Blog period 4

Background

One of the cases presented in the Brody and Engelhard reading is that of 48-year old Mr. A, who was recently laid off from his job (297). Both he and his wife were able to find new jobs, but without health insurance benefits. Mr. A is diagnosed with an inguinal hernia and is deemed too well-off to be treated at the county hospital. However, he is too poor to pay for the surgery himself, so his doctor sends him away, telling him to wear a truss and to come back to get the surgery once he can pay for it.

Dilemma

The dilemma lies in the question of whether or not the right response was to simply send Mr. A away without really alleviating his situation. A diagnosis and instructions for management were given, but ultimately, only surgery can treat the hernia. At this point, the hernia is probably simply a source of discomfort for Mr. A, but if left untreated, the hernia will not only induce more pain, but it can also be life-threatening, as it can lead to intestinal damage (“Untreated Hernia”) (Wint).

Reflections

Looking at the principles of beneficence and nonmaleficence alone, it might seem clear that the only correct course of action is to operate on Mr. A now and worry about the payment later. After all, the hernia is causing Mr. A harm, and sending him away without a more permanent treatment could potentially lead to his death. Looking at the principle of justice might suggest the same course of action: if Mr. A had not, as John Rawls might put it (McCormick), been a victim of the social lottery and had not been laid off or if he had been a wealthy man who could afford the payment, he would not have been sent away as he was.

However, resource allocation must be taken into consideration. Any time a hernia repair surgery is performed on a patient, time and resources are taken away from other people who also need potentially life-saving procedures. Many times, the resources are simply allocated to those who can afford it. However, as Beachamp and Childress listed under the capabilities theory, everyone should “[Be] able to live a normal life without dying prematurely or existing in a reduced state making life not worth living” (259). In this case, the hernia can be treated, the life can be potentially saved, and quality of life can be restored. Although resources might be limited, a patient should not be removed from consideration to receive treatment simply because he or she cannot pay for it.

Asking Mr. A to put off the surgery might not be feasible. The longer he puts off the surgery, the more pain and problems he will have to endure, and that might lower both his productivity at his current job and lower his prospects at finding a new one with insurance. More importantly, waiting longer puts him at risk for life-threatening complications.

I feel like the most appropriate direction in this situation, favoring the principles of nonmaleficence, beneficence, and justice with factors on both sides balanced out, involves scheduling the surgery and maybe even working out a payment plan now rather than waiting until later, when the hernia would get bigger and repair and recovery would be even more difficult and possibly more expensive. It seems that Mr. A and his wife are hard-working people who were trying to make the best out of a suboptimal situation, and after Mr. A’s surgery, he would be better able to work or find a higher paying job and can work towards paying off the hospital bills with the pain and potentially life-threatening situation taken care of.

Sources

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York: Oxford UP, 2009. 259. Print.

Brody, Baruch A., and H. Tristram. Engelhardt. Bioethics: Readings Cases. Englewood Cliffs N.J.: Prentice-Hall, 1987. 297. Print.

McCormick, Thomas. “Principles of Bioethics.” Bioethic Tools. University of Washington, 1 Oct. 2013. Web. 01 Apr. 2015. <https://depts.washington.edu/bioethx/tools/princpl.html>.

“Untreated Hernia.” Untreated Hernia. No Insurance Surgery, 2014. Web. 01 Apr. 2015. <http://www.noinsurancesurgery.com/hernia/untreated-hernia.htm>.

Wint, Carmella. “Hernia.” Healthline. N.p., 20 June 2012. Web. 01 Apr. 2015. <http://www.healthline.com/health/hernia#Overview1>.

**For Blog period 3**

Two very similar cases were mentioned in our reading for 3/18: that of the Havasupai Indians and that of the Nuu chah nulth Nation (Beauchamp and Childress 187-8; Thomas et al. 289-91).  I will be focusing on the former case.

Background

The Havasupai Indians live in the Grand Canyon, and several scientists at Arizona State University obtained consent from about 100 representatives of the Havasupai in order to “study the causes of behavioral/medical disorders” using the Havasupai’s DNA samples (Beauchamp and Childress 187).  Whereas the Havasupai understood this as consent to conduct diabetes treatment, the scientists took it as a license to conduct various types of genetic research, including research on schizophrenia and inbreeding, and the results were made available to the public.  The Havasupai attested that they never consented to research on their samples aside from the diabetes research, and they sued the university and won the lawsuit (Beauchamp and Childress 187-8).

