Background

Case 8.1 introduces the case of Janet. Janet is a 44-year old woman on welfare who was separated from her husband and is the mother of two children. Janet Greene, was admitted into the intensive care unit being severely injured in car accident. She was treated for her fractures and abdominal injuries. She developed acute renal failure, but was treated with peritoneal dialysis.  After recovering, Janet was discharged only to suffer from a second bout of acute kidney failure after being home for 3 months. Her physician expressed that Janet was in urgent need of dialysis because tests revealed high levels of potassium.  However, when Janet’s physician tried to get Janet’s admitted to two, different tertiary hospitals in the area, the hospitals reported back that they did not have any space for Janet to be treated.  After asking if Janet could take the place of another patient with a poorer prognosis, the hospital expressed that they had “first come, first serve” policy

Reflection

Janet’s case is one that is morally difficult because it raises challenging questions about micro-allocation and quality-of-life decision-making.  For many people including the hospital policy-makers in this particular case, a “first-come, first-serve” or lottery type of system is the most equitable way of deciding who gets to use the resources.  While I can understand having this type of system does not have to involve having to make quality of life decisions, I do not agree with the hospital’s decision to completely decline exploring the physician’s request as a possible option. Unfortunately, in a world with few resources, but many needed services, a “first-come, first serve” is not necessarily always morally justifiable.  A “first-come, first serve” policy in this case seems to be a “short-cut” or easy route in order to avoid making difficult decisions.  In Beauchamp and Childress, they write that the “first-come, first-serve rule” can have the potential to lead to injustice (Beauchamp & Childress 290). How can a first-come, first policy justify refusing treatment to a patient who has a moderate to high chance of survival in order to continue treating another patient who only has very small to no chance of survival?  In this particular case, Janet is being denied treatment even though there is a chance that she may have a higher chance of survival than another patient.  The hospital argues that this approach is “fair”. Although an egalitarian may agree that their approach is fair, a utilitarian would most likely argue that it is not fair. I am arguing that for utilitarian approach in this case. The ethical course of action would have been for the hospital to assess who would have the highest chance of benefiting from treatment.  The hospital should have made a decision based on medical/scientific evidence. The utilitarian approach is the most ethical because it minimizes the most harm for the most people.

I do understand, however, that making quality of life decisions is difficult. For the utilitarian approach to be morally just in this case, it is important that the quality of life decisions that are being made by the physicians are not based on age, ethnicity, socioeconomic status, etc.  In this particular case, the physician expresses that the fact that Janet is a mother should also be taken into consideration which raises additional ethical questions. Should a mother’s life be considered more important or have a higher priority when allocating scarce resources? I would argue that it should be taken into consideration.  Janet is responsible for the well-being for two children. Thus, not giving Janet adequate treatment is not only causing her harm to her, but also the children that depend on her. Of course, this does present challenges when deciding to allocate between mothers or people who have numerous persons depending on them. However, in this case, the hospital simply refused to even consider “bumping” another patient, so it is not possible to know whether the other patients were in a similar position to Janet.   In order for there to be justice in this case, quality of life and the patient’s role as a mother must be taken into account.  Ultimately, the way one views this case and their approach is largely going to be reflective of their definition of justice.  While the hospital has a more egalitarian approach, I do not find that approach to be appropriate nor “just” in this case.

 Work Cited

Beauchamp, Tom L., and James F. Childress. “Beneficence” Principles of Biomedical Ethics. Seventh ed. New York: Oxford UP, 2013. 249-296. Print.

Thomas, John E.,and Wilfrid J. Waluchow. “Dialysis Machine Shortages: Who Shall Live? “Well and Good: A Case Study Approach to Biomedical Ethics. 3rd ed. Peterborough, Ont.: Broadview, 1998. 215-221. Print.

