“Equals must be treated equally, and unequals must be treated unequally.”

The above quote is Aristotle’s view on justice.  It represents the principle of formal justice, that being the unspecified and unsubstantiated basic principle of justice. However there is a lot to be said for its simplicity. It lays a good groundwork for the original theories of justice. People who for whatever respects are considered equals must receive the same level of respect and in a medical sense treatment. It also allows for people who are not equals to be treat differently. Some would argue that this is grounds for the justification of discrimination. Which it could be, unless the terms are properly defined. It is stated in the Declaration of independence, one of the founding documents of the American government, that all men are created equal. Now this should clearly be expanded to include all women and everything in between, but it provides a definition of equality. The ideal of Justice as simply treating everyone equally sounds wonderful but is also kindergarten-ish in its simplicity and functionally impossible. The other option is to use some other definition of equality. And this is where the philosophy of this quote begins to seem barbaric. Say the equality was determined by intelligence, or success, or some other unequivocally good quality. There would always be people who did not possess such a quality merely because they were disadvantaged. This concept of being disadvantageous in the center point of the discussion of justice and equality. This is the idea that people are in fact perfectly equal but the circumstances of their life have the capability to render them unequal to others due to no fault of their own. This is perfectly true. There are certain external factors that can be very difficult or functionally impossible to overcome. This is being disadvantaged and in our ideals of equality society would bring these people up to whatever may be determined as a standard. This is sometimes referred to as the lottery of life. We attempt to help these people through genuine beneficence, sheer force of empathy, or the sense that if we had their place that we would want someone to help us.   However Aristotle would not have this happen. They are not under most senses equals. My other major concern with the philosophy of this quote is the use of the word must. On first reading it seems Aristotle would view programs and actions taken in an attempt to equalize the disadvantaged as unjust. Despite the random and blameless nature of their condition he holds that they must be treated differently. However this could possibly be interpreted that due to their unequal nature they must be given better treatment as it is not specified that unequals of a lower sense must be treating unequally in a lesser sense. This can in fact be interpreted as everyone must be treated as such that the outcome is equal for them. Thus this quote which at first seems barbaric may in fact provide a truly beneficent foundation of justice.

Much of this week’s reading concerned paternalism, particularly the point at which beneficence overrides autonomy. One of the most significant examples of this is the right to commit suicide. Historically this has been something prevented at all costs, even to the point of being illegal. However things are changing, very few people in the modern world would suggest that it should be a criminal and prosecutable offence. Beliefs go all the way to the other end of the spectrum as well, four states having authorized physician assisted death, in certain cases. However there is still debate about the right of competent and autonomous patients to commit suicide.

First let us look at the necessary requirements in those states where it is permissible. To begin the process most states require at least 2 oral requests and a written request in a period of no shorter than 15 days. The common requirements across three of the states include at least 18, that the next-of-kin is informed, and informed knowledge of alternatives. The two crucial requirements are the diagnoses of a terminal illness with an expected life span of less than 6 months and clear evidence of complete competence. Both of these must also be certified by a corroborating physician.

These requirements are those required to actively end a life, by the hand of the patient. However, many cases involving suicidal patients do not require active interference by the physician or anyone else. Simply a passive lack of intervention will lead to the patient’s death. The moral dilemma then becomes whether to act or not to.  This hinges on the idea that there is the possibility that there are situations that people have no wish to live through, and that this process is reasonable. Examples of this include incredibly painful or risky treatment that would be lifesaving. The exemplar case of this scenario is Dax Cowart, who was severely burned and underwent horrendously painful skin grafts to survive. He still insists years later that the doctors should have ceased treatment at his request and let him pass.

The important point here is that Dax did not meet the criterion that would allow a physician to let him kill himself, for the purpose of this argument we will ignore the anachronous nature of the rules compared to the case at hand. If these are the qualifications required to let someone end their life, would it not be morally wrong to do the same in a case such as Dax’s? He has given consent but suffers from no terminal illness and despite his declaration as competent by Dr. White, his judgment is ruled by his pain. This is the same effect that could be seen in broken torture victims. The patient only has the capability to make an informed choice after the completion of the treatment, when he is capable of understanding his quality of life and his judgment is not altered by pain. Given his probable recuperation and possibility to lead a functional and productive life, the doctor who follow the rules have a moral obligation to continue the treatment.

Works Cited

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

“State-by-State Guide to Physician-Assisted Suicide.” ProConorg Headlines. N.p., Feb. 2015. Web. 20 Mar. 2015. <http://euthanasia.procon.org/view.resource.php?resourceID=000132>.

Introduction

For many people family is important part of their life. That includes when they need medical care. These are the people who are often appointed medical proxies and moral agents. However if they are not fulfilling these allotted roles there place in the care situation may be ambiguous. Who exactly counts as family? What moral effects can the family have on the patient?

