Background:

            The CDC FastStats sheet states that, in 2013, there were roughly 30,000 deaths and 10.7 deaths per 100,000 people in the population from motor vehicle traffic accidents. In the case, “When to Give Bad News,” the victim of a serious car accident, Amira, is being treated for various severe injuries such as a collapsed lung and kidney damage. Meanwhile, her partner, Casey, passes away at the same hospital. As Amira is preparing for surgery that may or may not save her life, she asks about Casey as well as her daughter who was successfully treated at a different hospital.

Dilemma:

One dilemma that is important to discuss is whether the nurses should tell Amira about the passing of her partner before her surgery as she drifts in and out of consciousness. Amira does ask about the well-being of her child and Casey when she is conscious. Therefore, it can be argued that it is unethical to either lie about her partner being alive or to not respond to the question at all. This course of action would count as a violation of her autonomy regarding the decision of whether she wants to hear the truth. In addition, the medical staff could theoretically deliver the news after Amira recovers from the procedure, but as the case states, there is a possibility that Amira may not survive the surgery, so they may not have the chance to tell her later, which would lead Amira to pass away without knowing about Casey’s death.

However, there are also several reasons for not providing Amira with this information. For example, the case mentions that Amira’s condition is very serious, “Her physical status is unstable, and the nurses and their colleagues fear that any further stress might seriously impair her capacity to survive the surgery and post-operative care in a coma” (Moorhouse and Khan, 233). The medical team appears to believe that Amira may not be able to make a full recovery if she endures more stress. Learning about the death about her loved one would certainly count as the addition of a significant amount of stress.  The medical staff would, thus, be violating the nonmaleficence principle by endangering the health of their patient with this stressful news about the death of her partner.Therefore, the medical staff definitely must consider her medical well-being as they decide when to deliver the bad news.

Conclusion:

While it could be seen as unethical, assuming she dies during the surgery, to let Amira pass away without knowing about Casey’s death, I would argue it is even more unethical to increase Amira’s chances of not surviving the procedure by delivering this news as she is about to be operated on. Autonomy is a very important principle to uphold, but in this case, it would harm Amira, so nonmaleficence should outweigh autonomy. Ultimately, as medical professionals, it is the staff’s job to do all they can to save Amira’s life, and in this difficult situation, I suggest lying about Casey or withholding that information entirely and then hoping that Amira survives the procedure so that they can tell Amira the truth after she recovers.

References:

CDC. “Accidents or Unintentional Injuries.” Centers for Disease Control and Prevention. N.p., 06 Feb. 2015. Web. 13 Feb. 2015.

Moorhouse, A. and P. Khan “Case 3: Emergency and Trauma Nurses: When to Give Bad News” Concepts and Cases in Nursing Ethics. 232-242.

Source for the image: http://www.injurylawyers.com/wp-content/uploads/2014/11/2-car-crash-1-300×225.jpg

One of a physician’s prime objectives is to do no harm to their patients. So, based on that requirement and the principle of beneficence a physician administering a placebo treatment is not morally compromising. In administering placebo the physician limits and often times eliminates suffering with no major side effects to the patient (551 Lichtenberg et al). Looking only at the placebo being a substance that does not have active ingredients is missing its true purpose. As Lichtenberg et al imply, one must look beyond the biomedical perspective of healing in order to understand the placebo’s place in medicine. With the ethical guidelines Lichtenberg et al laid out for using placebo in mind, a placebo treatment is morally sound. That stated, I wanted to address the particular case where the physician did not administer a placebo as the more moral action to take.

In the second vignette from the Lichtenberg et al article it tells of a house call made to a 40 year old man diagnosed with gastroenteritis. The patient’s wife insisted her husband be given a shot of penicillin for his ailments despite the apprehension of the physician. Ultimately, the physician is able to leave without administering the antibiotics with a promise to come back if the patient wasn’t relieved in 24 hours. In this case it would have been highly unethical for the physician to use a placebo treatment because of the possible negative effects.

