Dilemma

In this case Mr. Joe Mulroney had a fatal reaction to an angiogram. The dilemma lies within the anaesthetist’s decision to not tell Mr. Mulroney about all of the possible risks of the procedure, which leads one to question if there was truly informed consent. After Mr. Mulroney died, his son was critical of the doctor’s morality. The son believed it was the doctor’s duty to tell his father of all possible risk factors. The doctor claimed that the risk of death from this procedure was so small therefore in his opinion it wasn’t necessary to disclose that to patients. The dilemma is whether or not the doctor ought to disclose patients of rare risks in a procedure (Thomas 276-277).

Discussion

In this case the doctor was working under the idea of intentional nondisclosure. He claimed that since the risk was so small there was no need to “burden” Mr. Mulroney with the small possibility because no benefit would come of disclosing the information. Intentional nondisclosure can justified by the principle of nonmalificance “if and only if the patient’s knowledge of the information would have serious health related consequences” (Beauchamp 128). This can be specified into the rule of “disclose all information regarding the situation except if it will cause serious health related consequences”. The doctor claimed that the possible risk of death may cause a patient to opt out of the procedure which would cause more harm to the patient than proceeding with it. In this case the doctor balanced the principles of autonomy and nonmalificance. He believed that telling the Mr. Mulroney could cause more harm to him than withholding the information therefore he chose nonmalificance. In my opinion the doctor did not adequately factor in Mr. Mulroney’s autonomy therefore preventing him from giving informed consent. Informed consent not only requires that the patient is aware of all of the information and understands it but also the ability for a doctor to give their opinion and help the patient make theirs. When the doctor was speaking with the patient’s son he described Mr. Mulroney as a “reasonable man”. If the doctor truly believed that he was a reasonable man then he would have been able to mention the very small risk of death to the patient. After mentioning the risk, the doctor could then further the conversation and help Mr. Mulroney understand that the probability of death is very low and the benefits of the procedure will outweigh that risk. The doctor ought to disclose this risk to his patients because it aids them in making an informed decision.

Similar Case

Another case that involved nondisclosure was Pauscher v Iowa Methodist Medical Center. In this case Mrs. Pauscher had an intravenous pyelogram six days after giving birth. In her medical records it stated that she had no allergies and she was not told of the risk of death from this procedure. She ended up going into anaphylactic shock (Towsley 86). If she was aware of the possible risks of the this procedure she may have been able to recall important information about her allergies and been able to survive. The court ruled that it was not the hospitals fault. This relates to Mr. Mulroney’s case because with rare risks the doctor is usually not held responsible if someone has an adverse reaction therefore it does not pose a threat to the doctor to inform his patient. Doctors ought to disclose all information to their patients and help them fully weigh the risks and rewards when making their decisions.

Sources

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 5^th ed. New York, NY: Oxford UP, 2001. 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.

Towsley-Cook, Doreen M., and Young, Terese. Ethical and Legal Issues for Imaging Professionals. 2^nd ed. Maryland Heights, Missouri: Mosby, 2007. Print.

Background:

A gynecologist examines a 63-year-old 5-foot, 315-pound patient named Marie with a diagnosis of stress incontinence in Canada. After performing an ultrasound, the gynecologist discovers an ovarian cyst and elects to perform a surgical hysterectomy and remove both her ovaries. The surgery injures her colon leading to post-operative complications. A surgeon confirms that leakage from her colon could kill her unless he conducts a second reparative surgery. Marie appears to be cognizant of her situation, but denies surgical treatment. When the doctor chooses to comply with her wishes, her son threatens legal action against the doctor unless he operates, claiming his mother is acting incompetent.

Dilemma:

The immediate dilemma is whether or not the surgeon should operate using surrogate consent under the principle of non-maleficence or respect Marie’s autonomy. However, from a medical standpoint an additional dilemma surrounds Marie’s initial surgery. For a diagnosis of ovarian cyst and stress incontinence, was invasive surgery the best treatment? Did Marie give truly informed consent if the surgeon did not educate her on other treatments? Without the initial surgery, the current dilemma between Marie’s surgeon and her family would not exist.

