Background

Upon reading this case I immediately thought of the institutions that were built in the early 1900’s that housed the physically and mentally disabled, of all ages, in which people would admit family members as they believed they were not fit for society. These institutions, such as Letchworth Village in upstate New York, were soon discovered to be severely mistreating the patients – including techniques of horrific experimentation (Abandoned NYC). However, as this became widely accepted as unethical and immoral in the 1950’s, experts began moving people out of institutions and into communities (History of Health Treatments). In Thomas, Waluchow & Gedge’s Well and Good, case number 6.4 presents Stephen, a seven-year-old boy with severe mental disabilities. Stephen was born prematurely and shortly after suffered extensive brain damage by meningitis that left him “profoundly mentally disabled with no control over his faculties, limbs or bodily functions” (Thomas, Waluchow & Gedge, 229). Stephen has passed through the hands of many different institutions for physically disabled children and even to a foster home.

Dilemma

The three main dilemmas I found after reading this case were:

1)   In such a situation, who gets to decide what is done with Stephen?

2)   What are the legal rights of the mentally disabled?

3)   In general, what makes it “okay” to not treat a patient?

In regards to the first question, we must turn to the principle of autonomy which acknowledges a person’s right to make choices, to hold views, and to take actions based on personal values and beliefs (Ethics Principles). In this case, Stephen lacks the cognitive capacity to make his own decision and therefore the decision should be turned over to his parents. However, the argument presented in this case is whether or not his parents should be given that right considering the fact that they are not his primary care givers and do not spend the majority of time with Stephen as the care givers in the institutions do. Some may argue that his parents hold the responsibility as they are his “next of kin” so to speak. However, in the case Justice Lloyd McKenzie claims that “the professionals who have been treating and observing Stephen since late 1982 are better qualified than [the parents] are to assess his condition and capacities because they, the parents, have hardly seen him” (Thomas, Waluchow & Gedge, 232). I agree with Justice McKenzie in putting the decision into the hands of Stephen’s caregivers.

In terms of the second question, regarding the rights of the mentally disabled, I believe the Citizens Commission on Human Rights has provided a very detailed declaration of human rights that clearly defines the rights of the mentally disabled. Some may argue that keeping Stephen alive is a waste of resources and time. However, I believe that ending Stephen’s life simply because of a disability and the immense effort necessary to keep him alive is simply inhuman. We don’t end the lives of people who are handicap because it is harder for them to perform tasks x, y, and z. Stephen was born, he is living, he is human and I believe that his rights deem it necessary to keep him alive – the declaration by the Citizens Commission states that “any patient has the right to be treated with dignity as a human being.”

The third question addresses the principle of non-maleficence described as an “obligation not to inflict harm intentionally” (Ethics principles). In this case, although the surgery would require an “extraordinary surgical intervention,” and would “constitute cruel and unusual treatment of Stephen,” the physicians have a duty to do everything in their power to treat their patients (Thomas, Waluchow & Gedge, 230). While some may believe that the pain that Stephen would suffer is grounds for making it acceptable to end his life, I believe that we must look at the case in terms of the long term rather than the short term. For Stephen, undergoing this surgery increases his chances for survival and, therefore, I believe the surgery should be performed.

Reflection

The two main dilemmas involve the principles of autonomy and non-maleficence. In terms of autonomy, Stephen lacks the cognitive capacity to make a decision for himself and therefore his parents should be responsible for making a decision. However, since Stephen’s parents do not spend much time with him, it is believed that the professionals who have been treating and observing him are better qualified to assess his condition and capacities. On the other hand, the decision as to whether or not the surgery should be performed revolves around non-maleficence. Is Stephen better off with or without the surgery? If it were up to me, I would have Stephen’s professional caregivers assess his conditions and if they agree that the surgery, despite the short-term pain, would improve his condition in the long term then I would respect their decision.

Works Cited

Abandoned NYC . N.p., n.d. Web. 17 Feb. 2015. <http://abandonednyc.com/2012/08/05/legend-tripping-in-letchworth-village/>.<http://nwabr.org/sites/default/files/Pri nciples.pdf>

Ethics Principles. N.p., n.d. Web. 18 Feb. 2015. <https://www.nwabr.org/sites/default/files/Principles.pdf>.

History of Mental Health Treatment . N.p., n.d. Web. 17 Feb. 2015. <http://www.dualdiagnosis.org/mental-health-and-addiction/history/>.

Thomas, John and Wilfrid Waluchow. Well and Good: A Case Study Approach to Biomedical Ethics. 3rd ed. Broadview Press Ltd., n.d. Print.