The Dilemma

The dilemma in this case is whether the scientists had obtained the proper consent to conduct additional research on the DNA samples of the Havasupai, aside from the research on diabetes, or if additional measures should have been taken to obtain proper consent.  This case involves the principles of autonomy, nonmaleficence, and beneficence.  The scientists made an effort to respect the autonomy of the Havasupai by having representatives sign a consent form.  The form was made basic to accommodate the limited English proficiency of the tribe members, but it was also made broad (Beauchamp and Childress 187).  The broadness of the consent form and a possible lack of effective communication between the scientists and the Havasupai representatives contributed to the harm of the tribe members.  There is no evidence that the scientists’ goal was to expose shameful or harmful aspects of the Havasupai to the general public.  By publishing the results, the scientists likely thought they were acting in beneficence to the general public by looking at the effects of inbreeding and at schizophrenia, as research is necessary in making progress in the remedy of certain conditions.  However, when findings were made beyond the research on diabetes, harm inadvertently resulted to the Havasupai.

Reflection

The scientists acted extremely irresponsibly in this case.  They did conduct the diabetes research that the Havasupai expected to be conducted and they likely conducted the research on mental illness to make progress in the field and to help those suffering from such conditions.  However, the scientists took advantage of the poor level of understanding of the Havasupai and clearly did not make sure that the representatives understood exactly what they were consenting to.  Although the Havasupai did legally consent to the “study [of] the causes of behavioral/medical disorders,” they obviously were not clear on what that entailed, and it is the scientists’ ethical responsibility to ensure proper understanding of the subjects of the implications of their consent (Beauchamp and Childress 187).

It would be virtually impossible to predict all possible consequences of the research, but a more comprehensive understanding would aid in the Havasupai’s evaluating the benefits and costs and making an informed decision.  Instead of writing up a vague consent form and giving it to the representatives to sign, the scientists should have explained in detail, both verbally and in writing, what they were planning to do and make it clear that they would likely be looking at factors beyond diabetes. To ensure proper understanding, the subjects should be asked to repeat what they are consenting to in their own words.  If the subjects make it clear that they only want the diabetes research to be conducted, their autonomous decision is to be respected.  The benefit to society of medical research is crucial, but it should not be done at the expense of the autonomy of and potential harm to anyone.

Works Cited

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York: Oxford UP, 2009. 187-8. Print.

Thomas, John E., Wilfrid J. Waluchow, Elisabeth Gedge.  Well and Good. a Case Study Approach to Health Care Ethics. 4th ed. Peterborough, Ontario: Broadview, 2014. 289-91. Print.

Background

In their discussion of understanding, Beauchamp and Childress present a case about a woman who was diagnosed with early stage cervical cancer while in the hospital for a hip injury.  The woman refused to get treatment, and the doctors later learned that it was because she was in denial that she had cancer.  The doctors questioned her competence to refuse treatment.  Eventually, she was successfully convinced to consent to the treatment (Beauchamp and Childress 136).

Dilemma

Early stage cervical carcinoma is very treatable, and when the woman refused the treatment, her doctor was conflicted as to whether or not to treat her despite the refusal.  The way the case was presented, it seems like as soon as the patient refused the procedure, the physician immediately concluded that she was not competent to make the decision, and the psychologists who analyzed her seemed to unfairly conclude that she was demented due to their own preconceived opinions.  It was only after the patient was asked why she refused treatment when it became clear that her refusal was out of denial and ignorance, not due to dementia or mental incompetency; she did not think believe she actually had cancer because she felt fine (Beauchamp and Childress 136).

Ultimately, the principles at play are the patient’s autonomy versus the doctor’s commitment to non-maleficence towards the patient.  The doctor has the patient’s best interests in mind and knows that the treatment is the best course of action in order to preserve the patient’s life.  In his expertise, he knows that she has cancer and needs treatment, despite the absence of physical symptoms.  In his view, non-maleficence might trump autonomy in this case, because even though the patient seems to have the mental capacity to make an informed decision, in his view, she is not doing so.

Reflection

It almost seemed like the doctors were too eager to mark the patient as mentally incompetent and proceed with the treatment.  In a case where the patient is refusing what appears to be the obvious rational choice, I cannot blame health care providers for initially questioning her mental competence.  However, rather than jump into conclusions, the first doctor should have communicated better with the patient and discovered the reason behind her refusal.  That her denial of her condition was not revealed until after the neurologists were consulted suggests the many of the appropriate conversations did not take place between the treating physician and the patient.

While in many cases, it is not appropriate to try to persuade a patient deemed mentally competent that they have not made the right choice, in this case, it is clear that the patient was not making a fully informed choice (Beauchamp and Childress 136-7).  In this case, it was definitely right for the doctors to intervene and undergo “intense and sometimes difficult discussions” with the patient to convince her to change her mind (Beauchamp and Childress 136).

If the patient was still not convinced she had cancer after having the truth explained simply but comprehensively multiple times by various physicians and family members, she might need another mental evaluation.  I would assume that this time, she would be more likely (and rightly) to be deemed mentally incompetent, and therefore, non-maleficence would take precedence over patient autonomy. However, if after these discussions, the patient was fully aware of the treatment and of her condition and possible consequences and still did not want treatment, to further argue against or be otherwise unsupportive of her decision would be an unjustified violation of autonomy.

