Dilemma:

A researcher is attempting to conduct an experiment of a new Alzheimer’s drug that may reduce progression of the disease. According to the chemistry of the drug, the experiment calls for patients that may experience varying degrees of competency. To enroll a patient in the experiment, a patient must have written consent from the patient’s closest relative and healthcare staff in addition to his/her own. The patient must also be deemed competent, but if they are intermittently competent, the patient may be excluded from the trial. The director of the nursing home then responds to the researcher by not allowing any of the nursing home patients to be included in the experiment so that the vulnerable group is not exploited(Thomas). Was the director right in her choice of refusing the experiment all together?

Discussion:

Working through the case of whether or not elderly Alzheimer’s patients should be able to participate in an experimental drug trial raises numerous tricky questions that seem to have no precise answer. The question of consent is perhaps one of the trickiest dilemmas we face, and this case starts with three parties (the elderly person with Alzheimer’s disease, the family of said person, and the director of the St. Mary’s Nursing home) potentially being involved with the consent of one party. The end result of the director taking responsibility over consent of the elderly patients and denying participation of all patients was one I thought was not exactly the best course of action here. I can see her side of wanting to protect the patients from being overstressed or taken advantage of, but I also see her taking the freedom of those competent enough to possibly assist in production of a drug that could treat the very disease affecting them. I believe that choice of being included in the experiment should be mostly determined in the competent mind of the patient with minor focus on family choice assuming that the current physician of the patient confirms the competency as well. A competent patient affected by Alzheimer’s being denied the chance to aid in research that could treat Alzheimer’s could easily be compared to shooting yourself in the foot, yet in this specific case someone else is holding the gun. The very thing that could lead to better treatment of Alzheimer’s is being inhibited at the choice of someone other than those affected by it.

The major problem with determining consent is the definition of competency used, which leads me to the point of discussing a competency continuum in exchange for the quantized two choice system that is used as mentioned in the book. The fact that the patients are in varying stages of Alzheimer’s should intuitively lead to a varying degree of competency, and to group them into groups of incompetent or competent would be too simple.Though a continuum to match the gradient of competency might better suit the ethics of the experiment’s design, ultimately, the patient is still going to be grouped into two groups of either being in the experiment or not being in the experiment. While this competency continuum may be more practical in the ethics of healthcare treatment such that patients receive varying degrees of treatment, I do not see a real use of dividing the subsets of Alzheimer’s patients only to reduce them back into a two choice system. It is not as if the differing classes of competency will receive differing levels of participation in the drug trial; it is either the patient is in the experiment or not. In this case it would seem to create a special class for elderly patients who just want live a normal life and not one of being burdensome. In summary, I believe the nursing home director overstepped her authority such that competent elderly patients could not have a voice in their participation in the experiment even with competency confirmed by healthcare staff and family.

References:

1.Thomas, John E, et al. “Case 3.2: Nonconsensual Electroconvulsive Therapy.” Well and Good: Case Studies in Biomedical Ethics, Broadview P, 1987. 62-94.

Dilemma

Simon is a financially-unstable, 53-year-old widowed male with one son. Simon was found unconscious in his home in close proximity to an empty bottle of Elavil, a prescribed and controlled antidepressant medication.  After being stabilized in a hospital’s ICU, Simon was moved to the Psychiatry Unit for further treatment.  Upon observation in the unit, Simon exhibited symptoms indicating severe mental depression; he was disheveled, upset, disconnected from activities, complained of inhibited brain function, suffered insomnia, and exhibited and mentioned suicidal intent.  A psychiatrist advised a two-week period containing six electroconvulsive shock treatments (ECT) as a more effective alternative to the previous drug regimen used in treating Simon’s depression.  Simon refused the ECT based on the risks involved and his lack of will to live.  Simon’s son concurred with his father’s decision and Simon was declared mentally competent despite his depression.  Should the psychiatrist appeal to proceed with the electroconvulsive shock treatments or should Simon’s decisions be honored even if they aren’t medically in his best interests (Thomas, et al. 124-125)?

Discussion

ECT is not an uncommon medical procedure, but its use is contested to this day (please learn more about the University of Michigan Health System’s ECT Program). As with any serious medical decision, there are significant risks involving ECT.  Its side effects can include short-term and long-term memory loss, confusion, muscle aches, nausea, and other medical complications concerning anesthesia (Mayo Clinic).  Besides the concern over these side effects, Simon was declared mentally competent, and therefore able to make decisions regarding his health although he expressed suicidal intent. Per the “three-condition” theory of autonomy (Beauchamp and Childress 104), Simon was (1) intentionally aware of the side effects of ECT and the risks of the procedure, (2) he understood the severity of his situation despite his mental illness and there was no lapse in communication between the patient and doctor, and (3) the only influence or control in Simon’s case was his mental state.  These reasons do not provide justification to override his autonomy altogether.

