Dilemma:

Janet Greene is a forty-four year-old victim of a traffic accident. She was treated fir multiple fracture and abdominal injuries, and was discharged once she recovered sufficiently from renal failure. She was able to live at home despite her lacking kidney function, however she soon developed a second round of acute kidney failure and when readmitted to the hospital, it was clear that her condition urgently needed dialysis. Ultimately, the issue is that both geographically accessible hospitals said that they did not have space to give Janet long-term dialysis. When her physician asked if there was any way to “bump” a patient with a less-dire prognosis in order to make room for Janet they refused; both hospitals had a “first come first serve” rule. So the issue is whether or not this first come first serve standard is the morally just way to run these establishments.

Discussion:

In this case we must distinguish between macro and micro-allocative decisions. While macro-allocative decisions are made when a hospital is tight financially and the hospital administrator has to make the tough decision about what programs they can afford to keep, and what ones they must cut. These kinds of resolutions, however, are impersonal as opposed to micro-allocative resolutions that are a part of the personal environment of clinical decision-making. Micro-allocative decisions come into play when a certain resource’s demand becomes greater than the supply. So the biggest question to face here is, “Who shall have the scare resource when no all can?” A question whose answer is synonymous with a life-or-death decision, and in Janet’s case, withholding the long-term dialysis to treat her condition would be the equivalent of signing her “death warrant.”

We must distinguish between two levels of decision-making in micro-allocation if we are to answer “who shall live when not all can live?” The first level is the Eligibility Criteria. Within this there is the constituency factor, stating, “patients in an outlying region may be denied access in favor of patients who reside in the city in which the hospital is located.” There is also the progress of science factor, “patients could be turned away in a micro-allocative crunch if their particular need for a resource failed to fit with the research interests of the hospital.” And the prospect of success factor, “it would be irresponsible to offer a scare medical resource to a patient who is not likely to benefit from it or is likely only to derive marginal benefit from it.” I agree with all three of these criteria, especially the last one. The prospect of success factor is in line with what Janet’s physician is saying, Janet’s condition is critical and if there is a patient who does not need the resources the hospital is providing, or a patient who is hardly benefitting from a certain resource, I believe it is the moral obligation of the hospital to put their resources to the best use possible – and in this case it would be in saving Janet’s life. The second level of criteria, the selection criteria, includes the criteria of comparative worth, which proposes that when distributing scarce resources at the bedside “the family role factor” must be taken into account. Janet is a single mother with two children, she is their only true source of financial, emotional, and physical support and we cannot know the extent of her situation, but since she and her husband are separated and she is the one taking care of the children, we can assume that the father would be of little to no help if this mother were to pass away, leaving her children stranded.

I believe that the only justified way of “bumping” someone off a machine is if they can sustain a good life without it, or if they are hardly hanging on and the machine/treatment is just elongating their inevitable road to death. In these two situations, I believe that either of the patients should be “bumped” in order to save someone who needs the treatment to live, and once on the machine, can live a happy, healthy life without death being in the near future. However, other criteria like the family role factor is important in a case like this. While I don’t believe that it is right to sacrifice one person in order to save another that has children, I do believe in it being an act of supererogation rather than obligation. Anyone that doesn’t meet the two criteria I listed above should not be “bumped” off of their machine – however if they want to volunteer their machine in order to benefit another, then that is the only way something of this sort would be morally justified.

Background

In “Principles of Biomedical Ethics,” a hypothetical situation about a woman with Alzheimer’s is described when looking at The Best Interests standard. The woman, Margo, is a very happy woman who seems to be enjoying her life. The medical student who visits Margo even described her as “one of the happiest people I have ever known.” So we can say that even though Margo is an Alzheimer’s patient, she is clearly living her life with a genuine smile on her face and a great deal of happiness. However, the conflict arises when we are told that during the beginning stages of her condition, Margo executed a living will, which stated that she did not want life-sustaining treatment if she were to develop another life-threatening illness. Well, Margo ends up developing pneumonia and this is where the problem begins.