Analysis:

When reading Marie’s case, it is easy to skim over her listed age, stature, and weight, but they are crucial to her medical diagnosis and avoidance of the dilemma described above. Marie is only 5 feet tall, but weighs 315 pounds. Marie’s calculated BMI of 61.5 (“Adult BMI Calculator: English”) categorizes her as morbidly obese. Obesity serves an additional risk factor for gynecologic surgeries.  According to a report released by The American College of Obstetricians and Gynecologists, “As BMI increases for women undergoing abdominal hysterectomy, so does the risk of surgical site infections and wound complication” (Committee Opinion 275) and “Obese patients commonly have comorbid conditions…that can complicate intraoperative and postoperative care” (Committee Opinion 277).

Marie is 63 years old, classifying her as a post-menopausal woman (According to the Canadian Women’s Health Network, the average age for menopause in Canada is 52). Ovarian cysts are common in women of reproductive age and often serve a functional purpose in ovulation, but they are a concern in menopausal-age women. Along with other symptoms of urinary urgency and frequency as in Marie’s case, cysts may indicate the presence of ovarian cancer (Le and Giede 669).

However, the case report made no mention of testing the cyst for malignancy—as is the standard recommendation in Canadian gynecology (Le and Giede 670)—beyond its discovery during the ultrasound. While we don’t have all the details of Marie’s pre-surgery health, it seems logical that the case report would have mentioned cancer had it been the operation’s cause. Instead, it suggests that the operation was to alleviate her incontinence caused by uterine pressure from the cyst. Surgery is the most invasive of available treatments for stress incontinence (less invasive options include vaginal cones and electrical stimulation) and the official recommendations of The Society of Obstetricians and Gynaecologists of Canada suggest, “As part of the management of stress incontinence, women should be encouraged to try non-surgical options, including weight loss (in obese women)” (Reid et al. 3). In terms of cases that do require surgery, the society agrees that a hysterectomy may be performed when removing a woman’s ovaries, but it acknowledges “whether there are any benefits of concomitant hysterectomy at the time of bilateral oophorectomy for conditions other than ovarian cancer…remains unknown” (Lefebvre et al. 4).

 Discussion:

What I’m asking is why her surgeon chose the most invasive treatment for a woman whose circumstances make surgery highly risky. Since this case revolves around autonomy, I’d like to focus on this principle in relation to Marie’s first surgery. The case report states that the “gynaecologist elected to perform a hysterectomy and bilateral oophorectomy” (Waluchow and Gedge 71). Notice it doesn’t say that Marie elected for surgery, which makes me wonder if the doctor educated her on other available treatments. Clearly, Marie voluntarily consented to the surgery, but was her consent informed? Beauchamp and Childress list disclosure, recommendation, and understanding as three necessary elements within the information component of informed consent (124). They also state that “Diagnoses, prognoses, the nature and purpose of intervention, alternatives, risks and benefits, and recommendations typically are essential” (132) parts of a disclosure.

In my opinion, Marie’s doctor did not rightly balance the principles of autonomy and beneficence. By not reviewing all treatments and corresponding risks (perhaps he viewed surgery as the best option), he violated Marie’s right to informed consent. I believe doing so would have resulted in Marie consenting to a different treatment. However, let us say that the case description’s language didn’t adequately describe Marie’s consent process and that she, herself, elected for surgery from the list of well-explained treatments. In this case I would advise the doctor to push her towards a less risky treatment as an act of beneficence, weighting beneficence higher than autonomy. This would avoid the complex colon surgery dilemma where one must make a judgment of Marie’s competence while she is in an impaired state.

Works Cited

“Adult BMI Calculator: English.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 21 Oct. 2014. Web. 06 Feb. 2015.

