Background:

Janet is a middle-aged single mother of two children with a serious drinking problem. After being discharged from the hospital where she was treated for injuries incurred in a traffic accident just three months prior, Janet has been readmitted for high blood potassium levels indicative of impending renal failure. In order to live, Janet requires long term dialysis. However, both of the tertiary care hospitals offering long term dialysis do not have any open dialysis machines. Her physician argues Janet’s case, but is met by heavy opposition. Both hospitals refuse to consider Janet’s case because of their “first come, first served” policy.

Discussion:
The moral principles at play in this distributive justice case are non-maleficence and justice. If we fail to treat Janet’s high potassium levels, we greatly increase the risk that her heartbeat will stop. Since we are not informed of alternative options for lowering her potassium levels, refusing Janet dialysis is effectively sentencing her to death. Therefore, if the tertiary care hospital does deny her access to the dialysis machine, the principle of principle of non-maleficence is being violated. If we treat Janet at the expense of other patients already on dialysis, we are also violating the principle of non-maleficence. Since doing harm is unavoidable in this case, we must turn to the principle of justice to make the most moral decision. In order to reach the most fair decision in this situation I will first determine Janet’s eligibility and then her perceived societal worth. If these exceed other patients’ eligibility and worth I would argue that the most just thing to do would be to allow Janet to take one of those patient’s places at the tertiary care hospital.

In the third edition of Well and Good, it is suggested that eligibility for having access to a scarce medical resource should first be established according to the following factors: constituency (proximity to the resource), the progress of science (research interests of the hospital), and the prospect of success (amount of benefit) (Thomas and Waluchow). As stated in the dialysis machine shortages case, the two tertiary care hospitals that Janet’s physician was attempting to negotiate with were both “geographically accessible.” Since no research on dialysis patients was mentioned, we can assume that the progress of science was a negligible factor. Janet’s physician also seems pretty confident that his patient has great promise of long-term benefits. Therefore, we might also assume that her prospect of success was pretty high, perhaps even higher than some of the current patients in the two tertiary care hospitals.
Since there is not enough of the medical resource after applying the eligibility criterion listed above, Thomas and Waluchow advise that one must then select individuals based on their “worth.” In Well and Good, the authors suggest that this “worth” is determined by the individual’s family role and contributions to society (Thomas and Waluchow). Although I would argue that Janet’s role as a single mother of two should factor into the assessment of her worth, in order to protect members of society that are mentally or physically handicapped or socioeconomically disadvantaged (like Janet, who is on welfare), I believe that it is important to also consider an individual’s vulnerability when establishing worth. Basing worth solely off family role and contributions to society effectively excludes the aforementioned populations who may not have access to the same resources that able-bodied, able-minded, financially stable individuals do. Without these resources, individuals in these groups in many cases do not have as many or as great of opportunities to contribute to their communities.  Yet another factor that must be taken into consideration is whether or not a patient’s behavior may be exacerbating the illness. As was mentioned previously, Janet is a heavy drinker. According to the National Kidney Foundation, chronic drinking can decrease the kidney’s ability to filter blood, and can cause liver disease and high blood pressure which, both of which can lead to kidney disease (National Kidney Foundation). Although it is difficult to discern just how much of Janet’s kidney damage can be attributed to her drinking, considering she had previously experienced kidney failure after sustaining injuries from an automobile accident and had never quite fully recovered, if Janet continued to drink heavily after returning from her first hospital visit, she at the very least increased her risk.

In any case, I believe that the tertiary care centers’ decisions to provide patients with dialysis on a first-come, first-served basis is morally wrong when applying the moral principle of justice. Although it would be arguably more difficult to take away care from someone with a poorer diagnosis than to deny it from them in the first place, when medical resources are limited, I believe that those resources should be allocated to individuals who have the greatest prospects of success. If we assume that all individuals all have the same prospect of success however, I would argue that the tertiary care centers should grant access based first on the individual’s family role and then, if there are still not enough resources available, degree of responsibility for ailment. Applying this to Janet’s case, I would argue that the tertiary care center should bump an individual with a poorer prognosis than Janet and, if there are none, bump an individual who is not providing for a family. If, by some chance, there are no individuals who have poorer prognoses or who do not have children or other individuals that are dependent upon them, I would make Janet wait on the tertiary care dialysis list.

Sources:

“Alcohol and Your Kidneys.” – The National Kidney Foundation. N.p., n.d. Web. 16 Apr. 2015.