Works Cited

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York: Oxford UP, 2009. 136-7. Print.

At the end of chapter 2 of Principles of Bioethics by Beauchamp and Childress, the issue of live organ donors was brought up, and a case of a prisoner who wanted to donate his one kidney to his teenage daughter was briefly mentioned (55).  I did some additional online research concerning the case of the daughter, Renada Daniel-Patterson and her father, David Patterson.

Background

Renada had been born with one malfunctioning kidney, and David, who was serving a prison sentence, was absent from the first decade or so of his daughter’s life.  However, when Renada was 13, she needed a kidney transplant, and her mother, as a diabetic, was not able to donate.  Her father contacted Renada, volunteering to donate a kidney, expressing guilt about not having been a competent and caring father (Nieves; “Inmate…”).  The transplant succeeded, but several years later, Renada began to reject the kidney David had given her.  At this time, David volunteered to give his daughter his remaining kidney.  This time, there were many ethical protests.  The procedure would put David’s life at great risk, and as a prisoner, the state would have to pay $40,000 a year for the dialysis he would need following the procedure.  Furthermore, there was no guarantee that the transplant would be successful; Renada’s body had already rejected one of her father’s kidneys, so it was possible that it would reject the other one as well.  An ethics committee discussed this case in great detail.  Some respected David’s offer and sympathized with his love for his daughter.  Others thought that it did not make sense for them to risk one life to save another.  Renada’s mother Vicki was upset that the matter was even up for discussion; David was a willing donor and Renada a willing acceptor, and to Vicki, that was all that mattered (Nieves).  Ultimately, the donation was decided against.  Renada later received a kidney from an uncle, but her body eventually rejected that kidney as well.  Renada passed away shortly before her 25^th birthday (Lagos).

The Dilemma

The ethics committee in this case are faced with two options: accept David’s offer or reject it.  The moral principles at play here include respect for autonomy, nonmaleficence, and beneficence (Beauchamp and Childress 13).  Beauchamp and Childress argue that “encouraging prospective living donors are ethically acceptable as long as they do not turn into undue influence or coercion” (Beauchamp and Childress 55).  David had not been part of his daughter’s life throughout her childhood, and he had never been coerced into giving his daughter a kidney (“Inmate…”).  Rather, he made the choice on his own and took the initiative to contact Renata and offer her the first kidney and later, the second.  However, the issue of nonmaleficence also arises.  If the physicians were to perform the procedure, they would be directly responsible for causing harm towards David; they would be putting the life of David, who I assume to be a relatively healthy man, into danger, and the transplant might not even be able to save Renata.  Additionally, the cost of David’s dialysis following the removal of the second kidney would place a great burden on the state.  However, the procedure could also provide great benefits, the most obvious being the prolonging of Renata’s life.  Additionally, David expressed guilt for not being there for his daughter throughout her childhood, and might feel that the pain and suffering he would have to endure following the procedure is the least he can do to make up for this (“Inmate…”).  Going through with the transplant would give David the chance to further reconcile with her daughter and help ease his guilt of not having been an ideal father.

Reflections

Beauchamp and Childress consider sacrificial acts to be examples of supererogation (Beauchamp and Childress 47), and I agree that David’s desire to donate his second kidney, and even his act of donating his first kidney to be not obligatory, but heroic.  While his intentions are admirable and understandable, I feel like the ethics committee chose the right course of action by refusing the transplant.  That they were later able to find an uncle to give Renata a kidney suggests that not all possible options had been considered prior to the discussion of the case.  Even if another donor had not been found, and although David, Vicki, and Renata were all in favor of the transplant, the doctor has a duty to preserve a patient’s life, but not at the cost of a healthy life.  In this situation, I feel like the goal of nonmaleficience takes precedence over the respect of the patient’s and family’s wishes.

Works Cited

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York: Oxford UP, 2009. 13, 47, 55. Print.

“Inmate Donates Kidney to Daughter.” Los Angeles Times. Los Angeles Times, 13 Mar. 1996. Web. 22 Jan. 2015. <http://articles.latimes.com/1996-03-13/news/mn-46515_1_pediatric-kidney>.

Lagos, Marisa. “BAY AREA / Woman Whose Inmate Dad Donated Kidney to Her Dies / She and Her Mom, from Oakland, Had Moved to Atlanta.”SFGate.  20 Mar. 2007. Web. 22 Jan. 2015. <http://www.sfgate.com/bayarea/article/BAY-AREA-Woman-whose-inmate-dad-donated-kidney-2609092.php>.

Nieves, Evelyn. “Girl Awaits Father’s 2d Kidney, And Decision by Medical Ethicists.” The New York Times. The New York Times, 04 Dec. 1998. Web. 22 Jan. 2015. <http://www.nytimes.com/1998/12/05/us/girl-awaits-father-s-2d-kidney-and-decision-by-medical-ethicists.html>.