Sometimes in healthcare, the value of someone else’s life must be placed over another person’s life when deciding who does or does not receive treatment. It seems unethical to decide who lives and who does not; however, sometimes it is necessary no matter how difficult. So, how do healthcare professional make such difficult decisions? One way these decisions can be made are by using QALY’s which are controversial in the field.

QALY stands for the Quality Adjusted Life Year and it is often used in a situation where resources are few. The QALY method is “a new measure of quality of life which combines length of survival with an attempt to measure the quality of that survival” (Harris, 1987). With this system, a year of healthy life expectancy is worth one, but a year of unhealthy life expectancy is worth less than one. The general statement behind this system is that if a person were given the choice, they would prefer a shorter and healthier life rather than to live a long life of suffering.

In this article, the author argues against the use of QALY’s. He believes that by using this system, everyone is ok with choosing death so that another person can live because they have a better chance at having a higher quality of life. QALYs acknowledges an individual situation but does not acknowledge a situation in which an individual’s quality of life is compared to another person’s quality of life. The author does make another point that QALYs can be ageist because it is typically easier and more productive to save the life of a young person than an older person. So, using the QALY’s can be quite biased in such a situation.

Initially, when reading about QALY’s, I thought that the system was reasonable; however, the author does make a good point that it may not be the most fair system to be used. However, in my opinion, in a situation where resources are scarce, choices like these have to be made and evaluated somehow and I believe that the use of QALY’s is efficient and logical. There are other alternatives to using QALY’s such as discounted future earnings (DFE’s) and willingness to pay (WTP). DFE determines a person’s quality of life based on what a person could be expected to earn if they survived. WTP considers how much a person would be willing to pay for treatment (238). I do not agree with these alternatives. They place the value of a person’s life on monetary matters which I do not believe have a place in the medical field. QALY’s takes into account a person’s potential length and quality of life after survival if they receive treatment. These are reasonable considerations that could be very useful in a case, such as an organ transplant, where resources are scarce.

Beauchamp, T. L., & Childress, J. F. (2013). The value and quality of life. In Principles of

biomedical ethics (pp. 238-239).

Harris, J. (1987). QALYfying the value of life. Journal of Medical Ethics, 13(3), 117-123. Doi:

10.1136/jme.13.3.117

This article deals with the topics of patient autonomy and doctor interference with patient decision making and selectively sharing information. Patient autonomy is a common ethical issue in the medical field because there are so many exceptions and specific situations that may compromise the initial principles of patient autonomy. Doctors are expected to give all known information to the patient and patient confidentiality can also bring up a variety of issues within this field. The author, T. F. Ackerman, includes several arguments stating that illness can often greatly affect the patient’s ability to make a reasonable decision. There are many psychological and physical constraints that can affect the decision making process. Therefore, physicians should be able to participate in the decision making process, especially if the patient does not fully understand the illness or lacks the psychological wellbeing to make life changing decisions (Ackerman, 1982).

In the 19^th century, patients were expected to completely trust the judgements and decisions of the physician based on the beneficence model of the “golden age of medicine” in America. However, malpractice was common. Physicians could make controversial decisions such as declaring a severely disabled newborn as a stillbirth in order to prevent the parents from having a difficult decision to make or even withholding medicine from a patient. Ethical discussions did not take place often within the medical field. Because of this, many changes were made regarding the patient-physician relationship as time progressed (Will, 2011).

During the early 1900s, the number of hospitals in the US and the availability of medical technology and knowledge increased. Medical malpractice litigation became more popular in the late 20^th century and there was even a “malpractice crisis” during the Nixon presidency. The Nuremburg Trials revealed many ethical issues with patient consent and autonomy. These issues brought about mistrust towards researchers and even between patients and their doctors. Because of these events, new discussions developed about ethical reformations in the medical field, bringing about new ideas of patient autonomy and consent (Will, 2011).

In my opinion, I agree with Ackerman’s point that the doctor should be a part of the decision making process to some effect. A research study published in 2005 about patient preferences for decision making showed that majority of their patient participants desired to share decision making with their physician. Furthermore, no matter what their preference was, participants mostly valued the physicians opinion in most cases (Mazur,Hickman, Mazur & Mazur, 2005). Overall, physicians are the most knowledgeable about the patient’s conditions and can provide the most helpful and specific information possible. It makes sense for the physician to be allowed to intervene in decision making processes. This does not mean that patient autonomy is overridden; however, it is the physician’s duty to prevent and to not harm the patient which may involve intervention.

References

Ackerman, T. F. (1982). Why Doctors Should Intervene. The Hastings Center Report, 12(4), 14. doi:10.2307/3560762

Mazur, D. J., Hickam, D. H., Mazur, M. D., & Mazur, M. D. (2005). The role of doctor’s opinion in shared decision making: what does shared decision making really mean when considering invasive medical procedures?1. Health Expectations, 8(2), 97-102. doi:10.1111/j.1369-7625.2005.00315.x

Will, J. F. (2011). A Brief Historical and Theoretical Perspective on Patient Autonomy and Medical Decision Making. Chest, 139(6), 1491-1497. doi:10.1378/chest.11-0516

Dilemma: Stephen Dawson was premature and suffers from extensive brain damage and lowered mental and physical capacities due to meningitis. He cannot be left alone and his parents have described his life as being “painful and unhappy.” It was found that he needed an operation to repair a blockage in his brain shunt and without this operation, he would die. Should Stephen undergo the operation or should he be allowed to “die with dignity” and avoid future suffering according to his parent’s wishes?

