Case

Lucy Mait, a 45-year-old woman, found out she has the BRCA1 gene mutation, which meant she has a high risk of developing breast cancer. Lucy was having a very hard time processing this information and was referred to post-test genetic counseling to make sure she was fully informed of the implications of these results. Lucy has a 29 year old daughter, who is planning a wedding, and an 18 year old nice. Her doctor, Dr. Braesecke, has encouraged her to share the information with her daughter and nice so they can be tested as well but she is very reluctant to tell them. She claims that she needs more time to process the situation herself and that she does not want to ruin the mood of the upcoming positive events. All three of these women have been lifetime patients of Dr. Braesecke and he is put in a very tough position because he knows that early diagnosis and preventative measures can save lives.

Dilemma

Dr. Braesecke is faced with the dilemma between sharing the information with Lucy’s family, which breaks confidentiality, and respecting Lucy’s wishes by not saying anything.

Analysis

Dr. Braesecke is aware that “confidentiality can sometimes be ethically broke if there is a direct, imminent, and avoidable threat to the life of a third party” (CITE 259), but he is not sure whether this case fits this description. I argue that Dr. Braesecke ought to act under the principal of beneficence and inform the daughter and nice of this information. One can argue that this decision will violate the trust that is in the physician-patient relationship, which is important for future ongoing care. Dr. Braesecke can act under the utilitarian principle of justice, which states we ought to “seek to produce the maximal balance of positive value over disvalue – or the least possible disvalue, if only undesirable results can be achieved” (Beauchamp and Childress 254). In this case the benefit of telling two patients they are at high risk of having this mutation can possibly lead to preventative actions being taken that can save their lives. The disvalue in this case is violating the wishes of Lucy, who is just one patient. In this simple reasoning, two patients will be benefitted and only one would be offended. One can also look at the risks of keeping this information confidential compared to the risks of telling. The benefit of saving lives outweighs the harm of violating one’s autonomous decision. It can also be argued that Lucy will tell her family in the future, it is only a matter of timing. In response to that, it is impossible for Dr. Braesecke to be certain that Lucy will tell her family. The fact that Lucy may want to tell her family in the future but is not entirely sure speaks to the validity of the autonomy in her choice. Lucy has just been told she is at risk high risk for cancer, which other women in her family have had. According to Beauchamp and Childress, illness can limit one’s understanding of the situation and therefore limit one’s autonomy. Lucy’s judgment may be clouded and she may not fully understand the consequences of not telling her family, which can be seen in how she states she needs more time to process the situation. As their doctor, Dr. Braesecke is obligated by the principle of beneficence to prevent evil or harm (Beauchamp and Childress 152). He is in a situation where he has the ability to prevent serious harm by catching breast cancer in its early stages. One can argue that if Dr. Braesecke told Lucy’s family this act would be an act of hard paternalism. This hard paternalism is justified because, as stated above, the prevention of harm outweighs the risks of the action taken (Beauchamp and Childress 222). In this case Lucy’s genetic information ought not to be seen as entirely confidential because it may have direct implications on the well-being of others.

Sources

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York: Oxford UP, 2009. Print.

Thomas, John E., Wilfrid J. Waluchow, and Elisabeth Gedge. “Case 9.3: Genetic Testing and Disclosure.” Well and Good: A Case Study Approach to Health Care Ethics. 4th ed. N.p.: n.p., n.d. 294-296. Print.

http://www.myriadtests.com/app/brac.htm

Case

Beauchamp and Childress describe a hypothetical case about woman with Alzheimer’s. She is described as being an extremely happy person. In the beginning stages of her disease, Margo had made a living will. In this living will she stated that she did not want life-sustaining treatment if she were to develop another life-threatening illness. Now, Margo has developed pneumonia. The health care team is now deciding whether or not to administer the antibiotics (Beauchamp and Childress 229).

Ethical Dilemma

The health care team and surrogate decision maker are faced with a dilemma between respecting ones autonomy or acting beneficently. Should they not administer an antibiotic, which respects her advance directive, and will likely result in her death, or should they ignore it and give her the antibiotic, which will probably save her life.

