The dialogue between Dax Cowart and Robert Burt is almost disturbingly paradoxical. On one hand, we have Dax who suffered injuries from a gas explosion, ten months of involuntary treatment and rehabilitation, and after being released, he faced seven years of severe depression riddled with unsuccessful attempts to take his own life. After all of the medical operations he endured, Dax was left without either of his hands, eyes, ears, and lost between 65 and 70 percent of the skin on his body. Throughout his hospitalization, he requested to cease further treatment so that he could die, and despite his remarkable recovery and successes he’s achieved following the procedures, Dax remains adamant that he was treated unjustly. On the other side of the argument is Dr. Robert Burt, who is an expert in the relationship between biomedical ethics and constitutional law. Within the debate against Dax, Burt takes a paternalist stance regarding the ethicality of how Dax’s case was handled. More specifically, he is arguing that patients who are suffering may not be able to refuse treatment in order to end their lives.

This discussion is peculiar for many reasons. Ironically, Burt is arguing with Dax about the sanctity of his (Dax’s) life with the underlying notion that he knows more about what is best for Dax than Dax himself. Burt’s opinion hinges on a paternalist interpretation of life, which seems to hinge on the idea that all lives are equally worth living. Another oddity with this is the concept of someone else deciding what your life is worth. Obviously no one can know what another person is experiencing—their thoughts, feelings, and perceptions—so without insight to these personal experiences, there is no way to truly evaluate another’s life. Furthermore, Burt in his argument seems to discount the pain and suffering Dax went through for several years, yet he maintains his view that Dax should not have been able to let die. To me this is disrespectful. And while this disrespect is not rooted in malice, it is the same disregard he received throughout his torturous process.

The core issues of this dialogue pertain to the autonomy of patients and how healthcare professionals should handle this autonomy. In short, Dax feels that with his autonomy being compromised and the forceful administration of various unpleasant treatments and procedures, the physician’s actions were immoral. Nonetheless, Burt is arguing that the doctors’ intervention and refusal to grant Dax’s requests was nothing short of acceptable. They each provided evidence and examples to support their positions. Much of the conservation revolved around what the ideal course of action would have been in retrospect and what it would be in hypothetically equivalent scenarios. Where Dax and Burt are somewhat able to superficially agree is on the topic of physician-patient discussion of the patient’s wishes. Both men concede that an interaction should necessarily take place; however, Burt posits that this conversation should be prolonged as long as possible, or until—as he seems to reluctantly admit, the physicians have exhausted all treatment options. From Dax’s perspective, it is easy to see the frustration with this proposal. Not only can Burt not comprehend the amount of agony that Dax endured, but also he is not acknowledging how slowly time passes when we are experiencing such suffering. As Dax states to the audience, one hour to him seemed like an eternity. This is reasonable given the documented proof of chlorinated baths and the excruciation of simply replacing bandages.

So Dax understandably disagrees with Burt here, but the pursuing objection Burt makes concerning how long the decision should be postponed after a patient requests to die. He addresses Dax in his opening statement, questioning the amount of time that would be appropriate for a physician to comply with the patient’s demand to let die. This is a fair issue to discuss considering how influential the emotional state that the patient would be in after a traumatic even may be on their decision to withhold further life-saving treatment. The trouble with raising this particular issue is that it results in a circular reasoning that could not render a realistic solution. When has enough time elapsed for the healthcare professionals to definitively say that there is nothing more that can be done to help the patient? This evokes the same issue. The issue is that there is no appropriate time to make such a decision. To contend that the patient should be willing to allow the physician an indefinite amount of time to look for other treatment options while they are experiencing so much pain is not only merciless but also unjustified.

A lack of empathy and justice are among the key concerns Dax has with the medical treatment he received, and within this argument, I believe, is a basic flaw of the healthcare system. In his statement, Dax mentions the distance that separates the doctor and patient and how this distance likely serves as the source of this merciless, unjustified, yet paternalistic approach.

