Image Source: http://emedicine.medscape.com/article/962643-overview

Background: Dr. Arman Asadour is a physician working in South Sudan for a vertical aid cholera treatment program funded by an NGO. His workstation has a mandate to only treat cholera patients and send those with other conditions to the local hospital. The local hospital is overflowing with patients and some patients arriving at the station have conditions treatable with NGO resources. Dr. Asadour is caught in two moral dilemmas in which he must decide whether to balance beneficence and justice. Treating non-cholera patients might cause an overflow of sick patients demanding NGO care, depleting resources that could be used to eliminate cholera. Admitting non-cholera patients for treatment might expose them to cholera patients at the facility. Overall, there the ethical question of whether the vertical treatment structure is the most effective way to improve the population’s overall health (Thomas, Waluchow and Gedge 267). The primary moral dilemma is whether to treat outside the mandate, and the secondary dilemma is whether he should ethically participate in the program at all.

Discussion: Dr. Asadour’s professional emphasizes beneficence, which provides the foundation for his uneasiness about selectively treating. He is facing an epidemic of cholera, but also an endemic presence of other diseases. It is a pandemic comprised of numerous illnesses. Brody and Avery provide evidence of why Asadour feels a strong duty to treat in such circumstances based on the ideas of social solidarity and vulnerable populations. Brody and Avery make a convincing argument that solidarity between fellow health care professionals and the larger lay community provides the basis for doctors’ duty to treat (44); they also argue that “a critical test of true social solidarity is whether we are willing to put the needs of vulnerable, underserved populations first” (45). When health systems neglect vulnerable populations it can result in mistrust of health officials by said populations, leaving them resistant to public health guidelines and therefore at risk for mortality (Brody and Avery 46).

No doubt this argument has to do with Dr. Asadour’s moral conflict over his station’s mandate. He is clearly invested in vulnerable populations because he chose to leave home country and work in an unstable, war-torn region. Employment with NGOs often pays less than other employment like private practice and many NGO physicians are volunteers and receive no payment at all. It would be frustrating for an individual who wants to generally serve the needy, to be hindered by a restrictive mandate. According to the case description, “Dr. Asadour wonders whether vertical aid programs simply undermine efforts by local authorities to develop sustainable health responses for their own communities and for health broadly,” (Thomas, Waluchow, and Gedge 267). This interplays with Brody and Avery’s argument of mistrust above. Clinics like Asadour’s may disrupt the normal flow of services in the area and establish a new norm for care delivery. If this new norm is one where only certain patients receive care while others are left to die while waiting for treatment at the overcrowded hospital, then it could result in community bitterness and frustration. These emotions may remain when Asadour’s NGO leaves, leaving the general community generally mistrustful of biomedicine. Mistrust of biomedicine could lead to continued spread of communicable diseases if patients refuse to seek treatment at local hospitals.

In context of justice, there are several aspects to consider that are in conflict with Dr. Asadour’s desire to treat non-cholera patients. The primary issue is how to allocate the NGO’s resources. While the NGO may have resources the hospital doesn’t, they were specifically provided to treat cholera and are limited in their own right. Cholera is a highly communicable disease spread by contaminated food and water. Death results from diarrhea-induced dehydration. Treatment involves intravenous fluids with electrolytes and antibiotics (WebMD). Therefore, it is reasonable to assume that the NGO workstation did not provide medical supplies for the treatment of viral conditions, chronic conditions, etc. If Dr. Asadour were to treat outside the mandate, he would likely still have to reject patients based on the supplies provided. When allocating scarce resources to equally needy individuals, one must also consider the prospect of success of treatment (Beauchamp and Childress 289). For example, if a patient reaches treatment before severe dehydration occurs, survival of cholera is highly likely. In the case of other diseases such as malnutrition, chronic diseases, etc., Dr. Asadour’s supplies might be used for the dual purpose of providing relief, but they will not be able to cure. His treatments are specifically effective in treating cholera.