As large as the medical risks of refusing ECT might be, Simon’s competency and valid autonomy must be honored.  Simon’s degree of competency may not equal that of somebody with less severe depression than he, but he has been declared within responsible realms to decide on a course of his own treatment.  Furthermore, his son wished to proceed with whatever his father chose.  The son’s concurrence with his father may lead doctors to believe that the son is confident that his father made his personal choice appropriately and in accordance with reason, although it was not medically advised.  The psychiatrist on the case presented possible courses of treatment, advised ECT as the best possible option to treat Simon’s depression, and should not appeal to proceed with the treatment against Simon’s wishes because Simon’s autonomy took priority in the case when he was declared competent.  Should Simon’s degree of competency be truly questioned, should his situation worsen or pose an immediate (not potential) harm to others, or should another option of treatment be found, then the psychiatrist is obligated to re-evaluate the situation with new factors. But for now, Simon’s decisions and autonomy should be regarded with credibility.

Works Cited

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York:  Oxford UP, 2009, 2013. Print.

Mayo Clinic Staff. “Electroconvulsive Therapy (ECT) Risks.” Electroconvulsive Therapy (ECT).   Mayo Clinic, 19 Sept. 2015. Web. 20 Jan. 2017. <http://www.mayoclinic.org/tests-      procedures/electroconvulsive-therapy/basics/risks/prc-20014161>.

Thomas, John, Wilfrid J. Waluchow, and Elisabeth Gedge. “Case 3.2: Non-Consensual      Electroconvulsive Shock Therapy.” Well and Good: A Case Study Approach to Health           Care Ethics. Peterborough, Ontario: Broadview, 2014. 124-31. Print.

University of Michigan. “University of Michigan Department of Psychiatry.” Electroconvulsive Therapy. University of Michigan, 2016. Web. 20 Jan. 2017.                             <http://www.psych.med.umich.edu/ect/>.

Background: Dr. Sandra Selleck is conducting a clinical research trial sponsored by the Alzheimer’s Society, to test a new drug that can possibly slow down the progression of Alzheimer’s disease. This research requires the inclusion of patients with mild Alzheimer’s, which is why Dr. Selleck has reached out to the director of St. Mary’s Nursing Home for Alzheimer’s patients, Ann Wilson, asking for residents to become participants in this study. Dr. Selleck has specified though that in order for these patients to participate, there must be no objection by any of the staff at the nursing home of the patient’s participation, and that the patients need to provide written consent or have their closest relative provide written consent. After hearing these conditions, Ann rejected Dr. Selleck’s request deeming this research trial as an exploitation of “extremely vulnerable people” (Thomas, Waluchow, and Gedge 116-117). The primary moral dilemma in this situation is the question of whether or not Ann actually has the right to reject Dr. Selleck’s request.

Discussion: I think Ann should not have rejected the subjects’ participation in this research trial on the basis of respect for autonomy. Firstly, the concept of autonomy is a person’s right to make their own decisions as long as they are deemed legally competent, and if they are not competent, then they will have a medical proxy to make those decisions for them. In this case, Ann is simply the director of the nursing home and not a medical proxy for any of these patients indicating that she lacks the right to make this decision for any of these patients. Secondly, as a health care professional, Ann must abide by the principle of respect for autonomy, which obligates her to disclose information; because Ann responds to Dr. Selleck’s request without disclosing even the existence of the research trial with any of the patients or the patients’ families, she is failing to uphold this obligation. Without giving the patients and their families information about said research trial, they do not even have the opportunity to bring about their own decisions (Beauchamp and Childress 106-107).

Concurrently, a secondary moral dilemma of this case is whether or not human subjects should be participants in research studies.  According to Ann, this research should not be conducted on the residents because these patients are not at their best and “have been through enough in their lives” (Thomas, Waluchow, and Gedge 116-117). While some people may believe in this statement, I disagree because of the support this research has already acquired. The Alzheimer’s Society, which often partners with research programs to further knowledge about the disease and ways to aid patients, has sponsored this specific research suggesting its wholehearted support for this research. Additionally, two ethics committees which are probably similar or related to the roles of the Department of Bioethics’ Clinical Center Ethics Committee and Institutional Review Boards, have carefully reviewed all aspects of the research approving it on the grounds of having one of the major focal virtues—moral integrity; the committees’ thorough examination of the research has ensured that it is being done for the right reasons. Thus, Dr. Selleck should be able to have patients from the St. Mary’s Nursing Home participate in the research study should they choose to do so.