Beauchamp, Tom L., and James F. Childress. “Respect for Autonomy.” Principles of Biomedical Ethics. 7th ed. New York: Oxford UP, 2009. 115-25. Print.

Committee Opinion: Gynecologic Surgery in the Obese Woman. Publication no. 619. The American College of Obstetricians and Gynecologists, Jan. 2015. Web. 7 Feb. 2015.

Le, Tien, and Christopher Giede. “Joint SOGC/GOC/SCC Clinical Practice Guideline: Initial Evaluation and Referral Guidelines for Management of Pelvic/Ovarian Masses.” Journal of Obstetrics and Gynaecology Canada (2009): 668-73. Web.

Lefebvre, Guylaine, Catherine Allaire, John Jeffrey, and George Vilos. “SOGC Clinical Practice Guidelines: Hysterectomy.” Journal of Obstetrics and Gynaecology Canada (2002): 1-12. Society of Obstetricians and Gynaecologists of Canada. Web.

“Menopause.” Menopause. Canadian Women’s Health Network, 2006. Web. 07 Feb. 2015.

Reid, Robert, Beth L. Abramson, Jennifer Blake, Sophie Desindes, Sylvie Dodin, Shawna Johnston, Timothy Rowe, Namrita Sodhi, Penny Wilks, and Wendy Wolfman. “Managing Menopause.” Journal of Obstetrics and Gynaecology Canada 36.9 (2014): 1-74. Web. 6 Feb. 2015.

Waluchow, Wilfrid J., and Elisabeth Gedge. “Case 1.1 When Physicians and Family Disagree.” Well and Good: A Case Study Approach to Health Care Ethics. By John Thomas. 4th ed. Peterborough, Ontario: Broadview, 2014. 71-76. Print.

Dilemma

In case 1.1, patient Marie François is refusing life-saving surgery. While analyzing this case, I focused on the physician’s major predicament – deciding whether to respect Marie’s autonomy in refusing a second surgery or complying with her children’s insistence. Each side merits valuable consideration because both parties believe they are acting in the patient’s best interest.

Reflection

This argument has multiple nuances, but I would like to center my reflection on the relationship between Marie and her medical team. It seems to me that one of the major reasons for Marie’s refusal for surgery is her mistrust of the health professionals who are providing her treatment and who are apparently disregarding her complaints. In fact, the case states, “she didn’t want the surgery because she no longer trusted the doctors providing her treatment and no one was taking her complaints seriously” (72). I think it is imperative for the healthcare team to regain Marie’s trust. The patient’s mistrust is negatively impacting her health outcomes because she has constructed a mental barrier against her physicians. I think this barrier is affecting the way the patient is processing and understanding information that is presented to her. I believe this issue of mistrust could potentially be mended and trust could be re-cultivated. If regaining her trust is not possible, the current surgeon should offer Marie (and her family) the option of working with a different medical team. I arrived at these conclusions due to the discrepancy between Marie’s willingness to receive the first operation and her refusal to consent to the second one. Marie’s children believe their mother’s expressed wishes are out of character. Specifically, her son Jacques “declared that his mother was behaving abnormally and insisted that she really did not understand the consequences of her refusal of surgery” (72). This discrepancy is possibly due to the suffering that Marie experienced following her first operation and the lack of acknowledgment and responsiveness from her healthcare team.

Comparison

According to the University of Washington’s Ethics in Medicine site, one of the elements of a fully informed consent is “assessment of patient understanding”. The following is the background information for a similar case involving patient refusal. A 55-year-old man with a 3-month history of chest pain and fainting spells needs cardiac catheterization. However, although he demonstrates understanding, he refuses the intervention. In the discussion section following the case description, the WashU bioethics resource recommends discussion and an exploration of the patient’s reasons for refusing treatment. Although a patient’s autonomy and treatment refusal should be honored, a refusal is not the end of a discussion. This patient’s refusal could be tainted with negative feelings towards the healthcare team, that should be discussed and addressed in an honest and straightforward way.