Examining the vertical aid structure of Dr. Asadour’s organization from a broader perspective beyond individual patients reveals that its treatment plan may be futile. Hunt’s article “Cholera and Nothing More” examines ethical considerations of humanitarian aid programs addressing the disease. He says, “An important question to ask is what steps are possible to contribute to developing local capacity for preventing and addressing future outbreaks and building up infrastructure,” (56). Prevention and public health efforts are as necessary as treatment to prevent spread. In cholera’s case, improved water and food sanitation coupled with rehydration and antibiotics would eliminate the current epidemic and prevent another one from occurring in the future. However, the vertical aid structure employed by Dr. Asadour’s does not provide any provision for improvement in the community’s infrastructure or sanitation education programs for refugees. In this way the agency is doing little to stop the propagation of the disease, but is their work unethical?

Regardless of intentions, the NGO is providing care with scarce resources and limited funding to some individuals and that, in itself, is an act of beneficence. I believe Dr. Asadour should continue to treat according to the mandate if he wants to make the most impact with his resources available. In other words, I would recommend taking utilitarian approach to treatment. However, the program’s structure may not be the most just or fair way to utilize aid funding. However, I don’t think this makes the organization’s action unethical. Only if the NGO’s work were to leave the area worse off than when it arrived or cause the failure of local healthcare delivery after its departure (i.e. the mistrust of the community or the disruption of local hospitals’ ability to treat) would I view it as and unethical organization.

Works Cited

Brody, Howard, and Eric N. Avery. “Medicine’s Duty to Treat Pandemic Illness: Solidarity and Vulnerability.” Hastings Center Report 39.1 (2009): 40-48. Web. 19 Apr. 2015.

Beauchamp, Tom L., and James F. Childress. “Justice.” Principles of Biomedical Ethics. 4th ed. New York: Oxford UP, 2009. 249-301. Print.

“Cholera: Causes, Symptoms, Treatment, and Prevention.” WebMD. WebMD, n.d. Web. 20 Apr. 2015.

Hunt, M. R. “‘Cholera and Nothing More'” Public Health Ethics 3.1 (2010): 55-59. Web. 20 Apr. 2015.

Thomas, John E., Wilfrid J. Waluchow, and Elisabeth Gedge. “Case 8.2 Ethics and Humanitarian Aid: Vertical Aid Programs.” Well and Good: A Case Study Approach to Health Care Ethics. 4th ed. Peterborough, Ontario: Broadview, 2014. 267-68. Print.

Background: Amelda is a 21-year-old female with anorexia nervosa admitted a total of 15 times over the previous threes to the hospital emergency room for symptoms of her disease. All traditional treatments by doctors thus far have failed. Amelda continues to view herself as overweight and rejects solid food and nutrients. She has gone to extreme measures, such as withdrawing supplements from her stomach using a syringe, to avoid gaining weight. Doctors have determined that the only effective way to stop these behaviors is through physical restraints and force-feeding using a naso-gastric tube. She exhibits depression and doctors declared her incompetent during all of her previous hospital visits.

Doctors and family members are considering withdrawing force-feeding although doing so may allow Amelda’s weight to drop to an even more dangerous level. Past incidents have shown that when Amelda’s weigh falls below 77 pounds, her vital signs drop to potentially fatal levels. Amelda has not exhibited any signs that she wishes to die. The primary moral dilemma here is whether or not to withdraw force-feeding under the principles of beneficence, non-maleficence, and autonomy. We previously debated this dilemma in class, so instead I will examine it in light of Beauchamp and Childress’s frameworks for surrogate decision-making and quality of life analyses.

Discussion: In my personal analysis of Amelda’s case, I supported the classification of Amelda as incompetent and the passing of informed consent on to her parents. Beauchamp and Childress present here standards for surrogate consent generally recognized in bioethics: substituted judgment, pure autonomy, and the patient’s best interests (226). Amelda’s parents could adopt their role (assuming it is morally and logically justifiable that Amelda is incompetent) under any of the three standards, however the patient’s best interests standard is the most fitting. According to Beauchamp and Childress, both the substituted judgment and pure autonomy standards require some form of previous knowledge of the patient’s wishes and values or official directives issued by the patient before they entered an incompetent state. Amelda is 21 and we know she has received medical care for anorexia for the past three years, but we don’t know if this the start of these three years marks the start of her symptoms that impaired her moral status and competence.

