The Ethical Principle of Justice:

The concept of justice in bioethics encompasses fairness in treating patients of different population groups; impartiality in providing both healthcare benefits and burdens to people in different communities or social organizations; and the equitable allocation of healthcare financial resources (Feinsod and Wagner). There are many questions that need to be answered in order to clarify the concept of real justice, also referred to as real distributive justice, in the healthcare system. Some of the questions that should be asked are: How can we apply fairness in deciding the kinds of treatment that would be administered?  Should decisions be based on the a) need of treatment, b) age of the patients, c) diagnosis of the diseases, d) financial capabilities of individuals? Are these factors sufficient to determine distributive justice in the healthcare system or should there be more topics to consider? The following case will answer the question of whether age must be a basis for allocating healthcare services and administering treatment.

The Case:

An orthopedic surgeon, Dr. Rossi, is a voting member of FutuRx Health Maintenance Organization’s (HMO) committees that underline the services that should be covered or excluded for the various FutuRx HMO plans (Morreim et al.).. In one of the committee meetings there was a discussion about the exclusionary age criteria for arthroplasty replacement. They proposed the age of 90 as a cutoff age for the surgery taking into consideration the median lifespan of the average adult American and the idea that most people will not live long enough after the age of ninety to justify the expenses of the surgery. The cost saving expenses of such surgeries will be reallocated toward lowering the premiums of various health plans and providing more comprehensive coverages for other younger members (Morreim et al.).  During this meeting, Dr. Rossi was hesitant to vote for or against this proposal as all what he was thinking of was, Mr. Turner his 91 years old patient.

Mr. Turner, a previous Olympic marathon runner, is in excellent health except for his right knee, which is burdened by severe osteoarthritis preventing him from enjoying and doing the things he love. One year ago, despite his right knee pain, he completed the full marathon in 4 hours and 45 minutes (Morreim et al.). However, currently, he can’t run at all. Mr. Turner is in acute pain that prevent him from enjoying his life. He told Dr. Rossi that running means everything to him and this activity is the source of his enjoyment and content. Dr. Rossi knows that there is no age risk for recommending a knee replacement surgery for him. Dr. Rossi also knows that Mr. Turner will not be affected with these changes as he is not a member of FutuRx HMO plans. All what Dr. Rossi was thinking of was that he doesn’t want to prevent others within the age group of Mr. Turner from doing such surgeries if they were healthy and members of FutuRx HMO plans. However, Dr. Rossi feels great about the re-allocation of the cost saving expenses of such surgeries in lowering the premium and offering more comprehensive coverage for others (Morreim et al.).

Dilemma: 

If doctor Rossi votes for the exclusionary age of 90 for such surgeries then his act will conflict with the rule of Beneficence that claims from the doctor to do what is medically righteous and helpful for the patient. His act will also conflict with justice bioethics rule as many patients within the age group of Turner and who are as healthy as Turner do not meet criteria for such procedures if they were members of Futu Health Maintenance Organization (HMO) plans. According to Beauchamp and Childress, “To deny benefits to some when others in the same class receive benefits are unjust, but it is also unjust to deny access to equally needy persons outside the delineated class, such as workers with no health insurance” (251). This made him think of that if he votes in favor of such a plan then he will be helping many other patients who are younger and in need of lowering their premiums and having better comprehensive coverages that promotes better services for their wellbeing and welfare. The question here is, “What alternative provides distributive justice, equality and fairness?” Or should the question be, “What alternative will provide more distributive justice than the other?” We say more distributive justice because both of these alternatives encompass injustice to many patients.

Discussion:

The principle of justice should imply that all the population, without limitation of age, gender, race, financial status, disease treatment and many more must have equal accessibility to healthcare services. “Everyone should be able to live a normal life without dying prematurely or forced to live at a lower quality making the life not worth living” Beauchamp and Childress (259). The above principle of justice together with the principles of beneficence and non-maleficence compel the doctor to do the surgery for Mr. Turner regardless of age, financial status and even if he was a member of Futu HMO plan. However, I also have learned that the allocation of the scarce financial resources must be taken into consideration especially when a surgery on Mr. Turner that improves his quality of life,  might deprive another younger patient from a lifesaving procedure. “Distributive justice refers to fair, equitable, and appropriate distribution of benefits and burdens determined by norms that structure the terms of social cooperation” (250).

