Background
Case 8.1 introduces the case of Janet. Janet is a 44-year old woman on welfare who was separated from her husband and is the mother of two children. Janet Greene, was admitted into the intensive care unit being severely injured in car accident. She was treated for her fractures and abdominal injuries. She developed acute renal failure, but was treated with peritoneal dialysis. After recovering, Janet was discharged only to suffer from a second bout of acute kidney failure after being home for 3 months. Her physician expressed that Janet was in urgent need of dialysis because tests revealed high levels of potassium. However, when Janet’s physician tried to get Janet’s admitted to two, different tertiary hospitals in the area, the hospitals reported back that they did not have any space for Janet to be treated. After asking if Janet could take the place of another patient with a poorer prognosis, the hospital expressed that they had “first come, first serve” policy
Reflection
Janet’s case is one that is morally difficult because it raises challenging questions about micro-allocation and quality-of-life decision-making. For many people including the hospital policy-makers in this particular case, a “first-come, first-serve” or lottery type of system is the most equitable way of deciding who gets to use the resources. While I can understand having this type of system does not have to involve having to make quality of life decisions, I do not agree with the hospital’s decision to completely decline exploring the physician’s request as a possible option. Unfortunately, in a world with few resources, but many needed services, a “first-come, first serve” is not necessarily always morally justifiable. A “first-come, first serve” policy in this case seems to be a “short-cut” or easy route in order to avoid making difficult decisions. In Beauchamp and Childress, they write that the “first-come, first-serve rule” can have the potential to lead to injustice (Beauchamp & Childress 290). How can a first-come, first policy justify refusing treatment to a patient who has a moderate to high chance of survival in order to continue treating another patient who only has very small to no chance of survival? In this particular case, Janet is being denied treatment even though there is a chance that she may have a higher chance of survival than another patient. The hospital argues that this approach is “fair”. Although an egalitarian may agree that their approach is fair, a utilitarian would most likely argue that it is not fair. I am arguing that for utilitarian approach in this case. The ethical course of action would have been for the hospital to assess who would have the highest chance of benefiting from treatment. The hospital should have made a decision based on medical/scientific evidence. The utilitarian approach is the most ethical because it minimizes the most harm for the most people.
I do understand, however, that making quality of life decisions is difficult. For the utilitarian approach to be morally just in this case, it is important that the quality of life decisions that are being made by the physicians are not based on age, ethnicity, socioeconomic status, etc. In this particular case, the physician expresses that the fact that Janet is a mother should also be taken into consideration which raises additional ethical questions. Should a mother’s life be considered more important or have a higher priority when allocating scarce resources? I would argue that it should be taken into consideration. Janet is responsible for the well-being for two children. Thus, not giving Janet adequate treatment is not only causing her harm to her, but also the children that depend on her. Of course, this does present challenges when deciding to allocate between mothers or people who have numerous persons depending on them. However, in this case, the hospital simply refused to even consider “bumping” another patient, so it is not possible to know whether the other patients were in a similar position to Janet. In order for there to be justice in this case, quality of life and the patient’s role as a mother must be taken into account. Ultimately, the way one views this case and their approach is largely going to be reflective of their definition of justice. While the hospital has a more egalitarian approach, I do not find that approach to be appropriate nor “just” in this case.
Work Cited
Beauchamp, Tom L., and James F. Childress. “Beneficence” Principles of Biomedical Ethics. Seventh ed. New York: Oxford UP, 2013. 249-296. Print.
Thomas, John E.,and Wilfrid J. Waluchow. “Dialysis Machine Shortages: Who Shall Live? “Well and Good: A Case Study Approach to Biomedical Ethics. 3rd ed. Peterborough, Ont.: Broadview, 1998. 215-221. Print.
Mekdes,
I think you address some interesting points when considering the moral dilemma at stake. This case places the principles of nonmaleficence and justice at the heart of the debate. I agree that the “first come, first served” policy appears fair and equitable at face value, but this policy overlooks what is best for society as a whole by focusing on whoever is first to seek medical treatment. Individuals in great need will be left untreated when following this “first come, first served” policy. While the utilitarian approach to justice also leaves some individuals underserved by addressing a policy with the greatest net utility, scarce resources prompt a utilitarian approach. Severity and prognosis following treatment should be taken into consideration in order to ensure that scarce resources are being utilized most effectively. While “bumping” a patient from treatment in order to treat a patient with a greater prognosis is not practicing nonmaleficence towards both patients, the utilitarian theory of justice prompts such action in the event of scarce resources. In this case, the hospital should have ensured that patients being treated from the dialysis machines would benefit the most in comparison to other patients. I think of organ transplant lists and how the severity of a patient’s case and chance of survival mediate the order in which they fall on the list. Individuals placed first on the transplant list are rarely “served” first as viable organs are in scarce supply and distributed according to need and utility in addition to compatibility.
Mekdes,
I agree with you and Michelle that “first come, first serve” is often taken at face value without much consideration about the utilitarian view. Personally, though, I have mixed feelings about “first come, first serve” policy of the hospitals. For the hospital, the patients who came first matter the most, and the physicians do their best to try to save their lives. It is unfortunate that the shortage of equipment limit the number of patients getting the care. Perhaps, they are too busy treating patients and don’t have the time to take other patients who aren’t under their direct care to consider about which patient has better chance of survival. This is where quality of life comes into play, I believe. I agree that given the choice between whom to save we should save the one who has better chance. Nevertheless, is it moral to stop treating someone because incoming patient has better chance of survival? I understand that the hospital should have at least given a thought about it without rejecting the idea of “bumping” but still I wouldn’t feel comfortable or think it is just if I were the physician abandoning the patient who was under my care to treat someone who has better chance of survival. However, I do believe that for those who are about to die really soon, “bumping” should be one of the options available. There need to be a guideline and further specifications done here, though.
I agree with your argument. While the hospital would be violating the nonmaleficence principle by causing harm to the person who is being “bumped,” they would also be causing harm to the person who they decide not to admit due to a lack of space. Therefore, the nonmaleficence principle does not justify the hospital refusing to admit Janet. Additionally, what if the situation was reversed? What if the mother of two was already being treated and now the other patient needed to be admitted as well but there was no space? The hospital’s policy would then be beneficial since Janet would stay in the hospital and would not be “bumped.” Although it is also true that she would not be “bumped” based on the other argument as well due to the same reasoning as for why she should replace the other patient in the original case (better prognosis and being a mother, for example). Ultimately, I agree with your discussion of the case, and I think Janet should have been admitted despite, unfortunately, the need to open a spot for her by removing the other patient.
There are some interesting arguments presented in this post. Although the “first come, first serve” policy seems rational, I believe there is more exploration needed to be made. From the utilitarian point of view it makes little sense to continue treating someone who has a very grim prognosis while that same treatment option has high chances to saving another individual’s life. However, such an action is considered going against the ethical principle of nonmaleficnece. How then should one rationalize this? I believe, in the situation where a scarcity of resources is causing some kind of hindrance, we must turn to the ethical principle of justice. In this case, fairly distributing the benefits and risks (justice) would lead to Janet “bumping” a patient from his/her treatment in order to utilize resources more effectively.