While it’s logical to assume that Amelda has not suffered from anorexia for her whole life (most new incidences of anorexia are in teens)(“Anorexia Nervosa”), we do not know whether or not she had other health issues that impaired her competence. Even assuming that Amelda’s disease began when she started treatment would put her age at the start of her illness at 18. She would have just entered into legal adulthood, making it unlikely that she had previously expressed any mature values or wishes about her health preferences that her parents could draw on in the present case. Therefore, the patient’s best interest standard seems the most ideal choice for Amelda’s parents to operate under because it does not require considerations of a patient’s previous opinions. Because of the key component of the case that states that Amelda does not express any interest in death, it seems in the patient’s best interests to take all measures necessary to preserve her life. Weighing the costs and benefits of Amelda’s options, preserving Amelda’s life with (hopefully) temporary force-feeding and continuing psychiatric treatment in a chronic care facility outweighs the risk of her sustaining psychological and emotional damage from her position of being physically restrained based on her want to live (even if it is expressed with a distorted view of survival).

Works Cited

“Anorexia Nervosa | National Eating Disorders Association.” Anorexia Nervosa | National Eating Disorders Association. N.p., n.d. Web. 1 Apr. 2015. <https://www.nationaleatingdisorders.org/anorexia-nervosa>.

Childress, James F. “Beneficence.” Principles of Biomedical Ethics. By Tom L. Beauchamp. 7th ed. New York: Oxford UP, 2013. 226-41. Print.

Wiegert, Carolyn. Exam 1: Morality and an Extreme Case of Anorexia Nervosa. N.p.: n.p., 14 Mar. 2015. PDF.

This week’s readings about end of life palliative care decisions and the struggle of their authors to morally define and establish ethical norms left me thinking about the recent media coverage of Britney Maynard. This past fall, it was difficult to walk into a grocery store without seeing Maynard’s face splashed across a tabloid or lifestyle news magazine cover. Brittany Maynard was a 29-year-old woman diagnosed with terminal stage IV glioblastoma multiforme brain cancer in January 2014. After her initial surgical treatment proved unsuccessful and her tumor returned, Maynard decided to forgo additional treatment of chemotherapy and radiation. According to her editorial for CNN, Maynard and her family reached the conclusion that all remaining treatments could not save her life and would destroy the months she had left to live. Maynard instead chose to establish residency in Oregon in order to gain access to a dosage of lethal barbiturates under Oregon’s Death with Dignity Act, passed and put into effect in 1997.

This law allows competent adults with a physician-diagnosed terminal illness the right to request lethal prescription drugs and use them to die should they voluntarily wish to do so. Individuals cannot qualify for the drugs solely based on age or disability status, nor can they receive them if they are deemed to have a psychological or psychiatric disorder, such as depression, that could infringe on their ability to make an informed decision about death (Oregon Death with Dignity Act). Once a person has received their prescription, they can choose to use or not use the medication at will. The law still forbids physicians from ending a person’s life in patient assisted suicide through “lethal injection, mercy killing or active euthanasia” and protects the patient’s death (should they choose to use their prescription) from being classified as “suicide, assisted suicide, mercy killing or homicide, under the law”.  Brittany chose to end her life surrounded by family members on November 1^st, 2014 by ingesting her prescription.

Brittany’s passing left me unsettled and I realized that Beauchamp and Childress and Thomas et al. do little to provide a moral code for judging end of life cases. Their writings detail the necessity for evaluating morality on a case-by-case basis for end of life decisions. Their frameworks for “killing” versus “letting die” and “active” versus “passive” measures explain the beliefs of the medical profession, but they decline to confirm or deny that these frameworks are logical or morally right.  On the other hand, Mcintyre, in her discussion about the principle of Double Effect, makes it clear that she would support “deliberate hastening of death” in circumstances where it could “relieve great suffering” (72).

