Do you think it is acceptable for health professionals to decide which patient is more important to save based on QALYs, quality-adjusted life-years? Using this method the number of years an individual can live is favored over the number of lives that can be saved. “QALYs are calculated by estimating the years of life remaining for a patient following a particular care pathway and weighting each year with a quality of life score” (Beauchamp and Childress 239).

The article “QALYfing the value of life” gives the following example: “Andrew, Brian, Charles, Dorothy, Elizabeth, Fiona, and George all have zero life-expectancy without treatment, but with medical care all but George will get one year complete remission and George will get seven years’ remission” (Harris 118). Using QALYs, George would be treated over the other six patients since he has a longer remission than the other patients. By valuing life-years, QALYs may require the physicians to sacrifice six lives in order to save one. This situation exemplifies the tension that can form between QALYs and beneficence. QALYs instructs the physician to assist the patient with the highest QALY score, while they are also obligated to help all of the patients due to their duty to rescue and help. Using this example as a baseline of how QALYs would be implemented in health policy, I think that QALYs should not be implemented into the system because it is ageist, favors patients that require relatively cheap treatments, and does not make a distinction between life-saving and life-enhancing treatments.

QALYs is ageist because younger individuals tend to have higher QALYs on average than older people. As a result, if there were ever a situation in which a physician had to choose to assist one of two patients, an older and a younger individual, the physician will always choose the younger patient. I believe that this is unethical and brings into question the issue of justice in bioethics. This method of valuing one’s life requires the disregard of the generalized assumption that every individual is considered equal, and no one person should be regarded as more important than another. By using QALY, physicians are obligated to prioritize younger patients over others, and thus consider those patients more important.

In addition to being ageist, this particular way of valuing one’s life also favors patients that require cheap treatments. Using this system, “the quality of life of those with illness or disability is ranked, on the QALY scale, below that of someone without a disability or illness” (Singer). In general, under QALY “if a ‘high priority health care activity is one where the cost-per-QALY is low, and a low priority activity is one where cost-per-QALY is high’” then individuals with conditions that are cheap to treat are prioritized over individuals that require more expensive treatments (Harris 119). This system discriminates against groups of patients that unfortunately suffer from a disease that is expensive to treat. QALY requires physicians to systematically save specific groups of patients, at the expense of others.

Lastly, this method of valuing life does not create a distinction between life-saving and life-enhancing treatments. In general, most people think that life-saving treatments should take priority to life-enhancing treatments; however, that is not the case with QALYs. Instead, QALYs prioritizes individuals that have higher QALYs on average, meaning that they can live longer and at a higher quality of life. As a result, if a patient who is seeking a life-enhancing treatment has higher QALYs than a patient seeking a life-saving treatment, the patient with the higher QALYs would be prioritized regardless of the treatment that they are seeking.

Calculating QALYs is also a debated topic because in order to calculate it, one must decide what the patient’s potential quality of life will be. As we have discussed earlier in this class, it is impossible for one to know how another individual would value their quality of life since we all have different experiences and values. Reflecting upon that, I think that the method of calculating QALYs is unethical because it involves making assumptions on another’s behalf that may not be entirely accurate.

Taking everything into consideration, while using QALYs would be beneficial in deciding which patient to treat first when the two patients in question are in all regards considered equal, it is not realistically practical since most two patients are not alike. Using QALYs as a method to decide which patient to treat first or which patient should be prioritized is not ethical as it discriminates against certain groups of individuals and forces an outsider to determine what the patient’s quality of life is. As a result, QALYs should not be used in health care.

Works Cited:

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York: Oxford UP, 2013. Print.

Harris, John. “Qalyfing the Value of Life.” Journal of Medical Ethics 13.3 (1987): 117-23. JSTOR [JSTOR]. Web. 30 Mar. 2017.

Singer, P., J. McKie, H. Kuhse, and J. Richardson. “Double Jeopardy and the Use of QALYs in Health Care Allocation.” Journal of Medical Ethics. U.S. National Library of Medicine, June 1995. Web. 30 Mar. 2017.

In Principles of Biomedical Ethics, Beauchamp and Childress present a hypothetical situation in which a psychiatrist “informs all patients that he may not keep information confidential if serious threats to other persons are disclosed” (Beauchamp and Childress, 208). After “learning of his patient’s intention to kill an identified woman… the psychiatrist may now either remain aloof or take measures to protect the woman by notifying her or the police, or both” (Beauchamp and Childress, 208). What does the principle of beneficence demand of the psychiatrist in this situation?