Dilemma

Margo’s physicians are faced with the issue of whether or not to administer their patient antibiotics in order to treat her pneumonia. If they decide not to give her the antibiotics, they would be acting according to the living will she created and respecting her precedent autonomy, resulting in her death. However, based on Margo’s current quality of life and pure happiness it would seem as though it would be in her best interest to go ahead with the antibiotics, treating her pneumonia and allowing her to continue living her happy life. But by doing so the physicians would clearly be violating the living will Margo executed as she developed Alzheimer’s.

Discussion

In this particular case, Margo’s physicians must administer the antibiotics to treat her pneumonia. In doing so, not only would they be acting under the best interests standard but also under the principle of beneficence, which refers to “a statement of moral obligation to act for the benefit of others,” (203). The health care team has a moral obligation to act in order to benefit Margo. Beauchamp and Childress even mention how “the best interests standard can in some circumstances validly override advance directives executed by formerly autonomous patients.”

The available options here are to either administer the antibiotics, save Margo’s life and allow her to continue living a happy one, or not to administer the antibiotics, act in accordance to her living will, and consequently result in her death. With these two options, the job is to determine the highest probably net benefit and act accordingly. And since the best interests standard requires a surrogate to assess both the risks and probable benefits of several treatments and alternatives – this is inevitably a quality-of-life criterion. That being said, while quality of life is a difficult topic to discuss, it is clear in the description of this hypothetical case that Margo’s quality of life is high. As previously mentioned, she is seen as one of the happiest people some of the people working with her have ever known.

Moreover, Beauchamp and Childress address the fact that as person “slips into incompetence,” as Margo is currently doing, their living condition can drastically change, sometimes for the better. They continue to say that “if so, it seems unfair to the now happily situated incompetent person to be bound by a prior decision that may have been under informed and shortsighted.” When Margo made her advance directive, she had just been informed about her condition and more likely than not thought of the worst rather than the possible best. She wasn’t in the right mental or emotional state to be able to make a completely cohesive decision about future treatments. Beauchamp and Childress even say that advance directives “generate practical and moral problems.” One of those problems being that they “fail to leave sufficiently explicit instructions.” In Margo’s case, she stated that she did not want life-saving treatment, but to what extent is something truly a “treatment?” Antibiotics are entirely different than having to undergo a major surgery; taking pills aren’t even invasive. So it would seem as though these antibiotics wouldn’t exactly fit the mold Margo made for “life-saving treatment,” as she most likely anticipated developing something much worse that required a more invasive course of action.

This is quite honestly all the information we need to make the ethically correct decision here. The fact is that Margo is an extremely happy woman enjoying her life – even if it’s one of incompetence – and as her surrogate decision maker and health care team, they have a moral obligation to act in her best interest, which is clearly prolonging her life.

Beauchamp, Tom L., James F. Childress. Principles of Biomedical Ethics. 7th ed. N.p.: Oxford University Press, 2012. Print.

Background

There are two very important cases presented in Well and Good titled “Don’t Let My Mother Die” and “Please Let Me Die.” I will be focusing on the latter. In this case you have a 26-year-old man named John who has been suffering with a neurological disease commonly known as “the elephant man’s disease” for 20 years now. Ultimately, over the course of his life he has had over 100 operations to remove tumors, which have lead to total deafness, partial blindness, total paralysis except for some movement in his right shoulder and total impairment of his breathing muscles. So John would be stuck on a respirator for the rest of his life and consequently, after everything, John does not want any more surgeries and he wants to die.

Dilemma

This case raises multiple concerns. One would be addressing the difference between letting someone die and killing them. However, the main moral issue here is whether to respect the patient’s autonomy or act out of nonmaleficence. Up to this point in John’s life it had been easy for the physicians to do both, considering that John agreed to his past procedures and by doing so the physicians were acting nonmaleficently. However, now John’s wishes would require the physicians to go against the principle of nonmaleficence because John now wishes to die. So what do you do here? Do you respect John’s decision and act based on his autonomy? Or do you act out of nonmaleficence and go against your patient’s wishes?

Analysis

Personally, I believe that the physicians must respect John’s decision and take him off of the respirator. There are many reasons behind my view. First of all, I believe that John has the right to make this decision and that he autonomy should be respected because of certain factors. The first factor being that John has been dealing with this disease for nearly all of his life, he has been dealing with it for 20 years. So when John finally decides that he would like to die, it is not like he has had this disease for one or two years and decides then that he doesn’t want to live anymore, he has been dealing with this for basically all his life, and since 20 years have gone by and the physicians know and tell him that there is no chance for remission, John’s decision is plausible. Moreover, respect for autonomy goes hand in hand with a competent, autonomous patient, and John was proven by his medical staff and social workers to be “fully alert, conscious, and in control of his mental faculties; he is able to make rational decisions and choices.” So where is the confusion? John’s decision must be upheld.

