anything (not even her diagnosis).

At any rate, after starting chemotherapy, she rapidly deteriorated: she was constantly nauseated and developed one infection after another. She began showing multiple signs of internal bleeding, including vomiting coffee-grounds like material. She was weak and dying and in significant pain – and frequently asked to be taken off the drug and allowed to die. But this was in the days before patients’ rights were considered and the physicians wanted to continue the regimen. I asked them, very respectfully, why they wanted to continue. And they responded that they needed to know what the drug would do.

Eventually, the woman vomited and aspirated the coffee-grounds like material. The suction machine was right next to her bed, and the thought went through my mind that it would be a mercy for her if I simply left the room; I had 12 other patients for whom I was caring. However, I could not watch her choke to death. I suctioned her, and she lived another week – in pain, crying, and begging the doctors to stop. My instructors required that I attend her autopsy. Every organ in her body was covered with lesions. According to the autopsy report, most of the lesions were caused by the drug. The doctors learned that they had to drastically reduce the amount and the frequency of the chemo…

To this day, I am sorry that I was right there in her room when she choked. I followed the “rules.” But it was not good – neither the suffering nor the patient outcome. I also, from that day onward, decided to work actively to promote patients’ rights, and eventually to seek a graduate degree in ethics — to write one of the first contemporary ethics texts for nurses, to teach ethics, to write these columns. Much has changed, but even today tears come to my eyes as I write about this lovely woman.

And there are so many more situations, like the time I was speaking with a group of Army nurses and medics in the Vietnam era: They spoke of the times that soldiers were badly wounded and the gunfire was intense. They could not evacuate the most severely wounded; should they give them an overdose on the battlefield or let the Vietcong capture and torture them? They decided it was not right to overdose them, but they agonized over it.

Other frustrating and terrible decisions involved home health patients because the “rules” demanded that caregivers could only continue treating them as long as they were either getting better or getting worse. Yet, for example, pressure wounds go into stasis for a considerable period of time, so according to the rules, we would have to stop treating the patient until the wound once again deteriorated and then we could go back…until the wound once again improved and went into stasis again, and once again we were required to stop. We tried to teach family members what to do, but it usually wasn’t sufficient to meet the patient’s needs. So the choice was to “lie” in the patient record or go into this cycle of treatment and neglect.

These are only three instances among hundreds. Why do so many of us choose to do the right thing rather than the “good” thing when they conflict? Because the right thing is so much more objective: we have ethical codes, laws, rules, and regulations to help guide us. The “good” thing is very subjective. It is influenced by personal value systems, culture, mores, past experiences, desired futures, pain threshholds, religious beliefs, and fears. Moreover, when the “right” thing to do is unjust, we can publicly discuss it with others, and change it so as to reduce or eliminate its conflict with what we see as the “good” thing to do. But the “good” thing to do is indeed subjective. No one person, however educated or well intentioned, ought to make decisions for someone else based on his or her personal perception of the good. That’s why we have — and debate and sometimes change — laws and rules and codes of ethics.

I thank this letter writer for giving me many opportunities to discuss why and how we handle one kind of really hard choice. There are others, and I will be writing about them in future columns: problems that involve right versus right, right versus wrong, moral problems versus ethical dilemmas (and why it’s important to know the difference), and the war between compassion and justice (with yourself as well as others).

*For a thought-provoking guide, I suggest reading a small but excellent book: Kidder RM. How Good People Make Tough Choices. Simon and Schuster; NY: 1995.

Leah Curtin is Executive Editor, Professional Outreach for American Nurse Today.