Works Cited

Ludwig, MaryJo, MD, and Wylie Burke, MD PhD. “Physician-Patient Relationship.” Ethics in Medicine. University of WashingtonSchool of Medicine, Web. 6 Feb. 2015. <http://depts.washington.edu/bioethx/topics/physpt.html>.

Thomas, John E. “Case 1.1 When Physicians and Family Disagree.” Well and Good: A Case Study Approach to Health Care Ethics. 4th ed. Peterborough, Ontario: Broadview, 2014. 71-76. Print.

Image Sources

http://blog.himss.org/2014/05/28/from-compliance-to-engagement-reimagining-the-patient-relationship/

http://sailthesevencs.weebly.com/why-the-cs.html

Within this scenario is the issue of whether the physician was neglectful and unjustified in not informing the patient or his family of the typically improbably risk of death during a particular procedure.  On behalf of the son, the physician ignored properly obtaining informed consent from the patient by not discussing with him all the details and risks of the procedure.  On the other hand, the physician asserts that due to the extreme unlikeliness of this occurring, for him to give this piece of information to the patient would only counter his best interests  (301).  In order to rationalize which option would have been more “morally correct,” it is necessary to assess the physician’s decision with respect to each of the four moral principles: nonmaleficence, beneficence, autonomy, and justice.

As mentioned in the text, the anesthetist along with most doctors, feel that it is unnecessary to inform the patients of the risk of death with an angiogram because despite the fact that the chances of this are so slim, simply knowing there is a chance may influence the patient to not have a procedure that is crucial to their health.  In fact, according to a study by Jansson and Fransson (1996), the mortality rate of a coronary angiography is between 0.10 and 0.25 percent.  The principles of nonmaleficence and beneficence, then, appear to be covered from the doctor’s position.  However, the argument being made my the patient’s son, that withholding these kinds of details from a patient is unethical, seems to imply an infringement on the other two principles, autonomy and justice.  From his standpoint, the doctor is limiting the amount of knowledge the patient has about the procedure to ensure his consent, thereby compromising his autonomy.  Futher, he probably would claim that the doctor is violating the principle of justice because the patient is inevitably unaware of all the costs and benefits when making the decision to agree to the procedure.

It is easy to consider the doctor negligent in not telling the patient all of the risks involved in the procedure because the patient died.  Had the procedure been successful and the patient remain alive and well, if the doctor were to subsequently approach the son and apologetically admit that he neglected to tell his father that he could die during the procedure, he likely would be disinterested in this fact.  Only in retrospect can the doctor be held responsible to an extent for the mishap.  Also, if we were to consider the amount of remote risks that are involved in any medical exam or procedure, for example the chance of infection with any kind of injection, there would be an even greater amount of unwarranted anxiety revolving around a visit to the doctor.  Therefore, more from a practical standpoint than anything else, I believe that it is not unethical for the doctor to avoid telling patients these kinds of details.

References:

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

Jansson, Kim, and Fransson, SG.  Mortality related to coronary angiography.  Clin Radiol.  1996 Dec. 51(20).

Blog 1:

Case 1:1 When Physicians and Family Disagree

Background:

Mrs. Francois was diagnosed with an ovarian cyst and underwent a hysterectomy and bilateral oophorectomy during which a bowel laceration occurred and was sutured. Six days after surgery, Mrs. Francois began to develop severe abdominal pain, became hypotensive, and later went into respiratory distress. Testing revealed that the suture line on her colon had split open. In spite of this, her condition improved, she appeared to be quite aware of her surroundings, and she was able to communicate via written notes. Upon informing Mrs. Francois of the need to operate, she refused surgery. Deeming her actions to be out of character and abnormal, her family attempted to consent to the operation on her behalf.

Dilemma:

The dilemma in this case is whether the doctor should operate, thus providing the patient with life-saving medical care, or not operate and thus honor the patient’s right to self-determination. The main tension in this case is that of autonomy vs. non-maleficence.