Works Cited:

“Alzheimer Society Research Program.” Alzheimer Society, http://www.alzheimer.ca/en/Research/Alzheimer-Society-Research-Program

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York, NY: Oxford University Press, 2001.

“The Department of Bioethics.” National Institutes of Health, https://www.bioethics.nih.gov/clinical/index.shtml

Thomas, John E., and Wilfrid J. Waluchow. Well and Good: Case Studies in Biomedical Ethics. Ontario: Broadview Press, 1987.

Research Involving Alzheimer Patients and Moral Status

The Question:

There is a new drug called Tetrahydroaminoacridine (THA) to be tested on Alzheimer’s patients which could possibly reduce Alzheimer’s disease. Dr. Selleck, who was running the trials, contacted Ann Wilson, the director of St. Mary’s, in order to recruit elderly patients. The guidelines for testing the patients would be that both the patient and their closest relative provided written consent. If the patient was unable to make a decision, then their only consent would be provided by their closest relative. Ann was strongly opposed to this study as she said “I will simply not permit elderly patients under my care to be used as guinea pigs” (Thomas, Waluchow, and Gedge 116).  Now the question presents itself of what an individual would do if he/she was in the position to make that decision.

Discussion:

Though there are many arguments and discussions about the case, one of the primary arguments made by Ann was that elderly Alzheimer’s patients are an especially vulnerable group who should not be used in medical experiments. Now with this in mind, a question of moral status arises. What constitutes the elderly deserving of special consideration and protection? And would Ann’s decision making be different if this wasn’t Alzheimer’s affecting the elderly but rather another disease affecting another age of patients?

Five main theories of moral status are discussed by Beauchamp and Childress and what stands out to me the most is the theory based on cognition. This theory implies that the more cognitively vulnerable individual tends to have a lower moral status. This could be seen in the case of experimenting on rats versus experimenting on humans, as rats have a lower cognitive ability and thus a lower moral status. In the case of Alzheimer’s, the brain shrinks as a result of nerve cell death and tissue loss. According to the NCBI, areas of the brain shrink dramatically and lesions occur that could impair cognitive ability to that lower than some monkeys.

So where do Alzheimer’s patients stand relative to other patients in terms of moral status? Are some patients valued below that of nonhuman primates? Therefore, an argument for the testing of Alzheimer’s patients could be made by devaluing their moral status. On the contrary, Ann’s argument to have the Alzheimer’s patients relieved of testing shows that she morally values elderly Alzheimer’s patients and thus ranks them high in terms of their relative moral status.

Though cognitive ability is an interesting thought, this dilemma cannot be sole attributed to that theory of moral status alone. There are other theories involved, as well as many other factors aside from moral status. In addition, I analyzed just a very small part of such a large case presented. The arguments both for and against are infinite and very complex.

Works Cited:

Colbert, Treacy. “What Does Alzheimer’s Do to the Brain?” Healthline. Healthline, 20 Sept. 2016. Web. 19 Jan. 2017.

Gold, Carl A, and Andrew E Budson. “Memory Loss in Alzheimer’s Disease: Implications for Development of Therapeutics.” Expert review of neurotherapeutics 8.12 (2008): 1879–1891. PMC. Web. 18 Jan. 2017.

Thomas, John E., and Wilfrid J. Waluchow. Well and Good: Case Studies in Biomedical Ethics. Peterborough: Broadview, 1987. Print.

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

Dilemma:

If you were the head of a nursing home and a researcher approached you and asked if she could use your patients as subjects in her study what would you do? Now suppose that your nursing home is for individuals suffering from Alzheimer’s disease. Would your decision on whether or not to allow your patients to participate waiver? In Case 3.1, Ann Wilson is the director of St. Mary’s Nursing Home, which cares for those suffering from Alzheimer’s disease. A researcher, Dr. Selleck, contacted Ann about her need for individuals suffering from Alzheimer’s who would be willing to participate in a trial to test a new drug that supposedly slows the progression of Alzheimer’s disease. Dr. Selleck asked for Ann’s permission to use her patients as potential subjects after explaining that she would only choose patients to participate if they had written consent, a relative’s written consent, and no one on the health staff had objections to the patient participating. Ann decided not to allow Dr. Selleck to use her patients at the nursing home (Thomas, et al. 116-124). Was Ann right to make this decision on behalf of her patients?