Gastroenteritis, otherwise known as the stomach flu involves your stomach and intestines being inflamed and irritated. The stomach flu has nothing to do with influenza (flu) and the cause of infection can either be viral or bacterial. If the cause is bacterial then it is caused by microbes, which are infectious microscopic single-celled organisms. Theses organisms can go undetected on foods and surfaces until they begin to cause infections in one’s body. Whereas, viral infections are also cause by microbes but these have an outer protein coat, which incases a DNA core that requires other cells to replicate. To treat a bacterial infection, most physicians prescribe antibiotics because they can kill bacteria and/or stop them from reproducing. However treating with antibiotics for viral infections has no effect on the actual virus and can cause antibiotic resistance. Antibiotics flush your system of bacteria both good and bad, but the full prescription must be taken in order to do this. If a patient does not take the full regimen of antibiotics the body can build a tolerance to antibiotics with the bacteria that remains. In the case of treating viruses, since there are no infectious bacteria to clear out the chances of your body building immunity to the antibiotics is much higher. As a result, an even stronger dose of antibiotics will be required for the next time an infection occurs or worst-case antibiotics become ineffective. Thus, future infections will be harder to treat and cause longer suffering for the patient.

Given the above information, if that physician were to administer penicillin, an antibiotic, in this instance to the patient he would have been enacting harm. Being antibiotic resistant is a problem for the medical field and detrimental to patients. In this case, the penicillin’s sole purpose would have been to mollify the patient, which Lichtenberg et al point out as unethical use of placebo. So some might argue that the physician had a dilemma of whether to acquiesce to the spouses request or not. However, with the potential of all that could go wrong with irresponsible use of antibiotics his choice is clear. Therefore, the physician – and any for that matter – would be violating his moral obligations in using antibiotics as placebo.

Works Cited

“Bacterial vs. Viral Infections: Causes and Treatments.” WebMD. WebMD. Web. 13 Feb.

2015. <http://www.webmd.com/a-to-z-guides/bacterial-and-viral infections?page=2>.

“Gastroenteritis (Stomach Flu): Symptoms, Causes, Treatments.” WebMD. WebMD.

Web. 13 Feb. 2015. <http://www.webmd.com/digestivedisorders/gastroenteritis>.

Lichtenberg, P., U. Heresco-Levy, and U. Nitzan. “The Ethics Of The Placebo In Clinical

Practice.” Journal of Medical Ethics 30.6: 551-54. JSTOR. Web. 13 Feb. 2015.

U.S National Library of Medicine. U.S. National Library of Medicine, 25 Aug. 2014.

Web. 14 Feb. 2015. <http://www.nlm.nih.gov/medlineplus/antibiotics.html>.

This case poses a challenging moral dilemma about when tragic news should be relayed to a patient. Amira Mullins is the featured patient, as she is in critical condition, is in desperate need of emergency surgery, and is questioning the state of her loved ones. The dilemma involves the issue of non-maleficence, beneficence, and autonomy. In this case, I argue that non-maleficence and beneficence temporarily outweigh autonomy. Maintaining a relationship based on trust between nurses and patients should be paramount while also promoting the health of the patient. In this instance, the concept of promoting the patient’s wellbeing and the concept of remaining honest and forthcoming are at odds. The moral dilemma is whether the nurses should immediately inform Amira of her partner’s death or wait and inform Amira when she is in a more stable condition. I argue that the nurses should wait to inform Amira of her partner’s death.

Beauchamp and Childress define nonmaleficence as “a norm of avoiding the causation of harm” (13). In this instance, Amira needs surgery in order to survive and prevent the risk of further harm. Immediately informing Amira that her partner died when she is in such a fragile state is not practicing nonmaleficence. It is never a good time to hear about the loss of a loved one, but hearing such news places further stress on Amira’s body, possibly pushes back surgery, and promotes risk of additional harm. Beneficence is defined as “a group of norms pertaining to relieving, lessening, or preventing harm and providing benefits and balancing benefits against risks and costs” (Beauchamp & Childress 13). The nurses in this case should emphasize the fact that her daughter Samantha is okay and stress that it is important for her to try and remain calm. Telling Amira that her partner died can only result in more harm.