Background

In the case, “Relational autonomy or undue pressure? Family’s role in medical decision-making,” a man referred to as Mr. M is in the intensive care unit due to respiratory failure. Mr. M specified to the healthcare team that he would not want any particular utilized to prolong his life. However, after speaking with his wife, Mr. M changed his mind. Since they were both immigrants who spoke a different language, the healthcare team did not know exactly what was said in their conversation. The doctor believed that Mr. M’s wife infringed upon his autonomy since he was competent at the time. This case therefore displays the worry some have regarding how involved families should be in adult patients’ medical decisions.

Dilemma

The main ethical dilemma involves whether a patient should make their own autonomous medical decisions or whether the family should play a role in helping the patient make a decision. Assuming the patient is competent, one viewpoint is that the patient should be responsible for deciding their course of action. Families may add pressure concerning their own interests or priorities, which may interfere with what is best for the patient. On the other hand, some feel that patients who are closely connected with their families may find it comforting and beneficial to discuss the situation with them. Together, they can review the options and come to a decision. In either case, the doctors should abide by what the patient determines.

 Reflection

There are valid arguments for both sides of the dilemma. I feel the ultimate decision lies with the patient. However, in my opinion, family plays an important role in helping the patient make a decision. It is morally correct to assume that family is genuine in aiding their loved ones. Family support in these difficult times makes the patient feel that they are not alone. If the patient has a close relationship with their family and wants them involved, then the healthcare team should respect that decision. If the patient does not want the family to participate, then the patient should inform the doctor. Doctors sometimes believe that getting family involved may not be favorable. However, unless the patient expresses otherwise, the doctor should trust that the patient understands the situation. It should not be assumed that the family and patient will have a conflict, such as pressure from the family to come to a specific conclusion. Additionally, the doctor can communicate and discuss with the patient if the interest of the family is sincere. In doing so, the doctor can be comfortable as well. In the case of Mr. M, he had a cultural difference and possibly had trouble understanding the doctors and our culture. Therefore, Mr. M probably found it more comforting to discuss the circumstance with his wife. Even though he altered his decision after speaking with his wife, it appears that it was a sincere change of mind. As I reflect on this situation, I feel that Mr. M represents the many patients that prefer to have their family involved in their medical decisions. Thus, the healthcare team should respect when patients choose to do so.

Works Cited

Ho, Anita. “Relational Autonomy or Undue Pressure? Family’s Role in Medical Decision-making.” Scandinavian Journal of Caring Sciences 22.1 (2008): 128-35. Web.

Image Sources

Patient-Centered Care: Giving Voice to Patients and Families

http://www.helpingyoucare.com/17013/nfca-calls-for-family-caregivers-to-help-support-the-center-for-medicare-and-medicaid-innovation-under-the-affordable-care-act

The case “Stephen Dawson: Should Severely Mentally Challenged Patients Be Treated?” outlines the story of a young boy, Stephen Dawson, who suffered from extreme brain damage after contracting meningitis shortly after being born (Thomas, Waluchow, Gedge 229). Dawson received life support surgery at the age of five and was thereafter cared for by his parents. This was an exhausting job as Dawson required frequent doctor’s visits, seizure medicine multiple times a day, and could never be left alone. After contracting the flu, leaving Dawson in even worse condition, the family found a place for him at a care facility. A few years later, Dawson needed another surgery and would most likely die without it. This case presents the dilemma: not to operate, most likely resulting in death, but letting Dawson die in dignity; or operating, which would prolong his life but Dawson would most likely continue to live in pain and suffering. The surgery should not be performed for two reasons: the decision should lie in the hands of the parents and performing the surgery would not be improving Dawson’s quality of life.

The case argued that perhaps Dawson’s parents lacked information about his responsiveness and progress and therefore the caregivers at the facility should make the decision. However, it is important to remember that Dawson’s parents cared for him for many years and spent hours per day feeding him, giving him his medicine, and ensuring his wellness as best as possible. Although the case does not specify how many times the parents visited him in the care facility, it is unlikely that they were uniformed about his condition after they had spent years caring for him. Therefore making them competent decision makers in this case.