Furthermore, there is great controversy in the distinction between “letting die” and “killing.” Beeauchamp and Childress address this problem. They say that “letting die” is “prima facie acceptable in medicine under one of two conditions,” the condition relevant in this case is the second one stating that “patients or their authorized surrogates validly refused a medical technology.” That is, if the patient’s refusal of treatment is valid, then letting that patient die is acceptable, and in the above paragraph it is shown that John’s refusal is definitely valid.

Now some may want to argue that since John’s family was at first against letting him die, but after several counseling session finally came around to his decision, their decision was not their own but rather one they were most likely persuaded into. But even so, if they are truly trying to act in the best interest of John then they would respect his wishes. We have to look at John’s life in the long run. The physicians have told him that there is no chance of remission, and John has been living a paralyzed and physically disabled life for 20 years now. Even though John can continue to live he is severely depressed and will not live a happy or fulfilling life is he is to continue with the respirator and surgeries. So his family wanting him to live is a selfish desire, and they aren’t acting out of beneficence for John, but rather what would make them happy. So ultimately, I strongly believe that John’s autonomy must be respected in this case and his medical team is entirely morally justified in disconnecting his respirator.

Works Cited

Beauchamp, Tom L., James F. Childress. Principles of Biomedical Ethics. 7th ed. N.p.: Oxford University Press, 2012. Print.

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

Background:

This article discusses three separate cases in which a placebo was administered in clinical settings. I am going to focus on Case 1. In this case we have a 45 year old man suffering from diabetes and hypertension who has just undergone a second leg amputation. Following the surgery, the man was facing severe pain and after being treated with multiple injections his pain still hadn’t subsided so the staff decided to administer him intramuscular saline, a placebo, which ultimately helped with the pain but was the patient deceived?

Dilemma:

The ethics of the placebo have typically been dealt with in a research setting, however here we are questioning the use of the placebo in clinical practices. In research studies, the use of the placebo is a very common method of evaluating a control group versus an experimental group. However when patients go to their physicians, they are seeking out a cure or treatment for whatever illness they are facing, they are looking for a prescription and generally they trust their physician’s opinion and ultimate method of treatment. So the issue here is was it right for the physician in Case 1 to administer his patient a placebo, while having his patient believe he was being treated with a legitimate pain killer

Discussion:

Placebos have been proven to be an effective method, so that is not where the ethical problem is. Rather, the ethical problem is whether or not administration of a placebo is deceiving the patient. If it is indeed deception, then the placebo treatment would always be unethical and a violation of the patient’s right to be fully informed at all times.

However, in this particular case, the patient was told that the injection he was going to be given would ease his pain. Not only was he told this but his physicians had full belief that the saline would indeed work as they had anticipated. And ultimately that is exactly what it did, the treatment, although it was a placebo, did in fact significantly reduce the patient’s pain. So where is the dishonesty in communication between doctor and patient? It doesn’t seem like there is any.

Yes, the patient has a right to know what he or she is being administered and any other medical information that they want. However, if they do not ask their physician for this information then the physician is not obligated to tell them. This is very different from a physician withholding potential negative side effects of a treatment or medication; we cannot confuse the two situations as they are entirely different and in the latter case I believe the physician does have an obligation to tell their patient any potential consequence of a treatment or prescription. But in this case there are no negative side effects that the physician is withholding, and if the patient were to ask for the name of the pill or how it works then yes, in any situation, he or she should morally be given that information in complete truth. But the patient did not ask the physician those questions, therefore that information is not required to be given.

For these reasons, I do not believe that the administration of the placebo in Case 1 was unethical or a violation of the patient’s rights in any way, shape or form. I believe that the physician was looking out for the best interest of his or her patient and since the patient did not ask for specific information about the pill he was being administered, it was unnecessary for the physician to say anything.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1733989/pdf/v030p00551.pdf