Unlike typical hospitals and healthcare settings, vertical aid programs focus on a specific disease or intervention technique. Well and Good outlines a case in which a physician, Dr. Asadour, is set up in a town in South Sudan to run an anti-cholera vertical aid program with the instruction to only admit and treat cholera patients. All patients whose symptoms did not resemble cholera, under the guidelines of a vertical aid program, were turned away and sent to a crowded, limited-resources local hospital (Thomas, Waluchow, Gedge 267). Dr. Asadour was confronted with a variety of moral dilemmas surrounding the ethicality of vertical aid programs. If a patient is admitted and upon closer review it is determined that he or she does not have cholera, is it ethical to turn the patient away if they were already admitted? If the program center has the resources to treat serious conditions, such as meningitis, that don’t fall under the specific purpose of the vertical aid program, should they? Are vertical aid programs in it of themselves unethical?

It is well established that there are not unlimited resources when it comes to healthcare and treatment of patients, but how does one decide how and on who to allocate the resources? In deciding how to allocate money and medical resources, “policymakers will examine various diseases in terms of their communicability, frequency, cost, associated pain and suffering, and impact on length of life and quality of life, among other factors” (Beauchamp, Childress 280). It is this type of examination that leads to the start of vertical aid programs; healthcare professionals come up with a disease or intervention technique that appears to provide the best cost-benefit analysis in a particular area based on the above factors. While in theory this might be a smart way to approach healthcare and allocate limited resources, is it ethical? In the case of a meningitis patient, both bacterial and viral meningitis can be fatal if not treated immediately with antibiotics. This disease, which consists of inflammation of the meninges of the brain and spinal cord, is potentially fatal yet easily treatable by medical professionals, so should physicians involved with vertical aid programs that are not geared towards meningitis treat this patient (“Meningitis”)? According to the program’s guidelines, physicians should be turning these patients away, but do the principles of nonmaleficence and beneficence say otherwise? Physicians have a duty to help their patients and prevent them from harm, so personally I believe turning away patients that they have the resources to treat is unethical. While resources may be limited, I imagine that the antibiotics needed for meningitis and treatment of cholera patients require different resources.

What if upon admission the patient is discovered not to have cholera? I believe that the principles of beneficence and nonmaleficence speak even stronger to this situation; if they have already been admitted to the clinic, I do not think it is ethical for the physicians to then turn them away. This situation is reminiscent of the argument between withholding and withdrawing treatment we discussed earlier this semester in regards to life-saving treatments. It is one thing to not admit the patient initially (withholding treatment); however if you admit the patient, examine them, determine their condition and have the appropriate resources to treat them, how can a physician turn that patient away in good conscience? I believe the latter scenario is similar to withdrawing life-saving treatment from a patient against their wishes; if the physicians have the resources to save a life that wants to be saved, why wouldn’t they?

Ultimately I believe the duty of physicians to uphold beneficence and nonmaleficence should override the policy of vertical aid programs to only treat those with a specific disease using a specific technical intervention. While that particular disease may be a larger issue in that specific area, it will not be the only illness that plagues the people in that area. Even if resources are limited, if the physicians have the resources necessary to admit and treat patients with other diseases, I believe they have a responsibility to do so.

References:

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

“Meningitis.” Mayo Clinic. Mayo Foundation for Medical Education and Research, 2017. Web. 14 Apr. 2017.

Thomas, John E., Wilfrid J. Waluchow, and Elisabeth Gedge. Well And Good: A Case Study Approach to Health Care Ethics. N.p.: Broadview, 2014. Print

Clinical trials are constantly viewed with scrutiny due to seemingly controversial methods including the use of placebos as well as experimental drugs with unknown effects. As referenced by Beauchamp and Childress, there has been a shift in the way in which society views clinical trials from being primarily concerned with protecting participants from “the burdens and risks associated with research” to now trying to make participation in clinical trials more accessible (Beauchamp and Childress 234). Although there has been an increase in participant interest, it brings about its own problems with regards to who should be illegible and what means are ethical in the name of research.