While Amira has a right to know about her partner’s condition, the timing of such knowledge could be detrimental. It is in Amira’s best interest for the nurses to focus on Amira’s wellbeing and postpone adding additional stress. There is the possibility that Amira could die during surgery without knowing about her partner’s death, but the nurses need to do all they can to lessen the psychological strain on the body. Waiting until Amira has recovered from surgery, is stable, and in a calmer environment is the only way to ensure that Amira can physically withstand news of the death of her partner. An emergency room setting is never ideal to notify a family of the death of a loved one. The fact that the patient is in and out of consciousness also prompts whether she is stable or competent enough to be interviewed by the police. The patient’s physical wellbeing in this instance overrides all else.

This case brings the moral obligations and responsibilities of nurses into consideration. The relationship between nurses and patients is often based on trust, but it can be challenging to make sure the patient’s physical wellbeing is always at the forefront. One study conducted in Sweden by Cronqvist, Theorell, Burns, and Lützén (2004) interviewed intensive care nurses. This study contrasts the tendency to “care for” versus the tendency to “care about” patients. Cronqvist et al. found that it can be challenging to balance “moral obligations and work responsibilities” (73). This furthers the notion that nurses may feel inclined to maintain a trustworthy relationship, as indicated by their profession’s code of ethics, while also weighing the moral implications of their actions.

Works Cited:

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

Oxford UP, 2009. Print.

Cronqvist, A., Theorell, T., Burns, T., & Lützén, K. (2004). “Caring about—Caring for: Moral

obligations and work responsibilities in intensive care nursing”. Nursing Ethics, 11(1),

63-76.

Background:

This article discusses three separate cases in which a placebo was administered in clinical settings. I am going to focus on Case 1. In this case we have a 45 year old man suffering from diabetes and hypertension who has just undergone a second leg amputation. Following the surgery, the man was facing severe pain and after being treated with multiple injections his pain still hadn’t subsided so the staff decided to administer him intramuscular saline, a placebo, which ultimately helped with the pain but was the patient deceived?

Dilemma:

The ethics of the placebo have typically been dealt with in a research setting, however here we are questioning the use of the placebo in clinical practices. In research studies, the use of the placebo is a very common method of evaluating a control group versus an experimental group. However when patients go to their physicians, they are seeking out a cure or treatment for whatever illness they are facing, they are looking for a prescription and generally they trust their physician’s opinion and ultimate method of treatment. So the issue here is was it right for the physician in Case 1 to administer his patient a placebo, while having his patient believe he was being treated with a legitimate pain killer

Discussion:

Placebos have been proven to be an effective method, so that is not where the ethical problem is. Rather, the ethical problem is whether or not administration of a placebo is deceiving the patient. If it is indeed deception, then the placebo treatment would always be unethical and a violation of the patient’s right to be fully informed at all times.

However, in this particular case, the patient was told that the injection he was going to be given would ease his pain. Not only was he told this but his physicians had full belief that the saline would indeed work as they had anticipated. And ultimately that is exactly what it did, the treatment, although it was a placebo, did in fact significantly reduce the patient’s pain. So where is the dishonesty in communication between doctor and patient? It doesn’t seem like there is any.

Yes, the patient has a right to know what he or she is being administered and any other medical information that they want. However, if they do not ask their physician for this information then the physician is not obligated to tell them. This is very different from a physician withholding potential negative side effects of a treatment or medication; we cannot confuse the two situations as they are entirely different and in the latter case I believe the physician does have an obligation to tell their patient any potential consequence of a treatment or prescription. But in this case there are no negative side effects that the physician is withholding, and if the patient were to ask for the name of the pill or how it works then yes, in any situation, he or she should morally be given that information in complete truth. But the patient did not ask the physician those questions, therefore that information is not required to be given.