We cannot deny the fact that in healthcare we have limited financial resources that prevent us from providing many healthcare interventions with credible benefits to everyone regardless of limitations. In economics, we have scarcity of resources (natural resources) that fall short to meet all humans’ needs and force those in charge to decide what to produce and how these resources should be allocated. If in economics, the scarcity of resources will limit the production of what are considered extras to the people’s primary needs, healthcare scarce financial resources will bring about medical restrictions that will affect patients’ life, quality of life, and wellbeing. The questions that should be asked is, “how can we add more money into healthcare system”? President Obama has founded the Affordable Care Act in order to bring about affordable health care costs that will expand health coverage to encompass a larger portion of the population and improve the quality of healthcare services. Under this Act, no one is denied access to medical insurance regardless of age, health, and status (“Patient Protection and Affordable Care Act”). Money is not a limited resource as natural resources and the studies should concentrate on the ways to increase financial resources in the healthcare system, rather than limiting some medical interventions that might be beneficial to those who are denied such an opportunity. Huge budgets and enormous financial resources are allocated for weapons productions and wars, while fewer financial resources and smaller budgets are allocated for healthcare that saves the lives of people.

I can’t deny the fact that age sometimes has to be one of the factors in deciding the allocation of healthcare financial resources considering people have a natural lifespan. However, life expectancy varies not only by different racial groups and gender, but also by different economic and social standards, besides the basic health conditions of different individuals (Morreim et al.). Since everyone is different and since there are many exceptions to any sort of categorization of people, any medical restrictions of age, gender, race, economic standard, even disease diagnoses, will not do justice to all patients in the healthcare system. Hence, the question that should be answered above is, “What alternative will provide more distributive justice than the other?” Though I do believe that everyone must have equal accessibility to healthcare services but, with all the shame, I agree that age restriction alternative will provide more distributive justice but will not provide real justice in the healthcare system.

After being exposed to the current rules of medical practice, I found myself shocked with the reality of medicine nowadays. I previously thought that doctors should only be medical care providers and reservoirs of hope, but I was confronted with the bitter reality that they can participate in life-ending measures by even starving a patient to death in the name of respecting the patient’s autonomy, as in the case of Margret Bentley. I realized that many people justify the legalization of physician assisted suicide (PAS), which visibly conflicts with the Hippocratic Oath, “I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect” (“Hippocratic Oath”). I came to realize that the sanctity of human life doesn’t exist because the value of life decreases with disability, illness, age and even financial capability that deprive one from certain medical interventions just because he/she can’t afford it. I understood that doctors are not free to do what they learned to do but rather they should be obliged to listen to the patients’ autonomous decisions and respect their choices even if it conflicts with the rule of beneficence and non-maleficence as Jehovah’s Witness cases and Alzheimer cases. I also was stunned to find myself among very few who do not believe in mercy killing options because according to me no one has the right to take the life of another person. However, this is life and this is the reality of current medicine.

Works Cited

Beauchamp, Tom L., and James F. Childress. “Justice.” Principles of Biomedical Ethics. New York, NY: Oxford UP, 2001. 249-67. Print.

Feinsod, Fred M., and Cathy Wagner. “The Ethical Principle of Justice: The Purveyor of Equality.” Annals of Long Term Care. HMP Communications, 5 Sept. 2008. Web. 03 Apr. 2015.

“Hippocratic Oath.” MedicineNet. N.p., n.d. Web. 03 Apr. 2015.

Morreim, Haavi, Ryan M. Antiel, David G. Zacharias, and Daniel E. Hall. “AMA Journal of Ethics.” Should Age Be a Basis for Rationing Health Care? American Medical Association, May 2014. Web. 03 Apr. 2015.

“Patient Protection and Affordable Care Act.” Wikipedia. Wikimedia Foundation, n.d. Web. 04 Apr. 2015. <http://en.wikipedia.org/wiki/Patient_Protection_and_Affordable_Care_Act>.