Discussion

In this case, I believe the health care team and surrogate decision maker ought to administer the antibiotics. The health care team would be acting under the principle of beneficence and would be able to save this woman’s life. They would be acting under the best interest standard. According to Beauchamp and Childress “the best interest standard can in some circumstances validly override advanced directives executed by formerly autonomous patients” (Beauchamp and Childress 228). In this case Margo made her advanced directive just as she had been informed of a devastating illness. At this point she may have assumed the worst possible outcomes of the course of her illness. With that assumption in mind, she may have not wanted to be kept alive in order to just suffer more from the notoriously devastating Alzheimer’s. According to the doctor, Margo was one of the happiest people she has ever known. This shows that Margo may have overestimated the severity of her Alzheimer’s. It is unclear that if Margo knew she would have a more mild case would she still have decided to forgo life-sustaining treatment in the case of acquiring an additional illness. It may be unfair to keep a now incompetent person bound to a prior decision, which could have been not adequately informed. This raises issues of advanced directives. One problem with an advanced directive is that it may not be sufficiently explicit (Beauchamp and Childress 189). In this case Margo is not clear about which types of measures she does not want to have taken. She may not want to spend her time in a hospital being kept alive by a ventilator or feeding tubes, but she may not oppose minor interventions. In this specific circumstance she has contracted pneumonia. This illness is life-threatening but it also can be cured with a relatively noninvasive treatment: antibiotics. Margo has also not shown any deep personal views against antibiotics. Giving her antibiotics is acting out of beneficence because it will ultimately save her life. This decision could be considered as an act of hard paternalism because it is acting against Margo’s autonomous preferences but it can be considered justified hard paternalism. It is justified because her pneumonia has put her at risk of significant, preventable harm (being death) and giving her antibiotics would most likely prevent death. This brings one to have to consider the treatment with antibiotics. It is not a futile treatment because it will produce a physiological effect, they are likely to be effective, and are more beneficial than burdensome (Beauchamp and Childress 169). “Actions that prevent major harms… while only trivially disrespecting autonomy have a plausible paternalistic rationale” (Beauchamp and Childress 221). The prevention of harm, giving Margo antibiotics, clearly outweighs the risk of death because they are relatively noninvasive and have a high probability of being effective. In this case the medical team ought to act beneficently because this act only slightly infringes on Margo’s autonomy and will provide a great benefit.

References 

Case

This is a case about John, a 26-year-old man, who has Neurofibromatosis, also known as elephant man’s disease, a neurological disease in which non-malignant tumors attach to the body’s nerves. This disease causes severe disfigurement and radical impairment of bodily functions. John was first diagnosed when he was 7-years-old and in the last 20 years, he has had over 100 surgeries to try to remove the tumors. These surgeries have had severe side effects resulting in John being deaf, partially blind, almost entirely paralyzed, and in need of a respirator to keep breathing. The medical professionals that have been caring for him say that there is no chance of remission. Based on his past experience, John has requested to not have anymore surgeries and for the medical professionals disconnect him from the respirator, which will inevitably cause his death. His family initially strongly disagrees with John but is ultimately convinced to support him. The medical team says that he would be able to live for years on the respirator but they too are prepared to disconnect it (Tomas and Wilfrid 209).

Dilemma

In this case the doctors face a dilemma between nonmaleficence and respect for autonomy. They have previously been acting under the principles of autonomy and beneficence because John had given consent to his previous surgeries and the acts that were taken were done so to save his life. The situation has changed and now beneficence has turned into a question of nonmaleficence.