Class Connection:

This case reminded me of Mr. G’s non-consensual electroconvulsive case that we discussed in class in that they both involve a conflict between autonomy and non-maleficence. However, in Mrs. François’s case we add yet another complicating factor: the family disagreeing with the course of action insisted upon by Mrs. François. It is interesting to consider the moral implications of Mr. G taking his life knowingly via action (suicide) vs. Mrs. François accepting death (also knowingly) through inaction.

Critical Analysis:

Mrs. François originally presented with stress incontinence or the leakage of urine during physical activity or exertion (Stress incontinence: MedlinePlus Medical Encyclopedia). Presumably, she sought out medical attention because she found this incontinence to be inconvenient and/or embarrassing. She now lies in a hospital bed in immense pain with a fever, a distended belly, and a perforated colon, and the prospect of death. Compared to her initial condition, her current condition is markedly worse. Her ovarian cyst was not presented as being life-threatening, but the dehiscence of her colonic suture could prove fatal. One might conclude that Mrs. François no longer trusts her gynaecologist and is therefore unwilling to undergo a second surgery for fear of further complications and more pain. Although one might argue that this fear may impede her ability to make an autonomous decision, I would argue that her fear should not be discredited and her decision honored.

Another consideration in this case is quality of life (should Mrs. François chose the life-saving surgery). Will Mrs. François be able to return to normal day to day activities? Or will future surgeries result in a reduced quality of life? Although the case does not state the potential consequences of a second surgery, it is likely that the dehiscence of the colonic suture line following Mrs. François’s first surgery has caused some of the surrounding tissue to become non-viable. This non-viable tissue would likely have to be resected and a colostomy procedure performed. A colostomy would require Mrs. Francois to empty her feces from a colostomy bag on a daily basis. Given her morbid obesity, it is likely that someone would have to assist her with this task. Perhaps Mrs. Francois wishes to preserve her dignity and does not want to deal with these consequences.

Although one might argue that it is the physician’s responsibility to minimize harm and thus to perform the life-saving surgery, we might also argue that the physician did not fulfill his responsibility during the first surgery as it resulted in physical harm that inflicted far more pain than her original ailment. Furthermore, by inflicting harm on others, he might be considered to be of lower moral status (and a less respected physician). Additionally, according to Childress, the requirement that a physician obtain the informed consent of his patient to perform a medical procedure is primarily in place to protect autonomous choice, not to minimize the potential for harm (Childress 63). Still, some might argue that Mrs. Francois is not competent and therefore incapable of making an autonomous decision. Based on her level of awareness, ability to communicate, and the fact that most of her family did not feel as if she was acting out of character, I would argue that Mrs. François is competent and fully capable of making an autonomous decision. Therefore, her family members should not exercise surrogate autonomy. Given these reasons, the physician ought to honor Mrs. François’s self-determination and with stain from operating.

References:

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 5th ed. New York, N.Y.: Oxford UP, 2001. 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.

Wolff, B. G., Viscusi, E. R., Delaney, C. P., Du, W., & Techner, L. (2007). Patterns of Gastrointestinal Recovery after Bowel Resection and Total Abdominal Hysterectomy: Pooled Results from the Placebo Arms of Alvimopan Phase III North American Clinical Trials. Journal of the American College of Surgeons, 205(1), 43–51. doi:10.1016/j.jamcollsurg.2007.02.026

Background

CASE 1.1: “When Physicians & Family Disagree”

In Case 1.1, “When Physicians and Family Disagree”, Mrs. Francois, a 63 year-old French Canadian women, is readmitted to the hospital shortly after being released. Six days after undergoing a hysterectomy and bilateral oophorectomy, Mrs Francois reported having a severe abdominal pain, and her blood pressure began to drop.  After examining Mrs. Francois, the doctor concluded that she had generalized peritonitis and that she would need an operation or she would probably die. However, despite the doctor’s straightforward explanation and her what was perceived as her stable mental condition, Mrs. Francois refused. Her family was distressed by her decision to refuse the surgery, and the son even threatened the physician to act or he would hold the physician responsible for his mother’s death. The case raises questions about autonomy and implied consent for patients who refuse treatment.

