Dilemma
In case 1.1, patient Marie François is refusing life-saving surgery. While analyzing this case, I focused on the physician’s major predicament – deciding whether to respect Marie’s autonomy in refusing a second surgery or complying with her children’s insistence. Each side merits valuable consideration because both parties believe they are acting in the patient’s best interest.
Reflection
This argument has multiple nuances, but I would like to center my reflection on the relationship between Marie and her medical team. It seems to me that one of the major reasons for Marie’s refusal for surgery is her mistrust of the health professionals who are providing her treatment and who are apparently disregarding her complaints. In fact, the case states, “she didn’t want the surgery because she no longer trusted the doctors providing her treatment and no one was taking her complaints seriously” (72). I think it is imperative for the healthcare team to regain Marie’s trust. The patient’s mistrust is negatively impacting her health outcomes because she has constructed a mental barrier against her physicians. I think this barrier is affecting the way the patient is processing and understanding information that is presented to her. I believe this issue of mistrust could potentially be mended and trust could be re-cultivated. If regaining her trust is not possible, the current surgeon should offer Marie (and her family) the option of working with a different medical team. I arrived at these conclusions due to the discrepancy between Marie’s willingness to receive the first operation and her refusal to consent to the second one. Marie’s children believe their mother’s expressed wishes are out of character. Specifically, her son Jacques “declared that his mother was behaving abnormally and insisted that she really did not understand the consequences of her refusal of surgery” (72). This discrepancy is possibly due to the suffering that Marie experienced following her first operation and the lack of acknowledgment and responsiveness from her healthcare team.
Comparison
According to the University of Washington’s Ethics in Medicine site, one of the elements of a fully informed consent is “assessment of patient understanding”. The following is the background information for a similar case involving patient refusal. A 55-year-old man with a 3-month history of chest pain and fainting spells needs cardiac catheterization. However, although he demonstrates understanding, he refuses the intervention. In the discussion section following the case description, the WashU bioethics resource recommends discussion and an exploration of the patient’s reasons for refusing treatment. Although a patient’s autonomy and treatment refusal should be honored, a refusal is not the end of a discussion. This patient’s refusal could be tainted with negative feelings towards the healthcare team, that should be discussed and addressed in an honest and straightforward way.
Works Cited
Ludwig, MaryJo, MD, and Wylie Burke, MD PhD. “Physician-Patient Relationship.” Ethics in Medicine. University of WashingtonSchool of Medicine, Web. 6 Feb. 2015. <http://depts.washington.edu/bioethx/topics/physpt.html>.
Thomas, John E. “Case 1.1 When Physicians and Family Disagree.” Well and Good: A Case Study Approach to Health Care Ethics. 4th ed. Peterborough, Ontario: Broadview, 2014. 71-76. Print.
Image Sources
http://blog.himss.org/2014/05/28/from-compliance-to-engagement-reimagining-the-patient-relationship/
http://sailthesevencs.weebly.com/why-the-cs.html
I agree that in this case Mrs. François was struggling with trusting her doctors but I do not think that is the whole story. In my opinion, part of autonomy involves adjusting your perspective to each new circumstance while keeping your values in mind. In this case, Mrs. François underwent a previous surgery that she fully consented to. In that surgery there were complications that led her to be in a state required another surgery to save her life. I think we should also consider Mrs. François hesitation for another procedure because the last one put her in serious harm. In the US, both doctors and patients are very quick to choose an aggressive surgical option instead of a more conservative route. Many of us forget to factor in the risk of any simple procedure. Medical errors are one of the leading causes of preventable deaths in the US a year. It is easy to overlook this fact because we have confidence in our medical professionals but in this case Mrs. François has every right to consider the risk of another procedure. I believe this dimension of the case was not correctly factored into Mrs. François reasoning.
When I read this case, the point the author of this comment focuses on was also the most salient to me. It appears to me that Ms. Francois has been traumatized by the poor results after her first surgery. However, it is also true that she used her autonomy to consent to the surgery as well as all that could result from it. She was, I assume, aware of the risks involved. Also, doctors are assumed to practice beneficence and non-maleficence. We can be fairly sure that the unfortunate consequences after the surgery were the result of honest mistakes. Ms. Francois is suffering, but she should also realized that refusing surgery to correct the mistakes made could cost her her life. I like the author’s idea that she seek out another physician to do the surgery. Then, she can avoid the negative associations here experiences have made her have between her previous medical team and her well-being.
As I said previously, Ms. Francois has been traumatized by the admittedly horrific aftermath of her surgery. Thus, she is no longer competent to make decisions about her own health. Her son, who we presume to know her very well and who noted that her decision was out of character, should give surrogate consent so that her life can be saved. He can request a different doctor to perform the surgery to provide his mother some peace, but he should ensure that the surgery does occur.
Beatrice,
I think that you make a valid point in addressing the reasoning behind why Mrs. François would refuse surgery. The relationship between the patient and physician is often critical in decision-making. I agree that the extenuating circumstances surrounding her first surgery may lead her to fear another surgery with additional complications. She may have lost faith in the medical team, as you suggested. I do not think she wishes to die but rather is experiencing great distress. The response from Mrs. François’s children is evidence that she is acting out of character, but she remains a competent and autonomous agent, as her notes seemed both “rational and sensible”. I do not think that the family can morally override her decision and consent on her behalf. If possible, gaining her reasoning behind refusing to have the surgery can shed light on her understanding and competency. I agree that the presence of a new medical team may change Mrs. François’s decision to refuse surgery. In light of the legal actions threatened to arise in the event that surgery is or is not performed, further educating Mrs. François about her situation and understanding why she feels so strongly against additional surgical intervention would be most effective.
I agree with Beatrice’s focus on the distrust that Mrs. François imparts on the medical team. Furthermore, I think it is imperative for the team to make attempts in order to regain their patient’s trust. If medical teams, in general, gave up after making a mistake during a surgery, then I believe a larger proportion of society today would hold a strong distrust in the medical system. According to the European Journal of Public Health, “rather than assuming that high standards of care will be provided, the public increasingly requires information that this is the case” (European Journal). This open and honest relationship between the patient and the healthcare official is essential in founding a basis of trust. Once that trust is breached, it is often difficult for the patient to reestablish that original open and honest relationship. However, in such scenarios I believe it is the medical team’s responsibility to assure the patient that their open and honest relationship is even stronger than before. In this case, unless the medical team goes above and beyond in providing Mrs. François with the truth, I agree with Beatrice that the medical team should extend an offer to Mrs. François to transport her to a different hospital with a new medical team.
Source:
Trust relations in health care—the new agenda. Rosemary Rowe , Michael Calnan. The European Journal of Public Health Feb 2006, 16 (1) 4-6; DOI: 10.1093/eurpub/ckl004