Judge Bryne also said that the surgery would, “…prolong a life inflicted with an incurable condition” and “constitute cruel and unusual treatment of Stephen” (Thomas, Waluchow, Gedge 231). As Beauchamp and Childress state, “…mental retardation is irrelevant in determining whether treatment is in the patient’s best interest. Proxies should not confuse quality of life for the patient with the value of the patient’s life for others” (Beauchamp and Childress 173). Based on Dawson’s intellectual disability, it is not reason enough to withhold the surgery. However, his constant discomfort and pain, blindness, epilepsy, and constant need for intense drugs gives enough reason to characterize his quality of life as very poor. The surgery would not be of benefit because it would do nothing to improve his existing conditions and would arguably cause him more harm than good.

In a journal from the American Academy of Pediatrics, they state that, “[f]or such serious matters as LSMT [life-sustaining medical treatment], the medical plan usually should conform to the values and choices of the patient and his or her family” (Guidelines on Forgoing Life-Sustaining Medical Treatment 532). Therefore, Dawson’s parents should be given the ability to make the decision for their son. Furthermore,“[p]hysicians and families should also consider whether continued treatment conforms with respect for the meaning of human life and accords with the interests of others, such as family members and other loved ones” (Guidelines on Forgoing Life-Sustaining Medical Treatment 535). Prolonging Dawson’s current condition does not fulfill the guideline of respecting “the meaning of human life” as his conditions make it difficult to live pain free. While withholding this surgery may seem like the equivalent to death, Dawson’s parents have argued that it would be better for him to die with dignity than to live suffering.

Beauchamp, Tom, and James Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford UP, 2009. Print.

“Guidelines on Forgoing Life-Sustaining Medical Treatment.” American Academy of Pediatrics 93.3 (1994): 532-36. Pediatrics. Web. 20 Feb. 2015. <http://pediatrics.aappublications.org/content/93/3/532.full.pdf>.

Thomas, John, Wilfrid J. Waluchow, and Elisabeth Gedge. “Stephen Dawson: Should Severely Mentally Challenged Patients Be Treated?”.” Well and Good. Toronto: Broadview, 2014. Print.

When I first read that Stephen’s parents wished to not continue with surgery, I thought this was justifiable. Stephen is a minor, and thus it is up to the parents to decide his fate. However, it becomes apparent that the parents did not have extensive interactions with Stephen once he was admitted to Sunny Hill. A professional at Sunny Hill who had worked with Stephen commented that he was a “happy little fellow…[who] responded to people and smiled.. and giggled often” (pg 231). After reading this I questioned whether it was up to the parents to decide his fate. The case states that the person who should make the decision should have “the best knowledge of the patient’s condition and day-to-day life, [be] most concerned, and …bear the fullest impact of the decision” (pg234). The parents certainly do not meet the first criteria and the second and third criteria could be argued against their interest. In terms of autonomy, it is not clear what would be in the best interest for Stephen. Does the family have the right to decide that he be “allowed to die with dignity rather than continue to endure a life of suffering” (pg 231)? We cannot fully understand the life condition of Stephen through his perspective and thus is it ok for the parents to passively allow him to die when in reality Stephen may be enjoying his very simple life? In the eyes of non-maleficence, it seems like the logical move would be to interfere and carry out the procedure. This would likely not only do no harm, but also improve Stephen’s quality of life.

Ultimately, I believe the parent’s wishes should be supported and the operation should not be performed. This was a difficult case for me, as the details presented highlighted personable characteristics in Stephen, such as giggling and smiling. However, ultimately if the parents do not want to continue supporting him and believe he is enduring a life of suffering (a thought justifiable by his current state), I think it is appropriate to respect their wishes in light of appropriate allocation of resources. If the government steps in and over powers the parents, insisting the surgery be performed, the government has now taken over the care of this child. The facilities responsible for caring for individuals like Stephen are very costly and arguably this money could be spent more effectively. For example, the money could be spent on researching a cure that could prevent future circumstances like Stephen’s from arising. It is mentioned that Stephen was removed from the institute and placed in foster care because “Stephen’s condition was so poor and of such low quality, that the services and facilities could be better used by others” (pg229). This mindset would likely agree that with costs considered, it does not seem necessary for the government to go against the parents wishes to keep Stephen alive. When we are talking about state driven actions, the state has to act in a manner that is most just for all of its citizens, and a manner that is blind to emotion. Consider the case of Terri Schiavo. Was it just for the government to spend hundreds of thousands of dollars on her life support when this money could have gone to shelters for battered woman or infinite other social needs?

Work Cited:

Cerminara, Cathy, and Kenneth Goodman. “Ethics Programs .” Schiavo Timeline, Part 1. N.p., n.d. Web. 18 Feb. 2015.

“Ernestine’s Women Shelter.” N.p., n.d. Web. 20 Feb. 2015. <http://ernestines.ca>.

