This week, I read a case entitled “Confronting Death: Who Chooses, Who Controls?,” which contained dialogue between Dax Cowart and Dr. Robert Burt. Dax was injured in a terrible gas tank explosion that left him blind and without the use of his hands. His father was also killed during the accident. Throughout the seven years that he was treated in an acute burn ward, he continually requested that treatment be stopped because of the extreme pain that he was going through, and he attempted suicide three times. Despite being declared competent by his psychiatrist, the doctors ignored his requests and continued treatments until the skin grafts were done, and he was able to walk again. Once again, this case brings up the recurring issue of autonomy versus benevolence. The dilemma is whether or not the patient’s power of autonomy should outweigh what the doctor believes is best for the patient. Should the patient be able to refuse life-saving treatment against doctor recommendation if he is deemed competent? Another question is whether or not the most benevolent act was actually to continue to treat the patient or let him die.
I believe that the doctor’s made the morally correct decision in treating Dax despite his competence and request to have treatment discontinued. Even though psychiatrists declared Dax competent, it doesn’t mean that emotionally he was in the right state to make life or death decisions. He lost his dad in the same accident and was in an incredible amount of pain while he was refusing treatments. It is possible that despite his competence, his judgment was still clouded enough for him not to see that treatment was the best thing for him. Along with the doctors, his family also wanted treatments continued despite his requests.
Usually when we see these cases of autonomy versus benevolence, the patient is refusing treatment and willing to die because he or she is terminal and simply speeding up the process of a quickly approaching, inevitable death. In this case, I don’t necessarily believe the most benevolent act would be to keep the patient alive. If they are in an incredible amount of pain and the treatments are futile, then I think refusing these treatments could be what is best for them. However, in Dax’s case, he is initially refusing treatments because of the pain and possible quality of life (which he later admits was not a factor in his current happiness), but the treatments were going to save his life. And isn’t that the doctor’s duty? To save lives? Of course we want to know that our doctor’s care about our opinions and aren’t being paternalistic, but I would much rather know that my doctor is doing everything in his or her power to save my life than being passive and just waiting for me to tell them what to do. Along with doing what is best for the patient, I would go as far to say that it is a doctor’s moral obligation to save lives when they can be saved. And while it is true that doctors can’t know exactly how much pain their patient is going through, I think it is safe to say that they understand pain more than a normal person. They’ve seen enough pain in their patients to know roughly what can be handled and what cannot. It’s not like they’re completely lacking in understanding of what it means to be in pain. Therefore, I don’t believe Dax’s doctors were acting purely paternalistically when they ignored Dax’s requests and continued to treat him. I believe they were doing what was best for their patient and fulfilling their moral duty by saving his life.
Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2013. Print.
Cowart, Dax, and Robert Burt. “Confronting Death Who Chooses, Who Controls?” The Hastings Center Report 28.1 (1998): 14-24. Web. 20 Mar. 2015.
I completely agree with you here. Dax’s doctors were definitely morally obliged to save his life because not only is the job of a doctor to save their patient’s life, like you said, but the Dax’s circumstances weren’t ones that would call for the doctors to “respect” his autonomy and wishes to die. While Dax was undoubtedly in an excruciatingly painful situation, his chance for survival and for the return to a good quality of life like he had before his accident were too high to respect his wishes to die due to the pain he was feeling in the current moment. Honestly, I would argue that Dax wasn’t even an autonomous individual capable of making that life-changing decision. My only reason for this would be his state of mind. Obviously if someone can escape any type of pain or discomfort they are going to do so – and Dax’s pain and discomfort was on an entirely different level that many of us are incapable of relating to. And I believe that a situation like that truly takes a toll on your mental and emotional capabilities. That being said, I do not believe that Dax was in the correct physical state to be able to make decisions regarding whether or not he wanted to live. While yes, he was experiencing an agonizing level of pain, his chances for survival were far too high for him to be allowed to autonomously choose to end his life.
I also agree with the doctor’s decision to treat Dax despite his competency and constant refusal. While I do recognize that treating a patient who is not mentally incompetent does violate their autonomy, I do believe that it is justified given this particular circumstance. Treating patients with severe burns is difficult for both the doctor to perform and the patient to endure because the patient is in severe pain. Because patients experience a lot of pain when treated for burns, they may express a desire to die. However this decision to die may solely be based on the temporary, short-term pain rather than a rationale analysis of the long term benefits of the treatment. The doctor is not physically enduring the pain that the patient is feeling which means they are more capable of understanding the long-term benefits of the treatment at that moment. Also, when burn patients express a desire to die, they are likely to be expressing a desire to end their pain/suffering. However, when doctors treat patients, they are also trying to end the patient’s suffering. They are not doing that by ending the patient’s life, but rather fulfilling what they believe is their moral obligations as doctors. The doctors in Dax’s case made the right decision because the risk of not treating the burn patient is death which is too great of a risk to take when there is not enough clarity on whether or not the patient’s wish to die is temporary.