For these reasons, I do not believe that the administration of the placebo in Case 1 was unethical or a violation of the patient’s rights in any way, shape or form. I believe that the physician was looking out for the best interest of his or her patient and since the patient did not ask for specific information about the pill he was being administered, it was unnecessary for the physician to say anything.

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

Background

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

Dilemma

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

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

Reflection

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

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

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

Works Cited

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

Nurses and doctors in emergency and trauma situations often walk a fine line of how to most effectively uphold their duty of causing no harm to the patient. While it is their duty to be honest with patients, they reach a crossroads when that honesty could do more harm than good.

The dilemma in “Case 3: Emergency and Trauma Nurses: When to Give Bad News” is when it is necessary to tell the truth to a patient in situations where delivering this news might jeopardize a patient’s health, or possibly even life. In this case, Amira’s partner Casey dies in the car crash, but the doctors are faced with a dilemma when she asks how Casey is doing. Amira is in very poor health and may not survive herself, so by telling her that her partner has died could put her body in such distress that it could possibly lead to her death as well.

On one hand, some nurses might argue that their first and foremost duty is honesty to the patient. According to an article in the Ghana Medical Journal, “a doctor who withholds information from a competent patient… violates the ethical principles of autonomy, beneficence and nonmaleficence.” By intentionally withholding information, the nurse is acting with intentional deception—a form of paternalism. And in turn, this reduces the patient’s autonomy.

On the other hand, other nurses could argue that in trauma cases like Amira’s, beneficence trumps autonomy. The nurse’s goal is to protect the health of the patient and to keep her alive, and by telling her this information, they are not displaying nonmaleficence or beneficence because it would do no good to the patient in dire need. It is also important to recognize that Amira might not be in a competent state; she is likely in a state of shock both physically, psychologically, and emotionally, and is also likely receiving drugs to alleviate the pain and prepare her for surgery.

Therefore, in trauma cases like these, I believe each situation must be contextualized in order to make the correct decision. If the patient is stable (and thus, the nurses have already upheld their duty to the health of the patient) and competent, then the nurse does need to uphold his or her obligation to tell the truth and deliver the bad news. However, if a patient is in a dire emergent situation (for example, near death and about to enter surgery, like Amira), lacking full competency, and the information would cause harm to the patient’s chances of survival, the duty remains to the health of the patient, and the information can be withheld until the patient is more stable.

Works Cited:

Yeo, Michael. “Case 3: Emergency and Trauma Nurses: When to Give Bad News.” Concepts and Cases in Nursing Ethics. 232-242.

Edwin, AK. “Don’t Lie but Don’t Tell the Whole Truth: The Therapeutic Privilege – Is It Ever Justified?” Ghana Medical Journal 42.4 (2008): 156–161.

Background

              In this article, the use of a placebo in a clinical setting is discussed through three separate cases. The first case references a 45 year old man that has suffered from diabetes and hypertension for numerous years. The man “underwent a second leg amputation. Severe pain following the surgery was treated…” The post-surgery pain was treated with proven medical techniques, but was unsuccessful in abating the pain. Hospital staff administered injectable saline that “had been used as an effective painkiller, and that they anticipated that it would help his pain…” The saline helped with his pain, which was just a placebo.

The second case refers to a 40 year old male complaining of diarrhea and abdominal cramps. This is a result of gastroenteritis. In desperation (and lack of medical knowledge and overall sense), the spouse of the man demands that her husband receive “a shot of penicillin in the butt”.