Thomas, John E., and Wilfrid J. Waluchow. “Case 6.4: Stephen Dawson: Should Severely Mentally Challenged Patients Be Treated?” Well and Good: Case Studies in Biomedical Ethics. Peterborough: Broadview, 1987. N. pag. Print.

Background

William Shroeder, a 52-year old native of Illinois, was the 2nd recipient of a permanent artificial heart.  In January 1983, he suffered from a massive heart attack, which severely damaged his heart and left him unable to walk a few feet without experiencing chest pain and shortness of breath. According to his family physician, if Shroeder received a transplant, the antirejection drugs would throw his diabetes out of control. Therefore, his only option was an artificial heart, which on average costs $150,000 per patient. Four years after he received his artificial heart, Shroeder passed away.

Case Discussion

The major dilemma in this case is whether or not our health care money should be spent on costly medical hearts, which are more cost than gain and only benefit a relatively small pool of people. Furthermore, could this money be better spent on early detection of disease and programs for preventative medicine?

According to the authors, “The bill for Will Shroeder’s operation ‘represents 790 days of hospital care equivalent to full treatment of 113 patients for an average stay of a week’ ” (Thomas, Waluchow, & Gedge, 172). Although the money it takes to treat one person for an artificial heart could clearly be used to save many more, a doctor cannot simply deny healing someone if there is a treatment option available, whether that option is extremely costly or not. The doctor has a duty to do no harm and to provide treatment to the patient. In fact by providing Shroeder with the artificial heart, the physician followed the three principles of beneficience, which according to Beauchamp and Childress are as follows:

1. One ought to prevent evil or harm.
2. One ought to remove evil or harm.
3. One ought to do or promote good.

The authors of this case also go on to say that, “exotic medical technologies have offered us only marginal returns in reducing illness and premature death” Thomas, Waluchow, & Gedge, 170). However, the improvement of other factors such as better air, improved sanitation, and more conscientious lifestyles work just as well and provide benefits to a larger population.

Analysis

The authors suggest that we must stop and “weigh out the short term losses against the long-term gains” and decide if it’s feasible to treat someone (Thomas, Waluchow, & Gedge, 173). The authors continuously bring up the dilemma over whether we should treat someone who has a preventable disease such as diabetes. According to the American Diabetes Association, with Type 1 diabetes, you inherit risk factors from both parents and an environmental trigger like exposure to a virus or even cold weather can trigger the onset of the disease.  Type 2 diabetes has a stronger link to family history, but both types can be triggered by early eating habits.

However, we also have to think of the socioeconomic factors that cause people to have preventative diseases like diabetes. What if cheaply made processed foods was all that someone could afford to eat and that person could not help that they developed diabetes? Despite his diabetes, Shroeder was responsibly managing his diabetes and could not help that he had a heart attack. You would not deny someone who got into a car accident medical treatment even if it was their fault for being drunk and getting themselves into the accident. So how can we debate whether or not we should deny people of an artificial heart?

Conclusion

Ultimately, in my opinion, there is no decision to be made when it comes to saving a person’s life: you should just do it. I think that it is unfortunate that a medical miracle like the artificial heart could be so expensive and offer such little marginal returns. Thus, more money should be allocated to public health programs that focus on preventative medicine, research to cure these diseases, and the improvement of factors that affect our living conditions, so that we are not faced with costly medical procedures like the artificial heart.

 Works Cited

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

“Genetics of Diabetes.” American Diabetes Association. American Diabetes Association, 20 May 2014. Web. 20 Feb. 2015. <http://www.diabetes.org/diabetes-basics/genetics-of-diabetes.html>.

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

Image:

http://transplants.ucla.edu/images/heart/SynCardia/SynCardia_Freedom_Portable_Driver.jpg

Introduction

For many people family is important part of their life. That includes when they need medical care. These are the people who are often appointed medical proxies and moral agents. However if they are not fulfilling these allotted roles there place in the care situation may be ambiguous. Who exactly counts as family? What moral effects can the family have on the patient?