Progressively throughout this course, I began to question, “Why do people value life so differently?” Social interactions, past experiences, upbringing and diseases/illnesses are only few of several factors that sculpt the way we view our lives.  Despite the struggles, hardships and obstacles we encounter, we are always told to keep going and never give up. Why? Wouldn’t it be easier to terminate our lives instead of enduring pain? Sometimes the easiest path isn’t necessarily the right path and we have to overcome obstacles to serve our purposes in our lives: to learn, to grow, to help others, to cure, to love, to nurture, to guide.

Background

The idea of legalizing, “physician assisted suicide” (PAS) has been a prolonged debate that entails several specifications that must be considered before siding with or against this option. “Oregon Death with Dignity Act” (ODWDA) enables physicians to write prescriptions for lethal drugs at the patient’s request.  Studies have shown that only one-third of the patients who are given the prescription, get the drugs. Patients who are granted this lethal medication are not “vulnerable to intimidation or abuse” and “have had, on average, a higher level of education and better medical coverage than terminally ill Oregonians who did not seek assistance in dying” (Beauchamp and Childress, 178-81). Those who oppose this option argue that despite the appearing competency of the Oregonian patients, they could possibly be depressed. If PAS is legalized, people suffering for serious or debilitating diseases will be erased from our societies which will provoke the issue of determining their value and quality of lives.  Healthcare is centered on the idea of protecting patients’ lives and protecting their right to life. As a result of legalizing PAS, it is feared that the quality of care for suffering patients will decrease.  Those who support PAS argue that palliative care is a form of restoring peace to a suffering patient and believe that the right to live is equivalent to the right to die. Nevertheless, as stated in Beauchamp and Childress, the moral dilemma “is not whether physicians are obligated to lend assistance in dying, but whether valid requests render it permissible for a physician to lend aid-in-dying.” (182)

I’ve always been the student who promotes prolonging of life and found myself strongly disagreeing with others who believed that death was a viable option for patients. However, for the first time, while questioning myself if I wanted to live after suffering from an accident that has dehumanized me and has made me “endure a loss of functional capacity, unremitting pain and suffering, and an inability to experience the simplest of pleasures”, I’ve encountered myself on the opposite side of the spectrum and decided that sometimes withholding or withdrawing treatments that hasten death may relieve acute pain. (178). Then I came across the famous case of Dax Cowart.

Case

In 1973, Donald, a pilot in Air Force, and his father visited a small valley that was unknowingly filled with propane gas and when they ignited the car, an explosion occurred which severely burned both men. When someone came to help, Donald asked the stranger if he had a gun because he already considered himself a dead man and wanted to put himself out of misery; however, the stranger replied gently that he couldn’t give him a gun.  While Donald’s father died on his way to the hospital, Donald was compulsorily treated for 10 months, which consisted of being immersed in a chlorinated bath and have bandages stripped and replaced almost daily. Despite insisting his desire to die, describing his treatment as being “skinned alive”, losing his ability to see, and losing more than 65-68% of his skin on his body, Donald was still treated until sufficiently healed. In 1986, Donald graduated from Texas Tech University with a law degree and subsequently opened his own practice. Because of his inability to see, Donald would feel embarrassed after mistakenly responding to his name when someone else was being addressed; therefore, he legally changed his name to, “Dax.” Then, Dax effectively sued the oil company responsible for the propane gas leak during his accident. He married twice and is currently still married to his second wife. This case is an example of preserving a man’s life against his wishes (despite having endured pain and suffering during treatment), who successively became a very successful and happily married person (“Dax Cowart”). Although not all stories result in such fantasy-like endings, it gives us hope that those who are genuinely suffering from unremitting pain and can only perceive death as their form of relief can be mistaken and become great leaders after treatment.