The third and final case addressed in this article discusses a 32 year old mother that is suffering from agitated depression. She is being treated with hypnotherapy. After a bad experience with the hypnotherapy, the patient refuses further treatment. The psychiatrist prescribes 25mg of a medicine that is only proven to have results with doses of 200-300mg. The patient begins to improve with this 25mg dose. (Lichtenberg, Heresco-Levy, Nitzan)

Dilemma

              In research studies, placebos are used frequently in order to gauge a control group versus a treatment group. When dealing with research, subjects are not consulting their physician looking for a proven cure, but rather an experimental fix. Alternatively, when patients visit their physician, they come in order to receive improvement on their illness. The job of the doctor is to prescribe the correct and proven medication to aid in the health improvement of the patient. The dilemma with using placebo is a clinical setting is whether a doctor should be able to give his patients a pill or a procedure that has the possibility of working on a psychological level as opposed to the doctor being required to supply the patient with the scientifically tested and proven treatment that is certain to cure the ailment of the patient.

Discussion

              There are numerous ethical considerations to ponder while analyzing the issue of clinical use of placebos. For every case, alternate considerations will be present, so each case must be looked at individually.

In case 1, since the hospital has exhausted their analgesic options, the only route left for staff to administer is a placebo. Since there are no scientifically proven alternatives left to attempt to administer, the next best option is to try a placebo. The placebo has no drawbacks in this case because it is the only treatment option left.

In case 2, no treatment options have been attempted. There are two placebo examples present here. The first is presented with the doctor. When the doctor says that he is certain that symptoms will subside within the upcoming 24 hours, the patient has in their mind the placebo effect that they will indeed improve condition in the next 24 hour period. The second placebo effect present in this case is that the wife is convinced that the only viable and cogent treatment is the penicillin that only treats bacterial infections. The penicillin would have rendered useless as antibiotics is not a treatment for gastroenteritis. “There’s no effective treatment for viral gastroenteritis (mayoclinic.org).” The wife’s insistence on the antibiotic administration forces the husband to also have the placebo effect in which he thinks he needs the penicillin to improve in health.

In case 3, again the doctor appears to have exhausted all possible proven treatments. The next option is to administer a placebo and see if symptoms persist.

Overall, the clinical use of placebos must be analyzed case by case because, of course, every case is different. In general, if the doctor has utilized every other possible proven treatment, then the doctor ought to prescribe a placebo in an attempt to see if symptoms persist or cease. Furthermore, if a patient has not tested all viable treatment options, the doctor ought to not prescribe a placebo until all other options have been tested. The doctor ought to do this because “The one thing of which we can be absolutely certain is that placebos don’t cause placebo effects.

Placebos are inert and don’t cause anything (Moerman DE, Jonas WB).” This statement may not be entirely valid, but the point is that placebos are not as effective as the correct treatment. “I don’t believe that the use of placebos is immoral or unethical. In reality, it seems that the medical profession’s lack of understanding and utilization of the mechanism of the placebo in the healing process is tragic, shortsighted and cowardly (wrf.org).” It may be easier for physicians to approach placebos and say that they do not work, but evidence proves that if used, placebos do work between 30%-60% of the time (wrf.org). As long as a patient is receiving the most beneficial treatments prior to administration of placebos, doctors ought to utilize placebos when no other viable treatment is present.

Works Cited

1. “The ethics of the placebo in clinical practice” by P. Lichtenberg, U Heresco-Levy, U Nitzan
2. http://www.mayoclinic.org/diseases-conditions/viral-gastroenteritis/basics/definition/con-20019350
3. Moerman DE, Jonas WB. Deconstructing the placebo effect and finding the meaning response. Ann Intern Med 2002; 136:41-6
4. http://www.wrf.org/alternative-therapies/power-of-mind-placebo.php
5. http://familyrights.us/images/pills101/
6. http://thedoctorweighsin.com/physicians-surveyed-gloomy-about-healthcare-reform/

          Informed consent requires the voluntary authorization for an action based on the complete understanding of such action. Thus, one cannot perform a treatment or intervention on another without gaining permission to do so. However, O’Neill articulates that limitations to informed consent exist. For example, incompetent patients, public health interventions, personal information, and vulnerable populations do not require informed consent in order to proceed with an ethical practice (O’Neill 2003). Although some of the aforementioned exceptions, such as public health interventions, do not warrant informed consent for an ethical practice, other limitations, such as vulnerable populations, should require informed consent.

