Summary:

Dr. Arman Asadour is a Canadian physician who got sent by the non-governmental organization to a town in South Sudan in order to participate in a global vertical aid anti-cholera program. The purpose of the program is designed to treat targeted cohort group with cholera disease. The dilemma raised because while the medical care staff from NGOs are only supposed to treat for one specific disease, refugees also demand other health care items from the stuff due to the scarcity of treatment locally. The physician would need to make a clear decision based on his legal and ethical obligation.

The legal obligation

To understand the issue concerning this topic, it is important to understand the definition of vertical programs. They are called so because they are “directed, supervised, and executed, either wholly or to a great extent, by a specialized service using dedicated health workers”. (Atun, Bennett, Duran) In this case, the physician is directed to work in South Sudan to reach the purpose of eradicating the cholera from the area. By the nature of the vertical aid program, its goal would be to achieve a concrete goal. It would be good for the funders to be aware that their funding would be bringing some changes to the problem. Also, because of the legal obligation bearing on the physician, the right thing to do would be to follow the project rules and obligation, making sure the resources are allocated to the targeted group.

Flaw of Vertical program

It could also argue that vertical program waste resource as it allows the inefficiency to happen within the system. Unable to utilizing the resource because of untargeted sickness is unfair and unjustifiable for the needed. Allocating health resource to one specific illness could reduce the health system effectiveness. Furthermore, the voices and priorities of the locals are also often overlooked rather than to achieve the main goal of the program.  (Thomas, Waluchow, and Gedge, 268) Although NGOs would have investigated the demand of people before entering for service, the need for health care could always change in time and vary in situation. While the health care service could be particularly rewarding to the certain targeted group, its policy would reject the treatment of people coming with various risks(such as HIV and cholera at the same time).

The ethical right thing

After all, the main purpose of the project is to aid the humanitarian purpose of the NGO. Leaving people in a worse-off condition without medical treatment would be against the mission. A physician’s duty would be to the patient he faces rather than the sponsor of the program even if the decisions are not legally correct. Balancing the legal obligation and the ethical right thing, Dr. Arman Asadour should follow his obligation first and then the obligation as the employee of the NGO.

Reference:

Thomas, John E., Wilfrid J. Waluchow, and Elisabeth Gedge. Well And Good: A Case Study Approach to Health Care Ethics. N.p.: Broadview, 2014. Print

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

Atun, Rifat A., Sara Bennett, and Antonio Duran. When do vertical (stand-alone) programmes have a place in health systems? Geneva: World Health Organization, 2008.

Background:

Current Federal law requires that any drug on the market needs to be approved of application before it is transported or distributed to the patients. However, there are earnest patient who are looking for experimental drug for their untreatable disease. Due to their sickness, there has been demand to enter the clinical trial in order to get a head-start of the cure.

Harald and Jim have been a loving couple together for a consecutive 10 years. During that time period, Herald have been experiencing sickness easily, having ulcers in his mouth and starting to lose weight. Worrying about his condition, Herald went for a physical exam and it turned out he has AIDS. Herald was really earnest in trying the experimental drug, but he was screened out because he was not diagnosed early and was then incompatible because of his health condition. Although Herald got treatment in the end through his persuasion to the group, he died shortly after the treatment.

But the question still remains, should clinical trial open arm to those who are trying to guide their self-autonomy?

Ethical challenge:

One perspective to look at this problem is from the ethical challenge it faces in this situation. Harold and Jim questioned the authority: “if there was a drug out there that showed promise, and if the alternative for harald was certain death, why shouldn’t he be given a chance to try it?” It is always better to have something over nothing. Especially when on a shortage of beneficial clinical medicines, a patient should choose on his own, whether or not to give up his spot for someone with a bigger chance of being cured.It is about defending self-autonomy. By leaving Harald in a situation which he could only be treated by symptoms appeared, physicians are acting against their ethical responsibility to perform for the wellbeing of their patient.  

In the case patient is screened out of a clinical trial, and physician has total control by law of whether to add the patient, his choice set changes, and therefore his autonomy does not include taking the trial anymore. On another note, an incurable disease has never been cured before, thus it cannot be certainly concluded that such a trial would not work on specific groups of patients. Taking away patients’’ opportunities to participate, especially based on severity of their conditions, poses the same question as whether to run over four people on the train track and save the one on another, or change the direction save the four people and sacrifice that one person.

Research Challenge:

Many might argue that in this situation, because of the unequal in knowledge and vulnerability, physicians should have the upperhand of deciding whether patients should be included in the trail. There are much more aspects to consider in order to enter the trail. It is important to access the gained knowledge. Without accessing the known knowledge, there could be little improvement over the trail. Furthermore, fair methods to protect privacy and confidentiality should be set in the rule book. Changing the selection of sample, like in Harald’s case, can gradually cause a lose of focus on research purpose. -because researchers and investigators are unequal in knowledge and vulnerability. Patient’s beneficence over the risk shall be measured and controlled by researcher in order to justified its purpose of determining whether this investigational therapeutic alternative is the better alternative than existing one. Only by fulfilling the criteria above, the trail could be justified. After all, experimental medicine was not about one single human being, but it is about benefiting the greater human society to have a better cure.
Therefore, If serving the patient’s best interest is against the purpose of promoting social goal of accumulating knowledge and benefiting future generation, the patient’s self autonomy should not be defended.

Thomas, John E., Wilfrid J. Waluchow, and Elisabeth Gedge. “Case 7.4: Access to Experimental Drugs in Catastrophic Circumstances.” Well and good: a case study approach to health care ethics. Peterborough, Ontario: Broadview Press, 2014. Print.

