Background
In “Principles of Biomedical Ethics,” a hypothetical situation about a woman with Alzheimer’s is described when looking at The Best Interests standard. The woman, Margo, is a very happy woman who seems to be enjoying her life. The medical student who visits Margo even described her as “one of the happiest people I have ever known.” So we can say that even though Margo is an Alzheimer’s patient, she is clearly living her life with a genuine smile on her face and a great deal of happiness. However, the conflict arises when we are told that during the beginning stages of her condition, Margo executed a living will, which stated that she did not want life-sustaining treatment if she were to develop another life-threatening illness. Well, Margo ends up developing pneumonia and this is where the problem begins.
Dilemma
Margo’s physicians are faced with the issue of whether or not to administer their patient antibiotics in order to treat her pneumonia. If they decide not to give her the antibiotics, they would be acting according to the living will she created and respecting her precedent autonomy, resulting in her death. However, based on Margo’s current quality of life and pure happiness it would seem as though it would be in her best interest to go ahead with the antibiotics, treating her pneumonia and allowing her to continue living her happy life. But by doing so the physicians would clearly be violating the living will Margo executed as she developed Alzheimer’s.
Discussion
In this particular case, Margo’s physicians must administer the antibiotics to treat her pneumonia. In doing so, not only would they be acting under the best interests standard but also under the principle of beneficence, which refers to “a statement of moral obligation to act for the benefit of others,” (203). The health care team has a moral obligation to act in order to benefit Margo. Beauchamp and Childress even mention how “the best interests standard can in some circumstances validly override advance directives executed by formerly autonomous patients.”
The available options here are to either administer the antibiotics, save Margo’s life and allow her to continue living a happy one, or not to administer the antibiotics, act in accordance to her living will, and consequently result in her death. With these two options, the job is to determine the highest probably net benefit and act accordingly. And since the best interests standard requires a surrogate to assess both the risks and probable benefits of several treatments and alternatives – this is inevitably a quality-of-life criterion. That being said, while quality of life is a difficult topic to discuss, it is clear in the description of this hypothetical case that Margo’s quality of life is high. As previously mentioned, she is seen as one of the happiest people some of the people working with her have ever known.
Moreover, Beauchamp and Childress address the fact that as person “slips into incompetence,” as Margo is currently doing, their living condition can drastically change, sometimes for the better. They continue to say that “if so, it seems unfair to the now happily situated incompetent person to be bound by a prior decision that may have been under informed and shortsighted.” When Margo made her advance directive, she had just been informed about her condition and more likely than not thought of the worst rather than the possible best. She wasn’t in the right mental or emotional state to be able to make a completely cohesive decision about future treatments. Beauchamp and Childress even say that advance directives “generate practical and moral problems.” One of those problems being that they “fail to leave sufficiently explicit instructions.” In Margo’s case, she stated that she did not want life-saving treatment, but to what extent is something truly a “treatment?” Antibiotics are entirely different than having to undergo a major surgery; taking pills aren’t even invasive. So it would seem as though these antibiotics wouldn’t exactly fit the mold Margo made for “life-saving treatment,” as she most likely anticipated developing something much worse that required a more invasive course of action.
This is quite honestly all the information we need to make the ethically correct decision here. The fact is that Margo is an extremely happy woman enjoying her life – even if it’s one of incompetence – and as her surrogate decision maker and health care team, they have a moral obligation to act in her best interest, which is clearly prolonging her life.
Beauchamp, Tom L., James F. Childress. Principles of Biomedical Ethics. 7th ed. N.p.: Oxford University Press, 2012. Print.
I would totally have to agree that in the end the physicians made the right decision. Prolonging Margos life is in her best interest. I really thought that it was important to reference Beauchamp and Childress discussion of advance directives “generate practical and moral problems.” As it brings to attention how specialized every one of kind- life-saving treatment can be. And because they are unpredictable its hard to make explicit instructions which will best suit the situation, as we see inn Margo’s case, the decision to give an antibiotic boils down to a life-saving treatment, which is not usually the case. Do you think Margo is going to happy with the doctors decision in this situation?
I agree that treating Margo was the correct decision. I believe that if Margo was still considered a competent person, then the decision over whether or not to treat her becomes much more complicated. Since Margo is not considered competent, the decision is ostensibly much more straightforward. To me, if Margo was considered competent, I would have had the opposite conclusion. Since Margo created the living will with full understanding of the ramification, if she got pneumonia, it ought to still be her decision to choose not to receive treatment. This would make the case a much more difficult one to solve.
I agree that treating Margo is the best choice. When creating a living will, people often think of the worst case scenarios such as being hooked up to a ventilator or put in a medially induced coma. They don’t consider minor life-saving treatments such as antibiotics. In order to live as long as she had, Margo had probably taken antibiotics before. I think that the living will becomes ambiguous in such a minor lifesaving intervention. Because it is not completely clear what Margo would have wanted, I do not think it violates the principle of autonomy to administer antibiotics to Margo.
Mikaila,
I think you make some interesting points. I agree with your argument that The Best Interests standard is applicable to this case when considering whether Margo should be treated for her pneumonia. It is in Margo’s best interest to be treated against this life-threatening illness. Allowing the patient to suffer from pneumonia when effective treatment exists violates the principle of nonmaleficence. Weighing the risks and benefits, administering antibiotics to Margo is the best choice. However, when considering living wills, I think that a patient’s autonomy at the time of the living will’s creation should be respected if the patient is later deemed incompetent. Patients create living wills in anticipation of future life-threatening medical decisions in order to ensure that their wishes are heard when they are unable to express them. Physicians and surrogate decision makers should not override living wills on the grounds that the patient was not educated about the current case at hand when making their will. It is impossible to predict every detail of future medical complications, but this notion should not negate the fact that living wills should be regarded as legitimate.
In Margo’s case, her living will states that she does not want “life-sustaining treatment” should she experience another life-threatening illness. Pneumonia if left untreated can lead to death, but treatment for pneumonia is relatively noninvasive and does not qualify as life-sustaining treatment, as you have stated. Taking this into consideration, treating Margo’s pneumonia does not violate her living will because the treatment is not a heroic or extraordinary procedure. Extending your argument, I agree that ambiguity surrounding living wills can be abated through more explicit and detailed instructions concerning medical care.
Great explanation of the case.I think the doctors rightfully treated the patient in this case. I believe that we need to thoroughly define “life-threatening illness” in this case. I think we need to define the illness based upon the treatment. I can understand that the patient would not want to go through an invasive treatment that had a harsh recovery, but i think a non invasive treatment is in a completely different category. The effects of chemotherapy are very different from the effects of antibiotics. I believe the rigorousness of the treatment needs to be taken into account when define what a ” life-threatening illness”.