          To begin with, public health interventions ignore the necessity to obtain informed consent, for they act on the principles of beneficence and nonmaleficence. For instance, vaccinations induce protection against a disease. Thus, by vaccinating a population, the risk of contracting a disease decreases. Unfortunately, many individuals in the United States are refusing to vaccinate their children against measles. Consequently, the prevalence of measles in the United States has greatly increased, as illustrated in Figure 1. Epidemiologists have traced the source of the outbreak to an individual in an amusement park in California (Centers for Disease Control and Prevention 2015). The source, an unvaccinated traveler, visited the amusement park while infectious (Centers for Disease Control and Prevention 2015). As a result of the abundance of unvaccinated individuals in the United States and the highly contagious characteristic of measles, herd immunity did not protect the seven-hundred individuals from the disease (Centers for Disease Control and Prevention 2015). Furthermore, the disease will likely spread to additional people in the United States, because individuals are refusing vaccinations against measles. Thus, the autonomy to give informed consent for an intervention does not adhere to the principle of nonmaleficence, for the unvaccinated individuals are causing harm to others. Therefore, public health officials should mandate the immunization of all individuals against the disease without requiring informed consent.

Figure 1.

Prevalence of measles in the United States.

    Although vaccinations support O’Neill’s claim of limitations of informed consent, prisoners challenge her idea of vulnerable populations. For example, O’Neill explains that individuals under duress have the capacity to consent but the inability to refuse (O’Neill 2003). However, ethical practices can still occur despite the lack of informed consent (O’Neill 2003). Unfortunately, history does not display ethical behavior towards prisoners. For instance, during the Nuremberg Trials, Nazis performed experiments on the prisoners without their consent (Emanuel  2003). For example, Nazis infected prisoners with malaria to test antimalarial drugs, placed prisoners in low-pressure tanks to analyze length of survival with little oxygen, and burned prisoners with phosphorus bombs to examine consequent wounds (Emanuel  2003). Although the Nazis were performing the experiments for the amelioration of society, the principle of beneficence does not apply. Therefore, the Nazis were not engaging in ethical behavior. Moreover, modern scientists have generally accepted the Nuremberg Trials as unethical practices. However, based on O’Neill’s explanation of the lack of requirement for informed consent of prisoners, society cannot prevent experiments such as the aforementioned examples from occurring again. Although prisoners do not have freedom, they should not lose the autonomy over their own bodies; prisoners should give informed consent as well.

          Thus, limitations of informed consent may exist, as illustrated with the public health interventions. However, treatment towards prisoners without informed consent does not equate ethical practice. Therefore, the context of the exception influences the limitation of informed consent and categorizes it as ethical or unethical.

Centers for Disease Control and Prevention. “Measles Cases and Outbreaks.” Centers for Disease Control and Prevention. February 02, 2015. Accessed February 02, 2015. http://www.cdc.gov/measles/cases-outbreaks.html.

O’Neill, O. “Some Limits of Informed Consent.” Journal of Medical Ethics 29, no. 1 (2003): 4-7. doi:10.1136/jme.29.1.4.

