The World Health Organization holds the ideal of a right to health, which includes the right to, “ access to timely, acceptable, and affordable health care of appropriate quality”( WHO: http://www.who.int/mediacentre/factsheets/fs323/en/). Here, the right to access extends to those with normal means and ability as well as those with defecates physical, economic, transportation, or informational resources. The United Nations document on the right to health also presents a similar view (UN: http://www.ohchr.org/Documents/Publications/Factsheet31.pdf). Also, both of these organizations, which lead the front in setting the standards of human dignity and rights, call for the access to resources such as sanitation, nutrition, and clean water, which form the underlying basis of health.

I believe that these idealistic, though not impossible, definitions of a right to health reflect Beauchamp and Childress’s egalitarian theories of justice. Also, they are reminiscent of John Rawl’s theory of justice that is applied to the right to health. It calls for the access by all members of society to, “an adequate, although not maximal, level of health care- the exact level of access being contingent on available social resources and public processes of decision making (Beauchamp 248). It is of note, also, that thought the WHO and UN have clauses which define a human right to health, no document of the United States of America calls for such a right.

Clearly, such lofty ideals are hard to meet within the constraints of social and economic reality. For example, Great Britain’s National Health Service is often highlighted as an equal and just form of health distribution. However, it does not respect the right to timely access since it discourages, “treatment sought on an elective basis through long queues,” and even more morally questionably, discourages the use of resources by those with more futile conditions (Brody). I believe that the National Health Service relies on the Utilitarian Theory of Justice in order to, “distribute justice as one among several problems of maximizing values.” (254 Beauchamp). Such a theory, however, is not compatible with the WHO and UN’s definition of a right to health. The National Health Service preserves justice by ensuring social welfare but does not ensure beneficence and non-malfeasance for all members of society since it discourages some elective surgeries that potential improve quality of life and has created a system of queues in order to discourage the pursuit of elective procedures.

Germany’s health care system does seem to embrace the egalitarian ideals that the WHO and UN hold since it’s, “comprehensive health-care system .. over 99% of the population is covered”(Brody). It ensures that almost every citizen has access to healthcare, thought not the maximal amount. This is how the German system institutes the utility theory of justice. It has three classes of care. Each one differs, however, mostly in only the setting of the care but not in the quality. For example, first class care provides a private room while in third class care, patients are in a general ward. Thus, all receive adequate care though perhaps not in the same type of setting. I think this model is a wonderful combination of the WHO and UN calls for universal care that also takes into account the utilitarian requirements of affordability and resource management. Currently, the United States is trying to achieve coverage of all its citizens. I think we, as a nation, would do well to see how other countries, such as Germany, are managing to balance different theories of justice to provide adequate care for all. Then, we too can be in accordance with the UN and WHO’s calls to respect all humans’ right to health.

http://www.who.int/mediacentre/factsheets/fs323/en/

http://www.ohchr.org/Documents/Publications/Factsheet31.pdf

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

RD B. Brody and T. Engelhard, “Access to Health Care,” Bioethics: Readings and Cases

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.

Background: Amelda is a 21-year-old female with anorexia nervosa admitted a total of 15 times over the previous threes to the hospital emergency room for symptoms of her disease. All traditional treatments by doctors thus far have failed. Amelda continues to view herself as overweight and rejects solid food and nutrients. She has gone to extreme measures, such as withdrawing supplements from her stomach using a syringe, to avoid gaining weight. Doctors have determined that the only effective way to stop these behaviors is through physical restraints and force-feeding using a naso-gastric tube. She exhibits depression and doctors declared her incompetent during all of her previous hospital visits.

Doctors and family members are considering withdrawing force-feeding although doing so may allow Amelda’s weight to drop to an even more dangerous level. Past incidents have shown that when Amelda’s weigh falls below 77 pounds, her vital signs drop to potentially fatal levels. Amelda has not exhibited any signs that she wishes to die. The primary moral dilemma here is whether or not to withdraw force-feeding under the principles of beneficence, non-maleficence, and autonomy. We previously debated this dilemma in class, so instead I will examine it in light of Beauchamp and Childress’s frameworks for surrogate decision-making and quality of life analyses.