In Case 7.4, Thomas, Waluchow and Gedge present three main ethical considerations with regards to clinical trial participation and procedures, but for the purpose of this post, I will only focus on one. The ethical dilemma questions if “the principle of autonomy means that very ill people should be able to access any drug they wish if they accept the risk” (Thomas, Waluchow and Gedge 258). In the specific hypothetical case presented, Harald discovered that he was HIV positive and due to his advanced case and poor health status he was rejected from a clinical trial. Although it was unclear exactly how the drug worked and what the outcomes would be, Harald had no better solutions to his rapidly deteriorating health condition. I agree with the approach Harald and his partner Jim pushed for in the case: enacting an open arm alternative where infected individuals who were too sick to be involved in the research aspect of the clinical trial could still receive the drug in the hopes that it would treat or maintain the disease. In this scenario, researchers can continue to explore potential risks, benefits and side effects in otherwise “healthy” individuals while still providing potential treatment to the more “unhealthy” infected patients. While having unknown risks and side effects may appear to violate the principle of nonmaleficence, the fact that the drug is in a clinical trial implies that there is reasonable belief that it has beneficial effects.

Although it is true that many drugs never make it from clinical trials to the market, in this case, as with many other cases we look at, patient autonomy must be taken into consideration. If a patient is fully competent and understands that the risks and benefits of a drug are not explicitly known and still wishes to continue, I believe that the patient should be allowed to try the trial drug if he or she wants to. In Harald’s case, he didn’t appear to have any other options. If his symptoms were worsening, no other treatments were helping and he thought he had nothing else to lose, why not give him the drug? Is it possible that the drug will have harmful effects and make his condition worse? Yes. Is it also possible that the drug could alleviate some of his symptoms or at least maintain the course of the disease? Also yes. I believe that as long as there is a possibility of benefits along with the possibility of harms, and there is no other viable treatment available, the use of trial drugs should be a legitimate option for terminal patients. While there is concern in the research community about how including certain types of participants may skew the results or imply false outcomes, I believe it to be unethical to refuse potentially life-saving drugs from individuals who are deemed to be “too sick” to provide useful information in the name of science. While breakthroughs in biomedical research are extremely important for future patients, physicians have an obligation to their current patients to respect their autonomy, prevent harm and try to alleviate suffering. If continuing without or with useless treatment would inevitably lead to death, offering a drug that could potentially prevent harm, in this case being death, is an act of beneficence as well as respect for autonomy.

On a slightly different note, would the situation change if the risks, benefits and side effects of a drug were all known and the drug was found to be associated with high risks? While recreational marijuana is still illegal in most of the United States, many states have legalized the use of medical marijuana for certain patients in order to alleviate pain. On a similar note, high dosages of morphine are prescribed to many patients in hospice to reduce suffering and keep such terminal patients as comfortable as possible (“Hospice Patients Alliance”). In these cases, the risks and side effects are known, yet still prescribed as viable treatments for certain patients due to the potential benefits. What makes the case of medical marijuana and high dosages of morphine different from a drug on a clinical trial? All three cases exhibit potential risks and benefits. Is it acceptable to prescribe patients drugs with high risks as long as the risks are explicitly known?

References

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

“Hospice Patients Alliance – When It Is Inappropriate to Have PRN Medical Orders for Morphine.” Hospice Patients Alliance – When It Is Inappropriate to Have PRN Medical Orders for Morphine. Hospice Patients Alliance, n.d. Web. 23 Mar. 2017.

Thomas, John E., Wilfrid J. Waluchow, and Elisabeth Gedge. Well And Good: A Case Study Approach to Health Care Ethics. N.p.: Broadview, 2014. Print

Beneficence and nonmaleficence are two ethical principles that our society relies heavily on and although they may have similar intentions, they each possess distinguishable characteristics. According to Beauchamp and Childress, nonmaleficence calls for prohibition of harm, is impartial (obligation not to harm people in general) and is often considered the moral basis for law. On the other hand, beneficence is a call for positive action, may be partial (not obligated to help all people in all situations) and, unless it is explicitly required for your profession, is not the moral basis of law (Beauchamp and Childress 205). Beauchamp and Childress also lay out a series of five conditions that comprise the duty to rescue which take into account the necessity and benefit to the person in need, burden to the helper and probability of the result/benefit (Beauchamp and Childress 207). One argument is that if the helper faces a low risk/burden to help someone in need, and such help has a high probability of positively affecting the person in need’s life, the helper has a moral obligation to do so. Situations in which the probability of success is low, there is a high risk for the helper or the help provided is not absolutely necessary to the survival of the person in need, there is no obligation to help this person, but doing so would be considered a supererogatory act.

https://www.youtube.com/watch?v=ufhKWfPSQOw

At the end of class we began to discuss where the principle of beneficence falls in terms of foreign affairs. Do we have a moral obligation to help other countries in need? Should we provide aid to countries in war that are our allies or intervene in countries with corrupt government? Attached to this post is a video of Yeonmi Park, a young woman who escaped from North Korea, recounting some of the horrors she experienced growing up at the One Young World conference. She talks about seeing parents of friends murdered for watching Hollywood movies, witnessing rape and even admitting that when she was younger she believed that the dictator could read her mind and that she could not think anything in opposition to the dictatorship. The stories she discusses are horrible, as is evidenced by the teary-eyed faces in the crowd and the pit in my stomach I felt as I watched the video. At the end of the video I wanted nothing more than to help or for someone to help this girl and other girls like her who are victims of the country they were born in. The conditions of North Korea are terrifying and inhumane, yet not much or at least not enough is done to protect those who are stuck living there.