Dax admits that he does not view the physician’s actions as a derivative from poor intentions. Indeed, he acknowledges his belief that they truly were acting in his best interest. However, a boundary was crossed was constantly denying his autonomy. The root of the problem, Dax offers, is the paternalistic outlook that a majority of doctors seem to adopt. As he discusses, this paternalism may perpetuate negligence for patients’ opinions and requests.

Today, it could be argued that the hierarchy of moral upstanding, God and doctors are a close one-two. Oftentimes medical professionals are held to a standard that provides them with permission to justify the means (whatever they may be) with the end (whatever it may be). Further, the product that results is conceptions that doctors always know what’s best for the patient or that they can’t do wrong, which may lead to an entitlement on behalf of the physician by which they can override any request made by a patient. This was certainly similar to the case in which Dax found himself. The main problem here is, as Dax explains, that our constitutional rights are not suspended when we enter a hospital. Perhaps the most basic of human rights is the right over one’s own body. This appears to be the foundation for Dax’s overall argument.

In general, it seems that the stance upheld by Dr. Burt is simply unrealistic. Paternalistic values may be beneficial to a certain degree, but at some point, when an individual loses the opportunity to make decisions for himself, this approach unjustly interferes with autonomy. Burt’s propensity to draw on all of Dax’s achievements as support for his argument in many ways highlights how unrealistic a paternalist approach to medicine actually is. Not many people would be able to recover and prosper to the extent that Dax was able to; so to argue that his case is evidence for paternalism is quixotic. If Dax had successfully killed himself after the years of rehabilitation, dying without a law degree or any remotely as impressive success story, would Burt persist in praising the doctors who prolonged Dax’s suffering against his will?

Sources:

Cowart, Dax, and Robert Burt. “Confronting Death Who Chooses, Who Controls?” The Hastings Center Report 28.1 (1998): 14-24. Web. 20 Mar. 2015.

Since the development of modern medicine, things such as euthanasia and physician-assisted suicide have frequently been the subject of media headlines and article titles, but furthermore this issue has been the focus of many medical, legal, and ethical discussions.  There are numerous reasons for this, but I argue that what attracts these cases to such extensive debates is the amount of ambiguity that complicates the dilemma, and this ambiguity is often filled in by personal belief or paternalistically skewed rationale.  But within these debates are the concepts or (a) sanctity vs. quality of life, (b) interests and consent, (c) the dying vs. non-dying, and  (d) active vs. passive measures (Thomas, Waluchow, & Gedge 210-213).  The two cases discussed in the book Well and Good serve as examples of the moral confusion that can arise from ambiguity in the obligatory duties for the physician, who is faced with the decision to either prolong the patient’s life or not, along with the countless considerations, both legally and ethically, to be made.

Carole is an 81-year-old woman on life support that makes it possible to sustain her semi-conscious state, where she is incapable of rational thought and communication.  The patient has no local family other than a son, who requests, despite the chronicity of his mother’s condition, that the doctors prolong her life by resuming life support treatment.  That is, until he can earn an unrealistic amount of money to fly his mother to Jamaica so she can pass away there or if someone is able to lift the curse that she put on him.  In other words, the physicians are faced with the decision to either continue providing the services and resources necessary to keep the woman at a state that straddles the line between life and death, or deny the woman of such needs as well as her son’s wishes to the doctor.  Obviously, as a healthcare professional, there is always an underlying obligation to preserve lives, but in many cases, perfectly exemplified by this scenario, it seems not only acceptable but right to discontinue the life, thereby reserving those resources for someone who could more genuinely benefit from the treatment, one of the points mentioned by Thomas et. al. (212).  What we ought to do if we were the physician can be determined by considering the situation from the angle of each of the four topics mentioned above that are outlined by Thomas et. al.

(a) Sanctity of life vs. Quality of life

People can say that every life is worth saving, but I think it would be tough to make an argument in cases such as this.  We can’t know for sure what is going on in Carole’s mind, but we can be confident in assuming she’s not having the best time of her life being connected to machines that she would die without.  There is no quality of life to evaluate for her and no real chance of her ever having a life of any true quality, so this life is not as sacred or valuable as a person with a chance of surviving/regaining a better quality of life.  Therefore, we can’t say that it would be reasonable or fair to turn away a patient who needs the same equipment and attention being given to Carole if it is likely that the treatment would have a greater impact on the new patient’s health and well-being.