Discussion: In my personal analysis of Amelda’s case, I supported the classification of Amelda as incompetent and the passing of informed consent on to her parents. Beauchamp and Childress present here standards for surrogate consent generally recognized in bioethics: substituted judgment, pure autonomy, and the patient’s best interests (226). Amelda’s parents could adopt their role (assuming it is morally and logically justifiable that Amelda is incompetent) under any of the three standards, however the patient’s best interests standard is the most fitting. According to Beauchamp and Childress, both the substituted judgment and pure autonomy standards require some form of previous knowledge of the patient’s wishes and values or official directives issued by the patient before they entered an incompetent state. Amelda is 21 and we know she has received medical care for anorexia for the past three years, but we don’t know if this the start of these three years marks the start of her symptoms that impaired her moral status and competence.

While it’s logical to assume that Amelda has not suffered from anorexia for her whole life (most new incidences of anorexia are in teens)(“Anorexia Nervosa”), we do not know whether or not she had other health issues that impaired her competence. Even assuming that Amelda’s disease began when she started treatment would put her age at the start of her illness at 18. She would have just entered into legal adulthood, making it unlikely that she had previously expressed any mature values or wishes about her health preferences that her parents could draw on in the present case. Therefore, the patient’s best interest standard seems the most ideal choice for Amelda’s parents to operate under because it does not require considerations of a patient’s previous opinions. Because of the key component of the case that states that Amelda does not express any interest in death, it seems in the patient’s best interests to take all measures necessary to preserve her life. Weighing the costs and benefits of Amelda’s options, preserving Amelda’s life with (hopefully) temporary force-feeding and continuing psychiatric treatment in a chronic care facility outweighs the risk of her sustaining psychological and emotional damage from her position of being physically restrained based on her want to live (even if it is expressed with a distorted view of survival).

Works Cited

“Anorexia Nervosa | National Eating Disorders Association.” Anorexia Nervosa | National Eating Disorders Association. N.p., n.d. Web. 1 Apr. 2015. <https://www.nationaleatingdisorders.org/anorexia-nervosa>.

Childress, James F. “Beneficence.” Principles of Biomedical Ethics. By Tom L. Beauchamp. 7th ed. New York: Oxford UP, 2013. 226-41. Print.

Wiegert, Carolyn. Exam 1: Morality and an Extreme Case of Anorexia Nervosa. N.p.: n.p., 14 Mar. 2015. PDF.

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>.

Background:

              Over the past couple of centuries, numerous countries have proposed the implementation of healthcare systems with a socialized approach. The United States of America has had lengthy debates over implementing a socialized medicine program. Currently, citizens of the United States of America have the opportunity to receive either Medicare or Medicaid if requirements for one of the programs are met. “Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities” (Medicaid.gov). Medicaid is geared toward the lower-income portion of the population that may not be capable of affording private health insurance. “Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease” (Medicare.org). Medicare, on the other hand, is designed to support the health of the elderly portion of the population that may require additional healthcare.

In B.Brody and D. Engelhard’s article, Access to Healthcare, there are three cases presented. Each case depicts an episode in which an individual is in a predicament over healthcare costs and/or accessibility to ample healthcare.

Case A refers to a man who needs surgery at some point in the future. The surgery is not urgent. The problem that the man has is that he cannot afford the surgery, and the company that he works for does not provide health insurance benefits.

Case B refers to a mother whose child is sick. The child needs to see a doctor about a high fever, but the doctor is effectively inaccessible. The journey would be too far and take too long to make it to the doctor.

Case C refers to an elderly couple. The husband is beginning to show symptoms of Alzheimer’s disease, and is in need of additional nursing care. The couple cannot afford to both keep their house and to send the husband to a nursing home. A lawyer tells the wife that the best financial and legal option is to divorce the husband and claim all assets. Once completed, the husband would comply with Medicaid guidelines.

Dilemma:

              In all three of these cases, shortcomings of America’s current healthcare system are presented. The question to be answered here is “to what extend at what cost ought a society attempt to provide equal healthcare for all?” (B. Brody and T. Engelhard, “Access to Health Care,” Bioethics: Readings and Cases).

