The world is unfair. The diversity through our city, state, country, and world require that there are differences in people’s life experiences. As a human race we should work to ensure that every person has the basic necessities to life a good life, however defining what a necessity is a very difficult task. Those living in different areas of the world view what is necessary and what is not differently. This discrepancy makes us ask what the difference is between something that is unfair and we need to live to learn with and what is unjust and we need to fight against to rectify in our world.

Beauchamp and Childress sate that “Properties distributed by the lotteries of social and biological life do not provide ground for morally acceptable discrimination between persons in social allocations if people do not have a fair chance to acquire or overcome these properties” But What properties create an injustice to require some form of assistance? Is it unfortunate or unfair? The example stated in Principles of Biomedical Ethics is the disparities have persisted in the management of acute myocardial infarction and acute coronary syndromes and that the End-stage renal disease Program pays in full for the kidney transplant but does not pay for the post-transplantation requirements such as immunosuppressant mendication needed for the rest of life. The denial of treatment due to the socioeconomic status of individuals is an injustice. While the programing are helping individuals and diagnosing illness to work to correct something that is unfair, they are also making it more of an injustice. It is not morally just to provide a service for a citizen that is not sustainable for their socioeconomic status. If you do not provide a service that will help them patient through their lifetime, and you know that they will be harmed in the future either emotionally or physically because of the stop to treatment, it is an injustice.

This makes me think of similar situation in New York. Froma Walsh discusses the case of Post Traumatic Stress Disorder (TSD) in New York neighborhoods. There are great discrepancies between the rates of symptoms and diagnosis of PTSD. There are higher rates of symptoms of PTSD, but there are higher rates of diagnoses of PTSD in upper middle class neighborhoods. While these disparities exist and it is unfair that mental health professionals take into account the socioeconomic background of a client before diagnosing them with something that may require expensive therapy and drugs that they cannot afford. Instead these clinicians provide ways to self regulate their symptoms for their PTSD that do not require diagnosing them with the disorder.

While it is important to work to fight injustices, it is important to accept that unfairness does exist. The same health conditions in different people may require different and more effective treatment based on their socioeconomic status and life experiences.

Walsh, F. (2003). Normal family processes: Growing diversity and complexity.

New York: Guilford Press.

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

When doctors should and should interfere is the basis of many bioethical questions. The wide range of scenarios that doctors face on a day to day basis, from whether or not they should force feed a patient to issuing a Do Not Resuscitate order, all share a common core that asks if the doctor should interfere or not. But what does it mean to interfere? Is interference anything that goes against the choice of the patient? But if the patient would benefit from the action is it interfering? Or is interference justified by the principle of beneficence? These questions, and many more are necessary in deciding what is the moral action in many bioethical decisions.

The Merriam-Webster dictionary defines interference as, “involvement in the activities and concerns of other people when your involvement is not wanted.” By this definition, any action taken by a health care professional that is not in agreement with the wishes of the patient is interference. So in order to respect a patient’s autonomy the physician must act according to what the patient wants and exercise no interference. However, the issue with this logic is that physicians, by the very nature of their profession, will encounter patients who do not want their involvement, but are not competent to make that choice. While every situation is different, Terrance Ackerman argues why doctors should intervene. He explains many reasons and justifications of when doctors should exercise their power and override the decision of the patient. While in the case of mental illnesses where competence and decision-making are compromised, I agree that decisions need to be made by a clear-thinking person, but I do not agree with many of the justification that Ackerman discusses.

One such discussion is surrounding fear. The article describes “fear as a cripple of patients to choose and make an autonomous choice.” It cites a story of a young man who refused neurosurgery because of the posiblity of neurologic damage who later died because of delayed treatment. I do understand that it must be difficult for physicians to see a patient refuse a life saving treatment, however ultimately it is their body, and they have the final decision if they are competent. Fear is a reaction to a person’s experiences and thoughts, which are difference for every individual and does not affect their competency. A competent individual should not be viewed as less autonomous because they have a differing opinion than a physician. Ackerman also quotes a phrase from The Healer’s Dilemma by Eric Cassell: “If I had to pick the aspect of illness that is most destructive to the sick, I would choose the loss of control. Maintaining control over ones self is so vital to all of us that one might see all of the other phenomena of illness as doing harm in their own right but doubly so as they reinforce the sick person perception that he is no longer in control.” If physicians abuse their power to override a competent patient’s autonomous decision because of fear, than physicians may lose the ability to override the decisions of patients who are not competent to make their own decisions and do need their assistance.

http://www.merriam-webster.com/dictionary/interference

Ackerman, Terrance “Why Doctors Should Intervene” The Hastings Center Report 12 (4): 14-17 (1982)

The case of Stephen Dawson, a seven-year-old boy with severe mental disabilities, discusses many difficult ethical issues. The influence of this case impacts other cases with severely mentally ill patients, but additionally impacts larger cases including different moral principles.  The first issue the case discusses is who is responsible for making the health care decisions of those who are not competent to make the decisions themselves. Secondly, it discusses the difference between withdrawing and withholding treatment. Lastly, and the issue that I want to discuss, is the moral status of those with disabilities.

In the case of Stephen Dawson, I believe that the state was morally correct in usurping parental control over the child and performing the life-sustaining surgery. Despite Stephen’s severe physical issues, he is still a human to whom, dependent on which theory you subscribe to, the principles of moral status apply.  He has sentience and therefore feels physical and emotional pain. He has human properties, including human DNA and being of the human species. But, because of his disability, the suffering of others overpowers his ability to be treated as someone who is not disabled.

