Bioethics Forum Essay

On the Razor’s Edge of Care

Case Narrative

Tarin, a 32-year-old male, was admitted to the emergency department after intentionally ingesting multiple razor blade fragments and then calling 911. In the ambulance, Tarin remained calm and cooperative as he reported that he had engaged in similar behavior multiple times and he anticipated the treatment he typically received in the hospital: intravenous pain medicine followed by endoscopic surgery to remove the razor blade fragments.

Tarin had a long history of self-injurious behaviors, including cutting and substance overdoses. He grew up in foster care and was estranged from his biological and foster families. He identified culturally as a person of color. He disclosed that he had experienced multiple traumas including abuse and family violence. He lived alone in a motel, his social support system was limited, and his engagement with healthcare services occurred only during hospital admissions.

The emergency department physician requested a gastroenterology consult. CT imaging revealed four razor blade fragments in his stomach and small intestine. As in the past, Tarin received intravenous pain medication for his mild gastric pain and gastroenterology recommended endoscopic surgery. This is the standard of care in such circumstances because the razor blade fragments posed a high risk of gastrointestinal perforation, internal bleeding, infection, and serious complications.

However, the ED team raised concern that the surgery would unintentionally reinforce Tarin’s pattern of swallowing sharp objects and seeking medical treatment. As an alternative, the ED team proposed a conservative strategy of close observation and repeated imaging to track the fragments’ progression through the GI tract to assess whether they could pass safely in the stool.

Some ED team members also expressed concern that Tarin’s actions might be linked to secondary gain, such as access to pain medication, the supportive hospital environment, or attention during medical crises. Given the possibility that psychosocial or psychiatric factors contributed to his behavior and interfered with his decision-making capacity, the ED team requested a psychiatry consultation. The psychiatric assessment found Tarin to be capable of healthcare decision-making and did not make a psychiatric diagnosis.

An attending physician was assigned to Tarin to decide how to proceed with his care. That physician requested an ethics consult to work through the tensions shared by the clinical teams.

Ethical Analysis and Process

The ethics consultation took place via telehealth because, in our rural area, there were no clinical ethicists available to come to the hospital. The ethics team connected virtually with Tarin’s care team and saw the documentation of Tarin’s wishes and health records.

The ethicists emphasized the importance of recognizing how early‑life trauma, unstable housing, and a lack of consistent healthcare could have contributed to Tarin’s repeated self-harm and trips to the ER. Rather than thinking of Tarin’s behavior as attention-seeking, the ethics consultants invited clinicians to consider a trauma‑informed perspective when planning his care. This approach would take into account that hospital care functioned as one of the few consistent supports in Tarin’s life.

The ethics team then encouraged the clinicians to balance foreseeable and imminent harms, acknowledging the ethical differences between them. Delaying the surgery could expose Tarin to serious and imminent medical harms. Additionally, withholding or delaying the surgery could be seen as discriminatory against Tarin since other patients in similar circumstances would have gotten it without delay. The consultation also noted that people who harm themselves often face stigma, especially when their behavior is dismissed as “attention seeking” or “medication seeking.”

Tarin communicated clearly that he wanted the surgical intervention. The ethical analysis prioritized Tarin’s wishes and clinical safety over the ED team’s concerns about reinforcing Tarin’s pattern of self-harm.

The ethics consultants recommended proceeding with the endoscopic surgery while also collaborating with social services to help connect Tarin with primary care and mental health providers in the community. Access to such care could help break Tarin’s patterns of self-harm and support improvements in his health and well-being.

Grounded in cultural safety and trauma‑informed care, the recommendations emphasized prioritizing Tarin’s safety and autonomy, and ensuring that care would be delivered without judgment, stigma, or bias.

Lingering Questions:

This case invited the ethics team to consider systemic gaps that contribute to fractures in the healthcare system, such as a lack of primary care providers, mental health supports, and adequate housing that cause further disparities for those living on the margins of society. This case occurred in Canada, where a social safety net exists. But even so, patients such as Tarin experience unstable housing and rely on the healthcare system to meet basic social needs. The ethics team grappled with his combined health and social needs, wondering how to best support his well-being withe limited resources.

Another lingering question concerned the remote ethics consult. In Canada, many ethics consultants must work remotely because they cover large territories. The ethicists didn’t speak with Tarin, which would have been preferable; it is the norm in many places, including the United States, for clinical ethicists to speak with patients when possible. In this case, the ethics consultants relied on the clinical team’s representation and documentation of Tarin’s wishes and prior hospitalizations. Fortunately, Tarin’s wishes were clear and consistent. But other cases may prove murkier, highlighting the challenges that can arise when ethics consultation occurs without direct patient engagement.

Jillian Boerstler, DBioethics, MPA, MA, HEC-C, is an ethicist and adjunct faculty UBC School of Nursing in Vancouver, Canada.

Donna Jansons, MSW, RSW, is adjunct faculty in the UBC School of Social Work in Okanagan, Canada


Series Editors’ Comment: The Importance of Recognizing Social Determinants of Health

We were disturbed by Tarin’s self-injurious behavior, but also by the possibility that any healthcare professional might consider allowing a patient like Tarin to suffer as a prevention tactic. We understand how difficult it is for care teams to continue to treat people who seem, at least based on their behaviors, to care little for themselves. Are we merely enabling such patients to continue to harm themselves? At the same time, it is hard to imagine that patients who self-harm do so merely as a way of seeking attention from medical professionals. How can medical professionals treat patients like Tarin, who have immediate medical needs, but also have underlying issues that emergency departments are ill-equipped to treat?

This case powerfully illustrates how clinical ethics teams can move beyond discrete beside dilemmas to address the broader social determinants of health. Ethics consultants can do more than resolve procedural conflicts about specific treatment plans. The initial question from the emergency department may have been about the appropriateness of endoscopic surgery, but the ethics question at the heart of any consult is often different from the question that was asked. In the course of their work, the clinical ethicists realized they needed to get a fuller picture of who Tarin was and what factors were contributing to his repeated self-injurious behaviors. What they found was a cycle of housing instability, a history of trauma, fragmented primary care, and stigma. These social determinants of health clearly influenced Tarin’s recurrent self-harm and healthcare utilization.

The ethics consultants in this case did three things worth highlighting. First, they adopted a trauma-informed perspective that helped to reframe the patient’s behavior as a trauma response rather than as “attention-seeking.” Next, they advocated for health equity by advising against withholding standard-of-care treatments from Tarin. The ethics team recognized how self-harm can increase stigma and compound inequity for patients like Tarin. Finally, the team went beyond advocating for a single treatment (surgery) and recommended seeking additional help from social services to address Tarin’s behavioral health needs.

We strongly advocate for other clinical ethicists to keep social determinants of health at the top of their minds when consulting on cases, especially those that involve patients from marginalized or stigmatized communities. Clinical ethics programs should include explicit and formal training on social determinants of health, especially since electronic health records often have inadequate and misleading information about what contributes to a patient’s health and healthcare journey. Hospitals can aid in this process by identifying local services that ensure people have access to preventive and follow-up care, including primary care, housing, community mental health, and substance use supports, as well as gaps in those services that need to be filled.

– Devan Stahl and Laura Guidry-Grimes