Discussion of First Problem

The first issue is who counts as family. For insurance provides the issue is as simple as a person, their spouse if they have one, and any underage children they have. For the children it includes only their parents or any adult relative they live with.      However there are always tricky issues. Consider a same-sex couple that has been together for a long period of time, but reside in a state that does not allow marriage. Many people would argue that despite their lack of an official marriage document their spouse has every right to the normal entitlements of a family member. There could also be many cases where the family is in fact not the individuals closest to the patient. An estranged sibling for example may not want his or her family present or given any rights in a medical scenario. There would also be cases where the family unit extends well beyond the nuclear family. Do aunts and uncles and cousins and grandparents have right in a healthcare practice? American as a whole tends to be an individually focused society. Other cultures place a significantly higher importance on family and the patient may view themselves as nothing more than a part of the family unit. The term family is excessively contacted and could feasibly be replaced with a tern like authorized patient relation, which would include the individuals decided on by the patient.  This entire convoluted mess could usually only be solved by the directive of the patient, which not always an option in an emergency scenario.

Discussion of Second Problem

The identification of the authorized patient relations aside, there is then the issue of what rights they are given. Foremost among these with the assumption of competent patients is information.  The patient’s loved ones are often desperate for information about the condition. Hospitals have waiting rooms for these people to be waiting on this information for a reason. Anyone who the patient has brought with them or who has brought the patient in likely has a desire and a right to information about the patient’s condition. However, if possible this should be all with the patients consent. There may be details the patients wish to have withheld or persons the wish to be excluded from the information. The authorized patient relations also have the right to see and speak to the patient if that is medically advisable. However the paramount value to observe in these situations is the autonomy of the patient. There wishes should be maintained if at all possible. Final decisions should be made in private to avoid familial influence and the advance directives of the patient are to be followed even against the wishes of the family. The exceptions are of course cases in which the competence of the patient is in question. In these cases the role of the family is elevated to the primary decision maker and the assumption of the responsibility for the patient.

Conclusion

A patient in a hospital is never just a patient. Each patient comes with their own accompaniment of people who love them, or don’t and baggage. There can and never will be a universal set of guidelines for every case to govern the rights of the family. The healthcare professional will always have to make some judgmental calls, but if they hold the autonomy of competent patients as the primary objective both in terms of who can and can’t be defined as family and what those people can do, the vast majority of issues should be prevented.

References

Definition of family from:

http://www.shadac.org/files/shadac/publications/SHADAC_Brief27.pdf

Ho, Anita. “Relational Autonomy or Undue Pressure? Family’s Role in Medical Decision-making.” Scandinavian Journal of Caring Sciences 22.1 (2008): 128-35. Web.

Background on Stephen

Stephen Dawson was born prematurely and suffered from extensive brain damage due to meningitis. As many as 25% of newborns who suffer from meningitis die, and of those who survive 15-25% develop serious brain and nerve problems. Stephen survived, however was one of the 25% who suffered pretty heavily: he was left blind and with no control over his limbs or bodily functions.

Stephen had surgery when he was little, and afterwards required 10 hours of sustained caring for at home prior to being sent to a foster home at the age of 3. His parents remarked that his condition was “so poor and of such low quality, that the services and facilities could be better used by others” (Thomas, Waluchow & Gedge, 229). They believed that his life was painful and unhappy.

 Stephen’s Case

Now at age 7, Stephen’s professional caretakers have a different view of the situation. They see Stephen as “a happy little fellow despite his handicaps” (Thomas, Waluchow & Gedge, p. 231). They state that his abilities have been underestimated, and they have been much more involved in his life over the past 4 years than his parents have been and allude that they therefore perhaps understand his situation better. Now Stephen requires another surgery due to a blockage in the shunt that will lead to more brain damage and likely death. At first, Stepehen’s parents consent – however after some deliberation, they decide they would rather him die with dignity than continue on a life of suffering. The major questionable points to consider are threefold:

1)    Who gets to decide?

2)    On what grounds is it justified to not treat a patient?

3)    What are the legal rights of the mentally disabled?

Analysis

To answer the first question, we must address autonomy. With autonomy, one has the right to “self-rule that is free from both controlling interference by others and limitations that prevent meaningful choice” (Beauchamp & Childress, p. 101). In this situation, Stephen does not have the cognitive capacity to make a decision in which he adequately understands. Therefore, the legal right would logically go to his parents. However, the reason we typically resort to a parent is because they tend to be their child’s primary caregiver. In this circumstance, the workers at the foster home spend more time with Stephen than do his parents, and the Justice even argues that the professionals are “better qualified than the parents are to assess his condition” (Thomas, Waluchow & Gedge, p. 232).

In order to address the second question, it is imperative to consider non-maleficence. Physicians have a duty to care for patients and to do what they can to treat them. In this situation, it is in Stephen’s best interest to undergo the surgery in order to have the best chance of survival. In deciding who decides, physicians “should be making the decision whether to withhold or withdraw treatment,” as they have the knowledge in this situation (Gedge, Giacomini, Cook & DeJean, p. 864).