CASE 2: “Family Struggles With Father’s Wish To Die”

I came across this story on NPR, and I thought it would be particularly interesting to discuss and compare this case to the one that was in the Well and Good book. In Case 2, 66 year-old man named Robert Schwimmer was diagnosed with pancreatic cancer in 2013.  Now, after being in hospice care, he has expressed that he does not want to prolong his life and would like to accelerate his death if he finds himself in excruciating pain.  In this case, the son is willing to help his father, but he admits it would be difficult for him to do so for both legal and spiritual reasons.  Legally, it would difficult to implement Robert Schwimmer’s decision because physician assisted suicide is not legal in Illinois. Spiritually, the son expresses that he feels uncomfortable playing any role in his father’s death. Despite these reservations, the children are willing to respect to the father’s wishes.

Analysis

Both of these cases are quite similar in that both cases the legal course of action does not necessarily dictate the morally correct course of action. In Case 1, the physician is faced with both legal conflicts as well as moral conflicts.  If the doctors abides by the law that requires consent from the patient before medical intervention, then he violates principle of minimizing harm and fails to commit to his professional obligations despite following the principle of autonomy. If he fails to act, however, and is legally charged with “criminal neglect” by not performing the surgery, and he may also be in violation of principles of minimizing harm because the patient would have died. The legal implications of the doctor’s possible decisions do not reveal what the ethical course of action would be in this situation. In Case 2, Robert Schwimmer does not want to prolong his life if his qualify of life declines.  However, the laws that are in effect in his state challenge his autonomy to make those choices.

By comparing these cases, it is possible to gain insight on how to approach situations where the patient is refusing life-sustaining treatment.  After reading Case 2, I would argue that the physician ought to perform the surgery in Case 1.1.   While the physician does has a moral obligation to respect a patient’s autonomy, the principle of autonomy​y can be specified in this case.  Mrs. Francois is entitled to her autonomy as long as she is fully competent to make these autonomous decisions.  While Mrs. François was visibly competent and appeared stable in eyes of the physician, the son asserted that “his mother was behaving abnormally” (Thomas & Waluchow 62) and that “she didn’t understand the consequences of her refusal of the surgery” (Thomas & Waluchow 62). The conflicting perception in Mrs. François competency and mental suggests that her autonomy may not be used to support her decision to refuse treatment.  In Principles of Biomedical Ethics, Tom L. Beauchamp and James F. Childress discuss the concept of “sliding-scale strategy”.  Writers that support sliding strategy argue that “as the risks of a medical intervention increase for patients, so should the level of ability required for a judgment of competence to elect or refuse the intervention” (Beauchamp & Childress 119) . The sliding strategy allow one to consider all the risk of intervention, or in this case, lack of intervention,  and use that set the expected level of competency to make that decision. In this case, Mrs. Francois’s risk for not having surgery is death. Thus, if her competency is not fully understood or clear than the doctor has more reasons to perform the surgery.