Conclusion:

              The sanctity of human life plays a major role in this dilemma. Is it morally just to not provide a portion of the population with accessible and high-quality healthcare? In my opinion, everyone is entitled to healthcare by their basic human rights. If someone does is not provided healthcare, they could die from a simple bacterial disease that in modern times, we can combat with just a few doses of antibiotics. This costs society just a few cents per dose, and yet saves lives. Society cannot justify not providing healthcare for all because if they do not do so, the poorer portion of the population will have no access to healthcare, and pass away from illnesses in which we have proven cures. Society is harming individuals that do not have healthcare.

Recently, America is moving towards healthcare reform in which a socialized medical approach will be instituted. President Obama has established the Affordable Care Act in order to help expand coverage, lower healthcare costs, and enhance the quality of care for participants. The implementation of this Act allows anyone who desires health coverage to acquire health coverage.

With this recent implementation of healthcare reform, all three cases will be resolved. In case A, the man can now afford to purchase a subsidized healthcare plan in order to afford surgery. In case B, the mother should be able to see a closer doctor because she no longer needs to go and visit a charity doctor. In case C, the health insurance prices could be lowered so that they are affordable for the elderly couple. Just like with any legal reform, there are individuals that are left out of the benefits. While this does not solve the problem of inaccessible healthcare for the entire population, this reform does benefit a significant number of individuals and is a step in the right direction for the morality of the United States healthcare system.

In conclusion, as a society, we have an obligation to ensure the health of our entire population. The sanctity of life is paramount. No matter the cost, society ought to attempt to provide equal healthcare for all.

Works Cited:

http://medicaid.gov/affordablecareact/affordable-care-act.html

https://www.medicare.gov/

B. Brody and T. Engelhard, “Access to Health Care,” Bioethics: Readings and Cases

http://goodtoknow.media.ipcdigital.co.uk/111/000000d5c/b9e6_orh220w334/elderly-couple-dementia-relationship-grandparents.jpg

https://dss.sd.gov/img/behavioralhealth/motherson.jpg

https://waxingtofull.files.wordpress.com/2012/01/horsey-healthcare-socialized-medicine1.jpg

Background

A few weeks ago my HLTH 410 class discussed several infamous clinical trials that were conducted on human subjects, one of which was the Bowery Series. The Bowery Series was a set of experiments performed on homeless, alcoholic men from New York’s skid row from 1951-1966. More than twelve hundred participants in the Bowery Series were subjected to perineal biopsies of the prostate gland, and, if these tissues samples proved to be cancerous, prostatectomies, surgical castrations, and estrogen treatments. Although some of the aforementioned treatments are now viewed as standard, not one of them was common or even established at the time of the series. For compensation, these men were provided with a clean bed and three meals for several days as well as free “treatment” should they be diagnosed as having prostate cancer (treatment being incredibly painful, invasive procedures like prostatectomies that had not been proven to work).

Conflict:

The basic moral principles of autonomy and non-maleficence are clearly violated by the researchers of the Bowery Series. The true dilemma arises when one considers whether non-maleficence towards the Bowery Series participants should be placed above the potential beneficence of future prostate cancer patients. In other words, is subjecting homeless, alcoholic men to radical, painful, and invasive surgeries morally justified if it could potentially lead to better outcomes for men with prostate cancer?

Discussion

As outlined in Tom Beauchamp and Jim Childress’ Principles of Biomedical Ethics, humans share basic moral principles of justice, non-maleficence, beneficence, and autonomy (Beauchamp and Childress 2009). In the case of the Bowery Series, the principles of autonomy and non-maleficence were violated. Earlier this semester, we discussed how society usually grants vulnerable populations extra protections and obligations to keep them in. However, the vulnerable population in Bowery Series was not protected. Instead, they were exploited.  As stated by Aronowitz, the Bowery experiments were conducted on homeless, alcoholic men from New York’s skid row because they could not conduct them on people with more power. Due to their position in society and the moral implications of alcoholism, these men were seen as having lower moral status and thus, less autonomy, than wealthier individuals at a nearby Presbyterian hospital (Aronowitz 2014).