In my opinion, the psychiatrist should contact the woman, the police, or both in an effort to protect the woman’s life. While the psychiatrist is under no obligation to act in this situation, the principles of positive beneficence overrides all opposing arguments. The “principle of beneficence refers to a statement of moral obligation to act for the benefit of others” (Beauchamp and Childress, 203). Conveniently, in this case the best interests of the patient and the woman are the same. By preventing the patient from causing any harm to the woman, the psychiatrist is acting in the best interest of the woman by saving her life, and the patient by preventing him from committing an act he will later regret.

Beneficence “is optional rather than obligatory;” however, there are some situations in which an individual is highly encouraged to act (Beauchamp and Childress, 205). One of the principles of positive beneficence, which holds an individual accountable in a situation, is  the duty to “prevent harm from occurring to others” (Beauchamp and Childress, 204). In this situation, the psychiatrist is responsible to prevent the harm that could potentially be caused to the woman and the harm that would be imposed on the patient if he followed through on his wish to kill the woman. An additional principle is the duty to “rescue persons in danger” (Beauchamp and Childress, 204). The woman in this situation is obviously in severe danger of being hurt, or killed, and as a result, the psychiatrist is under an obligation to circumvent the threat. The patient is also in danger of being imprisoned, most likely for the rest of his life. In terms of these principles, the psychiatrist is expected to act in this situation to protect the woman and the patient’s future.

“One of the most common ethical dilemmas arises in the balancing of beneficence and nonmaleficence” (“Beneficence vs. Nonmaleficence”). However, in this hypothetical situation, the principles of beneficence and nonmaleficence complement one another. If the two principles conflict with one another, like in Dax Cowart’s case, then you must decide which carries more weight in the situation and should be respected over the other principle. The principle of nonmaleficence means “to do no harm” (“Beneficence vs. Nonmaleficence”). By telling the woman, the police, or both, the psychiatrist is preventing any harm from occurring to the woman or possible harm to the patient that could arise as a consequence of his actions. In addition, the psychiatrist is obeying the principles of beneficence by taking actions that “help prevent or remove harms or to simply improve the situation of others” (“Beneficence vs. Nonmaleficence”). 

Taking everything into consideration, while the psychiatrist is under no obligation to act in this situation, due to the principles of beneficence and nonmaleficence, he should inform the woman, police, or both. The psychiatrist will suffer no risk or inconvenience by acting in this case. In addition, he is obligated to prevent harm and act in the best interest of the individuals involved.

Works Cited:

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

“Beneficence vs. Nonmaleficence.” Beneficence vs. Nonmaleficence. University of California Regents, School of Medicine, 2008. Web. 12 Mar. 2017.

I believe that Justice McKenzie made the correct decision when he “ordered that temporary custody [of Stephen Dawson] be assigned to the Superintendent of Family and Child Services and that the operation to replace the shunt be performed” (Gedge, Thomas, and Waluchow). Stephen’s case raises several contested topics regarding autonomy and the rights of disabled individuals.

In general, when a patient is found incompetent, their family is responsible for serving as the decision-maker for the patient because they are most likely to know what would be in the best interest of the patient. However, that is not necessarily the case when the family has not been in contact with the patient in question for an extended period of time. In those situations, should someone who is closer to the patient assume the decision-making rights of the family in order to make sure the patient’s best interests are respected? Physicians have the authority to “choose a surrogate for a patient with limited competence or to make decisions for a totally incompetent patient. The surrogate may be a relative, close friend, physician who knows the patient well, or someone provided by the hospital or government” (“Medical Decision Making for the Incompetent Patient”). I believe that Stephen’s physician or primary caregivers are appropriate surrogates and should be able to override the family’s decision to decline the surgery. Stephen has lived away from his family for an extended period of time and, as a result, they no longer know what is in his best interest. On the other hand, Stephen’s physician or primary caregivers have been working with Stephen for years and know more about his current state.