Case 1.1 handles the moral dilemma of who should decide whether or not Mrs. Francois should have the second surgery. Both the doctor and the patient’s family are in disagreement with the patient about her choice not to have the surgery. The family feels very strongly about Mrs. Francois having the surgery, whereas the doctor does not have the same emotional involvement, but feels that the surgery is the best medical decision for Mrs. Francois. This case deals with the moral issue of autonomy. As the patient on whom a medical intervention is being made, Mrs. Francois is legally granted full authority to decide whether or not to have the surgery. This case, however, questions many aspects of her decision.
As a precursor to an autonomous decision, the patient needs to be fully informed. The responsibility of this lies in Mrs. Francois’ doctor. As her doctor, he needs to adequately explain the surgery, as well as its potential risks and benefits. The case study does not provide details of what the surgeon said. The surgeon should take his responsibility a step further by also explaining other potential options to Mrs. Francois and their outcomes. He needs to not let his bias as a surgeon sway her towards surgery if there is another method available to her.
The doctor, however, still needs to make a recommendation. Medical recommendations inherently can be biased with doctors recommending prescriptions they commonly use, surgical methods they are used to, and methods of treatment they are most familiar with. This if not inherently bad, though, if their recommendations are most helpful to patients. It becomes as issue when financial biases are attached to their recommendations, which is why there are laws in place that require doctors to disclose medical practices in which they have a financial interest. In this case study, it would be incredibly wrong for Mrs. Francois’s doctor to recommend surgery if there was a better alternative, simply because he would earn more money from her insurance company from performing surgery. Recommendations are necessary because patients are in a vulnerable position because they do not have the same medical expertise as doctors. They need to rely on doctors to help them make decisions that are best for their health, which is why doctors need to give them a recommendation based on solely medical grounds.
After doctors make recommendations, they need to make sure patients understand the information they have disclosed and their recommendations. This element becomes much more ambiguous and difficult for a doctor to fulfill. In the case of Mrs. Francois, the doctor had difficulty knowing if Mrs. Francois fully understood the information given to her. While the doctor could be sure he told her everything he needed to tell and made a nonbiased recommendation, it was hard for him to be sure she fully understood everything. This was called into question because resisting the life-saving surgery seemed irrational and against her early behavior when she consented to the first surgery.
The overall issue in this case was whether or not Mrs. Francois was competent to make the decision. Because of all of the medical issues she has recently dealt with, her family argued that she was not competent, but the doctor felt she was because she could communicate in an intelligent manner. As the patient, the decision should ultimately be hers and the doctor needs to act in accordance with that. Because of the circumstances of Mrs. Francois’ health and her family’s disapproval, a third party should be brought in to judge her competence. The surgeon should receive a second opinion from a psychiatrist to judge whether or not Mrs. Francois is medically competent.
If the psychiatrist deems that Mrs. Francois is competent, then her decision to not have surgery should be honored. While the surgeon may be legally threatened by the son, this is not a reason for him to operate and he should stand by his decision to respect Mrs. Francois’ choice. If the psychiatrist feels Mrs. Francois is not competent, then the surgeon should honor the family’s wishes and perform the surgery. This could potentially save Mrs. Francois’ life and the surgery should not be forgone because she is temporarily mentally ill. In this situation, taking away Mrs. Francois’ autonomy to choose is the best choice because it can bring her the best outcome and reflect what she would have chosen if she was mentally competent.

Often times in our modern society life is valued far more highly than it should be. This weeks readings had a case on informed consent. Where the complication occurred where a patient was asked for consent and her life was at risk yet refused to be treated. Yet regardless of the doctors advice, her deep seated beliefs caused her to refuse surgery. Normally that would be the end of that yet her family all gave consent and even called into question her competency. In this case I would argue to let her follow out her wishes, barring complications to the case such as mental illness or drug abuse, she was making a conscious informed decision with the doctor having informed her thoroughly about the procedure and her chances of survival without. If she wants to take her chances, I would say let her.

While this may seem cold, there is one truth in economics and that is there is scarcity. With 7 billion people on this planet and growing there is no shortage of human life. Here’s a fun fact, it takes $2.8 million per prisoner per year for Guantanamo bay. The average American household incomes is only 50,000. That’s 5-6 families worth of money per year we are spending on prisoners.

How is this related to consent? This case reminded me of another controversy regarding saving someones life against there will. When prisoners go on hunger strikes, they are force fed to keep the alive. One recent one is the Guantanamo bay force feeding sessions (http://www.theguardian.com/us-news/2014/oct/03/guantanamo-force-feeding-videos-released). Something that is against there will, without consent, and yet is done in the name of preserving life. So is life preservation so noble a goal anymore when it comes down to something like this and when it costs so much?