Participants’ autonomy was further violated and undermined through manipulation by the Bowery Series’ researchers’ recruitment methods. Informed consent requires that the patient has given his or her permission for the intervention be taken, that the patient’s decision be voluntary, that the patient understands what he or she is consenting to. Although it is unknown as to whether or not some kind of consent was obtained from the subjects of the Bowery studies, it can be inferred that the Bowery Series research subjects’ decisions to participate in the study was neither voluntary nor informed. In fact, the Bowery series recruiters coerced, or at the very least manipulated their research subjects. The argument could be made that each party was getting what they wanted (the researchers, subjects to perform surgeries on and the homeless men, food and shelter). However, by offering homeless men food and shelter in return for their participation (two resources that this vulnerable population lacked but needed to survive) the researchers really only offered these men only one “choice”: join the study. Since these were relatively new procedures with unknown consequences, it is also fair to assume that the decision to participate in the study was not an informed decision. Additionally, consenting to one thing (i.e. prostatectomy) does not consent you to everything that is entailed with it (incontinence, impotence, etc.).

It is difficult to discern whether or not the researchers could be considered beneficent for providing free cancer treatment to their research subjects. The researchers very well might have been more concerned with answering questions pertaining to the prevention, diagnosis, and treatment of prostate cancer than the good of their research subjects. And yes, the procedures were incredibly painful and invasive and many resulted in complications. However, it is hard to imagine that these researchers didn’t at least believe that these procedures might benefit the homeless, alcoholic men that presented with prostate cancer. Additionally, these researchers surely wanted to benefit future patients with prostate cancer.

I recognize that medical research, especially medical research pertaining to the efficacy of invasive procedures, could not be advanced without violating the principle of non-maleficence to some degree. However, in this case I believe that the researchers’ obligations to protect a vulnerable population by preventing harm and increased risk (non-maleficence) should have taken precedence over their obligations to be beneficent (especially considering that they did not know whether or not the procedures would benefit future patients).

This case is very similar to “Well & Good: A Case Study Approach to Health Care Ethics” Case 3.1 that we recently discussed in class. Just as the director of the Alzheimer’s study should take extra care to ensure that the Alzheimer’s patients who are mentally incapable of giving informed consent should are not harmed (Thomas and Waluchow 2014), so too should the Bowery Series’ researchers have granted the homeless men extra protections instead of exploiting them. These researchers should have obtained informed consent from volunteers, not coerced homeless men into participating in their study.

Works Cited:

Aronowitz, Robert. “From Skid Row to Main Street: The Bowery Series and the Transformation of Prostate Cancer, 1951-1966.” Bulletin of the History of Medicine 88.2 (2014): 287–318. PubMed. Web.

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

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

Background

In “Principles of Biomedical Ethics,” a hypothetical situation about a woman with Alzheimer’s is described when looking at The Best Interests standard. The woman, Margo, is a very happy woman who seems to be enjoying her life. The medical student who visits Margo even described her as “one of the happiest people I have ever known.” So we can say that even though Margo is an Alzheimer’s patient, she is clearly living her life with a genuine smile on her face and a great deal of happiness. However, the conflict arises when we are told that during the beginning stages of her condition, Margo executed a living will, which stated that she did not want life-sustaining treatment if she were to develop another life-threatening illness. Well, Margo ends up developing pneumonia and this is where the problem begins.

Dilemma

Margo’s physicians are faced with the issue of whether or not to administer their patient antibiotics in order to treat her pneumonia. If they decide not to give her the antibiotics, they would be acting according to the living will she created and respecting her precedent autonomy, resulting in her death. However, based on Margo’s current quality of life and pure happiness it would seem as though it would be in her best interest to go ahead with the antibiotics, treating her pneumonia and allowing her to continue living her happy life. But by doing so the physicians would clearly be violating the living will Margo executed as she developed Alzheimer’s.

Discussion

In this particular case, Margo’s physicians must administer the antibiotics to treat her pneumonia. In doing so, not only would they be acting under the best interests standard but also under the principle of beneficence, which refers to “a statement of moral obligation to act for the benefit of others,” (203). The health care team has a moral obligation to act in order to benefit Margo. Beauchamp and Childress even mention how “the best interests standard can in some circumstances validly override advance directives executed by formerly autonomous patients.”