Discussion of First Problem

The first issue is who counts as family. For insurance provides the issue is as simple as a person, their spouse if they have one, and any underage children they have. For the children it includes only their parents or any adult relative they live with.      However there are always tricky issues. Consider a same-sex couple that has been together for a long period of time, but reside in a state that does not allow marriage. Many people would argue that despite their lack of an official marriage document their spouse has every right to the normal entitlements of a family member. There could also be many cases where the family is in fact not the individuals closest to the patient. An estranged sibling for example may not want his or her family present or given any rights in a medical scenario. There would also be cases where the family unit extends well beyond the nuclear family. Do aunts and uncles and cousins and grandparents have right in a healthcare practice? American as a whole tends to be an individually focused society. Other cultures place a significantly higher importance on family and the patient may view themselves as nothing more than a part of the family unit. The term family is excessively contacted and could feasibly be replaced with a tern like authorized patient relation, which would include the individuals decided on by the patient.  This entire convoluted mess could usually only be solved by the directive of the patient, which not always an option in an emergency scenario.

Discussion of Second Problem

The identification of the authorized patient relations aside, there is then the issue of what rights they are given. Foremost among these with the assumption of competent patients is information.  The patient’s loved ones are often desperate for information about the condition. Hospitals have waiting rooms for these people to be waiting on this information for a reason. Anyone who the patient has brought with them or who has brought the patient in likely has a desire and a right to information about the patient’s condition. However, if possible this should be all with the patients consent. There may be details the patients wish to have withheld or persons the wish to be excluded from the information. The authorized patient relations also have the right to see and speak to the patient if that is medically advisable. However the paramount value to observe in these situations is the autonomy of the patient. There wishes should be maintained if at all possible. Final decisions should be made in private to avoid familial influence and the advance directives of the patient are to be followed even against the wishes of the family. The exceptions are of course cases in which the competence of the patient is in question. In these cases the role of the family is elevated to the primary decision maker and the assumption of the responsibility for the patient.

Conclusion

A patient in a hospital is never just a patient. Each patient comes with their own accompaniment of people who love them, or don’t and baggage. There can and never will be a universal set of guidelines for every case to govern the rights of the family. The healthcare professional will always have to make some judgmental calls, but if they hold the autonomy of competent patients as the primary objective both in terms of who can and can’t be defined as family and what those people can do, the vast majority of issues should be prevented.

References

Definition of family from:

http://www.shadac.org/files/shadac/publications/SHADAC_Brief27.pdf

Ho, Anita. “Relational Autonomy or Undue Pressure? Family’s Role in Medical Decision-making.” Scandinavian Journal of Caring Sciences 22.1 (2008): 128-35. Web.

This is a case concerning the ethical considerations of research on a particular group of people. It is worth noting that there will almost always be someone objecting to any sort of research on some contrived arguments, however this case merits valid consideration. The group on question is the elderly, which is defined by the World Health Organization as those persons over 60. (http://www.who.int/healthinfo/survey/ageingdefnolder/en/) The more specific group is the elderly afflicted with Alzheimer’s and cognitive dementia. The question arises from a request to gather subjects in a drug trial from a nursing home. The director of the nursing home stalwartly refused all participation in the study over ethical concerns of exploitation. While her arguments contain some logical they are misguided. In the discussion of the case there are multiple issues raised, the first being the institutionalization of these patients and they effects that causes. Primarily there is a sense of dependence on the institution or a sense of debt. An institute for the elderly will also likely have the inevitable effect of lowering the self-worth of the occupant. This is likewise connected to the lack of a sense of purpose or contribution to society in the elderly. All of these could be considered coercive factors to provide consent for the study when they otherwise would not, which is the argument of the director.  Coercion is clearly an ethical wrongdoing, particularly in what is meant to be an impartial study as it hinders autonomy. However the determination as to whether there is an element of coercion in consent to the study is up to interpretation. The review boards of several hospitals found no problem in the sampling procedures. There is consideration made to the fact that the mental competence of these patients, but that problem is solved by the need for consent in triplicate from the patient if possible, the closest relative and the caretakers. The director seems to be acting out of an irrational paternalism towards her patients in an overprotective manner.  There is a suggested dualism in the elderly and the juvenile. The juvenile are certainly given a special set of rules. Some seem to believe that the elderly deserve a special classification in the same way, just at the other end of their life. The reason juveniles are treated differently is due to incomplete maturation, which is not something that is in play for the elderly.  With each piece of the argument in the consideration I come to the conclusion that the director was in the wrong to deny her patients the opportunity to participate in the study.  Given the common feeling of lack of contribution in the elderly, the best remedy is an opportunity to contribute. The consequences of the study would be limited compared to the gain provided by the psychological relief. This is regardless of the potential benefit provided by the study if the study is effective.  The progression of the Alzheimer’s could be slowed providing great personal benefit and benefit to other afflicted with the disease. There is little to no corruption of autonomy truly present as participation is voluntary and consent is validated by the addition of the consent of the family member.  In addition if there was it could be justifiably balanced by the potential to medically improve the conditions of these patients. This trial is not an example of maleficence towards the patients but rather beneficence.

Jake Johnson