Background

A couple months ago, NPR featured a news story titled “If You Have Dementia, Can you Hasten Death As You Wished?”   The news story discusses the case of Margaret Bentley, a former registered nurse, who decided, and even expressed in a written will, years ago that she wanted to stop eating if she ever became completely disabled. However, now, she has sunk so far into dementia that she needs the help of other people to carry out the wishes that she had expressed while she was competent.  Margaret Bentley’s case has resulted in a conflict between the administrators of her nursing home who do not want to carry the wishes she expressed when she was autonomous while her family wants her to be allowed to die.

For a while, the family hoped she would die peacefully in her sleep. However, as the years dragged on, Bentley became progressively more demented, and her family continued to fight to put her living will into action.  By 2011, 8 years after being institutionalized, Bentley was living at her second nursing home. At this point, the aides were doing everything for her “including diapering, moving, lifting and feeding her”.   The aides as well as the Fraser Health Authority collectively decided that it was time to stop giving her food and water. However, one person at the nursing home, did not want to stop feeding Bentley because she would open her mouth when they brought a spoon to her lips which he or she believed signified that she actually did actually want to eat.  However, the daughter insists that it is simply a reflex and that her mother opens her mouth even when the spoon is empty.

Dilemma

Should the caregivers work with the family to carry out the wishes that Margaret expressed while she was fully competent? Or should they grant Margaret’s immediate wishes who wants to eat when she is hungry?

Reflection

In this particular case, I would have to agree with the Margaret’s family rather than the aides.  The most ethical course of action would be to respect and carry out the wishes that Margaret expressed while she was a competent individual. It is unethical to go against Margaret’s wishes because she gave clear directions of what she wanted to happen if she were to be disabled while she was autonomous, and it is unethical to go against a patient’s autonomy.

The specification used for autonomy is that the patient must be competent in order to make autonomous decisions.  Thus, a possible argument that one of the aides would make would be that because Margaret is currently incompetent, then she cannot express any of her immediate wishes or any changes in her decision.  Because she is currently incompetent, then she does not meet the requirements to carry out the autonomous decisions she made when she was competent. Therefore, it is important to continue feeding her because as an incompetent patient, she may not be able to express what she does or does not want in the present moment as opposed to what she may have wanted in the past.  However, I find this counterargument morally questionable and problematic. Because Margaret is clearly an incompetent patient suffering from Alzheimer’s, then why is it automatically assumed that she wants to eat and continue to live because she opens her mouth when a spoon is placed in front of her? If she cognitively unable to refuse food because of her condition, then shouldn’t her immediate actions be interpreted with more skepticism? Moreover, it is clear that Margaret lacks to the ability to reason when she opens her mouth even when the spoon is empty.  Alzheimer’s has prevented Margaret from expressing that her end-of-life plan be executed in the immediate moment.  Margaret expressed clear preferences not to be fed food and water when reaching a particular condition, and those advance directives should be respected.

In the “Beneficence” chapter of PBE, Beauchamp and Childress outline three different standards that have been proposed for surrogate decision makers for incompetent patients. The three standards are the substituted judgment, pure autonomy, and the patient’s best interests (Beauchamp & Childress 226). The substituted judgment standard requires the surrogate decision maker to “make the decision the incompetent person would have made if competent” (Beauchamp & Childress 227). The pure autonomy standard is  “asserts that whether or not a formal advance directives exists, caretakers should act on the patient’s prior autonomous judgments” (Beauchamp & Childress 228). Lastly, the best interest standards protects seeks “to protect and incompetent person’s welfare interests by requiring surrogates to assess the risks and probable benefits of various treatments and alternatives to treatment” (Beauchamp & Childress 228). When applying the substituted judgment standard and the pure autonomy standard, Margaret’s advance directives should not be overridden, and the aides should stop feeding her food and water.  Margaret clearly outlined that she wanted to stop eating if she became disabled which automatically answers any questions about what she would of wanted or what her decision would have been if she was autonomous.  According to Beauchamp & Childress, the best interests standard is the standard often used to override a patient’s advance directive.  However, even if the best interest standard is applied to Margaret’s case, it is still not morally ethical to continue feeding her. Over time, Margaret has become increasingly disabled and needs help to do anything including moving, eating, and diapering. There are no benefits to continue feeding her to keep her alive because her cognitive and motor abilities will not improve.   Because there are no real benefits, the best interest standard cannot be used as justification to override Margaret’s advance directives. Moreover, the NPR article writes that death “brought by cessation of eating and drinking might sound scary in prospect, but it’s said to be relatively painless if done correctly” (Hening). Thus, if not feeding Margaret does not causes her immediate pain or harm and is is respecting her autonomy, then her advance directives should not be overridden.