The available options here are to either administer the antibiotics, save Margo’s life and allow her to continue living a happy one, or not to administer the antibiotics, act in accordance to her living will, and consequently result in her death. With these two options, the job is to determine the highest probably net benefit and act accordingly. And since the best interests standard requires a surrogate to assess both the risks and probable benefits of several treatments and alternatives – this is inevitably a quality-of-life criterion. That being said, while quality of life is a difficult topic to discuss, it is clear in the description of this hypothetical case that Margo’s quality of life is high. As previously mentioned, she is seen as one of the happiest people some of the people working with her have ever known.

Moreover, Beauchamp and Childress address the fact that as person “slips into incompetence,” as Margo is currently doing, their living condition can drastically change, sometimes for the better. They continue to say that “if so, it seems unfair to the now happily situated incompetent person to be bound by a prior decision that may have been under informed and shortsighted.” When Margo made her advance directive, she had just been informed about her condition and more likely than not thought of the worst rather than the possible best. She wasn’t in the right mental or emotional state to be able to make a completely cohesive decision about future treatments. Beauchamp and Childress even say that advance directives “generate practical and moral problems.” One of those problems being that they “fail to leave sufficiently explicit instructions.” In Margo’s case, she stated that she did not want life-saving treatment, but to what extent is something truly a “treatment?” Antibiotics are entirely different than having to undergo a major surgery; taking pills aren’t even invasive. So it would seem as though these antibiotics wouldn’t exactly fit the mold Margo made for “life-saving treatment,” as she most likely anticipated developing something much worse that required a more invasive course of action.

This is quite honestly all the information we need to make the ethically correct decision here. The fact is that Margo is an extremely happy woman enjoying her life – even if it’s one of incompetence – and as her surrogate decision maker and health care team, they have a moral obligation to act in her best interest, which is clearly prolonging her life.

Beauchamp, Tom L., James F. Childress. Principles of Biomedical Ethics. 7th ed. N.p.: Oxford University Press, 2012. Print.

Text Discussion

According to Terrence Ackerman, a physician’s non-interference is essential for respecting a patient’s autonomy in the post-1982 health system. However, Ackerman argues that noninterference fails to account for the transforming effects of illness. Without the adequate knowledge and skills, a patient cannot accurately assess his or her own condition. Additionally, mental health factors such as denial, depression, or fear may hinder patients from making choices that are in harmony with their life plans. For example, depression may prompt a patient to refuse treatment, which is out of character with a previous full commitment to treatment. Ackerman argues that noninterference is not the best course of action. However, the alternative creates a slippery slope in which vulnerable patients may be harmed by carelessness.

I do not think autonomy is upheld when a patient refuses life-saving treatment out of denial, depression, or fear, and the physician accepts this decision without question. In certain cases, there should be limits to how much autonomy a patient has. In my understanding, in order to help the patient maintain as much desirable autonomy and control as possible, patients should be able to, for example, choose what they would like to consume (from a list of approved food items), what they would like to do in terms of entertainment in their hospital room, which visitors they would like to have, and other such considerations.

Our society has entrusted the health of individuals in the skilled hands of physicians. However, the physician cannot always take the totality of a patient’s experiences into consideration. By engaging in a thorough conversation with the patient and family members, the physician can begin to ascertain the patient’s psychological and social situation and help them make a decision that promotes optimal autonomy.

Current Event Application

On Tuesday, March 24th, Germanwings flight 4U 9525 from Barcelona to Duesseldorf crashed in the French Alps, killing all 150 people on board. Investigators found antidepressants in the co-pilot’s apartment and discovered that co-pilot Lubitz had been treated for severe depression in the past. A Duesseldorf clinic confirmed that Lubitz visited the clinic as recently as March 10th to receive a mental health diagnosis. Torn sick notes were found in his home, which showed that the co-pilot was suffering from an illness that should have grounded him on the day of the tragedy.

Lubitz was declared “unfit to work” by a physician, but he concealed his condition both from the Lufthansa airline and his immediate professional environment.  Under the current aviation system, pilots are required to self-report if they are deemed unfit to fly by a physician. It seems to me that this self-reporting system presents a conflict of interest. What happens if a pilot is afraid of losing his work? What happens if a pilot is in denial about his condition?

With the knowledge that the patient was responsible for hundreds of lives besides his own, the physician should have reported the condition to the most relevant and important individuals at the airline. In the least, the physician could have made certain that the patient had initiated the self-reporting process. The condition was not a minor one that could be easily overlooked. I believe the physician would have protected the co-pilot’s future autonomy by intervening and reporting the condition to the airline. Potentially, all 150 innocent lives could have been spared, including the co-pilot’s.