Discussion:

This is a very conflicting case in my opinion; however, I believe that Stephen Dawson should be allowed to pass away as his quality of life is very low and his chances of ever improving or being able to live on his own without constant care are low as well.

In cases such as this one, I believe that Stephen’s present and future quality of life must be considered. While the case study states that he has not officially consented to refusing treatment, he is also not competent to do so. Because he is incompetent, it is fair for his parent’s, who have spent much time caring for him and observing the struggles he has had to undergo, to decide whether it is worth allowing him to undergo the operation. If it were an operation to help him gain some of his mental and physical capacities, then I would agree that the surgery should take place. However, this surgery does not hold that promise and would simply serve to “prolong a life inflicted with an incurable condition (Thomas, et al. 229-235).”

Simultaneously, this does bring up the issue of the value of the life of a disabled person. Do they not have rights as well? While this is a serious question, I believe that in this case, the value of Stephen’s is not being questioned or determined but simply his quality of life. Stephen would continue to live with great difficulty and would never achieve independence or be able to fully enjoy life. Involuntary passive euthanasia is appropriate in this case. This form of euthanasia occurs when the patient is unable to consent and life sustaining treatments are withheld (Nordqvist).” There are many reasons why passive euthanasia would be utilized. In this case, Stephen’s medical situation would progressively get worse and his “expected quality of life is so poor that life will be worse… than death (Garrard).” Stephen cannot feed himself and he has the capabilities of an eight-week-old infant according to the case study. I am not arguing that because of these disabilities, Stephen is not worth preserving; however, I do believe that it is within his best interests to not suffer any longer than he has to. The surgery would not cure him but would only serve to keep him alive. He would still have to face these challenges and most likely many more as he gets older.

Works Cited

Thomas, John E, et al. “Case 6.4 Stephen Dawson: Should Severely Mentally Challenged Patients Be Treated?” Well and Good: A Case Study Approach to Health Care Ethics, 4th ed., Broadview P, 2014, pp. 229-235.

Garrard E, Wilkinson S Passive Euthanasia Journal of Medical Ethics 2005;31:64-68.

Nordqvist, Christian. “Euthanasia and Assisted Suicide.” Medical News Today, 8 Apr. 2016, www.medicalnewstoday.com/articles/182951.php.

Image Source: http://www.psych.med.umich.edu/ect/how-does-ect-work.asp

Dilemma:  

Simon, a 53-year-old widower and father is admitted to the psychiatric ward after overdosing on antidepressant medication. Simon is agitated and reluctant to interact with others and according to his son, he is in a state of financial instability. Simon feels much sadness over the loss of his wife and also blames himself for his mother’s death 32 years ago. He threatens to commit suicide because he has nothing to live for. His psychiatrist proposes of electroconvulsive shock therapy (ECT). Simon refuses and his son also has worries about the risks of ECT and refused to go against his father’s wishes. ECT offers great benefits if successful; however, there are risks. The dilemma is whether the psychiatrist should go against the will of the father and his son and administer the treatment or if the father should be allowed to make his own decision about his life (Thomas, et al. 124-31).

Discussion:

The potential risks and benefits of ECT must be considered. ECT is a controversial treatment that involves administering anesthesia and running an electric current through the brain to cause a seizure. This is repeated from 6-12 times. Memory loss and confusion follow the procedure and it could provide relief from severe depression (“Electroconvulsive Therapy (ECT)”). There are risks of brain damage post-treatment, however the prognosis has improved over the years and it offers a quick solution when compared to prescribed drugs.

It is important to consider patient autonomy and the moral status of the patient. In medicine, patient autonomy is essentially the patient’s right to make intentional and well informed decisions about the course of treatment without pressure from the physician (Beauchamp and Childress). It is a basic human right to have autonomy; however, the level of autonomy a person may have can be determined by their competency. In this case, although Simon is severely depressed, he is not mentally incompetent. So shouldn’t he be able to make his own decision?  Often in psychiatry, patients may refuse to take medications and sometimes, covert medication may occur where medicine is hidden in foods and beverages without the patient’s knowledge which is unethical but may be ethically justifiable. For example, for an Alzheimer’s patient who is losing cognitive function, forcibly giving medication may seem justifiable because they are not able to fully realize that the medication will help them (Latha). However, does this reasoning apply to Simon who is severely depressed but fully competent?

There are differences between the case of the Alzheimer’s patient presented previously and Simon. The Alzheimer’s patient is not competent while Simon is competent and giving prescription drugs covertly does not compare to applying electric current through a patient’s brain forcibly. One can argue that Simon’s unstable emotional state may inhibit his judgement to the point where he would rather die than to try any more treatment. However, this would be operating under assumption which is not the duty of the physician. Because this treatment is so severe and risky, I believe that Simon should be able to make his own decision about his life. This argument does require accepting that Simon may commit suicide; however, from the psychiatrist’s standpoint, I do not believe that is his or her choice to make. If the psychiatrist has done all that they can in terms of informing the patient of their options and allowing the patient to make an informed decision, they have done their job.

Works Cited

Beauchamp, Tom L, and James F. Childress. “Respect for Autonomy.” Principles of Biomedical Ethics, Oxford UP, 2001, p. 101.

“Electroconvulsive Therapy (ECT).” Mental Health America, www.mentalhealthamerica.net/ect.

Latha, K. S. “The Noncompliant Patient in Psychiatry: The Case For and Against Covert/Surreptitious Medication.” PubMed Central (PMC), www.ncbi.nlm.nih.gov/pmc/articles/PMC3031933/.

Thomas, John E, et al. “Case 3.2: Nonconsensual Electroconvulsive Therapy.” Well and Good: Case Studies in Biomedical Ethics, Broadview P, 1987.