Background

A few weeks ago my HLTH 410 class discussed several infamous clinical trials that were conducted on human subjects, one of which was the Bowery Series. The Bowery Series was a set of experiments performed on homeless, alcoholic men from New York’s skid row from 1951-1966. More than twelve hundred participants in the Bowery Series were subjected to perineal biopsies of the prostate gland, and, if these tissues samples proved to be cancerous, prostatectomies, surgical castrations, and estrogen treatments. Although some of the aforementioned treatments are now viewed as standard, not one of them was common or even established at the time of the series. For compensation, these men were provided with a clean bed and three meals for several days as well as free “treatment” should they be diagnosed as having prostate cancer (treatment being incredibly painful, invasive procedures like prostatectomies that had not been proven to work).

Conflict:

The basic moral principles of autonomy and non-maleficence are clearly violated by the researchers of the Bowery Series. The true dilemma arises when one considers whether non-maleficence towards the Bowery Series participants should be placed above the potential beneficence of future prostate cancer patients. In other words, is subjecting homeless, alcoholic men to radical, painful, and invasive surgeries morally justified if it could potentially lead to better outcomes for men with prostate cancer?

Discussion

As outlined in Tom Beauchamp and Jim Childress’ Principles of Biomedical Ethics, humans share basic moral principles of justice, non-maleficence, beneficence, and autonomy (Beauchamp and Childress 2009). In the case of the Bowery Series, the principles of autonomy and non-maleficence were violated. Earlier this semester, we discussed how society usually grants vulnerable populations extra protections and obligations to keep them in. However, the vulnerable population in Bowery Series was not protected. Instead, they were exploited.  As stated by Aronowitz, the Bowery experiments were conducted on homeless, alcoholic men from New York’s skid row because they could not conduct them on people with more power. Due to their position in society and the moral implications of alcoholism, these men were seen as having lower moral status and thus, less autonomy, than wealthier individuals at a nearby Presbyterian hospital (Aronowitz 2014).

Participants’ autonomy was further violated and undermined through manipulation by the Bowery Series’ researchers’ recruitment methods. Informed consent requires that the patient has given his or her permission for the intervention be taken, that the patient’s decision be voluntary, that the patient understands what he or she is consenting to. Although it is unknown as to whether or not some kind of consent was obtained from the subjects of the Bowery studies, it can be inferred that the Bowery Series research subjects’ decisions to participate in the study was neither voluntary nor informed. In fact, the Bowery series recruiters coerced, or at the very least manipulated their research subjects. The argument could be made that each party was getting what they wanted (the researchers, subjects to perform surgeries on and the homeless men, food and shelter). However, by offering homeless men food and shelter in return for their participation (two resources that this vulnerable population lacked but needed to survive) the researchers really only offered these men only one “choice”: join the study. Since these were relatively new procedures with unknown consequences, it is also fair to assume that the decision to participate in the study was not an informed decision. Additionally, consenting to one thing (i.e. prostatectomy) does not consent you to everything that is entailed with it (incontinence, impotence, etc.).

It is difficult to discern whether or not the researchers could be considered beneficent for providing free cancer treatment to their research subjects. The researchers very well might have been more concerned with answering questions pertaining to the prevention, diagnosis, and treatment of prostate cancer than the good of their research subjects. And yes, the procedures were incredibly painful and invasive and many resulted in complications. However, it is hard to imagine that these researchers didn’t at least believe that these procedures might benefit the homeless, alcoholic men that presented with prostate cancer. Additionally, these researchers surely wanted to benefit future patients with prostate cancer.

I recognize that medical research, especially medical research pertaining to the efficacy of invasive procedures, could not be advanced without violating the principle of non-maleficence to some degree. However, in this case I believe that the researchers’ obligations to protect a vulnerable population by preventing harm and increased risk (non-maleficence) should have taken precedence over their obligations to be beneficent (especially considering that they did not know whether or not the procedures would benefit future patients).

This case is very similar to “Well & Good: A Case Study Approach to Health Care Ethics” Case 3.1 that we recently discussed in class. Just as the director of the Alzheimer’s study should take extra care to ensure that the Alzheimer’s patients who are mentally incapable of giving informed consent should are not harmed (Thomas and Waluchow 2014), so too should the Bowery Series’ researchers have granted the homeless men extra protections instead of exploiting them. These researchers should have obtained informed consent from volunteers, not coerced homeless men into participating in their study.

Works Cited:

Aronowitz, Robert. “From Skid Row to Main Street: The Bowery Series and the Transformation of Prostate Cancer, 1951-1966.” Bulletin of the History of Medicine 88.2 (2014): 287–318. PubMed. Web.

Beauchamp, Tom L, and James F. Childress. Principles of Biomedical Ethics. New York: Oxford University Press, 2009. Print.

Thomas, John E., and Wilfrid J. Waluchow. Well and Good: A Case Study Approach to Health Care Ethics. 4th ed. Toronto: Broadview, 2014. Print.

