Text Discussion
According to Terrence Ackerman, a physician’s non-interference is essential for respecting a patient’s autonomy in the post-1982 health system. However, Ackerman argues that noninterference fails to account for the transforming effects of illness. Without the adequate knowledge and skills, a patient cannot accurately assess his or her own condition. Additionally, mental health factors such as denial, depression, or fear may hinder patients from making choices that are in harmony with their life plans. For example, depression may prompt a patient to refuse treatment, which is out of character with a previous full commitment to treatment. Ackerman argues that noninterference is not the best course of action. However, the alternative creates a slippery slope in which vulnerable patients may be harmed by carelessness.
I do not think autonomy is upheld when a patient refuses life-saving treatment out of denial, depression, or fear, and the physician accepts this decision without question. In certain cases, there should be limits to how much autonomy a patient has. In my understanding, in order to help the patient maintain as much desirable autonomy and control as possible, patients should be able to, for example, choose what they would like to consume (from a list of approved food items), what they would like to do in terms of entertainment in their hospital room, which visitors they would like to have, and other such considerations.
Our society has entrusted the health of individuals in the skilled hands of physicians. However, the physician cannot always take the totality of a patient’s experiences into consideration. By engaging in a thorough conversation with the patient and family members, the physician can begin to ascertain the patient’s psychological and social situation and help them make a decision that promotes optimal autonomy.
Current Event Application
On Tuesday, March 24th, Germanwings flight 4U 9525 from Barcelona to Duesseldorf crashed in the French Alps, killing all 150 people on board. Investigators found antidepressants in the co-pilot’s apartment and discovered that co-pilot Lubitz had been treated for severe depression in the past. A Duesseldorf clinic confirmed that Lubitz visited the clinic as recently as March 10th to receive a mental health diagnosis. Torn sick notes were found in his home, which showed that the co-pilot was suffering from an illness that should have grounded him on the day of the tragedy.
Lubitz was declared “unfit to work” by a physician, but he concealed his condition both from the Lufthansa airline and his immediate professional environment. Under the current aviation system, pilots are required to self-report if they are deemed unfit to fly by a physician. It seems to me that this self-reporting system presents a conflict of interest. What happens if a pilot is afraid of losing his work? What happens if a pilot is in denial about his condition?
With the knowledge that the patient was responsible for hundreds of lives besides his own, the physician should have reported the condition to the most relevant and important individuals at the airline. In the least, the physician could have made certain that the patient had initiated the self-reporting process. The condition was not a minor one that could be easily overlooked. I believe the physician would have protected the co-pilot’s future autonomy by intervening and reporting the condition to the airline. Potentially, all 150 innocent lives could have been spared, including the co-pilot’s.
Works Cited
Ackerman, Terrence F. “Why Doctors Intervene.” The Hastings Center Report (1982): 14- 17. JSTOR. Web. 28 Mar. 2015. <http://www.jstor.org/stable/3560762>.
“Andreas Lubitz: Torn-up Sick Note and ‘mystery Illness’ Raise More Questions about Co-pilot.” Euronews. Web. 28 Mar. 2015. <http://www.euronews.com/2015/03/27/andreas-lubitz-torn-up-sick-note-and- mystery-illness-raise-more-questions-about/>.
“Doctor Had Excused Co-pilot from Work on Day of Tragic Flight 9525.”Euronews. Web. 28 Mar. 2015. <http://www.euronews.com/2015/03/28/doctor-had-excused-co-pilot-from-work-on-day-of-tragic-flight-9525/>.
“Reports: Antidepressants Found at Home of Co-pilot Andreas Lubitz.” CNN. Cable News Network. Web. 28 Mar. 2015. <http://www.cnn.com/2015/03/28/europe/france-germanwings-plane-crash-main/>.
Beatrice –
I wholeheartedly agree with your assertion that a self-reporting system of medical disclosure at the workplace is internally flawed. Aside from the general fears of losing one’s job, there is also the understood stigma and judgment that comes with the label of any mental illness. I believe this protocol, however, is more an issue of medical privacy laws that are currently in effect. HIPAA states that disclosure of medical information to persons not immediately pertinent to the diagnosed illness or care-giving of the affected individual is illegal and that only personal disclosures can be allowed, meaning that for further information regarding someone’s condition you would have to ask them directly. This, likewise, works both ways. The same way an employer cannot force someone to disclose medical knowledge, a physician cannot assure themselves that disclosure has occurred. Such is commonly the problem with Parkinsons’ patients that believe for as long as they are not showing tremor symptoms, they don’t have to tell anyone what is going on – even if they work in a dangerous field where the slightest mistake could mean death like handling construction equipment.