By electing to not complete the surgery on their son, the Dawsons are dismissing the value in the life of their son. In the case discussion, the Supreme Court Justice of British Columbia, Justice Lloyd McKenzie, stated the life of a severely handicapped child had been placed above a healthy child. All throughout this case, Stephen’s welfare was often not the priority, and his life was viewed as disposable. Many of the statements from Judge Bryne, who ruled that the Dawsons should “allow their son die”, discuss the great burden placed on parents of Stephen as evidence for his ruling. The needs of his parents were placed above the needs of Stephen. Additionally, when Stephen was removed Sunny Hill (the home for physically disabled children), he was placed into foster care, and not the care of his parents. The case does not explicitly state the reasoning for this placement, however, I suspect that it was to not burden the family of Stephen again after they had acclimated to having him outside the household, especially the life of their other, healthy child.  Overall, this case displays that the welfare of Stephen was not a priority to his parents and their lives, and the life of their other child was placed above their physically disabled son. Luckily for Stephen, the government of British Columbia fought for what the moral just ruling.

While this case in British Columbia eventually ruled in the favor of Stephen’s welfare, I question if the logic of Stephen’s parents and Judge Bryne, would have held in the United States.  The trend of placing the life of a healthy child over the right of a mentally or physically disabled child has been shown in the decreasing birth rates of Down Syndrome Children in the United States. Dr. Brian Skotoko, a pediatric geneticist at Children’s Hospital Boston showed a fifteen percent decreases in Down Syndrome children born in the United States between 1989 and 2005. This decrease may be attributed to the larger increase in women choosing to terminate their pregnancies with Down Syndrome Children. Without even discussing the dilemma of abortion, terminating a pregnancy with a Down Syndrome child that you would not have terminated otherwise, is a clear invalidation of the lives of disabled children.  Based on this data, would this case have been ruled different here in the United States?

Sources: 

Beauchamp, Tom L and James F. Childress, Principles of Biomedical Ethics (Oxford, Seventh Edition).

James, Susan Donaldson. “Down Syndrome Births Are Down in U.S.” ABC News. ABC News Network, 02 Nov. 2009. Web. 21 Feb. 2015. <http://abcnews.go.com/Health/w_ParentingResource/down-syndrome-births-drop-us-women-abort/story?id=8960803&page=2>.

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The moral principle of autonomy is one of the four major principles of bioethics. Despite its monumental influence over the beliefs and choices of bioethicists, physicians, and patients’ families, it is difficult to specify the exact definition of this complex principle. In Principles of Biomedical Ethics, Beauchamp and Childress examine a variety of theories surrounding autonomy. In order to apply the principle of autonomy to any case, we must understand what makes a choice autonomous and who is able make an autonomous choice.

The Three Condition Theory of Autonomy outlines terms that are necessary for a choice to be deemed autonomous. An autonomous act must be intentional, have been executed with understanding, and without controlling influences over the action (Beauchamp and Childress). Using this basis, I would like to now apply this idea to the case of Simon, a 53 year old who is depressed and is denying Electroconvulsive Shock Therapy (Thomas, Waluchow & Gedge). The moral issue lies in deciding whether or not the psychiatrist should petition to force the Electroconvulsive Shock therapy and go against the principle of autonomy. In this case we must decide if the principle of autonomy should be placed higher than the principle of non-maleficence.  His decision was intentional as his action to refuse treatment is in accordance with his wish to be left alone (Andre). Also, his decision is not being influenced by any outside source. Which leaves the issue of if he understands the severity of refusing his potentially life-saving treatment.

It is difficult to determine in his depressed state if he fully understands the probable outcome of his life without the electroconvulsive shock therapy. Due to the complex nature of depression and our incomplete understanding of its influences over the brain and decision making skills, we are unable to determine if Simon is competent enough to understand his actions. In a similar case to Simon, Paul Henri Thomas tried to deny electroconvulsive shock therapy, however the court ruled he was incompetent to make his own decision. By allowing the deciding factor to be the competence of the patient, there is almost a guarantee that the patient will receive the treatment. In the eyes of physician, if a depressed patient is competent, they will accept the therapy, and if they deny the therapy, they are incompetent, and therefore the therapy should the forced upon them (Andre). This paradox makes Simon’s case difficult, however we have another person’s opinion to help us make a decision: Simon’s son.

The presence of Simon’s son, and his ability to be his proxy for his therapy choices greatly reduces the complexity of this ethical dilemma. Simon’s son is intentional in his actions, is not being influenced by an outside source (besides the patient himself), and understands the risk associated with the electroconvulsive shock therapy. My decision in this case is to respect the autonomy of not only Simon, but also his son. While it may be difficult as a physician to see a patient forgo a possibly life saving therapy, ultimately in this specific circumstance, they must support the patient.

Works Cited:

Andre, Linda. “Deciding Competence.” Ect.org. N.p., n.d. Web. 27 Jan. 2015. <http%3A%2F%2Fwww.ect.org%2Fnews%2Fcatch22.html>.

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

Thomas, John,  Wilfrid Waluchow, and Gedge, Elisabeth. Well and Good: A Case Study Approach to Biomedical Ethics. 3rd ed. Broadview Press Ltd., n.d. Print.

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