It’s also important to highlight that Margaret worked a registered nurse, and was probably very familiar with conditions such as Alzheimer’s and how previously competent people lived when they became disabled.  Margaret’s decision to stop being fed was likely to be a well-reasoned decision that should continue to be respected though she is not able to express them in the present moment. Also, why are the aides, rather than the immediate family, making the surrogate decision for Margaret? The aides of the nursing home are assuming that they know what is better for Margaret than her immediate family. The immediate family probably understands Margaret’s values and wishes far more than the aides who are not familiar with how Margaret was before she was diagnosed with Alzheimer’s. Margaret’s family should be allowed to assume the role of being the primary surrogate decision-makers in order to allow Margaret to end her life the way she clearly wanted as expressed in her will.

Work Cited

Hening, Robin. “If You Have Dementia, Can you Hasten Death As You Wished?”. National Public Radio (NPR). 27 Mar. 2015. Web. 10 Feb. 2015.< http://www.npr.org/blogs/health/2015/02/10/382725729/if-you-have-dementia-can-you-hasten-death-as-you-wished>

Beauchamp, Tom L., and James F. Childress. “Beneficence” Principles of Biomedical Ethics. Seventh ed. New York: Oxford UP, 2013. 222-241. Print.

Background

On October 24, 1993, Robert Latimer decided to end the life of his 12 year-old daughter, Tracy, who suffered from cerebral palsy.   He placed his daughter in the back of his pick-up truck and piped in carbon monoxide, which ultimately caused her death.   Robert justified his act by arguing that he committed a “mercy killing” for his daughter who was perpetually suffering despite undergoing numerous surgeries.  Ultimately, the court decided to convict Robert Latimer of second-degree murder and sentenced him to one year in prison and one year of house arrest.  Advocacy groups on end of the debate were outraged because they argued that court’s response is sending a message that the life of people with disabilities “is of diminished value” (Thomas & Waluchow 193). However, the court saw the Mr. Latimer’s action as one of “compassionate homicide” and that he was assuming the role of a “surrogate decision-maker”(Thomas & Waluchow 195).

Analysis 

Interestingly, in this case, the court’s decision reflects more of an adherence to moral principles as opposed to judicial laws.   Although his decision was in “clear conflict with the law” (Thomas & Waluchow 195), the court’s decision to give a “lighter” punishment seems to suggest otherwise.   This case illustrates that illegal actions are not necessarily unethical actions. After considering how the principle of non-maleficence applies in this case, I would agree with the court’s decisions. In the “Non-maleficence” chapter, Beauchamp and Childress outline a set of qualifications of surrogate decision makers for incompetent patients (Beauchamp & Childress 190). These qualifications include:

1. Ability to make reasoned judgments (competence)
2.  Adequate knowledge and information
3. Emotional Stability
4. A commitment to the incompetent patient’s interests, free of conflicts of interests and free of controlling influence by those who might not act in the patient’s best interests.

When taking these qualifications and applying it to this particular case, then Mr. Latimer’s decision seems to be morally justified.  His ability to make reasonable judgments is suggested by the fact that he characterized by others as “responsible and hardworking”.  It was also made clear that he was not in need of any sort of rehabilitation (Thomas & Waluchow 194).   As for the second qualification, it can be assumed that as the father and primary caregiver of his daughter that he had a lot of information about his daughter’s health  (past effectiveness of drugs/treatments as well as prognosis for quality of life).  Opponents would most likely argue that he lacks a medical background to fully understand the impact of future surgeries on Tracy’s health. However, he is probably more likely to understand the extent of her suffering because he is around his daughter far more than any other healthcare professional. Thirdly, Mr. Latimer’s emotional stability is not completely clear; though, those around him that describe him as “responsible” does suggest that he acts according to rationale as opposed to pure emotion. The final qualification is quite evident in Mr. Latimer.  The evidence showed that “his relationship with Tracy was that of a loving and protective parent” (Thomas & Waluchow 194).  Thus, after evaluating Mr. Latimer’s actions on the basis of these qualifications, his actions do seem morally “right” as he claims them to be.