Discussion

When is the use of PAS morally justified? I believe PAS shouldn’t be legalized because we embark on a slippery downward slope when determining where the line should be drawn to permit physician to intervene in the natural trajectory of a human’s life. Even in the cases of terminally ill patients, such as Sue Rodrigues, who only have an estimated and limited number of months to live and would rather hasten their inevitable death than prolong their suffering, doctors have to be the reservoir of hope (Thomas and Waluchow, 214). Like Sue Rodrigues, Stephen Hawking, a world known physicist and cosmologist, was diagnosed with ALS and told he had only 2 years to live. He is currently 73 years old and is still considered one of the brightest men in the world (“Stephen Hawking”). My use of, as what some of you would describe, “miraculous” stories is not to portray the large probabilities of a well lived life after suffering from an accident or being told that you will have few days to live, but rather to enlighten the importance of hope for a better future. If a patient is severely experiencing pain then withdrawing or withholding treatment, and administration of prescribed pain medicine can be used; however, a physician must never prescribe or administer a lethal medication to end the life of any patient. A doctor’s duty is to prolong life and instill in people the will and strength to live because every life is valuable, regardless of disabilities and other disadvantages.

Works Cited

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

“Dax Cowart.” Wikipedia. Wikimedia Foundation, n.d. Web. 13 Mar. 2015. <http://en.wikipedia.org/wiki/Dax_Cowart>.

“Stephen Hawking.” Wikipedia. Wikimedia Foundation, n.d. Web. 08 Mar. 2015. <http://en.wikipedia.org/wiki/Stephen_Hawking>.

Thomas, John E., and Wilfrid J. Waluchow. Well and Good: A Case Study Approach to Biomedical Ethics. 4th ed. Peterborough, Ont.: Broadview, 1998. Print.

Background

Should the doctor or a nurse lie in favor of the patient’s interest or should they tell the truth to fulfill the biomedical moral ethics? Before answering this question, we should remember that the doctor’s primary vow must always be to ensure the patient’s health and interests. The Biomedical ethics compels the doctor to act in favor of the patient’s health and welfare (beneficence) and cause no harm to patients (non- maleficence) while respecting patient’s autonomy and choices. Despite the aforementioned, truth-telling is also a medical ethics principle that requires the doctor not to lie and instead tell the whole truth, even if this truth will harm the patient’s psychological welfare (“Ethics in Clinical Practice”). The question is, “What should the doctor do if the truth will harm the patient and violates the privacy code between the patient and the doctor? Isn’t it better for the doctor to lie than to break the ethical principles of non-maleficence and privacy?”(Mathies). The following case will elaborate on when and why the doctor is forced to lie. Justification for this lie is debatable. There is no medical ethics principle that justifies lying, even for therapeutic privilege; it only allows the doctor to withhold or tailor information that might cause harm to the patients, but not actively lying ((Mathies). However, in the following case the doctor needed to give a “Yes” or “No” answer. Any other answer would provoke doubt and curiosity to know the truth. If I were in this doctor’s place I will do exactly what he did…I would lie.

Case:

A doctor planned to do a “radical nephrectomy on a patient.” The patient’s son informed the doctor that he and his father were Jehovah’s Witnesses and they do not want to receive blood transfusion, regardless of the situation. The doctor asked the patient if this was his wish too and the father reluctantly agreed. After explaining the procedure and the consequences of their choice, the doctor made the patient sign documents (informed consent) that would release the doctor from any negligence if the patient would need a life-saving blood transfusion. However, one day before the surgery, the patient confessed to the doctor that he wasn’t that religious and he doesn’t mind to receive blood transfusion if he needs to. However, he asked the doctor not to tell him or tell his son if he was to receive any blood. The doctor documented the conversation on the patient’s chart and informed the blood bank to hold some units of the patient’s matched blood. During the surgery, the patient lost a substantial amount of blood and the subsequently became anemic and hypotensive. The doctor ordered the blood transfusion to be delivered to the patient in the recovery room. The doctor informed the nurse not to tell the family about the blood transfusion and not to let any of them into the recovery room during the transfusion. Also, to cover any tracks of having received blood, the doctor requested from the nurse to remove all respective IV tubing prior to having the family visit. When the doctor met the patient’s son after the surgery, he explained that the surgery was more difficult than expected but his father is stable. Then the son asked if his father received a blood transfusion since the family was contacted by the blood bank to ask if anyone wanted to donate matched blood.  Here the doctor didn’t know what to say. The dilemma faced in this situation was, should he lie and say “no there was no blood transfusion” or shall he reveal the truth and harm the patient’s relationship with his family, not to mention disobeying the patient’s privacy? The challenge was to either tell the truth and break the relationship between the father and son as well as between the doctor and patient or tell a lie and protect the patient’s wishes and his relationship with his son.  The doctor lied and assured the son that his father didn’t receive any blood transfusion. The son was relieved (“Transfusing a Jehovah’s Witness during Surgery”)