I believe simply changing this system isn’t the solution either given that the privacy acts are there as a measure of protection. Were every HIV-positive patient required to disclose their condition to any person that has even the slightest chance of being in contact with the body fluids (so everyone on a bus would need to know in case they sneeze or cough, for example), the humiliation and potentially danger these patients would face would be exponential. I do believe this is an issue that must be tackled however. Catastrophes like this plane crash that are completely avoidable must be avoided if possible. We just need a way to do so without putting others at jeopardy either.
I too agree completely with Beatrice and you, Kelsea, that the self-reporting system of medical disclosure is internally flawed. However, while HIPAA may be a valid excuse in some instances, in this particular case, concern for the pilot’s medical privacy does not hold precedence; the safety of the flight’s passenger’s does. Therefore, I would not find it morally unjustified if the doctor made sure that the his patient, the pilot, disclosed his medical illness to the airline company. If the pilot was afraid of stigma, there must be a way to simply say, “My doctor said I’m not clear for flying.” If his employers ask why he can just say, “I do not feel comfortable disclosing that information.” He is not obligated to explain what his medical condition is; he could just leave it at that.
Furthermore, the fact that the pilot was severely depressed and the doctor did not report it makes the doctor even more at fault in my opinion. The depression has already compromised the pilot’s mental soundness and the pilot was most likely in denial since he ripped up the doctor’s reports of depression. Ultimately, I think there is nothing wrong with a doctor violating his patient’s right to privacy. One of the many roles a doctor has is to ensure that the least harm is done to as few people as possible, and this doctor clearly failed at that task.
As we are familiar with HIPAA. I began to research if it was the doctors jobs to take initiative and inform the employer if they feel the patient is unfit to continue with work. HIPAA states that basically there are stipulations which would allow for an entity’s breach notification. The website outlines that obligations differ based on whether the breach affects 500 or more individuals or fewer than 500 individuals. If the number of individuals affected by a breach is uncertain at the time of submission, the covered entity should provide an estimate, and, if it discovers additional information, submit updates in the manner specified below. As i began thinking more about the case I wondered if the doctor knew that the pilot was currently working. As it is the doctors responsibility to have collected and reviewed this information, I find it strange that the doctor did not begin accessing how such a serious diagnosis would impact the patient. Asking questions like “Are you currently working?”, may have saved the lives of the innocent soul on the plane, and also helped him rationalize how imperative it was to make sure that the employer is made aware of the patients new mental state. Though I do think that HIPAA is a good thing, in situations like this it is a doctors responsibility to make sure that all possible parties involved be made aware of the risk that the patients new diagnosis poses. I think there is nothing wrong with a doctor violating his patient’s right to privacy.
I see a similarity here in a way between this case and the case we dealt with earlier regarding the physician who was informed of the murderous intentions of his patient. He did not disclose this information to anyone and his patient killed the woman. This case is functionally the same. It seems like in certain fields there would need to be some system in place for medical officials to remove their patients from their jobs. Pilots would be clear example, though it could include other fields like law enforcement. These are places where the medical condition of the one person has the potential to affect many others, and disclosure should potentially be an option for the physician if they need to.
Beatrice, I think your assertion that the intervention of the physician would preserve the future autonomy of the pilot patient is a really intriguing one. As you mentioned, Ackerman argues that disease inevitably affects a patient’s perspective and decision-making. As a result, a disease can heavily impact a person’s autonomy in the sense that it impedes their normal line of thinking. Therefore, the intervention of a physician can preserve a patient’s future autonomy by protecting the patient during the time frame that they are experiencing disease. I think that there is a lot of merit to this idea, particularly because of your example where a pilot’s mental illness led to the death of 150 civilians. However, my concern is that this assertion seems to disregard the decisions made during the time frame of patient illness. If taken to the extreme, this mentality can easily lead to hard paternalism by physicians because the line of thinking becomes “the patient is not in their right mind because they are ill.” Though I think there are cases where a patient’s autonomy should be limited based on the severity of their illness, this assertion should also be taken with a grain of salt.
I really find this discussion about the recent case both complex and delicate. It is true that the self-reporting system is problematic as it relies on the pilot being in an altruistic state of mind. However, conditions like depression and anxiety disorder can make taking the step of notifying one’s employer unpleasant. Also, it seems that both Beatrice and the other commenters feel that doctor’s should report or check to ensure the pilot, or others who are diagnosed with a mental illness, report their illness to the appropriate supervisor or authorities. It is true that, in the Germanwings case, such a report would have most likely saved 150 lives as well as the death of the co-pilot.