Another question presented in this case addresses when it is justified to withhold treatment for an incompetent patient. In this case, the specific question is whether surgery will improve  Stephen’s quality of life or make it more burdensome for himself and those who care for him. To answer this question, I would speak to Stephen’s primary caregivers to gather information pertaining to his general happiness and progress over the years. After hearing that “the professionals at Sunny Hill who have worked with Stephen over the years found him to be ‘a happy little fellow despite his handicaps,’” I would declare that the surgery is in no way extraordinary, and instead necessary (Gedge, Thomas, and Waluchow). While the surgery will not fix Stephen’s handicaps, it will help him to continue to live a happy life. I think that it is Stephen’s right to life. In no way does death seem like the better alternative to surgery in this case.

I think the hardest aspect of cases dealing with incompetent, mentally disabled individuals is determining when they are suffering and in pain. For example, in case 6.3, Mr. Latimer deliberately killed his daughter in an effort to “relieve his daughter’s continued and inevitable suffering” (Gedge, Thomas, and Waluchow). How did Mr. Latimer know that his daughter was suffering? In general, those who are incompetent and mentally disabled are unable to formulate sentences or demonstrate their feelings. As a result, I think it is absurd for Mr. Latimer or Stephen’s parents to claim that their children should die to relieve their suffering. While I do not have a solution to ascertain whether incompetent and mentally disabled patients are suffering, I think it is a violation of their autonomy for others to decide on their behalf if they should die to end their suffering.

Works Cited:

“Medical Decision Making for the Incompetent Patient.” Health Progress (Saint Louis, Mo.).U.S. National Library of Medicine, n.d. Web. 10 Feb. 2017.
Thomas, John E., Wilfrid J. Waluchow, and Elisabeth Gedge. Well and Good: A Case Study Approach to Health Care Ethics. Peterborough, Ontario: Broadview, 2014. Print.

Dilemma:

If you were the head of a nursing home and a researcher approached you and asked if she could use your patients as subjects in her study what would you do? Now suppose that your nursing home is for individuals suffering from Alzheimer’s disease. Would your decision on whether or not to allow your patients to participate waiver? In Case 3.1, Ann Wilson is the director of St. Mary’s Nursing Home, which cares for those suffering from Alzheimer’s disease. A researcher, Dr. Selleck, contacted Ann about her need for individuals suffering from Alzheimer’s who would be willing to participate in a trial to test a new drug that supposedly slows the progression of Alzheimer’s disease. Dr. Selleck asked for Ann’s permission to use her patients as potential subjects after explaining that she would only choose patients to participate if they had written consent, a relative’s written consent, and no one on the health staff had objections to the patient participating. Ann decided not to allow Dr. Selleck to use her patients at the nursing home (Thomas, et al. 116-124). Was Ann right to make this decision on behalf of her patients?

Discussion:

Ann’s decision raises the question of whether Ann is protecting her patients, or doing a disservice to them by denying the patients the opportunity to participate in the study.  By making a decision on behalf of a patient without consulting them, Ann is violating the patient’s right of autonomy. However, the amount of autonomy an individual deserves in a situation is based on their competency. By law, someone is either considered competent or not competent. After further research, I found the criteria lawyers follow to classify someone into one of these two categories. As you can see in the article, the steps of classifying an individual into one of these categories is very black and white. Legally there is no in-between, while in reality there are several degrees of competency (Israel).   This case deals with the two moral principles of autonomy and nonmaleficence. The only way to “solve” this case is to find a balance between these two opposing principles. How can one respect the autonomy of a patient while also protect them from experiencing harm?

I do not agree with Ann’s response in the case presented. I think that the best response in this situation would be to allow the patients to be interviewed as potential subjects in the study. This gives the patients the option to make the decision of whether or not they want to participate for themselves. However, in order to protect the patients, I would only allow those who are considered competent to participate. In addition, I would ask the patients and their relatives what they want as a way of respecting their autonomy, but also let the health care staff contribute to the conversation to decide whether or not the patient would be safe to participate in the study. If the risk of harm is too high, I would allow the health care staff’s opinion to outweigh the patient’s autonomy. If the patient is not competent I would protect them from harm rather than respect their autonomy. However, if the patient was considered competent, as in Case 3.2 where Simon competently chooses to not receive electroconvulsive shock therapy, I would respect the patient’s autonomy (Thomas, et al. 124-131).

Works Cited:

Israel, Laurie. “Elder Competency – When Can You Make Your Own Decisions?” IVKDLaw. IVKD Law, 2010. Web. 20 Jan. 2017.

Thomas, John E, et al. “Case 3.1: Research Involving Alzheimer Patients” Well and Good: Case Studies in Biomedical Ethics, Broadview P, 1987.

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