Displaying Moral Courage in Providing Discretionary Treatment in a Technologically Advanced, yet Resource-Limited Setting.

In our day-to-day clinical practice, we face several ethical dilemmas. Although we have a moral conscience, we are constrained by many factors in executing the right decision. It is in this context that courage to stand up for one's ethical values and make the right decision, even if we get penalized, is important. Four case scenarios from a large tertiary care hospital which provides care to patients belonging to all socioeconomic strata are described. The institution offers subsidized/free treatment to "deserving patients", and this subsidy is entirely decided upon by the treating medical team. With limited resources for subsidized treatment, we are often in a dilemma as to how much of financial support should be given and how to prioritize beneficiaries between those with acute illnesses versus those with chronic disabilities/cognitive impairment. With access to advanced investigations and treatment modalities, management individualized to patients becomes a daily challenge for the medical team. The ethical dilemma associated with these case scenarios and the moral courage shown by the decision makers in each case are discussed. Clinicians often rely on "phronesis"-the ethical decision-making grounded in an accumulated wisdom-when confronted with ethical dilemmas. The professional virtues such as compassion, discernment, empathy and integrity form an integral part of decision-making intertwined with the basic ethical principles of beneficence, nonmaleficence, autonomy and justice. Moral courage is often required to implement these virtues especially in the face of the opposing pragmatic realities of clinical practice.