However, I also think that it is important to consider the reason why doctors almost always try to ensure their patient’s privacy and partly why HIPPA was created to enforce this privacy. Without absolute trust, many people would never seek out healthcare. Whether it be that one is involved with illegal substances or has received a wound after an illegal activity, currently, most people trust that they can receive unbiased care from a doctor. Also, one of the arguments presented for why doctor’s respect Jehovah’s Witnesss’s choice to not receive blood is that this prevents general animosity by a fairly significant population against the healthcare system. At the end of the day, healthcare is primarily focused on the care of the health of the patient first and then of others secondary, if at all. Thus, if a patient is diagnosed with a mental illness, I think that it most likely best for society in general if doctor’s are held to the same standard of privacy. Without such a maintenance of privacy, many more would avoid going to receive mental health services in the first place and it is possible that more harm would come about. In this case, I think that respecting a patient’s autonomy by maintaining confidentiality is of primary importance in order to ensure that beneficence is available to all people who are in need.
Pushing what was stated above further, I think this case calls into question where the line needs to be drawn. Should this say that every employee in a profession that may involve the safety of others should be required to disclose their medical history to their employer? Even though there are regulations and the self resorting system is in place, I couldn’t help but to think what if it was required that these types of professions required all of it’s employees to lessen their autonomy so they could be monitored to prevent harm to innocent others. Would the employer be responsible for this monitoring and deciding if one is unfit? If so, would they have to hire their own set of doctors? What would this monitoring entail? There is such a fine line because seemingly harmless actions can ultimately affect one’s cognitive and/or physical abilities; therefore, the employers would have to monitor almost every aspect of the employees life to ensure the highest level of safety. For example, what if a pilot forgot to eat breakfast. This lack of food could lead them to have slower reaction time, trouble focusing, etc. Would each employee be required to submit their daily actions in order to meet the standards required of them to function at a safe level? I do realize that mental illnesses carry more weight than daily meals but I think there is a very slippery slope because seemingly unimportant factors may lead add up and lead to functioning deficits. I also think that requiring access to all medical records can lead to stigma. If an employee is having a bad day or is tired they may be reduced to their medical label rather than having their full circumstance taken into consideration. I do not know what the answer would be to ensure peoples’ safety but I think going forward they need to be very careful when thinking about how much monitoring should be allowed because it can easily start to reduce autonomy and breech privacy.
I agree that the doctor should’ve intervened and at least made sure the patient started the process of self-report, but i do not think we can say that in all cases. I believe it depends on the occupation. In some lower paying and risk jobs, people are fired due to a diagnoses that a company does not want pay for. So what do we do in those situations? A doctors obligations is to the patient, and doing what is best for the patient is at times very complicated. A diagnosis could cause a patient to loose his/her only source of income and that is very detrimental to the patient.
Clearly the airline should have been notified of the physician’s declaration of the pilot’s status, but I do not think the physician is to blame. If the system is one of self-report, then it is the duty of the pilot to inform the airline, not that of the physician. While I do believe the pilot should have probably made some form of an effort to make sure the airline received the report, the physician realistically was busy and had many patients to cater to. The self-report system itself is flawed in the sense that the pilots may be receiving external pressures to continue working, resulting with the failure to submit the report. In an industry such as aviation, where many lives are at risk, the protection of the pilots needs to be a top priority, as they are the ones who are depended on every day. With the self-report system, the protection of the pilot on flight 4U 9525 was not adequate. The system needs to be changed for the protection of the pilots, and also the clients as well. While a direct notification from the physician to the airline would, in a way, be in violation of the pilot’s autonomy, withholding crucial medical information about the pilots can be argued to violate the autonomy of the clients. When a client purchases a plane ticket, he or she is making a competent and educated decision to board an aircraft which is supposed to be safe with a healthy and approved pilot. If the pilot is clinically depressed, then the client is unknowingly making an uneducated decision to purchase the ticket. Typically when we discuss autonomy, we refer to overriding the decision-making of an individual. In this case, it’s from the opposite angle – instead of overriding the decision-making, the decision-making is now misled. Purchasing the ticket for that flight was not to Duesseldorf, it was to the French Alps. So while a change in the system may violate the autonomy of the pilot, the autonomy of all the clients will be protected.