Discussion:

Ann’s decision raises the question of whether Ann is protecting her patients, or doing a disservice to them by denying the patients the opportunity to participate in the study.  By making a decision on behalf of a patient without consulting them, Ann is violating the patient’s right of autonomy. However, the amount of autonomy an individual deserves in a situation is based on their competency. By law, someone is either considered competent or not competent. After further research, I found the criteria lawyers follow to classify someone into one of these two categories. As you can see in the article, the steps of classifying an individual into one of these categories is very black and white. Legally there is no in-between, while in reality there are several degrees of competency (Israel).   This case deals with the two moral principles of autonomy and nonmaleficence. The only way to “solve” this case is to find a balance between these two opposing principles. How can one respect the autonomy of a patient while also protect them from experiencing harm?

I do not agree with Ann’s response in the case presented. I think that the best response in this situation would be to allow the patients to be interviewed as potential subjects in the study. This gives the patients the option to make the decision of whether or not they want to participate for themselves. However, in order to protect the patients, I would only allow those who are considered competent to participate. In addition, I would ask the patients and their relatives what they want as a way of respecting their autonomy, but also let the health care staff contribute to the conversation to decide whether or not the patient would be safe to participate in the study. If the risk of harm is too high, I would allow the health care staff’s opinion to outweigh the patient’s autonomy. If the patient is not competent I would protect them from harm rather than respect their autonomy. However, if the patient was considered competent, as in Case 3.2 where Simon competently chooses to not receive electroconvulsive shock therapy, I would respect the patient’s autonomy (Thomas, et al. 124-131).

Works Cited:

Israel, Laurie. “Elder Competency – When Can You Make Your Own Decisions?” IVKDLaw. IVKD Law, 2010. Web. 20 Jan. 2017.

Thomas, John E, et al. “Case 3.1: Research Involving Alzheimer Patients” Well and Good: Case Studies in Biomedical Ethics, Broadview P, 1987.

Thomas, John E, et al. “Case 3.2: Nonconsensual Electroconvulsive Therapy.” Well and Good: Case Studies in Biomedical Ethics, Broadview P, 1987.

Background:

A pregnant young woman, “G”, has a history of glue-sniffing addiction. She currently has three other children, all taken away by the Winnipeg Child and Family Service for their own well-being. Due to their mother’s addiction, two of these children are physically and mentally disabled. Considering “G’s” addiction and parenting history, The Child and Family Services Agency was able to have her put in a treatment facility, against her will, in an attempt to prevent “G’s” unborn child from harm. According to the Canadian Charter of Rights and Freedom, though, individuals are guaranteed a right to security. With this in mind, the Manitoba Court of Appeal overturned the decision to admit “G” and despite Supreme Court appeal, “G” remained out of treatment. Eventually, “G” stopped sniffing glue, gave birth to a healthy baby, and is now expecting another child. The dilemma here is based on if the state or court should have control over a woman’s body if she could possibly endanger an unborn child, but also what rights an unborn child technically has in this situation.

Discussion:

When beginning a discussion on this case, two things must be taken into consideration: the rights of the mother and the rights of the unborn child, if they even exist. As a woman, “G” by law has the right to control her own body and put into her body what she pleases. Where the line begins to blur is when “G” moves from a woman to a pregnant woman. According to the law by the Canadian Chart of Rights and Freedoms, “every individual [is guaranteed] a right to security of the person” despite whether that person is with child or not. Essentially, by law, a pregnant woman is able to ingest and do as she pleases and the state cannot force her to do anything that she does not necessarily want to.

Where this case begins to get complicated, though, is when we take into account the rights, if any, of the unborn child. Personhood is a human being’s status of having individual rights and has been a highly debated topic in many abortion discussions. At what point do we consider when a fetus has the same rights to life and protection as a born human being? Almost all laws and principles alike state that a person has the right to be protected from harm, but do not clarify what is considered a “person”. Based on current abortion law (in the United States), some fetuses can be considered human beings that have these rights as early as 24 weeks into a pregnancy. In this case then, technically one could say that the state does have the right to place “G” in a treatment facility in order to protect the well-being of this unborn child who also has rights to that protection from harm.