Case 8.1 “Don’t Let My Mother Die”

Background:

Mrs. Jones is an 81-year old, deeply religious Jamaican native. Although we are not informed as to what type of religion Mrs. Jones’ practices, one might assume that it is a some sort of mix of Christianity and Myalism. Myalism is a religion deeply rooted in African tradition, adopted by Jamaican slaves to recreate their past. In the late 18^th century, the beliefs and practices of Myalism began to be mixed with Christian traditions to form a religion that is still practiced by many Jamaicans today (Morrish 45-47). Having identified closely with her homeland’s traditions, she believes that her soul will be “condemned to wander the universe aimlessly for an eternity (Thomas and Waluchow 175)” if she dies in a foreign land, a belief consistent with Myalism. We are told that, at some point in time, Mrs. Jones moved to Edmonton, Canada with her son.  A “fair bit of time (Thomas and Waluchow 175)” later, Mrs. Jones’ health began to decline and her breathing muscles eventually became paralyzed, resulting in multiple cardio-respiratory arrests. Due to the paralysis of her breathing muscles, Mrs. Jones had to be placed on a respirator and was admitted to the Intensive Care Unit. Despite attempts to wean her off of the respirator, she was unable to regain the ability to breathe on her own and, we are told, likely never would. Additionally, Mrs. Jones has lapsed into semi-consciousness and is unaware of her surroundings. Before losing consciousness, Mrs. Jones placed a curse on her son should he not return her to Jamaica to die. Although the son wants to arrange her return, he lacks the financial means. The hospital is also unable to transport her back to her native land. The attending physicians, recognizing the likelihood of a future cardiac arrest, are trying to decide whether or not a Do-Not-Resuscitate order should be issued.

Dilemma:

The dilemma that the attending physicians face is three-fold. The first dilemma is whether or not it is moral to passively cause the death of Mrs. Jones. Is passively causing death a violation of the moral principle of non- maleficence? The second concerns how best to minimize harm and what types of harm they should minimize. More specifically, should they minimize biological harm to Mrs. Jones by not resuscitating? Or should they resuscitate in hopes of returning Mrs. Jones to Jamaica and thus minimizing spiritual harm to both Mrs. Jones and her son? This raises an interesting question about what rights someone has in choosing how they die (if they are to die in the first place). The second dilemma involves autonomy and whether or not surrogate autonomy should be awarded to Mrs. Jones’ son.

Analysis:

I believe that the attending physicians should grant Mrs. Jones’ son surrogate autonomy and thus allow him to make the decision as to whether or not Mrs. Jones should be resuscitated if she suffers another cardiac arrest. Additionally, I think that Mrs. Jones’ son should demand that the physicians attempt to resuscitate Mrs. Jones while arrangements for her return to Jamaica are being made.

According to Warren and Fletcher, a human life must have the following distinctive qualities to be worthy of protection: rationality, self-awareness, and autonomy. In Mrs. Jones’ semi-conscious state she is both unaware of her surroundings and unable to hold rational conversations. Due to this limited capacity, Mrs. Jones is regarded as a non-autonomous being and deemed incapable of giving informed consent by the attending physicians. One might conclude that, by Warren and Fletcher’s standards, Mrs. Jones’ life is no longer worthy of protection and that she should therefore not be resuscitated should she suffer another cardiac arrest. Although I recognize that Mrs. Jones’ quality of life in her present state is very low, I believe that protections should still be granted for her “afterlife” and that one should not only respect the sanctity of life, but the sanctity of death as well.

When looking at this case from a solely biomedical perspective, it is easy to dismiss Mrs. Jones and her son’s wishes concerning the fate of their souls. Along the same vein, it is easy to be critical of a Jehovah’s Witness who declines a life-saving blood transfusion. However, it is important to recognize that the experiences of health, illness, and death are not just biological, but cultural, religious and social. When considering non-maleficence, then, we must consider not only the harm done to the person physically, but socially, mentally, and spiritually as well.  Just as a Jehovah’s Witness would mourn the loss of their soul if they were to receive blood products, so too would Mrs. Jones’ son suffer if he was not able to return his mother to her native land to die. Along with extreme guilt, he would also likely feel paranoid about having a conditional curse put on him.

Additionally, it is important to consider that Mrs. Jones’ son is perfectly capable of assuming surrogate autonomy. Although his inability to pay for Mrs. Jones’ trip to Jamaica makes the return to her native land more complicated and less likely, this in no way inhibits his ability to make a decision about whether or not to resuscitate on his mother’s behalf.

Works Cited:

Beauchamp, Tom L., James F. Childress. Principles of Biomedical Ethics. 7th ed. N.p.: Oxford

University Press, 2012. Print.