Does the principle of beneficence apply here? As stated above, beneficence is sometimes partial and not the moral basis of law, so legally we do not have an obligation to help, but should we? Other women and citizens of North Korea like Yeonmi are in desperate need of help and face serious risks everyday; however would actions on behalf of the United States realistically prevent this harm? Are the risks and burdens involved for the United States too great to overcome the potential benefits to the North Koreans?

While intervening in foreign affairs is often controversial, do we as moral beings have an obligation to step in in the name of beneficence? Or is any such action of beneficence to another country considered supererogatory?

Citations

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

OneYoungWorld. “Escaping from North Korea in Search of Freedom | Yeonmi Park | One Young World.” YouTube. YouTube, 18 Oct. 2014. Web. 14 Mar. 2017.

Physician-assisted suicide is controversial in the medical world due to the conflicting ethical principles of autonomy, beneficence and nonmaleficence that could be argued both for and against such a procedure. This form of voluntary euthanasia has caught media attention after the District of Columbia passed its Death with Dignity Act as of February 20, 2017, marking it the sixth jurisdiction in the United States to have a policy allowing physician assisted suicide. According to this new act, certain individuals with terminally ill diagnoses can “voluntarily and legally request and receive a prescription medication from their physician to hasten their death in a peaceful, humane, and dignified manner” (“District of Columbia Current Status”). It appears as if this act prioritizes patient autonomy and respecting the wishes of the terminally ill individual; however autonomy in this case is at odds with the duty of the physician to do no harm and help the individual. Or is it?

In the case of Sue Rodriguez, a woman suffering from ALS, she petitioned to the court to legalize physician-assisted suicide so that she could end her life in a humane way when she was no longer able to enjoy it. Rodriguez was aware of the specifics of the condition and knew that by the time her life was too painful and miserable to tolerate, she would be physically incapable to end her life. All she wanted was to try as best she could to enjoy the life she had before the disease fully took over and made life unbearable, at which point she wanted to have the option to have access to “’technological means by which she might, by her own hand, at the time of her choosing, end her life’” (Thomas, Waluchow, Gedge, 214). When it comes to life-ending issues, it is important first to assess the competency of the individual. Although suffering from ALS, Rodriguez appears to be a mentally competent individual who is fully capable of making her own decisions regarding the course of her life and consequently death. If the patient is competent, which she appears to be, is that enough to override the physician’s duty to protect the patient’s life at all costs?

With respect to this scenario, I believe that patient autonomy should trump the duty of the physician to “do no harm” and keep the patient alive regardless of her wishes. The truth of the matter is, physicians and Supreme Court Justices who are making these decisions do not know what it is like living with the unbearable pain and life restrictions that individuals suffering with ALS or other terminal diseases face every single day, and if that is the case who are they to decide if such an individual should live or die? I do not believe that every terminally ill person should opt for assisted suicide; however I do believe that they should all have a choice. In class we discussed the shift from Sanctimonious Life (SL) to Quality of Life (QL) with regards to end of life issues and deciding when it is acceptable to withhold or withdraw treatment. I believe that the shift to focusing on quality of life is a huge stepping stone in medical practice because it allows the patient to have a choice; a choice to end their life in a peaceful way rather than endure unbearable suffering when they no longer wish to live.

On that note, is it possible that by not allowing the patient to peacefully end her life, the physician is acting against the principles of nonmaleficence and beneficence? If a patient is suffering, a physician’s job is to ease their pain; therefore if the state of living is the cause of unwavering suffering, is it the duty of the physician to end the pain and subsequently end the patient’s life? As I said earlier, I am not advocating that all those who, on a daily basis, suffer extreme amounts of pain should end their life, but I can also follow the argument that for some such individuals, being able to end their life with dignity by the hand of a doctor would fall in support of the principles of beneficence and nonmaleficence.