To answer the third question, to completely compromise and invalidate a human being based on a cognitive disability is acting as if their life is lesser than others. Similarly to how some feel strongly about keeping a fetus alive, a human being at age 7 is a living, breathing being and must be treated as so. Just because they are not fully cognitively able to make a decision does not mean that it is the best decision to passively let them die or even to “die with dignity.” Similarly to our previous situation involving the suicide case, would he have died “with dignity” if he had killed himself? Just as I believed it was important to save that individual’s life, it is important to save Stephen’s life. The staff at the foster home is technically the primary care management of Stephen, and in addition to the doctors who care for him, the team has indicated that treatment is in his best interests, and thus I believe that they have every right to go ahead with the surgery.

Resources

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

Gedge, Elizabeth, Giacomini, Mita, Cook, Deborah, and DeJean, Deirdre, “Decision Tools for Life Support: A Review and Policy ANalsis,” Critical Care Medicine 34, no. 3 (March 2006): 864-70.

Meningitis in Children. Merck Manuals. February 19, 2015. http://www.merckmanuals.com/home/childrens_health_issues/bacterial_infections_in_infants_and_children/meningitis_in_children.html.

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

Background

According to the National Trauma Institute, 30% of all life years lost in the United States is lost to trauma accidents. This is in contrast to the relatively smaller number, 16%, who are lost to cancer. In this case, Amira, her partner Casey, and their daughter Samantha, are victims of a crash that kills Casey and injures Samantha. Meanwhile, Amira is in very critical condition and needs to quickly enter the operation room in order to save her life. However, as she goes in and out of consciousness before surgery, she asks how her family is. After quickly telling Amira that her daughter will be fine, the nurses pause to consider if they should tell her about the death of her partner.

Dilemma

The case highlighted that one of the main moral dilemmas was in deciding whether the roles of the nurses as beneficent and non-maleficent outweighed the patient’s autonomy.  Also, I think, a case can be made that treating the patient justly is also important. It is possible that telling Amira the news that her partner is dead could hasten the deterioration of her present condition. This reality would support withholding the information in the interests of non-maleficent. However, in order to treat the patient justly and to respect her still intact autonomy, Amira must be told the truth

Conclusion

In this case, the nurses ought to tell Amira about the death of her partner as well as that her daughter is still alive. In this case, the patient is autonomous. Though her consciousness ebbs and flows as her physical condition changes, her personality and character are intact. By asking about her daughter and partner, even as her own body struggles to stay alive, she displays appropriate behavior. Thus, no case about incompetence can be made to validate disregarding Amira’s autonomy. Also, a nurse’s duty to be non-maleficent and only beneficent supports telling Amira the truth. Though telling Amira will cause her much sadness and distress, it also gives her peace of mind in knowing the truth. Also, telling her would keep her trust in the healthcare team intact and help prevent her from jeopardizing her own delicate condition after the surgery by refusing to comply with the healthcare team’s directions during her recovery.

A case can also be made for telling patients the truth in these tragic cases by looking at statistics. If 30% of deaths are from traumas, then it can be assumed that many situations like this occur. If in every situation like this, the patient was spared distressing news at critical times, then the patient’s right to autonomy would be continuously disrespected even when he or she is competent. Telling patients the truth is the best choice because it respects the autonomy of the patient and helps maintain the patient-health care relationship, which is grounded in trust. Trust is the root of justice, a principle which a competent patient has access to. The patient must already depend on the team to save her physical body. In order to remain just, the nurses must accept that Amira is entitled to have any and all information pertaining to the status of her family. Upon disclosing the information, the nurses need to be prepared to provide moral support and to help Amira focus on her role as her daughter’s caretaker.

Sources

National Trauma Institute page: http://www.nationaltraumainstitute.org/home/trauma_statistics.html

RD Moorhouse, A. and P. Khan “Case 3: Emergency and Trauma

Nurses: When to Give Bad News.” Concepts and Cases in Nursing Ethics

Images from http://www.preparliament.com/wp-content/uploads/2013/12/scales-of-justice1.jpg   and   https://9to20.files.wordpress.com/2012/01/trauma_center_memorial_hospital_cost_of_violence.jpg