This argument, though, leads to a slippery slope of debating whose rights take a higher priority: the rights of the mother who is born and capable of speaking her own opinion or the unborn child who is essentially helpless as he/she has no way of voicing an opinion or even asking for help. Furthermore, is a state able to determine if a mother is fit enough to make the decision of whether she can properly protect the well-being of the fetus outside of a treatment facility? The court here is placed in a moral versus lawful dilemma of wanting to protect the unborn child from mother-inflicted maltreatment and honoring the written law to protect a woman’s right to her body. In this case, while I do agree that it seems unlawful to force “G” into a treatment facility, I strongly believe in the idea that an unborn child, who is entirely helpless, deserves a chance at life that is unaltered by his/her mother’s actions that he/she cannot control. The court and the state should remain out of the decision of women’s reproductive rights, until the well-being and potential harm of the fetus comes into play.

Topic Relevance: 

Personhood was a very debated topic during the Presidential Debate series and throughout the entire 2016 election. It remains, and will likely remain, one of the most disagreed upon subjects in modern politics.

Works cited:

Beauchamp, Tom L, and James F. Childress. “A Theory Based on Human Properties.” Principles of Biomedical Ethics, Oxford UP, 2001, p. 66-68.

Beckwith, Francis J. “Abortion, Bioethics, and Personhood: A Philosophical Reflection.” The Center for Bioethics and Human Dignity, Trinity International University, 2001.

“Bioethical Issues- Abortion.” Adelaide Centre for Bioethics and Culture, 2014. http://www.bioethics.org.au/Resources/Resource%20Topics/Abortion.html

Thomas, John E, et al. “Case 5.4: Protecting an Unborn Child.” Well and Good: Case Studies in Biomedical Ethics, Broadview P, 1987.

Image Source: http://www.psych.med.umich.edu/ect/how-does-ect-work.asp

Dilemma:  

Simon, a 53-year-old widower and father is admitted to the psychiatric ward after overdosing on antidepressant medication. Simon is agitated and reluctant to interact with others and according to his son, he is in a state of financial instability. Simon feels much sadness over the loss of his wife and also blames himself for his mother’s death 32 years ago. He threatens to commit suicide because he has nothing to live for. His psychiatrist proposes of electroconvulsive shock therapy (ECT). Simon refuses and his son also has worries about the risks of ECT and refused to go against his father’s wishes. ECT offers great benefits if successful; however, there are risks. The dilemma is whether the psychiatrist should go against the will of the father and his son and administer the treatment or if the father should be allowed to make his own decision about his life (Thomas, et al. 124-31).

Discussion:

The potential risks and benefits of ECT must be considered. ECT is a controversial treatment that involves administering anesthesia and running an electric current through the brain to cause a seizure. This is repeated from 6-12 times. Memory loss and confusion follow the procedure and it could provide relief from severe depression (“Electroconvulsive Therapy (ECT)”). There are risks of brain damage post-treatment, however the prognosis has improved over the years and it offers a quick solution when compared to prescribed drugs.

It is important to consider patient autonomy and the moral status of the patient. In medicine, patient autonomy is essentially the patient’s right to make intentional and well informed decisions about the course of treatment without pressure from the physician (Beauchamp and Childress). It is a basic human right to have autonomy; however, the level of autonomy a person may have can be determined by their competency. In this case, although Simon is severely depressed, he is not mentally incompetent. So shouldn’t he be able to make his own decision?  Often in psychiatry, patients may refuse to take medications and sometimes, covert medication may occur where medicine is hidden in foods and beverages without the patient’s knowledge which is unethical but may be ethically justifiable. For example, for an Alzheimer’s patient who is losing cognitive function, forcibly giving medication may seem justifiable because they are not able to fully realize that the medication will help them (Latha). However, does this reasoning apply to Simon who is severely depressed but fully competent?

There are differences between the case of the Alzheimer’s patient presented previously and Simon. The Alzheimer’s patient is not competent while Simon is competent and giving prescription drugs covertly does not compare to applying electric current through a patient’s brain forcibly. One can argue that Simon’s unstable emotional state may inhibit his judgement to the point where he would rather die than to try any more treatment. However, this would be operating under assumption which is not the duty of the physician. Because this treatment is so severe and risky, I believe that Simon should be able to make his own decision about his life. This argument does require accepting that Simon may commit suicide; however, from the psychiatrist’s standpoint, I do not believe that is his or her choice to make. If the psychiatrist has done all that they can in terms of informing the patient of their options and allowing the patient to make an informed decision, they have done their job.

Works Cited

Beauchamp, Tom L, and James F. Childress. “Respect for Autonomy.” Principles of Biomedical Ethics, Oxford UP, 2001, p. 101.

“Electroconvulsive Therapy (ECT).” Mental Health America, www.mentalhealthamerica.net/ect.