Discussion

Beauchamp and Childress suggest that there are three elements of informed consent: understanding, voluntariness, and authorization of intervention (Beauchamp and Childress, 131). In this case, the patient’s voluntariness is questioned only because of external constraints and not because of lack of adequate knowledge or “absence of psychological compulsion”. Beauchamp and Childress state that a person is considered to act voluntarily in the absence of another person’s control (138); unlike persuasion, manipulation and coercion control the patient and are thought to diminish voluntariness and autonomy (138). In this case, the patient, who is not an extremely devout Jehovah Witness, feared that his relationship with his son would deteriorate if he authorized blood transfusion. That is why the patient authorized blood transfusion in the absence of his son’s presence and influence. The patient also asked the doctor not to tell him if he receives blood transfusion so that he wouldn’t feel guilty for disobeying the rules of his religion.

This is also a patient case touching on the controversial and complicated dilemma of a physician deciding between moral beliefs, patient privacy, and non-maleficence. I totally agree with what the doctor did. The doctor’s dishonesty in this situation is justifiable as it avoids violating the patient’s privacy, non-maleficence, as well as, preserving both the son-father and the doctor-patient relationship. According to the “Declaration of Geneva” the doctor-patient relationship is the cornerstone of medical practice and medical ethics. The physician has to place the patient’s heath as his number one priority (Palaez). I personally believe that when physicians take the oath of Hippocrates and abide by HIPAA laws, they are destined to act on behalf of the patient they are treating and to do all that they could to preserve patient privacy and rights.  I certainly agree with the case where the physician should at all-time keep the patient’s privacy as a number one priority during the care of a patient and their family.  In this specific situation, I agree that the physician has been given the authority, per the patient, to not disclose any information about blood transfusion to the patient himself and his family.  For that reason, the fact that the meeting with the patient and what he requested was clearly documented, that removes any liability from the physician and thus he is permitted to act in such a manner to avoid disclosing any information that may harm the patient or his relationship with his family.  Furthermore, the legal consequences related to blood transfusion in Jehovah’s Witness patients permit the doctor to meet with the Jehovah’s patient alone and even outside the presence of close family members to confirm the patient’s actual wish and faith in relation to this issue (“Transfusing a Jehovah’s Witness during Surgery”). This was exactly what the doctor did. Education alone cannot teach a physician to the best at what he does. It is the doctor’s courage, compassion and moral goodness that impacts medical practice.

Why is the doctor’s dishonesty morally justified in this case compared to that of Amira’s?

In the “Emergency and Trauma Nurses” case, it is debatable whether Amira should be deceived about her partner’s death, Casey. In this case, the nurses have a moral dilemma between Amira’s beneficence, non-maleficence, and autonomy. The blatant truth may destabilize Amira’s fragile medical condition. As the trauma nurse, I would avoid answering Amira’s question by saying, “we will inform you as soon as we know” or “our primary concern right now is your health”. Although this is considered a form of deception, as mentioned above, therapeutic privilege allows the doctor, or the nurse, to withhold or tailor information that might cause harm to the patients (Mathies).

Works Cited

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

“Ethics in Clinical Practice.” NursingLink. N.p., 2015. Web. 14 Feb. 2015.

Mathies, M., and N. Hogg. “Absence of Monocyte Procoagulant Activity during the Immune Response to Influenza Virus.” Journal of Clinical Microbiology. U.S. National Library of Medicine, n.d. Web. 14 Feb. 2015.

Paleaz, Jose. CHAPTER TWO – PHYSICIANS AND PATIENTS (n.d.): n. pag. Web.

