This case deals with a woman, Marie, who has just undergone surgery to remove both ovaries and soon after had a splitting of the suture, which caused colon leakage. Besides that issue, she was stable and able to communicate. When the physicians explained she needed another operation to fix the potentially fatal matter, she refused stating that she no longer trusted their medical staff after the problematic first surgery and would call the police if they attempted to operate. Her family did not agree with her reasoning and her son, Jacques, who claimed his mother was in a compromised cognitive state, threatened to take legal action if the physicians did not operate (Thomas et al., 2014).
As a decision is made, we consider weighting two principles: patient autonomy and physician’s obligation (Beauchamp, 2009). The patient clearly expressed her wishes and it is the responsibility of the physician to respect that. In this case, the physician’s obligation to provide necessary medical treatment is in direct conflict with the obligation to respect the patient’s autonomy. Which principle has greater value? As stand-alone rights, neither remains valid. If patient autonomy and refusing treatment were an absolute right, then medical ethics would boil down to just the wishes of the patient. On the other hand, physician’s obligation as an absolute right would mean their word trumped all, disregarding the patient as an object. Neither is the case, and therefore some kind of middle ground needs to be found in order to reach a decision to act or not.
Another component of making a decision is the question of Marie’s competence. It comes into play when her son arrives at the hospital and deems his mother incompetent. Her refusal to consent to the operation is taken at face-value in the beginning, as she appears to be fully competent. But what else has to happen in order for her consent to be deemed legitimate? For her consent to be considered valid, two criteria have to be met: necessary and sufficient information must be presented and that information must be presented in a manner familiar to the recipient (Appelbaum, 2007). The physicians seem to stress how critical this procedure is to her survival and provide relevant information to aid her in making an informed decision so in my opinion, they have done due diligence. So if she is determined competent, her consent should be considered valid. However, if her competency remains in question, who else can consent to the surgery?
If it can be demonstrated that Marie’s judgment is out of character and irrational, her expressed wishes do not have to be respected by her physicians. In that case, surrogate consent can be granted to her family and they are responsible for “promoting the patient’s best interests” (Thomas et al., 2014). There is much ambiguity in this description and it shows the consistent struggle between the two principles at either end of the argument. To promote Marie’s best interests her son should consider not only the importance of his mother’s survival but also honoring her values that are in direct opposition of the first point. Simply put, it’s a decision of life and quality of her potential future life. If her survival meant a lifetime of pain and suffering, then death being the favored option can be considered rational. But since the second surgery gives her a much better chance at survival and full recovery, I believe if her son is granted surrogate consent, he should promote her best interest for the future, which is to go through with the second operation.
Sources:
Appelbaum PS. Assessment of patient’s competence to consent to treatment. New England Journal of Medicine. 2007; 357: 1834-1840.
Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2013. Print.
Thomas, John E, Wilfrid J Waluchow, and Elisabeth Gedge. Well and Good: A Case Study Approach to Health Care Ethics. N.p., 2014. Print.
You touch on the conflict between patient autonomy and physician obligation, asking: which principle has great value? My answer is either principle can be “more” valued because how people rank values is subjective. With values in mind, I would like to touch on the subject of life and death and the value which people seem to place on living. Many people value living/life to a great extent and have thanatophobia, the fear of death. I have often heard those around me talk about death with a negative connotation. With ‘wanting to live’ as the social norm, would you consider those who are “okay” with death/dying as incompetent or irrational? Personally, I would be okay with dying a natural death. Merriam Webster’s dictionary defines natural death as “death occurring in the course of nature and from natural causes (as age or disease) as opposed to accident or violence.” At what point is it okay to “let someone die”. Considering this definition, could it be said that it is “unnatural” use surgical/medical means to prolong life?
Thank you for your response Pamela! To continue on the topic of value, we can bring in today’s class conversation about whether or not we are in a place to judge the values of others? In this case (1.1) I think I was trying to communicate that neither can be valued more than the other because they’re weighed in comparison to each other. I agree that people rank their own values subjectively and they have the right to do so but I think there has to be some sort of established metrics to go by when evaluating as a spectator. Your point about dying a natural death is okay for many physicians because they usually take some sort of measure to prolong the life before allowing their patient to die. If you think about it, most of us tend to actively work towards prolonging our lives every day by living a moderate lifestyle. The argument is there that the doctor can act on the assumption that if the person is legally sane, they’ve been working towards extending their life through their choices and actions.
Hi,
I really appreciate your analysis of the moral dilemma at hand. The patient’s decision to forgo the operation should be respected if she is deemed competent. However, what are the limitations of transferring the patient’s authority to a potentially biased individual if the patient is declared incompetent? In other words, can we trust the son to make an unbiased decision that prioritizes his mother’s autonomy?
Before the son’s arrival, the patient’s decision was respected by the physicians and her family. The patient’s persistent refusal to surgery, despite being presented with the benefits of the operation, was respected. The physicians stated that the patient was “conscious and apparently competent.” However, the son declared that his mother “did not fully understand the consequences of the operation.” Therefore, he declared that his mother did not have the authority to deny the treatment, as she was “behaving abnormally.” It is imperative to consider that the son may be biased, as he wants his mother to survive. Should we really trust the son to make the best decision for his mother–considering both the benefits of surgery and his mother’s autonomy? I do not think that the son should be granted with this authority due to his inherent bias.
The son should not be granted the sole authority to act on his mother’s behalf. As a resolution, the physicians should choose to perform the surgery if the patient is deemed incompetent.