Latha, K. S. “The Noncompliant Patient in Psychiatry: The Case For and Against Covert/Surreptitious Medication.” PubMed Central (PMC), www.ncbi.nlm.nih.gov/pmc/articles/PMC3031933/.

Thomas, John E, et al. “Case 3.2: Nonconsensual Electroconvulsive Therapy.” Well and Good: Case Studies in Biomedical Ethics, Broadview P, 1987.

Image Source: http://emedicine.medscape.com/article/962643-overview

Background: Dr. Arman Asadour is a physician working in South Sudan for a vertical aid cholera treatment program funded by an NGO. His workstation has a mandate to only treat cholera patients and send those with other conditions to the local hospital. The local hospital is overflowing with patients and some patients arriving at the station have conditions treatable with NGO resources. Dr. Asadour is caught in two moral dilemmas in which he must decide whether to balance beneficence and justice. Treating non-cholera patients might cause an overflow of sick patients demanding NGO care, depleting resources that could be used to eliminate cholera. Admitting non-cholera patients for treatment might expose them to cholera patients at the facility. Overall, there the ethical question of whether the vertical treatment structure is the most effective way to improve the population’s overall health (Thomas, Waluchow and Gedge 267). The primary moral dilemma is whether to treat outside the mandate, and the secondary dilemma is whether he should ethically participate in the program at all.

Discussion: Dr. Asadour’s professional emphasizes beneficence, which provides the foundation for his uneasiness about selectively treating. He is facing an epidemic of cholera, but also an endemic presence of other diseases. It is a pandemic comprised of numerous illnesses. Brody and Avery provide evidence of why Asadour feels a strong duty to treat in such circumstances based on the ideas of social solidarity and vulnerable populations. Brody and Avery make a convincing argument that solidarity between fellow health care professionals and the larger lay community provides the basis for doctors’ duty to treat (44); they also argue that “a critical test of true social solidarity is whether we are willing to put the needs of vulnerable, underserved populations first” (45). When health systems neglect vulnerable populations it can result in mistrust of health officials by said populations, leaving them resistant to public health guidelines and therefore at risk for mortality (Brody and Avery 46).

No doubt this argument has to do with Dr. Asadour’s moral conflict over his station’s mandate. He is clearly invested in vulnerable populations because he chose to leave home country and work in an unstable, war-torn region. Employment with NGOs often pays less than other employment like private practice and many NGO physicians are volunteers and receive no payment at all. It would be frustrating for an individual who wants to generally serve the needy, to be hindered by a restrictive mandate. According to the case description, “Dr. Asadour wonders whether vertical aid programs simply undermine efforts by local authorities to develop sustainable health responses for their own communities and for health broadly,” (Thomas, Waluchow, and Gedge 267). This interplays with Brody and Avery’s argument of mistrust above. Clinics like Asadour’s may disrupt the normal flow of services in the area and establish a new norm for care delivery. If this new norm is one where only certain patients receive care while others are left to die while waiting for treatment at the overcrowded hospital, then it could result in community bitterness and frustration. These emotions may remain when Asadour’s NGO leaves, leaving the general community generally mistrustful of biomedicine. Mistrust of biomedicine could lead to continued spread of communicable diseases if patients refuse to seek treatment at local hospitals.

In context of justice, there are several aspects to consider that are in conflict with Dr. Asadour’s desire to treat non-cholera patients. The primary issue is how to allocate the NGO’s resources. While the NGO may have resources the hospital doesn’t, they were specifically provided to treat cholera and are limited in their own right. Cholera is a highly communicable disease spread by contaminated food and water. Death results from diarrhea-induced dehydration. Treatment involves intravenous fluids with electrolytes and antibiotics (WebMD). Therefore, it is reasonable to assume that the NGO workstation did not provide medical supplies for the treatment of viral conditions, chronic conditions, etc. If Dr. Asadour were to treat outside the mandate, he would likely still have to reject patients based on the supplies provided. When allocating scarce resources to equally needy individuals, one must also consider the prospect of success of treatment (Beauchamp and Childress 289). For example, if a patient reaches treatment before severe dehydration occurs, survival of cholera is highly likely. In the case of other diseases such as malnutrition, chronic diseases, etc., Dr. Asadour’s supplies might be used for the dual purpose of providing relief, but they will not be able to cure. His treatments are specifically effective in treating cholera.