Nevertheless, a decision like the one made by Maynard makes us uncomfortable because of preexisting personal convictions and values that differ beyond the “common morality” we generally use to evaluate ethical situations. Diversity in faiths and upbringings will always create minute differences in the value and purpose of physical life. As Beauchamp and Childress say, it’s not so much what causes death that results in the debate of whether a death is unjustified a “killing” or justified as a “letting die”. They state: “The validity of the authorization—not some independent assessment of causation—determines the morality of the action.” (Beauchamp and Childress 177). Different backgrounds mean people will place validity in the hands of different individuals.

Some may place the validity of the authorization of death only with god, while others may believe it lies with the ill individual alone. In the case of Brittany Maynard, I personally believe that the acceptance or disagreement with Maynard’s decision and Oregon state law comes down to the sanctity of life versus quality of life debate that Thomas et al. describe (210). Those who believe that quality of life is more important than the sanctity of life will choose to honor the principle of autonomy over the non-maleficence/beneficence of prolonging life. And, those who choose sanctity of life as more important will see the prolonging of life as an act of beneficence that is more important than personal autonomy in Brittany’s case—regardless of Oregon law.

Works Cited

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford UP, 2013. Print.

 “Death, Dying, and Euthanasia.” Well and Good: A Case Study Approach to Health Care Ethics. 4th ed. Peterborough, Ontario: Broadview, 2014. 208-14. Print.

Maynard, Brittany. “My Right to Death with Dignity at 29.” CNN. Cable News Network, 02 Nov. 2014. Web. 11 Feb. 2015.

Mcintyre, Allison. “The Double Life of Double Effect.” Theoretical Medicine and Bioethics 25.1 (2004): 61-74. Web.

United States of America. Oregon Health Authority. Public Health. The Oregon Death with Dignity Act: Oregon Revised Statutes. N.p., n.d. Web. 28 Feb. 2015. <http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/statute.pdf>.

Background:

A gynecologist examines a 63-year-old 5-foot, 315-pound patient named Marie with a diagnosis of stress incontinence in Canada. After performing an ultrasound, the gynecologist discovers an ovarian cyst and elects to perform a surgical hysterectomy and remove both her ovaries. The surgery injures her colon leading to post-operative complications. A surgeon confirms that leakage from her colon could kill her unless he conducts a second reparative surgery. Marie appears to be cognizant of her situation, but denies surgical treatment. When the doctor chooses to comply with her wishes, her son threatens legal action against the doctor unless he operates, claiming his mother is acting incompetent.

Dilemma:

The immediate dilemma is whether or not the surgeon should operate using surrogate consent under the principle of non-maleficence or respect Marie’s autonomy. However, from a medical standpoint an additional dilemma surrounds Marie’s initial surgery. For a diagnosis of ovarian cyst and stress incontinence, was invasive surgery the best treatment? Did Marie give truly informed consent if the surgeon did not educate her on other treatments? Without the initial surgery, the current dilemma between Marie’s surgeon and her family would not exist.

Analysis:

When reading Marie’s case, it is easy to skim over her listed age, stature, and weight, but they are crucial to her medical diagnosis and avoidance of the dilemma described above. Marie is only 5 feet tall, but weighs 315 pounds. Marie’s calculated BMI of 61.5 (“Adult BMI Calculator: English”) categorizes her as morbidly obese. Obesity serves an additional risk factor for gynecologic surgeries.  According to a report released by The American College of Obstetricians and Gynecologists, “As BMI increases for women undergoing abdominal hysterectomy, so does the risk of surgical site infections and wound complication” (Committee Opinion 275) and “Obese patients commonly have comorbid conditions…that can complicate intraoperative and postoperative care” (Committee Opinion 277).

Marie is 63 years old, classifying her as a post-menopausal woman (According to the Canadian Women’s Health Network, the average age for menopause in Canada is 52). Ovarian cysts are common in women of reproductive age and often serve a functional purpose in ovulation, but they are a concern in menopausal-age women. Along with other symptoms of urinary urgency and frequency as in Marie’s case, cysts may indicate the presence of ovarian cancer (Le and Giede 669).