Interestingly, while I do feel that the physician ought to perform the surgery for Mrs. François, I would argue that Robert Schwimmer should be allowed to accelerate his death if, and only if, he is in excruciating pain or his quality of life declines. The primary difference between this case and Mrs Francois’ is the concept of harm,pain, and competency. In Mrs. François case, she is currently having “abdominal pain”, yet is refusing treatment that would save her life. Thus, by neglecting to treat her, the physician is not minimizing her harm, but rather allowing it to continue.  If her autonomy is questionable on the basis of her competency, then there is more of reason to follow the principle of minimizing harm and performing the surgery than following the principle of autonomy. However, in Robert’s case, he is refusing life-sustaining treatment if he is a state of pain or decreased quality of life.  Robert was only interested in accelerating his death under a specific set of conditions. Although the details of Robert’s competency are not completely clear, his wishes and reasoning do seem to reflect rational. His family also does not point to any abnormalities in behavior which is not the case with Mrs. François. In Robert’s case, if the physician refuses to intervene and remove the life sustaining treatment, he is not minimizing harm nor is really respecting the choices of him and his family.   If Mrs François was to have the operation, she would most likely have a more promising future and quality of life than Robert, who is likely to become progressively worse in his health over time.  Whereas the physician is deciding between life and death for Mrs. Francois in Case 1.2, the physician is Case 2 is coping with the question of sustaining Robert’s life.  The different conditions in these cases require different moral actions on the part of the physician despite seeming somewhat contradictory.

Work Cited:

Thomas, John E., and Wilfrid J. Waluchow. “When Physicians and Family Disagree.”Well and Good: A Case Study Approach to Biomedical Ethics. 3rd ed. Peterborough, Ont.: Broadview, 1998. 71-76. Print.

NPR STAFF. “Family Struggles With Father’s Wish To Die.”. National Public Radio (NPR). 1 Feb. 2015. Web. 4 Feb. 2015

Beauchamp, Tom L., and James F. Childress. “The Meaning and Justification of Informed Consent.” Principles of Biomedical Ethics. Seventh ed. New York: Oxford UP, 2013. 120-25. Print.

Blog 1: When Physician’s and Family Disagree

Dilemma: In the case of Mrs. François there is a dilemma to operate or not to operate. If the doctor operates, it seems that the patient’s autonomy is violated because she has clearly expressed that she does not want to have surgery. On the other hand, the doctor has an obligation to do what is best for the patient, and if he does not operate Mrs. François will die. I believe the doctor can operate without violating the principle of autonomy. First, we have to determine what the patient’s choice is because she has made more than one decision. Mrs. François has made the following 2 conflicting choices: to have surgery in order to live, and to not have surgery and die. Which choice accurately represents the patient?

Personal Opinion: I will argue that the doctor should operate on the patient, and that this action does not violate the patient’s autonomy.  I believe the doctor should operate based upon the principle of autonomy, under the following specification: respect choices that accurately represent the desires of the patient. Mrs. François initial choice to have surgery on her ovaries shows that she values her own life and wants to live. I think that the side effects of the hysterectomy and bilateral oophorectomy have created a fear in the patient that undermines her competence. She rightfully has a fear of having another operation because the first operation got her into her current situation. The doctors have tried to explain to Mrs. François that her situation is life-threatening and she needs surgery in order to live; but I think Mrs. François is not competent enough to understand due to her fear. I believe that Mrs. François does not want to have surgery because she does not want to die. She wants to live. She feels better and is most likely afraid to go under the knife again due to the outcomes of her previous surgery. Therefore, she does not agree to have another surgery because she feels fine, and probably does not trust the doctors to have her best interest in mind.  The case states that, “respect for the autonomy of individuals does not require respecting their expressed wishes if these can be shown to be seriously out of character and irrational” (66). Assuming that Mrs. François wants to live, then her choice to not have surgery is out of character. Also, the son has expressed that his mother is not acting like herself, and that she does not fully understand the consequences of her choice. Therefore, I believe that the doctor ought to operate with the consent of the son because Mrs. François is acting out of character. The patient’s decision is made out of fear rather than her true desires.

Comparison: This case is very similar to Mr. Z case. Mr. Z was severely depressed to the point of suicide, but refused electroshock therapy. His son also refused to consent to him having the treatment. In class, we questioned when we should respect one’s autonomy. We concluded that we should respect autonomy when it does not harm the individual. In both of these cases, the principle of autonomy and non-benevolence overlap. Through specification and balancing, it is possible for these principles to intertwine and produce the best outcome.