Examining the vertical aid structure of Dr. Asadour’s organization from a broader perspective beyond individual patients reveals that its treatment plan may be futile. Hunt’s article “Cholera and Nothing More” examines ethical considerations of humanitarian aid programs addressing the disease. He says, “An important question to ask is what steps are possible to contribute to developing local capacity for preventing and addressing future outbreaks and building up infrastructure,” (56). Prevention and public health efforts are as necessary as treatment to prevent spread. In cholera’s case, improved water and food sanitation coupled with rehydration and antibiotics would eliminate the current epidemic and prevent another one from occurring in the future. However, the vertical aid structure employed by Dr. Asadour’s does not provide any provision for improvement in the community’s infrastructure or sanitation education programs for refugees. In this way the agency is doing little to stop the propagation of the disease, but is their work unethical?

Regardless of intentions, the NGO is providing care with scarce resources and limited funding to some individuals and that, in itself, is an act of beneficence. I believe Dr. Asadour should continue to treat according to the mandate if he wants to make the most impact with his resources available. In other words, I would recommend taking utilitarian approach to treatment. However, the program’s structure may not be the most just or fair way to utilize aid funding. However, I don’t think this makes the organization’s action unethical. Only if the NGO’s work were to leave the area worse off than when it arrived or cause the failure of local healthcare delivery after its departure (i.e. the mistrust of the community or the disruption of local hospitals’ ability to treat) would I view it as and unethical organization.

Works Cited

Brody, Howard, and Eric N. Avery. “Medicine’s Duty to Treat Pandemic Illness: Solidarity and Vulnerability.” Hastings Center Report 39.1 (2009): 40-48. Web. 19 Apr. 2015.

Beauchamp, Tom L., and James F. Childress. “Justice.” Principles of Biomedical Ethics. 4th ed. New York: Oxford UP, 2009. 249-301. Print.

“Cholera: Causes, Symptoms, Treatment, and Prevention.” WebMD. WebMD, n.d. Web. 20 Apr. 2015.

Hunt, M. R. “‘Cholera and Nothing More'” Public Health Ethics 3.1 (2010): 55-59. Web. 20 Apr. 2015.

Thomas, John E., Wilfrid J. Waluchow, and Elisabeth Gedge. “Case 8.2 Ethics and Humanitarian Aid: Vertical Aid Programs.” Well and Good: A Case Study Approach to Health Care Ethics. 4th ed. Peterborough, Ontario: Broadview, 2014. 267-68. Print.

I do not believe it is unethical to treat the refugees for additional conditions, especially when treatment is straightforward and does not take away vital resources from patients seeking cholera treatment. I think the decision would be questionable if treating a patient for meningitis required a significant amount of Dr. Asadour’s time, and he could no longer perform his duty to treat cholera patients. However, it seems from the information given in the case study that Dr. Asadour feels confident that he can balance caring for both cholera patients and for several patients with other serious, but treatable conditions.

Dr. Asadour acknowledges that he has emergency medical supplies to save the lives of those with non-cholera conditions. It sounds like the local hospital cannot easily access such supplies. By treating such conditions, Dr. Asadour is relieving the local hospital from expending additional time and limited precious resources. This will allow the local hospital to care for a higher number of other patients. It seems just to me that a greater number of patients overall are accessing care. Also, since these patients are also refugees, they might encounter obstacles to accessing care at the local hospital.

Dr. Asadour feels obligated to treat a patient with a serious condition who is already on his door step. However, his staff and current resources could not meet the needs of an influx of other patients. Dr. Asadour should create an informal agreement with each of these patients not to advertise the cholera station as a tent to treat all conditions. It would be unethical for the healthcare team to fail to meet the needs of the cholera patients they formally agreed to treat.

Since cholera is communicable, it would be unethical to directly and knowingly expose a non-cholera patient to a cholera patient. Yes, Dr. Asadour feels a duty to treat the patient he faces at the admissions tent. However, a line must be drawn at the point where the risks of contracting cholera outweigh the benefits of receiving treatment at the tent for another condition. Above all else, Dr. Asadour must not do any harm, so nonmaleficence is also part of the argument.

If a patient presents with a serious condition that Dr. Asadour can treat with the available medical supplies (which are not readily available at the local hospital), Dr. Asadour must first be confident that the patient will not contract cholera in the designated treatment space. This is critical – if this patient contracts cholera, he or she can spread the illness further into the community. In this case, Dr. Asadour’s beneficent act of treating the initially non-cholera patient would be highly unjustified.

I do not believe it is unethical to treat a patient who has no other options. However, due to the principle of justice, I do believe it is unethical to prioritize the health of one individual over the health of tens of others.