Vaughn, Lewis. Bioethics: Principles, Issues, and Cases. New York: Oxford University Press, 2010. Print.

Sue Rodrigues, a Canadian citizen, has amyotrophic lateral sclerosis. Sue decides to enjoy life as she can. However, as the time has passed and she began to experience difficulty  to physically enjoy her life, she began to explore the possibility of suicide. She is determined in physician assisted suicide and she bring this case to court which demands the physician to set up certain “technological means” for determining her terminated life. As Sue argued to the higher court, as suicide itself is not a criminal, her determination to end life should be considered legal as well. But lawmakers and physicians obviously still held in doubt about this issue for reasonable causes: First, the act of “aid or abets a person to commit suicide is guilty of an indictable offence and liable to imprisonment for a term not exceeding fourteen years”. Second, there a few guideline existed with relevance to this topic.

It is important to honor her autonomy rights and human dignity. From a patient’s perspective, Sue made the decision based on her own self interest. As she has stated in her conscious state, she wish to have control over when she died and spare herself from the pain she is destined to experience. She made the rational decision which consisted of her careful planning. As a physician and law maker, it is important to respect individual’s decision. As the medical care professional, they could request Sue to revisit her decisions by poses her more open ended questions. Sue should also always keep in mind her given informations, like: her health condition, her family member’s well being, her influence on other people and her funeral arrangement.

With the given guideline for assisted-suicide, it is far less enough. From the perspective of court and physician, it is hard to kill. As stated by Hippocratic Oath, “Thou shalt do no harm”, it is against ethics to kill or harm people not only as a physician but also as another human being on earth. For the court, it is hard to make decisions because every single cases are so different. Its ruling would insist on the given law because once the law is broken it is hard to know the boundaries. And it is hard to predict if there are going to be cases which used the allowance of assisted suicide as a criminal method. Fear also appear that the individual might be influenced over the process of her decision making. For example, the patient would not want her/his family to be broken because of the illness dragged along. I personally know a relative who jumped off the hospital window because he wish not burden his family further. This tragic event is a reflection of the lack of managed system which cause more trauma to the family and public than ever.

In Sue’s case, I believe we should respect the individual’s decision more than evaluating the current legal system. While it is important to acknowledge the concern of the court and physicians. Individual’s decision should be prioritized. As Sue has made such clear statement about her situation, it is important to support her as a friend, family and medical care professionals. There could be definitely more assessment and guidelines to be developed in the future years. It is important not to follow blindly of the patient’s interest but it is not right to secondize their needs or determination. After all, it is Sue’s life and it deserved to be respected and dignified.

Citation:

Valente, Sharon M. “End-of-Life Challenges.” Cancer Nursing 27, no. 4 (2004): 314-19. doi:10.1097/00002820-200407000-00008.
Thomas, John E., Wilfrid J. Waluchow, and Elisabeth Gedge. Well and good: a case study approach to health care ethics. Peterborough, Ontario: Broadview Press, 2014.

Background:

Amira’s family got into a car accident where her partner got a severe injury and were soon announced death. Her daughter was in light injury upon this incident. Amira was placed in the hospital’s trauma room, as she woke up and acquired immediate information about her family. Her health condition was critical and she had a big surgery to go through. The nurses were informed about Amira’s partner’s death and were hesitated to tell. They made the decision for Amira that, if Amira survived the surgery, she could learn the truth about her family tragedy in her recovering period.

Dilemma:

The Dilemma of this scenario was whether to announce the news or not. Most of the nurses insisted that under such condition, learning her partner’s death might severely threaten her own health well-being. As a nurse, one obligation is to make good health decision for the patient. It is important to implement actions which would help the patient survive. Many may claim that the patient might not show full comprehension to their own health status in emergency situation. So it might be the best idea to ask the medical professional to make the decision under those situations. In Amira’s cases, her vital signs are losing and one lung already collapsed. She is concerned about her family, and her health well-being might be the main goal from the nurse’s perspective.

A few other nurses stated that Amira deserved to get information as she acquired even in her endangered state.  Many may have claimed that she deserves to get information as she acquired. There have been researches done in the past that most patent would like to know the truth rather than white lie during the situation. In Amira’s situation, she acquired to learn about her family situation upon her wake up. This could further state the importance of her family’s well-being to her. She is concerned about her family situation like any other human beings, and she deserved to be informed of the real situation.

My decision:

Balancing both ends, I would choose to tell the patient about the truth for the sake of her well-being. There could be professional people handling the wording of the truth telling process to make it more acceptable. The truth could be hard for her to accept during the moment, but there could be professional health communicator facilitating the process who help the nurse know, when, whom, and how to tell the tragedy. The nurse could state by: “Your daughter is still waiting for you outside the emergency room, and there is a hardcore surgery you need to fight over.” By setting up faith and encouraging the patient, the truth could be told.

Another important reason is patient deserve to know the information they acquire. Even the best medical care team could make decisions for individuals. From professional’s perspective, their main objective is to cure and to save, but individual’s thoughts should play a stronger factor in their own decisions. Whatever happens, individual should get the information they acquire to know and make their own decision. Although people claimed that sometimes patient’s pain could not balance with their decision, the decision is still upon patient’s. “We don’t know what we don’t know.” As there are many circumstances going on in patient’s life, physicians should not make decisions thinking “it would be the best for patients.” We all wear different shoes in life, and only our own decisions could determine the road we are heading to.

Citation

RD Yeo, M., A. Moorhouse and P. Khan “Case 3: Emergency and Trauma Nurses: When to Give Bad News” Concepts and Cases in Nursing Ethics.