In your post, you mention that you do not believe that Dax’s doctors were acting completely paternalistically. I think it is important to remember that paternalistic acts by doctors can be justified. Beauchamp and Childress write that the following conditions can justify hard paternalism 1) A patient is at risk of a significant, preventable harm, 2) The paternalistic action will probably prevent the harm, 3) The prevention of harm to the patient outweighs risks to the patient of the action taken, 4) There is no morally better alternative to the limitation of autonomy that occurs, 5) The least autonomy-restrictive alternative that will secure the benefit is adopted (Beauchamp & Childress 222). If we apply these conditions to Dax’s case, then the “paternalistic” actions of the doctor can become justified. In the first condition, Dax is at risk of dying which in the doctor’s eyes is a considerable harm. Thus, the doctor’s intervention to treat Dax fulfills the second condition because the treatment will prevent death. Of course, one could make the counterargument, that if the “temporary pain” that Dax is experiencing is the harm, then the paternalistic action is not justified. However, in my opinion I view the harm as being the one that would happen in the long-term as opposed to the short-term. The third condition is dependent on how one makes risk analysis. Because I believe that harm is death, then preventing harm through treatment outweighs the risk of the treatment. For the fourth condition, there isn’t a morally better alternative because as I wrote earlier, it is not possible for the doctor, unless the doctor has a long-standing relationship with the patient to know what principles the patient truly values or if their wishes are restricted to that specific time or place. For the last condition, in order to secure the benefits, the doctors must override Dax’s autonomy, so while this may not be granting the patient very much autonomy, it is the only course of action that will secure Dax’s life which is a benefit.
Beauchamp, Tom L., and James F. Childress. “Beneficence” Principles of Biomedical Ethics. Seventh ed. New York: Oxford UP, 2013. 222-241. Print.
Alyssa,
This was a very challenging case for me. I cannot deny the excruciating pain that burn victims experience when undergoing treatment. I can sympathize with the fact that ending one’s suffering by withholding treatment may seem favorable when future peace is inconceivable. While considering his level of agony in analyzing the morality surrounding this case, I agree with your argument that Dax’s physicians made the right decision to paternalistically act on his behalf. Dax may have been declared competent in two different instances by psychiatrists, but I agree that his emotional stability, as a result of the level of physical and emotional pain he was enduring, is compromised and thus impairs his competency.
It is interesting that you draw a distinction between Dax’s case and cases involving futile treatment. I think this distinction is important to keep in mind when addressing overriding autonomy to act in the patient’s best interests and promote life. I agree that physicians have an obligation to respect the autonomy of competent patients suffering from terminal illnesses and undergoing futile treatments. There was a prognosis of recovery following treatment for Dax, which allows for beneficence and nonmaleficence to outweigh autonomy. However, we have to ask ourselves whether promoting life at all costs overrides the allowance of death. I think that autonomy is fundamental to us as humans and suggesting that paternalistic behaviors can deny one’s right to autonomy is worrisome, regardless of the outcome.
I agree with Michelle that we can’t make a blanket statement saying that promoting life at all costs outweighs death. Sometimes I do think that the patient should be allowed to make this decision on their own, and it doesn’t even necessarily have to be when the treatments are futile. If the patient is of course competent and not being persuaded by pain, family, etc., I believe he or she should be able to make their own decisions on whether or not they want to pursue treatment IF the treatment doesn’t have a high probability of working. If the treatments have a high chance of saving their life, I think doctors need to begin to question what is making a patient refuse life-saving treatment, and whether or not they are in the right state of mind (competent or not) to choose death over life. Doctors shouldn’t be able to make quality of life decisions for patients because they don’t know what a patient can or cannot handle. However, I do believe they should make sure the patient understands what can be done to help them after the treatments to deal with their new quality of life, and even express their opinion as healthcare providers with experience dealing with patients in all states of health.
Your idea that it is a doctor’s “moral obligation to save lives when they can be saved”I do not agree with. As the above comments have discussed, saving a patients life is not always the best option. There are circumstances where the harm of living would outweigh the harm done by death. Cancer being the most prominent example as terminal stage cancer patients who have no chance of treatment and are in a lot of pain should in my opinion be allowed to end their life on their terms. Yes, treatment can prolong a patients life and thus “save” it but for only so long. So the question becomes now how to define saving a life. Because you can save a life but in the end everyone dies, so how long of life that a treatments gives or prolongs does it count as saving? Also who gets to decide all of this becomes a major issue.
Second issue I have is that in your argument you argue a doctor should know a patients pain because they’ve seen a lot of pain in other patients. However I would say there is no substitute for experience and thus unless a doctor has gone through the same issues they cannot fully comprehend a patients pain. By your definition of being able to comprehend pain then a torturer would make the best doctor because they can comprehend the most kinds of pains by seeing it.
Third you run into the issue that by using your argument that a doctor should always save something if it can be saved a doctor could justify many things. Power corrupts and so while we would like to assume our doctors to be above that, they are only human. Morally speaking there is no argument that acting in such a way is wrong. However that won’t stop people from abusing the system. One abuse I can see is that the issue with pharmaceutical companies, some doctors may use that principle of saving a patient to put them on a large amount of drugs. And while they may prolong the patients life a little more they are merely earning money for the companies that sponsor them.
Final issue is that in your argument you say that the patient is incompetent emotionally, yet I would argue that because he was certified competent that the effects of emotion were factored into that test. Thus him being emotionally compromised no longer works as a reason for why the doctor could force treatment on him. If he was emotionally incompetent then we could treat him like a depressed patient and since we already have a precedent set this case would be very clear. For depressed patients or other patients who have been declared incompetent physicians have a duty to act on what they think is the best care for the patient. However this is not the case because he was declared competent multiple times and hence the controversy behind the case.