“Transfusing a Jehovah’s Witness during Surgery.” KevinMD.com. N.p., 13 May 2011. Web. 14 Feb. 2015.

The current kidney donor shortage in relation to the number of patients suffering from renal failure creates responsibilities for transplant professionals to seek new methods to increase kidney donation.  Although this is a dire effort to help save the lives of many who rely on it, unfortunately many die as they wait for a match. According to the United Network for Organ Sharing around 31,000 potential recipients are on the waiting list for organ transplantation. Only around one third get the transplant while many others die in the interim (Nelson). There were many efforts to try to establish a financial incentive for kidney donation, especially with live donors, which in most cases, is non-maleficence for the donor. However, under the National Organ Transplant Act, it is illegal to exchange an organ for money but there have been efforts that are statistically supporting such an exchange.  That would facilitate the decrease in insurance expenses and increase in the number of living patients (Koren). The perspective of kidney donation is two-fold; with one party thinking that the financial incentive for a living kidney donor meets ethical bases if it preserves the donor’s autonomy, be non-maleficent for the donor, and help in saving lives; however, the other party views this process unethically where it decreases the sacredness of the human body by turning it into a commodity assessed by the donor’s financial need leading to unjust inducement, undue inducement, and even a decrease of altruistic donation (Allen, Peter). Therefore, the moral dilemma is: Should we allow people to donate kidneys in exchange for money or prohibit financial exchange for donation and risk the death of more patients with renal failure?

Virtue ethics is another form of approach in the analysis of medical dilemmas that don’t only depend on reason but also on the importance of emotion.  Those against the financial incentive emphasize that there will be an emotional disrespect of life in general, the human body in particular, and a loss of human connection during the donation process. Moreover, the financial incentive will intimidate the needy people into accepting risks that might be unacceptable in the absence of financial rewards leading to “undue inducement.” For instance, donors who possess certain diseases, such as coronary vascular disease or diabetes, might ignore the risks of being operated on, as they are compelled to accept for the sake of the financial reward. This will also lead to “unjust inducement” as only the poor may feel guilty if they do not sell their kidney to satisfy their family’s financial needs (Allen, Peter). This will lead donors to violate the moral principle of beneficence by increasing harm on them despite potentially relieving harm on patients. However, a discerned physician should be able to determine if donors are competent, from a health standpoint, to make such a decision. A doctor with integrity has an essential responsibility to assess the calculated risks and determine the need for transplantation that would better the quality of life for both the patient and donor.

More questions need to be answered before a decision is made on this moral dilemma. Who would incur the responsibility for the financial reward, insurance company or recipient’s family? If the insurance company is held responsible then only the insured will benefit from such a program and if the recipient’s family are to bear the cost, then only patients who come from a particular socioeconomic status will survive as there will be a decrease in altruistic donation after the introduction of financial incentives.  Therefore, patients are being discriminated based on their ability to pay or their respective insurance coverage. This dilemma appears to be more of a business negotiation as opposed to an ethical issue.

I think that, based on the aforementioned, kidney donation, under financial incentives, will encourage more donors to step forward and help in saving more lives despite the risks donors may endure throughout the procedural process. However, I disagree with the whole concept of financially benefiting from such a humanistic act of courage and altruism for the greater good of those in a terminal position. The whole concept of human relationship, the sacredness of human body, the decrease of altruistic donation and discrimination among patients, will alter the process of donation from being a moral act to being a business transaction.

Works Cited

Allen, Matthew B., and Peter P. Reese. “Financial Incentives for Living Kidney Donation: Ethics and Evidence.” Clinical Journal of the American Society of Nephrology : CJASN. American Society of Nephrology, 24 Oct. 2013. Web. 23 Jan. 2015.

Koren, Marina. “Would You Donate a Kidney for $10,000?” Www.nationaljournal.com. National Journal, 28 Oct. 2013. Web. 23 Jan. 2015.

Nelson, Edward W. “Organ Procurement and Transplantation Network.” Ethics. Health Resources and Administration Services, 20 June 1993. Web. 23 Jan. 2015.