Thomas, John E., and Wilfrid J. Waluchow. Well and Good: A Case Study Approach to Health

Care Ethics. 4th ed. Toronto: Broadview, 2014. Print.

Blog 1:

Case 1:1 When Physicians and Family Disagree

Background:

Mrs. Francois was diagnosed with an ovarian cyst and underwent a hysterectomy and bilateral oophorectomy during which a bowel laceration occurred and was sutured. Six days after surgery, Mrs. Francois began to develop severe abdominal pain, became hypotensive, and later went into respiratory distress. Testing revealed that the suture line on her colon had split open. In spite of this, her condition improved, she appeared to be quite aware of her surroundings, and she was able to communicate via written notes. Upon informing Mrs. Francois of the need to operate, she refused surgery. Deeming her actions to be out of character and abnormal, her family attempted to consent to the operation on her behalf.

Dilemma:

The dilemma in this case is whether the doctor should operate, thus providing the patient with life-saving medical care, or not operate and thus honor the patient’s right to self-determination. The main tension in this case is that of autonomy vs. non-maleficence.

Class Connection:

This case reminded me of Mr. G’s non-consensual electroconvulsive case that we discussed in class in that they both involve a conflict between autonomy and non-maleficence. However, in Mrs. François’s case we add yet another complicating factor: the family disagreeing with the course of action insisted upon by Mrs. François. It is interesting to consider the moral implications of Mr. G taking his life knowingly via action (suicide) vs. Mrs. François accepting death (also knowingly) through inaction.

Critical Analysis:

Mrs. François originally presented with stress incontinence or the leakage of urine during physical activity or exertion (Stress incontinence: MedlinePlus Medical Encyclopedia). Presumably, she sought out medical attention because she found this incontinence to be inconvenient and/or embarrassing. She now lies in a hospital bed in immense pain with a fever, a distended belly, and a perforated colon, and the prospect of death. Compared to her initial condition, her current condition is markedly worse. Her ovarian cyst was not presented as being life-threatening, but the dehiscence of her colonic suture could prove fatal. One might conclude that Mrs. François no longer trusts her gynaecologist and is therefore unwilling to undergo a second surgery for fear of further complications and more pain. Although one might argue that this fear may impede her ability to make an autonomous decision, I would argue that her fear should not be discredited and her decision honored.

Another consideration in this case is quality of life (should Mrs. François chose the life-saving surgery). Will Mrs. François be able to return to normal day to day activities? Or will future surgeries result in a reduced quality of life? Although the case does not state the potential consequences of a second surgery, it is likely that the dehiscence of the colonic suture line following Mrs. François’s first surgery has caused some of the surrounding tissue to become non-viable. This non-viable tissue would likely have to be resected and a colostomy procedure performed. A colostomy would require Mrs. Francois to empty her feces from a colostomy bag on a daily basis. Given her morbid obesity, it is likely that someone would have to assist her with this task. Perhaps Mrs. Francois wishes to preserve her dignity and does not want to deal with these consequences.

Although one might argue that it is the physician’s responsibility to minimize harm and thus to perform the life-saving surgery, we might also argue that the physician did not fulfill his responsibility during the first surgery as it resulted in physical harm that inflicted far more pain than her original ailment. Furthermore, by inflicting harm on others, he might be considered to be of lower moral status (and a less respected physician). Additionally, according to Childress, the requirement that a physician obtain the informed consent of his patient to perform a medical procedure is primarily in place to protect autonomous choice, not to minimize the potential for harm (Childress 63). Still, some might argue that Mrs. Francois is not competent and therefore incapable of making an autonomous decision. Based on her level of awareness, ability to communicate, and the fact that most of her family did not feel as if she was acting out of character, I would argue that Mrs. François is competent and fully capable of making an autonomous decision. Therefore, her family members should not exercise surrogate autonomy. Given these reasons, the physician ought to honor Mrs. François’s self-determination and with stain from operating.

References:

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 5th ed. New York, N.Y.: Oxford UP, 2001. Print.

Thomas, John E., and Wilfrid J. Waluchow. Well and Good: A Case Study Approach to Health Care Ethics. 4th ed. Toronto: Broadview, 2014. Print.

Wolff, B. G., Viscusi, E. R., Delaney, C. P., Du, W., & Techner, L. (2007). Patterns of Gastrointestinal Recovery after Bowel Resection and Total Abdominal Hysterectomy: Pooled Results from the Placebo Arms of Alvimopan Phase III North American Clinical Trials. Journal of the American College of Surgeons, 205(1), 43–51. doi:10.1016/j.jamcollsurg.2007.02.026