(b) Interests and Consent

The patient in this case is clearly unable to make any rational decisions for herself, so the issue of consent is justly directed towards her immediate family, her son.  It is understandable for the son to want to prevent his mom’s death, but at one point or another, he will have to deal with the loss and its consequences.  It cannot be the physician’s responsibility to see to it that every patient’s dying wish is granted.  This is a situation where the amount of care and resources would outweigh the physician’s responsibility to maintain treatment, given the state of the patient and the unrealistic request by the son.

(c) Dying vs. Non-dying

The distinction made between patients who are dying or not dying is not necessarily applicable to this case.  It is more of a concern for those patients who are not dying but are requesting to die.  Clearly for Carole because of her incapacity to communicate, we can’t be sure what her desires are, but it is likely that discontinuing treatment would save her a good amount of suffering.

(d) Active vs. Passive measures

When assessing the moral correctness of a decision that involves the death of a patient, one of the primary details is whether the physician’s behavior reflected an active or passive effort in contributing to the patient’s survival.  Additionally, this idea is commonly associated with the killing vs. letting die debate.  In the particular case of Carole, however, the physician’s action of discontinuing life support is difficult to evaluate ethically because in order for the patient to die of “natural” causes, the plug would first need to be pulled.  So it seems that you could pin the doctor with killing the patient, although her services prolonged the life significantly.  I don’t think it is fair to judge the doctor’s actions in this way.

Overall, after analyzing the case and the details within it that pertain to the four principle dilemmas described above, I think it would be just to cease life support treatment for the patient if another patient requires the use of the same equipment.  This is a very economical way of viewing the situation, but it is suitable because it would be impossible to consider any input from the patient.

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

Within this scenario is the issue of whether the physician was neglectful and unjustified in not informing the patient or his family of the typically improbably risk of death during a particular procedure.  On behalf of the son, the physician ignored properly obtaining informed consent from the patient by not discussing with him all the details and risks of the procedure.  On the other hand, the physician asserts that due to the extreme unlikeliness of this occurring, for him to give this piece of information to the patient would only counter his best interests  (301).  In order to rationalize which option would have been more “morally correct,” it is necessary to assess the physician’s decision with respect to each of the four moral principles: nonmaleficence, beneficence, autonomy, and justice.

As mentioned in the text, the anesthetist along with most doctors, feel that it is unnecessary to inform the patients of the risk of death with an angiogram because despite the fact that the chances of this are so slim, simply knowing there is a chance may influence the patient to not have a procedure that is crucial to their health.  In fact, according to a study by Jansson and Fransson (1996), the mortality rate of a coronary angiography is between 0.10 and 0.25 percent.  The principles of nonmaleficence and beneficence, then, appear to be covered from the doctor’s position.  However, the argument being made my the patient’s son, that withholding these kinds of details from a patient is unethical, seems to imply an infringement on the other two principles, autonomy and justice.  From his standpoint, the doctor is limiting the amount of knowledge the patient has about the procedure to ensure his consent, thereby compromising his autonomy.  Futher, he probably would claim that the doctor is violating the principle of justice because the patient is inevitably unaware of all the costs and benefits when making the decision to agree to the procedure.

It is easy to consider the doctor negligent in not telling the patient all of the risks involved in the procedure because the patient died.  Had the procedure been successful and the patient remain alive and well, if the doctor were to subsequently approach the son and apologetically admit that he neglected to tell his father that he could die during the procedure, he likely would be disinterested in this fact.  Only in retrospect can the doctor be held responsible to an extent for the mishap.  Also, if we were to consider the amount of remote risks that are involved in any medical exam or procedure, for example the chance of infection with any kind of injection, there would be an even greater amount of unwarranted anxiety revolving around a visit to the doctor.  Therefore, more from a practical standpoint than anything else, I believe that it is not unethical for the doctor to avoid telling patients these kinds of details.

References:

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

Jansson, Kim, and Fransson, SG.  Mortality related to coronary angiography.  Clin Radiol.  1996 Dec. 51(20).