Works Cited

Ackerman, Terrence F. “Why Doctors Intervene.” The Hastings Center Report (1982): 14-     17. JSTOR. Web. 28 Mar. 2015. <http://www.jstor.org/stable/3560762>.

“Andreas Lubitz: Torn-up Sick Note and ‘mystery Illness’ Raise More Questions about       Co-pilot.” Euronews. Web. 28 Mar. 2015.             <http://www.euronews.com/2015/03/27/andreas-lubitz-torn-up-sick-note-and-    mystery-illness-raise-more-questions-about/>.

“Doctor Had Excused Co-pilot from Work on Day of Tragic Flight 9525.”Euronews. Web. 28 Mar. 2015. <http://www.euronews.com/2015/03/28/doctor-had-excused-co-pilot-from-work-on-day-of-tragic-flight-9525/>.

“Reports: Antidepressants Found at Home of Co-pilot Andreas Lubitz.” CNN. Cable News Network. Web. 28 Mar. 2015. <http://www.cnn.com/2015/03/28/europe/france-germanwings-plane-crash-main/>.

Moral issues arise when patient autonomy conflicts with family interests. This generally occurs when the patient’s decision conflicts with what the family thinks is best. Conflicts can also occurs when the patient’s decision may not be in the best interest of his or her family, even though the family may not vocalize their disagreement. Patient autonomy grants patients’ the right to make their own medical decisions after having all information made available to them. In some cases, though, patients do not make decisions that doctors would deem most logical. Sometimes these decisions do not just affect the health of the patient, but also the well being of the patient’s family. Difficult cases like these force ethicists to question when it is appropriate and necessary for doctors to intervene.
Nadya Suleman started a media forest fire when she gave birth to octuplets in 2009. Her babies were born via IVF technology at the service of her doctor, Michael Kamrava. Controversy arose when the media publicized that Ms. Suleman was unmarried, had six other children, and was receiving welfare assistance. Many critics turned to Ms. Suleman who made a choice to have more children. Others, however, questioned her doctor for agreeing to Ms. Suleman’s request by providing IVF services. This case brought up the question of whether Ms. Suleman’s patient autonomy should have been more important than the interests of her family and own health.

When considering patient autonomy, it first is necessary to highlight that Ms. Suleman was a fully competent patient. She had received IVF treatment and had children before, so she was aware of the risk of multiple births pregnancy and the responsibilities of raising a child. A proponent of her patient autonomy could argue that Ms. Suleman’s own decision to have a child through IVF should be the only thing that matters in her doctor providing IVF services. While many criticize Dr. Kamrava’s decision to treat Ms. Suleman when she was a single mom and had six children, this criticism could be critiqued as very moralistic. As a doctor, his role is to provide his patients with medical services without judging their personal decisions and let that intervene with treatment. One could also argue that not providing Ms. Suleman with IVF treatments is a form of eugenics, because it claims that she should not have more children. Because she cannot get pregnant without IVF treatments, a eugenics argument could be used to claim that Dr. Kamrava refusing to treat Ms. Suleman is a form of him deciding she cannot have more children because of her socio-economic or marital status.
The interests of Ms. Suleman’s family and health arguably could be considered a higher priority than her patient autonomy. While it may have been Ms. Suleman’s choice to receive IVF treatments, critics argue that this was a bad choice and that Dr. Kamrava should have intervened by refusing to treat her. The nonmaleficence principle dominates this argument. Ms. Suleman had six embryos implanted in her, which far exceeds the recommended amount for IVF treatment. This arguably had the potential to cause great harm to her health and the health of the embryos because of the risks of multiple fetus pregnancies.
Another argument supports the idea that her having more children brings potential harm to the children she already has, as well as the new babies who will be born. The interests of the children were arguably compromised through this because now their parental attention and financial resources available to them are depleted more with eight new children. Ms. Suleman’s parents were also involved in the care of their grandchildren and disagreed with the availability of IVF treatments to their daughter, because of the harm caused to the family. One also could consider the financial harm and burden on the state, because Ms. Suleman cannot fully support herself and was relying on government assistance. All these arguments highlight potential harm that could be caused not to the patient, but to others as a result of both Ms. Suleman’s decision and Dr. Kamrava’s compliance.
In the case of Nadya Suleman, I think that the interests of her own health and family should were more important than the moral need for patient autonomy. Dr. Kamrava acted in a way that was medically and morally irresponsible. Ms. Suleman’s own health was compromised by implanting so many embryos and the harm to her family proves to be an issue financially. Ultimately, professionals agreed that Dr. Kamrava acted negligently and he lost both his California medical license and membership to the American Society for Reproductive Medicine. As a doctor, Dr. Kamrava should have stepped in and considered the moral consequences of his decisions, not just Ms. Suleman’s choice as his patient.