Much of the resistance to permitting non-voluntary euthanasia as well as aid-in-dying requests seems to stem from feelings of fear of what may happen in the future if it is widely permitted across different cases. Pat Danforth of the Council of Canadians with Disabilities, expressed his concerns that the decision made in Robert’s Latimer’s case sends a message to “every senior citizen, every quadriplegic, anyone in a car accident that their life is of diminished value” (Thomas & Waluchow 193). There is an underlying fear that if these actions and requests are permitted, that it will result in unnecessary deaths based on poor judgments and/or hasty decision-making.  Moreover, there seems to be an assumption that the use of euthanasia i is also an is an indication of how an individual’s life is valued  which is something I find particularly problematic.  Mr. Latimer’s decision to relieve his daughter’s continuous pain does not suggest that he does not value his daughter’s life.  Rather, his actions show that he values her enough to make a difficult decision and end her pain away. Fear of what may happen in the future is not adequate reasoning to prohibit aid-in-dying where it may be the sensible course of action as well and the action that the patient or surrogate decision-maker may want. With proper protocol, non-voluntary euthanasia and aid-in-dying can be implemented in a systematic manner into healthcare systems.

Work Cited

Thomas, John E., and Wilfrid J. Waluchow. “When Physicians and Family Disagree.”Well and Good: A Case Study Approach to Biomedical Ethics. 3rd ed. Peterborough, Ont.: Broadview, 1998. 192-199. Print.

Beauchamp, Tom L., and James F. Childress. “Nonmaleficence” Principles of Biomedical Ethics. Seventh ed. New York: Oxford UP, 2013. 150-193. Print.

Background

CASE 1.1: “When Physicians & Family Disagree”

In Case 1.1, “When Physicians and Family Disagree”, Mrs. Francois, a 63 year-old French Canadian women, is readmitted to the hospital shortly after being released. Six days after undergoing a hysterectomy and bilateral oophorectomy, Mrs Francois reported having a severe abdominal pain, and her blood pressure began to drop.  After examining Mrs. Francois, the doctor concluded that she had generalized peritonitis and that she would need an operation or she would probably die. However, despite the doctor’s straightforward explanation and her what was perceived as her stable mental condition, Mrs. Francois refused. Her family was distressed by her decision to refuse the surgery, and the son even threatened the physician to act or he would hold the physician responsible for his mother’s death. The case raises questions about autonomy and implied consent for patients who refuse treatment.

CASE 2: “Family Struggles With Father’s Wish To Die”

I came across this story on NPR, and I thought it would be particularly interesting to discuss and compare this case to the one that was in the Well and Good book. In Case 2, 66 year-old man named Robert Schwimmer was diagnosed with pancreatic cancer in 2013.  Now, after being in hospice care, he has expressed that he does not want to prolong his life and would like to accelerate his death if he finds himself in excruciating pain.  In this case, the son is willing to help his father, but he admits it would be difficult for him to do so for both legal and spiritual reasons.  Legally, it would difficult to implement Robert Schwimmer’s decision because physician assisted suicide is not legal in Illinois. Spiritually, the son expresses that he feels uncomfortable playing any role in his father’s death. Despite these reservations, the children are willing to respect to the father’s wishes.

