Blog 1:

Case 1:1 When Physicians and Family Disagree

Background:

Mrs. Francois was diagnosed with an ovarian cyst and underwent a hysterectomy and bilateral oophorectomy during which a bowel laceration occurred and was sutured. Six days after surgery, Mrs. Francois began to develop severe abdominal pain, became hypotensive, and later went into respiratory distress. Testing revealed that the suture line on her colon had split open. In spite of this, her condition improved, she appeared to be quite aware of her surroundings, and she was able to communicate via written notes. Upon informing Mrs. Francois of the need to operate, she refused surgery. Deeming her actions to be out of character and abnormal, her family attempted to consent to the operation on her behalf.

Dilemma:

The dilemma in this case is whether the doctor should operate, thus providing the patient with life-saving medical care, or not operate and thus honor the patient’s right to self-determination. The main tension in this case is that of autonomy vs. non-maleficence.

Class Connection:

This case reminded me of Mr. G’s non-consensual electroconvulsive case that we discussed in class in that they both involve a conflict between autonomy and non-maleficence. However, in Mrs. François’s case we add yet another complicating factor: the family disagreeing with the course of action insisted upon by Mrs. François. It is interesting to consider the moral implications of Mr. G taking his life knowingly via action (suicide) vs. Mrs. François accepting death (also knowingly) through inaction.

Critical Analysis:

Mrs. François originally presented with stress incontinence or the leakage of urine during physical activity or exertion (Stress incontinence: MedlinePlus Medical Encyclopedia). Presumably, she sought out medical attention because she found this incontinence to be inconvenient and/or embarrassing. She now lies in a hospital bed in immense pain with a fever, a distended belly, and a perforated colon, and the prospect of death. Compared to her initial condition, her current condition is markedly worse. Her ovarian cyst was not presented as being life-threatening, but the dehiscence of her colonic suture could prove fatal. One might conclude that Mrs. François no longer trusts her gynaecologist and is therefore unwilling to undergo a second surgery for fear of further complications and more pain. Although one might argue that this fear may impede her ability to make an autonomous decision, I would argue that her fear should not be discredited and her decision honored.

Another consideration in this case is quality of life (should Mrs. François chose the life-saving surgery). Will Mrs. François be able to return to normal day to day activities? Or will future surgeries result in a reduced quality of life? Although the case does not state the potential consequences of a second surgery, it is likely that the dehiscence of the colonic suture line following Mrs. François’s first surgery has caused some of the surrounding tissue to become non-viable. This non-viable tissue would likely have to be resected and a colostomy procedure performed. A colostomy would require Mrs. Francois to empty her feces from a colostomy bag on a daily basis. Given her morbid obesity, it is likely that someone would have to assist her with this task. Perhaps Mrs. Francois wishes to preserve her dignity and does not want to deal with these consequences.

Although one might argue that it is the physician’s responsibility to minimize harm and thus to perform the life-saving surgery, we might also argue that the physician did not fulfill his responsibility during the first surgery as it resulted in physical harm that inflicted far more pain than her original ailment. Furthermore, by inflicting harm on others, he might be considered to be of lower moral status (and a less respected physician). Additionally, according to Childress, the requirement that a physician obtain the informed consent of his patient to perform a medical procedure is primarily in place to protect autonomous choice, not to minimize the potential for harm (Childress 63). Still, some might argue that Mrs. Francois is not competent and therefore incapable of making an autonomous decision. Based on her level of awareness, ability to communicate, and the fact that most of her family did not feel as if she was acting out of character, I would argue that Mrs. François is competent and fully capable of making an autonomous decision. Therefore, her family members should not exercise surrogate autonomy. Given these reasons, the physician ought to honor Mrs. François’s self-determination and with stain from operating.

References:

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 5th ed. New York, N.Y.: Oxford UP, 2001. Print.

Thomas, John E., and Wilfrid J. Waluchow. Well and Good: A Case Study Approach to Health Care Ethics. 4th ed. Toronto: Broadview, 2014. Print.

Wolff, B. G., Viscusi, E. R., Delaney, C. P., Du, W., & Techner, L. (2007). Patterns of Gastrointestinal Recovery after Bowel Resection and Total Abdominal Hysterectomy: Pooled Results from the Placebo Arms of Alvimopan Phase III North American Clinical Trials. Journal of the American College of Surgeons, 205(1), 43–51. doi:10.1016/j.jamcollsurg.2007.02.026