Background

Should the doctor or a nurse lie in favor of the patient’s interest or should they tell the truth to fulfill the biomedical moral ethics? Before answering this question, we should remember that the doctor’s primary vow must always be to ensure the patient’s health and interests. The Biomedical ethics compels the doctor to act in favor of the patient’s health and welfare (beneficence) and cause no harm to patients (non- maleficence) while respecting patient’s autonomy and choices. Despite the aforementioned, truth-telling is also a medical ethics principle that requires the doctor not to lie and instead tell the whole truth, even if this truth will harm the patient’s psychological welfare (“Ethics in Clinical Practice”). The question is, “What should the doctor do if the truth will harm the patient and violates the privacy code between the patient and the doctor? Isn’t it better for the doctor to lie than to break the ethical principles of non-maleficence and privacy?”(Mathies). The following case will elaborate on when and why the doctor is forced to lie. Justification for this lie is debatable. There is no medical ethics principle that justifies lying, even for therapeutic privilege; it only allows the doctor to withhold or tailor information that might cause harm to the patients, but not actively lying ((Mathies). However, in the following case the doctor needed to give a “Yes” or “No” answer. Any other answer would provoke doubt and curiosity to know the truth. If I were in this doctor’s place I will do exactly what he did…I would lie.

Case:

A doctor planned to do a “radical nephrectomy on a patient.” The patient’s son informed the doctor that he and his father were Jehovah’s Witnesses and they do not want to receive blood transfusion, regardless of the situation. The doctor asked the patient if this was his wish too and the father reluctantly agreed. After explaining the procedure and the consequences of their choice, the doctor made the patient sign documents (informed consent) that would release the doctor from any negligence if the patient would need a life-saving blood transfusion. However, one day before the surgery, the patient confessed to the doctor that he wasn’t that religious and he doesn’t mind to receive blood transfusion if he needs to. However, he asked the doctor not to tell him or tell his son if he was to receive any blood. The doctor documented the conversation on the patient’s chart and informed the blood bank to hold some units of the patient’s matched blood. During the surgery, the patient lost a substantial amount of blood and the subsequently became anemic and hypotensive. The doctor ordered the blood transfusion to be delivered to the patient in the recovery room. The doctor informed the nurse not to tell the family about the blood transfusion and not to let any of them into the recovery room during the transfusion. Also, to cover any tracks of having received blood, the doctor requested from the nurse to remove all respective IV tubing prior to having the family visit. When the doctor met the patient’s son after the surgery, he explained that the surgery was more difficult than expected but his father is stable. Then the son asked if his father received a blood transfusion since the family was contacted by the blood bank to ask if anyone wanted to donate matched blood.  Here the doctor didn’t know what to say. The dilemma faced in this situation was, should he lie and say “no there was no blood transfusion” or shall he reveal the truth and harm the patient’s relationship with his family, not to mention disobeying the patient’s privacy? The challenge was to either tell the truth and break the relationship between the father and son as well as between the doctor and patient or tell a lie and protect the patient’s wishes and his relationship with his son.  The doctor lied and assured the son that his father didn’t receive any blood transfusion. The son was relieved (“Transfusing a Jehovah’s Witness during Surgery”)

Discussion

Beauchamp and Childress suggest that there are three elements of informed consent: understanding, voluntariness, and authorization of intervention (Beauchamp and Childress, 131). In this case, the patient’s voluntariness is questioned only because of external constraints and not because of lack of adequate knowledge or “absence of psychological compulsion”. Beauchamp and Childress state that a person is considered to act voluntarily in the absence of another person’s control (138); unlike persuasion, manipulation and coercion control the patient and are thought to diminish voluntariness and autonomy (138). In this case, the patient, who is not an extremely devout Jehovah Witness, feared that his relationship with his son would deteriorate if he authorized blood transfusion. That is why the patient authorized blood transfusion in the absence of his son’s presence and influence. The patient also asked the doctor not to tell him if he receives blood transfusion so that he wouldn’t feel guilty for disobeying the rules of his religion.