In “Why Doctors Should Intervene”, Terrance Ackerman discusses various constraints on autonomy. For example, he explains how mental and social constraints have the ability to impede autonomous behavior. In class, we have debated over the relationship between incompetence and a lack of autonomy. However, we have not discussed in depth another constraint mentioned by Ackerman: physical constraints.

Ackerman states, “There are physical constraints- confinement in prison is an example- where internal or external circumstances bodily prevent a person from deliberating adequately or acting on life plans,” (1985). Thus, imprisonment removes not only the freedom from an individual but also the autonomy as well, which poses ethical questions. For instance, pregnant prisoners experience morally unjust treatment. A recent study published a “report card” for various components of medical care for pregnant prisoners. According to the scoring in the report, thirty-right states failed prenatal care, thirty-one states do not have a policy to hold the institution accountable without adequate justification, and forty states have laws that may allow shackling during labor (The Rebecca Project for Human Rights, 2010). Although all of the aforementioned statistics present ethical issues, the use of shackles strikes me the most.

http://www.theguardian.com/commentisfree/2012/jun/06/women-born-free-give-birth-in-chains

To begin with, as illustrated, the use of restraints during labor appears extremely painful. One woman explains how she had deep cuts from the shackling during labor and delivery (Law, 2015). In addition, shackles, especially waist chains, limit a physician’s ability to assess the condition of the mother and the baby, which puts both individuals at risk. Furthermore, restraints can limit mobility, which will interfere with vaginal delivery or slow down the process of an emergency cesarean section. Thus, institutions are violating the principle of nonmaleficence by causing additional harm or additional risk of harm to the patients.

Moreover, one can argue the role of a lack of freedom in the diminished autonomy. For example, since the women committed a crime and lost their freedom, then they do not have the right of autonomy. Although status affects autonomy, such as a minor, the status of an imprisoned person should not override the status of a human being. Human beings posses a high moral status that enable them to make autonomous decisions. However, by removing the autonomy of the pregnant prisoners, then the institutions are treating them as less than human.

Furthermore, institutions and physicians usually make their decisions about autonomy based on competency and understanding. For instance, physicians may deem an individual with a mental disease as incompetent, so a proxy will make the medical decisions for him or her. In the case of the pregnant prisoners, however, competency does not seem to matter. Although the women have the mental capacity to make their decisions about prenatal care and the labor and delivery process, they do not have the opportunity to do so. Therefore, the typical criteria for determining competency does not apply to prisoners either, which one cannot morally justify.

Moreover, Ackerman articulates that doctors should intervene in certain situations, including those with physical constraints. However, as illustrated above, physicians should not impede on the autonomous behavior of incarcerated pregnant patients, for it results in morally unjustifiable treatment of the women.

Ackerman, T. F. (1982). Why Doctors Should Intervene. The Hastings Center Report, 12(4), 14-17. Retrieved March 26, 2015, from http://www.jstor.org/stable/10.2307/3560762?ref=no-x-route:368d91fb989e22ecddae6d166c31991c

Law, V. (2015, February 13). Giving birth while shackled may be illegal, but mothers still have to endure it. Retrieved March 26, 2015, from http%3A%2F%2Fwww.theguardian.com%2Fus-news%2F2015%2Ffeb%2F13%2Fmothers-prison-illegal-shackled-while-giving-birth

The Rebecca Project for Human Rights. (2010). Mothers behind bars: A state-by-state report card and analysis of federal policies on conditions of confinement for pregnant and parenting women and the effect on their children. National Women’s Law Center.