Discussion

I argue that the doctors ought to disconnect the respirator and allow John to die. Nonmaleficence is in question because if they unplug the respirator they are technically doing an act that will cause harm because they are aware that John’s body cannot sustain his life alone. Since John has changed his mind about what he consents to, the doctors now have to balance between their respect for his autonomy and their value of doing no harm. The basis of autonomy starts with John’s competence. The doctors have described him as “fully alert, conscious, and in control of his mental faculties” (Tomas and Wilfrid 209). That description proves that John is considered a competent patient. The doctors ought not to question John’s competence when he expressed his wishes to allow his disease to take his life. He has shown a full understanding of his situation. He is aware that he has had countless surgeries yet he is not improving. This case also calls one to look at the distinction between killing and letting die. These doctors are technically killing John because they are taking an action that will result in his life ending but it is not that clear. This case blurs the lines between killing and letting die. Once the doctors take that action they are letting him die because once he is unable to breath they will intentionally not put him back on a respirator. Beauchamp and Childress state that part of letting one die is that “disease, system failure, or injury causes death” (Beauchamp and Childress 175). I argue that John’s brain disease will ultimately end his life, not the doctors. The medical team also does not feel comfortable with giving him a strong enough dose of medication that will accelerate his death. They are morally correct in this because that would enter the realm of killing rather than letting him die. Beauchamp and Childress go on to state that it is acceptable to let one die if the “medical technology is useless… or patients or their authorized surrogates validly refused a medical technology” (Beauchamp and Childress 175-176). In John’s case both of these conditions are met. The medical technology, surgeries and a respirator, have not been successful in treating him rather they have just kept him alive and, as stated above, he has now refused the technology. McIntyre gives further support of the moral acceptability for a physician to withdraw a life sustaining treatment because he is doing it “only to respect his patient’s wishes and ‘to cease doing useless and futile or degrading things to the patient when [the patient] no longer stands to benefit from them” (McIntyre 62). Nonmaleficence can be further specified in this case as do no harm except if the patient is competently refusing medical treatment and has no real hope for improvement. The medical team ought to disconnect the respirator and is morally justified in doing so.

References

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.

Picture

http://geneticdisorders247.wikispaces.com/Neurofibromatosis

Dilemma

In this case Mr. Joe Mulroney had a fatal reaction to an angiogram. The dilemma lies within the anaesthetist’s decision to not tell Mr. Mulroney about all of the possible risks of the procedure, which leads one to question if there was truly informed consent. After Mr. Mulroney died, his son was critical of the doctor’s morality. The son believed it was the doctor’s duty to tell his father of all possible risk factors. The doctor claimed that the risk of death from this procedure was so small therefore in his opinion it wasn’t necessary to disclose that to patients. The dilemma is whether or not the doctor ought to disclose patients of rare risks in a procedure (Thomas 276-277).

Discussion

In this case the doctor was working under the idea of intentional nondisclosure. He claimed that since the risk was so small there was no need to “burden” Mr. Mulroney with the small possibility because no benefit would come of disclosing the information. Intentional nondisclosure can justified by the principle of nonmalificance “if and only if the patient’s knowledge of the information would have serious health related consequences” (Beauchamp 128). This can be specified into the rule of “disclose all information regarding the situation except if it will cause serious health related consequences”. The doctor claimed that the possible risk of death may cause a patient to opt out of the procedure which would cause more harm to the patient than proceeding with it. In this case the doctor balanced the principles of autonomy and nonmalificance. He believed that telling the Mr. Mulroney could cause more harm to him than withholding the information therefore he chose nonmalificance. In my opinion the doctor did not adequately factor in Mr. Mulroney’s autonomy therefore preventing him from giving informed consent. Informed consent not only requires that the patient is aware of all of the information and understands it but also the ability for a doctor to give their opinion and help the patient make theirs. When the doctor was speaking with the patient’s son he described Mr. Mulroney as a “reasonable man”. If the doctor truly believed that he was a reasonable man then he would have been able to mention the very small risk of death to the patient. After mentioning the risk, the doctor could then further the conversation and help Mr. Mulroney understand that the probability of death is very low and the benefits of the procedure will outweigh that risk. The doctor ought to disclose this risk to his patients because it aids them in making an informed decision.

Similar Case

Another case that involved nondisclosure was Pauscher v Iowa Methodist Medical Center. In this case Mrs. Pauscher had an intravenous pyelogram six days after giving birth. In her medical records it stated that she had no allergies and she was not told of the risk of death from this procedure. She ended up going into anaphylactic shock (Towsley 86). If she was aware of the possible risks of the this procedure she may have been able to recall important information about her allergies and been able to survive. The court ruled that it was not the hospitals fault. This relates to Mr. Mulroney’s case because with rare risks the doctor is usually not held responsible if someone has an adverse reaction therefore it does not pose a threat to the doctor to inform his patient. Doctors ought to disclose all information to their patients and help them fully weigh the risks and rewards when making their decisions.

Sources

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 5^th ed. New York, NY: Oxford UP, 2001. 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.

Towsley-Cook, Doreen M., and Young, Terese. Ethical and Legal Issues for Imaging Professionals. 2^nd ed. Maryland Heights, Missouri: Mosby, 2007. Print.