The aforementioned case is a difficult one as it presents a moral dilemma between two guiding principles in conflict: beneficence and respect for patient autonomy (Beauchamp, 2009). In Marie’s case, she does not consent to the recommended surgery and the consequences could be lethal (Thomas et al., 2014). To add more complexity to this case, Marie’s family members urge the physician to operate against the patient’s wishes. So, what is the physician to do?
In order to provide an informed decision for this dilemma, one must consider both sides of the argument. I will first focus on the importance of respecting patient autonomy and discuss its applicability in this case. In its broadest sense, respect for autonomy is respect of the decisions of a competent patient (Davenport, 1997). So, what is competence? According to doctor of medicine and law, John Davenport, a physician must consider three aspects of the patient’s decision-making ability before determining their competence. These include (1) the demonstration of a clear understanding about the proposed treatment, (2) the ability to explain their decision in accordance with their values, and (3) consistent choices over a period of time (Davenport, 1997).
In Marie’s case, the evaluation of competency is a little more complex. Before her most recent diagnosis, Marie opted for the surgery that fixed one problem but led to another. Until Marie was notified of the need for a second operation, she appeared “rational and sensible” (Thomas et al., 2014). However, immediately after she learned of the necessary treatment, she refused to give consent, even after the surgeon explained the deadly alternative. Her reasoning for refusing the surgery was due to her mistrust in healthcare professionals. Up until now, Marie is meeting the 2/3 qualifications for a competent individual. She has been informed about the procedure, explained her reasoning, and is consistent with her choice. However, it is unclear if she has a solid grasp of the benefits of the treatment as her thoughts may be muddled by her fear and distrust.
Soon after, her family arrives and asks to override Marie’s decision. Most notably, her son states that his mother is exhibiting abnormal behavior and believes she does not fully understand the consequences of her decision. This is where the physician’s determination of her competency comes into question. Does Marie truly understand the impact of her refusal of surgery or is she simply afraid of another surgical mistake? Does her distrust in the surgical staff warrant her refusal of a lifesaving surgery?
In this case, it would be ideal to give Marie some time to calm down and really consider the impact of her decision. However, if a quick decision was necessary, I would proceed with the surgery for two reasons. First, I believe Marie is not in the right mind to make this decision. Even though she was determined to be sensible early on, her response following the surgical recommendation was inconsistent with her prior behavior. She was hostile, threatening to call the police and demanding to be released from the hospital. This sudden change in demeanor is inconsistent with her previous actions and it is most likely due to her fear and distrust of medical professionals. This is further evidenced by the son’s account of her abnormal behavior. As stated by the authors of Well and Good, “respect for autonomy of individuals does not require respecting their expressed wishes if these can be shown to be seriously out of character and irrational” (Thomas et al., 2014). In Georgia, for example, physicians can complete a 1013 form which authorizes involuntary transport to an admitting facility (Blow, 2016). To be eligible for this, the individual must meet one or more of the following criteria: recent threats toward others, recent acts of violence toward oneself, or the presentation of an “imminently life endangering crisis to self because he/she is unable to care for his/her own health and safety” (Blow, 2016). In my opinion, Marie meets the first and last criteria, which gives the physician a justified reason to override patient autonomy in this case. The second reason I would proceed with the surgery stems from the principle of beneficence. As this is a life-threatening condition, it is the duty of any physician to help the patient and relieve them from pain. As supporters of the 1013 form assert, it is in the patient’s best interest to save their life, even if that means denying their right to self-determination (Blow, 2016).
REFERENCES
Beauchamp, T. & Childress, J. (2009). Principles of Biomedical Ethics. Oxford University Press, 7, pp. 13.
Blow, R. (2016). The Ethical Use of 1013s in Georgia and Client’s Rights. Development Counts. Retrieved from http://developmentcounts.com/ethical-use-1013s/
Davenport, J. (1997). Ethical Principles in Clinical Practice. The Permanente Journal. 1 (1), pp 21-24. Retrieved from http://www.thepermanentejournal.org/files/Summer1997/principles.pdf
Thomas, J.; Waluchow, W.; Gedge, E. (2014). Well and Good. Broadview Press, 4, pp. 71-76.
Julia,
I think you make a good argument about why Marie should have the surgery in relation to beneficence and respect for patient autonomy. You also do a great job explaining the moral dilemma of competency in this case. However, I think another important factor to address under these circumstances is the autonomy of the family. Despite Marie refusing the surgery, she does not seem fully competent as explained by her son. Even though Jacques warns the surgeon that he will sue if he does not perform the surgery, the surgeon should not make this decision based on a threat. I still believe that the surgeon should perform the surgery, but make this decision for the benefit of the patient’s best interest and through respecting the family’s consent and plea. Since Marie seems somewhat irrational and possibly incompetent, I think her family should be permitted to give consent for the surgery. Marie’s body has been through a lot of stress physically and mentally and no longer trusts the healthcare professionals that are trying to help her. I feel this somewhat proves Marie is incompetent in that she would rather choose to die than go through another surgery with this staff. I understand that surgery and medicine are not fool proof and mistakes do happen. I can understand Marie’s frustration, but her refusal for surgery seems irrational and I think that the surgeon should accept the family’s consent.
Hi Rylee! Thank you so much! I appreciate your comments and agree! Your point about making the decision based on her best interest instead of the fear of legal action is great. I agree that it is more important to worry about the moral implications than the legal ramifications. This was definitely a tricky and controversial case (as we learned from our in-class discussion this week)! However, I still agree that she should have the surgery based on the points I discussed and the argument you posed! I look forward to hearing what others think of this case tomorrow in class!
Hi Julia,
I like your blog post on this topic. I think you brought in a nice discussion of why Marie should have the surgery in the way of respecting her autonomy and saving her life. I think this is a difficult situation in terms of balancing beneficence and patient autonomy. Since Marie is fully competent and away of the situation, she can refuse any medical procedure asked of her. She is not obligated to comply to a life saving surgery if she is medically competent to do so. The patient is fully in control of their treatment even if their life is at stake. In this situation however becomes difficult when Marie’s competency is put into question as well as her irrationality in this decision. Once her family becomes involved, they deem Marie as not fully competent to make this decision and feel they should have the autonomy to force her into the life saving surgery. This puts the medical professional in a bind between doing no harm and respecting the patients wishes. I believe that if the patient is deemed incompetent then yes the family has the right to make this decision for her. Her decision is evidently irrational in terms of risking her life due to a mistrust of doctors and her competency should rightfully be questioned. Overall I agree with your conclusion and while I understand the importance of respecting patient autonomy, I think Marie’s competency should be greatly observed before she is allowed to make this decision.
References:
Muirhead, P. (2004, February). When parents and physicians disagree: What is the ethical pathway? Retrieved February 10, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2720466/
Thomas, J. E., & Waluchow, W. J. (1998). Well and good: a case study approach to biomedical ethics. Peterborough, Ont.: Broadview Press.