As long as he does not harm others in the process – by neglecting to properly treat the cholera patients who arrive at the tent – I do not believe Dr. Asadour’s attempts to provide additional care for needy, non-cholera patients will be morally questionable. This additional care, however, should be at the expense of additional clinic time from Dr. Asadour, to ensure that he is delivering the level of care that he promised to deliver to cholera patients. I write this because first and foremost, Dr. Asadour’s professional duty is to cholera patients. Then, with available time and resources, Dr. Asadour can tend to other serious conditions.

After noting further experiences and observations at the tent clinic, Dr. Asadour can advocate to the donors to either expand the pool of money for treating serious, non-cholera patients who cannot receive adequate care at the local hospital, such as meningitis patients, or to fund the clinic as a horizontal aid program, so that Dr. Asadour and his staff can meet the shifting needs of their patients more holistically.

Thomas, John, Wilfrid J. Waluchow, and Elizabeth Gedge. “Case 8.2 Ethics and Humanitarian Aid: Vertical Aid Programs.” Well and Good A Case Study Approach to Health Care Ethics. 4th ed. Ontario, Canada: Broadview, 2014. 267-68. Print.

Dilemma:

Janet Greene is a forty-four year-old victim of a traffic accident. She was treated fir multiple fracture and abdominal injuries, and was discharged once she recovered sufficiently from renal failure. She was able to live at home despite her lacking kidney function, however she soon developed a second round of acute kidney failure and when readmitted to the hospital, it was clear that her condition urgently needed dialysis. Ultimately, the issue is that both geographically accessible hospitals said that they did not have space to give Janet long-term dialysis. When her physician asked if there was any way to “bump” a patient with a less-dire prognosis in order to make room for Janet they refused; both hospitals had a “first come first serve” rule. So the issue is whether or not this first come first serve standard is the morally just way to run these establishments.

Discussion:

In this case we must distinguish between macro and micro-allocative decisions. While macro-allocative decisions are made when a hospital is tight financially and the hospital administrator has to make the tough decision about what programs they can afford to keep, and what ones they must cut. These kinds of resolutions, however, are impersonal as opposed to micro-allocative resolutions that are a part of the personal environment of clinical decision-making. Micro-allocative decisions come into play when a certain resource’s demand becomes greater than the supply. So the biggest question to face here is, “Who shall have the scare resource when no all can?” A question whose answer is synonymous with a life-or-death decision, and in Janet’s case, withholding the long-term dialysis to treat her condition would be the equivalent of signing her “death warrant.”

We must distinguish between two levels of decision-making in micro-allocation if we are to answer “who shall live when not all can live?” The first level is the Eligibility Criteria. Within this there is the constituency factor, stating, “patients in an outlying region may be denied access in favor of patients who reside in the city in which the hospital is located.” There is also the progress of science factor, “patients could be turned away in a micro-allocative crunch if their particular need for a resource failed to fit with the research interests of the hospital.” And the prospect of success factor, “it would be irresponsible to offer a scare medical resource to a patient who is not likely to benefit from it or is likely only to derive marginal benefit from it.” I agree with all three of these criteria, especially the last one. The prospect of success factor is in line with what Janet’s physician is saying, Janet’s condition is critical and if there is a patient who does not need the resources the hospital is providing, or a patient who is hardly benefitting from a certain resource, I believe it is the moral obligation of the hospital to put their resources to the best use possible – and in this case it would be in saving Janet’s life. The second level of criteria, the selection criteria, includes the criteria of comparative worth, which proposes that when distributing scarce resources at the bedside “the family role factor” must be taken into account. Janet is a single mother with two children, she is their only true source of financial, emotional, and physical support and we cannot know the extent of her situation, but since she and her husband are separated and she is the one taking care of the children, we can assume that the father would be of little to no help if this mother were to pass away, leaving her children stranded.

I believe that the only justified way of “bumping” someone off a machine is if they can sustain a good life without it, or if they are hardly hanging on and the machine/treatment is just elongating their inevitable road to death. In these two situations, I believe that either of the patients should be “bumped” in order to save someone who needs the treatment to live, and once on the machine, can live a happy, healthy life without death being in the near future. However, other criteria like the family role factor is important in a case like this. While I don’t believe that it is right to sacrifice one person in order to save another that has children, I do believe in it being an act of supererogation rather than obligation. Anyone that doesn’t meet the two criteria I listed above should not be “bumped” off of their machine – however if they want to volunteer their machine in order to benefit another, then that is the only way something of this sort would be morally justified.