Ultimately I believe that physician-assisted suicide should be an option to certain individuals with terminal conditions that cause excessive amounts of pain and suffering with no hope of recovery. If the patient is deemed competent enough to make the decision, patient autonomy should overshadow the idea that physicians must prolong the life of a patient at all costs. Those who are opposed to physician-assisted suicide argue “individuals can always find the means to kill themselves without a Doctor’s assistance” (220). While this argument is technically true, I believe that as a society we should not force suffering, terminally ill individuals to take matters into their own hands and end their lives in less humane ways. Whether physician-assisted suicide is legal or not, it will happen and some individuals may choose to commit suicide themselves, cutting their life shorter than they would if they knew that they could engage in a dignified, assisted suicide later.

Citations:

“District of Columbia Current Status.” Death With Dignity. Death With Dignity, n.d. Web. 23 Feb. 2017.

Thomas, John E., Wilfrid J. Waluchow, and Elisabeth Gedge. Well And Good: A Case Study Approach to Health Care Ethics. N.p.: Broadview, 2014. Print

The use of a placebo as a legitimate treatment in both a medical and research setting has been under scrutiny based on the nontraditional nature of the treatment. The Lichtenberg paper focused primarily on the controversy of whether or not physicians should be allowed to offer their patients “knowingly ineffective remedies … in order to assuage the patient’s discomfort” or if it is unethical to offer a placebo if alternative, traditional medications will suffice (Lichtenberg, Heresco-Levy, Nitzan 2004). In order to address this issue, it is first important to decide what exactly constitutes an effective treatment. Most people would deem medication as a sufficient treatment to virtually any medical condition due to its explicit physiological mechanisms and tangible effects, but is this the only “legitimate” form of treatment? The argument against the use of a placebo in medicine comes from a standpoint in which sufficient treatment is “purely biomedical” while all other alternatives are inadequate (Lichtenberg, Heresco-Levy, Nitzan 2004). Although modern medicine is both impressive and reliable, it is not the only means of recovery.

In some cases, such as depression, medicine has been observed to be equal or even less successful compared to some alternative methods, such as cognitive therapy. There is empirical data to support that therapy is “as efficacious as antidepressant medications at treating depression” and appears to have lasting effects (DeRubeis, Siegle, Hollon 2009). Cognitive therapy consists of identifying the cause or belief behind the depressive episode and then separating and questioning the reasons behind the belief. Antidepressant medication is also effective in managing or treating depression, but cognitive therapy provides an equally qualified treatment that does not require prescription drugs and also offers a protective method to prevent future depressive episodes (DeRubeis, Siegle, Hollon 2009). Unlike a placebo, the physiological mechanisms behind the success of cognitive therapy are known and respected among the healthcare field. However, is cognitive therapy, as well as other behavioral therapies, considered to be a biomedical treatment? If not, is it still considered to be a justified alternative treatment to medicine?

Another treatment that has been shown to reduce depressive symptoms is a method called Deep Brain Stimulation (DBS). DBS consists of implanting and stimulating electrodes in the brain. Although the mechanisms of these stimulations are not well understood, it seems to “improve mood and give the people an overall sense of calm” (Taylor 2016). Although it is recommended that patients try both therapy and antidepressants before DBS, it is still a viable option for patients.

Considering medication, therapy and DBS, which treatments are considered an effective treatment? Therapy is not considered purely medical, but the physiological mechanisms are well understood, while the mechanisms of DBS are not understood, but proven to be effective. Should either of these methods be considered an effective form of treatment? If so, I return to my initial question of what constitutes an effective treatment, both ethically and physically? Is it necessary for the physiological mechanisms to be explicit or is it just enough for positive outcomes to be observed? Although all of these treatments are different from the use of a placebo, I believe the same underlying principles apply in terms of effectiveness. While the controversy of deception is also part of the picture, it is important first to determine whether or not the treatment in it of itself is rendered effective enough. Based on the same underlying principles of cognitive therapy and DBS, I believe that although the mechanisms for why placebos work is not explicitly known, if it has positive effects and does not impose risks to the patient, it should be deemed a viable option for effective treatment.

DeRubeis, Robert J., Greg J. Siegle, and Steven D. Hollon. “Cognitive Therapy vs. Medications for Depression: Treatment Outcomes and Neural Mechanisms.” Nature reviews. Neuroscience 9.10 (2008): 788–796. PMC. Web. 4 Feb. 2017.

Lichtenberg, P., U. Heresco-Levy, and U. Nitzan. “The Ethics of the Placebo in Clinical Practice.” Journal of Medical Ethics 30.6 (2004): 551-54. BMJ, Dec. 2004. Web.

Taylor, Mara. “Deep Brain Stimulation (DBS).” Healthline. N.p., 10 Aug. 2016. Web.