Case
This is a case about John, a 26-year-old man, who has Neurofibromatosis, also known as elephant man’s disease, a neurological disease in which non-malignant tumors attach to the body’s nerves. This disease causes severe disfigurement and radical impairment of bodily functions. John was first diagnosed when he was 7-years-old and in the last 20 years, he has had over 100 surgeries to try to remove the tumors. These surgeries have had severe side effects resulting in John being deaf, partially blind, almost entirely paralyzed, and in need of a respirator to keep breathing. The medical professionals that have been caring for him say that there is no chance of remission. Based on his past experience, John has requested to not have anymore surgeries and for the medical professionals disconnect him from the respirator, which will inevitably cause his death. His family initially strongly disagrees with John but is ultimately convinced to support him. The medical team says that he would be able to live for years on the respirator but they too are prepared to disconnect it (Tomas and Wilfrid 209).
Dilemma
In this case the doctors face a dilemma between nonmaleficence and respect for autonomy. They have previously been acting under the principles of autonomy and beneficence because John had given consent to his previous surgeries and the acts that were taken were done so to save his life. The situation has changed and now beneficence has turned into a question of nonmaleficence.
Discussion
I argue that the doctors ought to disconnect the respirator and allow John to die. Nonmaleficence is in question because if they unplug the respirator they are technically doing an act that will cause harm because they are aware that John’s body cannot sustain his life alone. Since John has changed his mind about what he consents to, the doctors now have to balance between their respect for his autonomy and their value of doing no harm. The basis of autonomy starts with John’s competence. The doctors have described him as “fully alert, conscious, and in control of his mental faculties” (Tomas and Wilfrid 209). That description proves that John is considered a competent patient. The doctors ought not to question John’s competence when he expressed his wishes to allow his disease to take his life. He has shown a full understanding of his situation. He is aware that he has had countless surgeries yet he is not improving. This case also calls one to look at the distinction between killing and letting die. These doctors are technically killing John because they are taking an action that will result in his life ending but it is not that clear. This case blurs the lines between killing and letting die. Once the doctors take that action they are letting him die because once he is unable to breath they will intentionally not put him back on a respirator. Beauchamp and Childress state that part of letting one die is that “disease, system failure, or injury causes death” (Beauchamp and Childress 175). I argue that John’s brain disease will ultimately end his life, not the doctors. The medical team also does not feel comfortable with giving him a strong enough dose of medication that will accelerate his death. They are morally correct in this because that would enter the realm of killing rather than letting him die. Beauchamp and Childress go on to state that it is acceptable to let one die if the “medical technology is useless… or patients or their authorized surrogates validly refused a medical technology” (Beauchamp and Childress 175-176). In John’s case both of these conditions are met. The medical technology, surgeries and a respirator, have not been successful in treating him rather they have just kept him alive and, as stated above, he has now refused the technology. McIntyre gives further support of the moral acceptability for a physician to withdraw a life sustaining treatment because he is doing it “only to respect his patient’s wishes and ‘to cease doing useless and futile or degrading things to the patient when [the patient] no longer stands to benefit from them” (McIntyre 62). Nonmaleficence can be further specified in this case as do no harm except if the patient is competently refusing medical treatment and has no real hope for improvement. The medical team ought to disconnect the respirator and is morally justified in doing so.
References
Beauchamp, Tom L., James F. Childress. Principles of Biomedical Ethics. 7th ed. N.p.: Oxford University Press, 2012. 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.
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http://geneticdisorders247.wikispaces.com/Neurofibromatosis
I agree that the team should respect the patients wishes and withdraw the respirator. In Beauchamp and Childress they also discuss the tricky concept of withdrawing and withholding. Withdrawing a treatment is often more controversial because it is an active decision that leads to death. However, in this case we are also considering the patients wishes as well as their quality of life.
Great analysis of the moral dilemma of removing the respirator. Perhaps another aspect on nonmaleficence that was not touched on as much is examining the potential harm of continuing to treat John. Multiple surgeries in the future could be physically very painful and John’s tumors, blindness, deafness, and need to be on a respirator damage his quality of life which could also cause him significant psychological distress. One could examine nonmaleficence from the standpoint of whether dying peacefully causes more harm than continuing to live a life filled with constant and growing pain.
In response to Elizabeth, I completely agree with you. John has already suffered from many adverse side effects of his treatment. We can consider the direct side effects of procedures but we often forget about the risk of medical errors and hospital borne infections. The more procedures John undergoes, the greater the risk for a mistake to happen. It is estimated that medical errors and hospital borne infections either contribute or cause about 400,000 deaths a year (this estimate is on the high side) (http://www.propublica.org/article/how-many-die-from-medical-mistakes-in-us-hospitals). Keeping John alive and exposing him to more procedures can very well end up causing him harm due to pure risk of treatments.
I think this case is clear cut in the action that should be taken. The patient himself seems to be competent and is making a conscious decision. If he were unconscious then it would bring up the argument how to judge his quality of life yet as the person living his life he himself knows his own life the best. Now the question of non-maleficence is up in the air but it’s more of a debate that would dying cause more or less harm then living his life. However as stated above the patient himself believes his quality of life will not improve and experts of told him he will be unable to remove the disease. Thus I believe it would cause far more harm to the patient to keep him alive against his will than to let him die. Furthermore if he is not allowed to die then that brings up the slippery slop argument of the family being able to override a conscious competent adults decision. Thus the best course of action would be to comply with the patients wishes.
In my opinion, the team has every right and responsibility to respect John’s wishes in removing the respirator. In balancing the patient’s autonomy (respecting one’s wishes) and nonmaleficence (minimizing harm), it is essential to assess the patient’s competence. As John has been ruled fully competent, it is ultimately his decision to be taken off of the support that the respirator provides him. Furthermore, as a competent individual, John has assessed his quality of life to be so poor that the thought of enduring more surgical procedures is unbearable. Why should he continue to suffer?