Summary

William Schroeder, a previously healthy man with an active lifestyle suffered a massive heart attack that left him with terminal arteriosclerosis. This led to Schroeder becoming the second person ever to receive an artificial heart. Humana hospital agreed to cover the costs of the transplant and even build a special house for Schroeder to stay in after his recovery was complete. The procedure was a success and Schroeder would seemingly live out the rest of his days without much discomfort, but things gradually took a turn for the worst, and Schroeder suffered a total of 3 strokes and eventually passed away after living 620 days with the Jarvik-7 heart in his chest (2).

Case Discussion

The primary moral dilemma discussed in the text is about the allocation of funding in healthcare. Should we spend exorbitant amounts of money on things such as artificial hearts that would only benefit a small percentage of patients, or should this money be better allocated to other programs associated with early detection and prevention that could benefit more people?

While I think this is an interesting issue to consider, I was particularly interested in Schroeder’s individual experience. Namely, I am concerned with whether the principles of nonmaleficence were upheld by Schroeder’s healthcare team. Beauchamp and Childress state these 5 rules about nonmaleficence:

1. Do not kill
2. Do not cause pain or suffering
3. Do not incapacitate
4. Do not cause offense
5. Do not deprive others of the goods of life

Surely, by giving Schroeder the artificial heart, all of these rules were being upheld. However, after his first stroke, Schroeder was left with severely impaired speech and memory problems. The patients wife stated:

“I see it as more of a research experiment. The longer he lives, the more information [doctors] will get. Only for us it’s so hard sometimes.”

This brings up an interesting situation to consider. While doctors are upholding the first and last of the moral rules stated above, some might consider keeping Schroeder alive on the artificial heart as violating the second rule. We are given little insight into Schroeder’s mental state, but we are told that Barney Clark, the first to receive an artificial heart, complained to psychiatrists that he wanted to die on several occasions.

While I do not think it is any of the doctors intent to cause pain or suffering, one must think about who is benefitting more from the artificial heart, the doctors or the patient? The data being gathered from Schroeder’s experience could be invaluable to improving the procedure for future recipients of artificial hearts, but it seems that he is in considerable suffering without a hopeful chance for living a normal life. It would be interesting to read what was in the extensive consent form that Schroeder and his wife agreed to before undergoing the procedure.  Furthermore, I have been unsuccessful in finding any studies that assess mental health of artificial heart recipients.

References

1. Beauchamp, Tom L., and James F. Childress. “Nonmaleficence” Principles of Biomedical Ethics. New York, NY: Oxford UP, 2001. 150-193. Print.

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

Summary

Simon, a widowed father of a single son was brought to the hospital after an attempted suicide. Simon has been suffering severe depression, and treatment with anti-depressants seems to have had no benefit. Once hospitalized, Simon attempted suicide again. This led Simon’s psychiatrist to propose an electroconvulsive shock treatment therapy over a course of two weeks (1).

Discussion

One of the moral dilemmas that are being addressed in this case is: Should the psychiatrist respect the father’s autonomy and allow him to refuse treatment, or should the principle of beneficence take precedence and the treatment be given against the wishes of the Father and Son. 

First, we should explore whether or not simon is competent enough to have his autonomy respected. According to Beauchamp and Childress, a person may be declared incompetent if they are unable to give a rational reason for their actions (1). Now this brings into question, is there any rational reason for suicide? To Simon, escaping constant mental distress may take precedence over preserving physical wellness. If this were the case, Simon could be declared competent enough for his autonomy to be respected, and the psychiatrist should respect his decision to refuse treatment; however, from the psychiatrist’s point of view, he could state that Simon’s chronic depression prevents him from understanding relevant information or the consequences of his choice, and therefore would classify Simon as incompetent, and give the psychiatrist reason to apply to the review board to go ahead with the treatment.

Second, we must look at the psychiatrist’s obligation to beneficence. As a healthcare professional, the psychiatrist must take actions to prevent harm and promote good. If the psychiatrist should allow Simon to refuse the treatment, and Simon ends up committing suicide, one could determine that the psychiatrist failed to uphold this principle. But achieving this goal could prove challenging for the psychiatrist. By promoting autonomy through providing accurate information about ECT to the father, the psychiatrist is doing his best to promote good; however, if even after providing accurate and understandable information to both Simon and his son, the pair still refuse treatment and Simon commits suicide, one could say the psychiatrist failed to prevent harm. So at what point does the psychiatrist’s attempts to convince Simon to accept ECT violate Simon’s autonomy through coercion or manipulation?

Personal Response

One might say that Simon’s depression renders him incompetent and temporarily nullifies his right to refuse treatment. But Simon previously agreed to receive anti-depressants, which would not have been prescribed unless Simon had been already been depressed. On that note, is it acceptable to overlook a patients mental illness if their decision could potentially preserve their physical condition as opposed to threaten it? Is someone only deemed incompetent if their actions produce a negative consequence for their healthcare provider? I would say that Simon is indeed in a more severe mental state than when he agreed to take anti-depressants, but not severe enough that he should be declared incompetent and have his autonomy violated.

Furthermore, the efficacy of ECT should be called into question when determining whether or not to respect Simon’s autonomy. While it has been shown that ECT can produce promising effects short-term, chances of relapse still remain high. The common strategy with ECT is that it allows time for anti-depressants to take effect. However, the anti-depressants obviously did not work for Simon before, so the question becomes, would the ECT be enough of a catalyst for the drugs to be effective? The results are conflicting. Earlier studies showed that ECT in conjunction with continued anti-depressant use effectively reduced the symptoms of major depressive disorder with low rates of relapse (2), but some later studies showed that the relapse rates are relatively high. One study showed a 57% relapse in patients receiving ECT and continued antidepressant use in 6 months (3), with another study showing a 51% relapse rate (4). I believe that the high relapse rates of the ECT make it unjustifiable for the psychiatrist to obtain approval for the ECT. The chances that Simon would relapse into depression and be subject to further mental distress should be enough to justify his autonomous decision to refuse of treatment.

References

1. Beauchamp, Tom L., and James F. Childress. “Respect for Autonomy.” Principles of Biomedical Ethics. New York, NY: Oxford UP, 2001. 101-40. Print.

2. Gagné, G. G., M. J. Furman, L. L. Carpenter, and L. H. Price. “Efficacy of Continuation ECT and Antidepressant Drugs Compared to Long-Term Antidepressants Alone in Depressed Patients.” The American Journal of Psychiatry 157, no. 12 (December 2000): 1960–65.

3. Rehor, G., A. Conca, W. Schlotter, R. Vonthein, S. Bork, R. Bode, M. Hüll, et al. “[Relapse rate within 6 months after successful ECT: a naturalistic prospective peer- and self-assessment analysis].” Neuropsychiatrie: Klinik, Diagnostik, Therapie Und Rehabilitation: Organ Der Gesellschaft Österreichischer Nervenärzte Und Psychiater 23, no. 3 (2009): 157–63.

4. Jelovac, Ana, Erik Kolshus, and Declan M. McLoughlin. “Relapse Following Successful Electroconvulsive Therapy for Major Depression: A Meta-Analysis.” Neuropsychopharmacology 38, no. 12 (November 2013): 2467–74. doi:10.1038/npp.2013.149.