This is also a patient case touching on the controversial and complicated dilemma of a physician deciding between moral beliefs, patient privacy, and non-maleficence. I totally agree with what the doctor did. The doctor’s dishonesty in this situation is justifiable as it avoids violating the patient’s privacy, non-maleficence, as well as, preserving both the son-father and the doctor-patient relationship. According to the “Declaration of Geneva” the doctor-patient relationship is the cornerstone of medical practice and medical ethics. The physician has to place the patient’s heath as his number one priority (Palaez). I personally believe that when physicians take the oath of Hippocrates and abide by HIPAA laws, they are destined to act on behalf of the patient they are treating and to do all that they could to preserve patient privacy and rights.  I certainly agree with the case where the physician should at all-time keep the patient’s privacy as a number one priority during the care of a patient and their family.  In this specific situation, I agree that the physician has been given the authority, per the patient, to not disclose any information about blood transfusion to the patient himself and his family.  For that reason, the fact that the meeting with the patient and what he requested was clearly documented, that removes any liability from the physician and thus he is permitted to act in such a manner to avoid disclosing any information that may harm the patient or his relationship with his family.  Furthermore, the legal consequences related to blood transfusion in Jehovah’s Witness patients permit the doctor to meet with the Jehovah’s patient alone and even outside the presence of close family members to confirm the patient’s actual wish and faith in relation to this issue (“Transfusing a Jehovah’s Witness during Surgery”). This was exactly what the doctor did. Education alone cannot teach a physician to the best at what he does. It is the doctor’s courage, compassion and moral goodness that impacts medical practice.

Why is the doctor’s dishonesty morally justified in this case compared to that of Amira’s?

In the “Emergency and Trauma Nurses” case, it is debatable whether Amira should be deceived about her partner’s death, Casey. In this case, the nurses have a moral dilemma between Amira’s beneficence, non-maleficence, and autonomy. The blatant truth may destabilize Amira’s fragile medical condition. As the trauma nurse, I would avoid answering Amira’s question by saying, “we will inform you as soon as we know” or “our primary concern right now is your health”. Although this is considered a form of deception, as mentioned above, therapeutic privilege allows the doctor, or the nurse, to withhold or tailor information that might cause harm to the patients (Mathies).

Works Cited

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

“Ethics in Clinical Practice.” NursingLink. N.p., 2015. Web. 14 Feb. 2015.

Mathies, M., and N. Hogg. “Absence of Monocyte Procoagulant Activity during the Immune Response to Influenza Virus.” Journal of Clinical Microbiology. U.S. National Library of Medicine, n.d. Web. 14 Feb. 2015.

Paleaz, Jose. CHAPTER TWO – PHYSICIANS AND PATIENTS (n.d.): n. pag. Web.

“Transfusing a Jehovah’s Witness during Surgery.” KevinMD.com. N.p., 13 May 2011. Web. 14 Feb. 2015.

Background:

This particular case study describes two clinical scenarios, which show a placebo being administered. Case 2 describes a 40-year-old man who is diagnosed with gastroenteritis. The patient reports that he is suffering from diarrhea and abdominal cramps. As the doctor explains to the patient that the symptoms will subside, the wife of the patient demands that the patient be given an injection of penicillin. As the doctor refuses, he insures the wife that he will make another house visit if the symptoms do not subside within 24 hours of him leaving.

Dilemma:

The ethical problem with the placebo is that as it is usually used only for control groups in research studies.  When used in clinical settings the question of whether the patient is being misled if given a placebo or if any harm can come from such usage becomes a concern. As we know the problem is not that the patient is receiving ineffective medicine but it can be useless or produce less desire side effects. Raising the issue that the doctor is deceiving the patient is a violation of the patient’s rights to be honestly and fully informed about the treatment. So the issue here is if it is right for the physician in Case 2 to administer his patient a placebo, if that is what the wife is demanding.

Discussion:

Research has proven that in some cases placebos have resulted in effective therapies, but as discussed previously the problem is the deception and harm the doctor can become responsible for. However, in this particular case, the patient has been advised that the symptoms that he is experiencing will subside with due time. As the doctor has fully assessed him and concluded that prescribing pain medications or an antibiotic is not a necessity in this matter it only would be right for him to do what’s in the patients best interest. But there is a possibility that the suggestion to give an injection may cause the symptoms the patient is experiencing to subside. Now we need to assess if the possibility of this “cure” is worth the doctor trying the placebo. Penicillin is an antibiotic, which is commonly to treat a bacterial infection. However treating with antibiotics for viral infections has no effect on the actual virus and can cause antibiotic resistance. Which is probably why in this situation the doctor chooses not to give an antibiotic.

For these reasons, I do not believe that the administration of the placebo in Case 2 was unethical or a violation of the patient’s rights.  From a professional viewpoint I believe the physicians duty is always to keep the patient out of harms way. So his decision not to administer the penicillin reflects that the physician knew that it was unnecessary. To elaborate the doctor knew that the administration of the unnecessary drug could cause antibiotic resistance for the patient, which can impede on the patient ability to relieve proper care if he is to have a viral infection in the future. As we look at the bigger picture its important to always remember that doctors are always to make sound decisions based on what is best the patients health.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1733989/pdf/v030p00551.pdf