Analysis

Both of these cases are quite similar in that both cases the legal course of action does not necessarily dictate the morally correct course of action. In Case 1, the physician is faced with both legal conflicts as well as moral conflicts.  If the doctors abides by the law that requires consent from the patient before medical intervention, then he violates principle of minimizing harm and fails to commit to his professional obligations despite following the principle of autonomy. If he fails to act, however, and is legally charged with “criminal neglect” by not performing the surgery, and he may also be in violation of principles of minimizing harm because the patient would have died. The legal implications of the doctor’s possible decisions do not reveal what the ethical course of action would be in this situation. In Case 2, Robert Schwimmer does not want to prolong his life if his qualify of life declines.  However, the laws that are in effect in his state challenge his autonomy to make those choices.

By comparing these cases, it is possible to gain insight on how to approach situations where the patient is refusing life-sustaining treatment.  After reading Case 2, I would argue that the physician ought to perform the surgery in Case 1.1.   While the physician does has a moral obligation to respect a patient’s autonomy, the principle of autonomy​y can be specified in this case.  Mrs. Francois is entitled to her autonomy as long as she is fully competent to make these autonomous decisions.  While Mrs. François was visibly competent and appeared stable in eyes of the physician, the son asserted that “his mother was behaving abnormally” (Thomas & Waluchow 62) and that “she didn’t understand the consequences of her refusal of the surgery” (Thomas & Waluchow 62). The conflicting perception in Mrs. François competency and mental suggests that her autonomy may not be used to support her decision to refuse treatment.  In Principles of Biomedical Ethics, Tom L. Beauchamp and James F. Childress discuss the concept of “sliding-scale strategy”.  Writers that support sliding strategy argue that “as the risks of a medical intervention increase for patients, so should the level of ability required for a judgment of competence to elect or refuse the intervention” (Beauchamp & Childress 119) . The sliding strategy allow one to consider all the risk of intervention, or in this case, lack of intervention,  and use that set the expected level of competency to make that decision. In this case, Mrs. Francois’s risk for not having surgery is death. Thus, if her competency is not fully understood or clear than the doctor has more reasons to perform the surgery.

Interestingly, while I do feel that the physician ought to perform the surgery for Mrs. François, I would argue that Robert Schwimmer should be allowed to accelerate his death if, and only if, he is in excruciating pain or his quality of life declines. The primary difference between this case and Mrs Francois’ is the concept of harm,pain, and competency. In Mrs. François case, she is currently having “abdominal pain”, yet is refusing treatment that would save her life. Thus, by neglecting to treat her, the physician is not minimizing her harm, but rather allowing it to continue.  If her autonomy is questionable on the basis of her competency, then there is more of reason to follow the principle of minimizing harm and performing the surgery than following the principle of autonomy. However, in Robert’s case, he is refusing life-sustaining treatment if he is a state of pain or decreased quality of life.  Robert was only interested in accelerating his death under a specific set of conditions. Although the details of Robert’s competency are not completely clear, his wishes and reasoning do seem to reflect rational. His family also does not point to any abnormalities in behavior which is not the case with Mrs. François. In Robert’s case, if the physician refuses to intervene and remove the life sustaining treatment, he is not minimizing harm nor is really respecting the choices of him and his family.   If Mrs François was to have the operation, she would most likely have a more promising future and quality of life than Robert, who is likely to become progressively worse in his health over time.  Whereas the physician is deciding between life and death for Mrs. Francois in Case 1.2, the physician is Case 2 is coping with the question of sustaining Robert’s life.  The different conditions in these cases require different moral actions on the part of the physician despite seeming somewhat contradictory.

Work Cited:

Thomas, John E., and Wilfrid J. Waluchow. “When Physicians and Family Disagree.”Well and Good: A Case Study Approach to Biomedical Ethics. 3rd ed. Peterborough, Ont.: Broadview, 1998. 71-76. Print.

NPR STAFF. “Family Struggles With Father’s Wish To Die.”. National Public Radio (NPR). 1 Feb. 2015. Web. 4 Feb. 2015

Beauchamp, Tom L., and James F. Childress. “The Meaning and Justification of Informed Consent.” Principles of Biomedical Ethics. Seventh ed. New York: Oxford UP, 2013. 120-25. Print.