However, the case report made no mention of testing the cyst for malignancy—as is the standard recommendation in Canadian gynecology (Le and Giede 670)—beyond its discovery during the ultrasound. While we don’t have all the details of Marie’s pre-surgery health, it seems logical that the case report would have mentioned cancer had it been the operation’s cause. Instead, it suggests that the operation was to alleviate her incontinence caused by uterine pressure from the cyst. Surgery is the most invasive of available treatments for stress incontinence (less invasive options include vaginal cones and electrical stimulation) and the official recommendations of The Society of Obstetricians and Gynaecologists of Canada suggest, “As part of the management of stress incontinence, women should be encouraged to try non-surgical options, including weight loss (in obese women)” (Reid et al. 3). In terms of cases that do require surgery, the society agrees that a hysterectomy may be performed when removing a woman’s ovaries, but it acknowledges “whether there are any benefits of concomitant hysterectomy at the time of bilateral oophorectomy for conditions other than ovarian cancer…remains unknown” (Lefebvre et al. 4).

 Discussion:

What I’m asking is why her surgeon chose the most invasive treatment for a woman whose circumstances make surgery highly risky. Since this case revolves around autonomy, I’d like to focus on this principle in relation to Marie’s first surgery. The case report states that the “gynaecologist elected to perform a hysterectomy and bilateral oophorectomy” (Waluchow and Gedge 71). Notice it doesn’t say that Marie elected for surgery, which makes me wonder if the doctor educated her on other available treatments. Clearly, Marie voluntarily consented to the surgery, but was her consent informed? Beauchamp and Childress list disclosure, recommendation, and understanding as three necessary elements within the information component of informed consent (124). They also state that “Diagnoses, prognoses, the nature and purpose of intervention, alternatives, risks and benefits, and recommendations typically are essential” (132) parts of a disclosure.

In my opinion, Marie’s doctor did not rightly balance the principles of autonomy and beneficence. By not reviewing all treatments and corresponding risks (perhaps he viewed surgery as the best option), he violated Marie’s right to informed consent. I believe doing so would have resulted in Marie consenting to a different treatment. However, let us say that the case description’s language didn’t adequately describe Marie’s consent process and that she, herself, elected for surgery from the list of well-explained treatments. In this case I would advise the doctor to push her towards a less risky treatment as an act of beneficence, weighting beneficence higher than autonomy. This would avoid the complex colon surgery dilemma where one must make a judgment of Marie’s competence while she is in an impaired state.

Works Cited

“Adult BMI Calculator: English.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 21 Oct. 2014. Web. 06 Feb. 2015.

Beauchamp, Tom L., and James F. Childress. “Respect for Autonomy.” Principles of Biomedical Ethics. 7th ed. New York: Oxford UP, 2009. 115-25. Print.

Committee Opinion: Gynecologic Surgery in the Obese Woman. Publication no. 619. The American College of Obstetricians and Gynecologists, Jan. 2015. Web. 7 Feb. 2015.

Le, Tien, and Christopher Giede. “Joint SOGC/GOC/SCC Clinical Practice Guideline: Initial Evaluation and Referral Guidelines for Management of Pelvic/Ovarian Masses.” Journal of Obstetrics and Gynaecology Canada (2009): 668-73. Web.

Lefebvre, Guylaine, Catherine Allaire, John Jeffrey, and George Vilos. “SOGC Clinical Practice Guidelines: Hysterectomy.” Journal of Obstetrics and Gynaecology Canada (2002): 1-12. Society of Obstetricians and Gynaecologists of Canada. Web.

“Menopause.” Menopause. Canadian Women’s Health Network, 2006. Web. 07 Feb. 2015.

Reid, Robert, Beth L. Abramson, Jennifer Blake, Sophie Desindes, Sylvie Dodin, Shawna Johnston, Timothy Rowe, Namrita Sodhi, Penny Wilks, and Wendy Wolfman. “Managing Menopause.” Journal of Obstetrics and Gynaecology Canada 36.9 (2014): 1-74. Web. 6 Feb. 2015.

Waluchow, Wilfrid J., and Elisabeth Gedge. “Case 1.1 When Physicians and Family Disagree.” Well and Good: A Case Study Approach to Health Care Ethics. By John Thomas. 4th ed. Peterborough, Ontario: Broadview, 2014. 71-76. Print.