References

Thomas, John E., and Wilfrid J. Waluchow. “Case 1:1 When Physicians and Family Disagree”. Well and Good: A Case Study Approach to Health Care Ethics. 4th ed. Toronto: Broadview, 2014. Print.

Thomas, John E., and Wilfrid J. Waluchow. “Case 6:1 Non-Consensual Electro-Convulsive Shock Therapy”. Well and Good: A Case Study Approach to Health Care Ethics. 4th ed. Toronto: Broadview, 2014. Print.

Summary

Simon, a widowed father of a single son was brought to the hospital after an attempted suicide. Simon has been suffering severe depression, and treatment with anti-depressants seems to have had no benefit. Once hospitalized, Simon attempted suicide again. This led Simon’s psychiatrist to propose an electroconvulsive shock treatment therapy over a course of two weeks (1).

Discussion

One of the moral dilemmas that are being addressed in this case is: Should the psychiatrist respect the father’s autonomy and allow him to refuse treatment, or should the principle of beneficence take precedence and the treatment be given against the wishes of the Father and Son. 

First, we should explore whether or not simon is competent enough to have his autonomy respected. According to Beauchamp and Childress, a person may be declared incompetent if they are unable to give a rational reason for their actions (1). Now this brings into question, is there any rational reason for suicide? To Simon, escaping constant mental distress may take precedence over preserving physical wellness. If this were the case, Simon could be declared competent enough for his autonomy to be respected, and the psychiatrist should respect his decision to refuse treatment; however, from the psychiatrist’s point of view, he could state that Simon’s chronic depression prevents him from understanding relevant information or the consequences of his choice, and therefore would classify Simon as incompetent, and give the psychiatrist reason to apply to the review board to go ahead with the treatment.

Second, we must look at the psychiatrist’s obligation to beneficence. As a healthcare professional, the psychiatrist must take actions to prevent harm and promote good. If the psychiatrist should allow Simon to refuse the treatment, and Simon ends up committing suicide, one could determine that the psychiatrist failed to uphold this principle. But achieving this goal could prove challenging for the psychiatrist. By promoting autonomy through providing accurate information about ECT to the father, the psychiatrist is doing his best to promote good; however, if even after providing accurate and understandable information to both Simon and his son, the pair still refuse treatment and Simon commits suicide, one could say the psychiatrist failed to prevent harm. So at what point does the psychiatrist’s attempts to convince Simon to accept ECT violate Simon’s autonomy through coercion or manipulation?

Personal Response

One might say that Simon’s depression renders him incompetent and temporarily nullifies his right to refuse treatment. But Simon previously agreed to receive anti-depressants, which would not have been prescribed unless Simon had been already been depressed. On that note, is it acceptable to overlook a patients mental illness if their decision could potentially preserve their physical condition as opposed to threaten it? Is someone only deemed incompetent if their actions produce a negative consequence for their healthcare provider? I would say that Simon is indeed in a more severe mental state than when he agreed to take anti-depressants, but not severe enough that he should be declared incompetent and have his autonomy violated.

Furthermore, the efficacy of ECT should be called into question when determining whether or not to respect Simon’s autonomy. While it has been shown that ECT can produce promising effects short-term, chances of relapse still remain high. The common strategy with ECT is that it allows time for anti-depressants to take effect. However, the anti-depressants obviously did not work for Simon before, so the question becomes, would the ECT be enough of a catalyst for the drugs to be effective? The results are conflicting. Earlier studies showed that ECT in conjunction with continued anti-depressant use effectively reduced the symptoms of major depressive disorder with low rates of relapse (2), but some later studies showed that the relapse rates are relatively high. One study showed a 57% relapse in patients receiving ECT and continued antidepressant use in 6 months (3), with another study showing a 51% relapse rate (4). I believe that the high relapse rates of the ECT make it unjustifiable for the psychiatrist to obtain approval for the ECT. The chances that Simon would relapse into depression and be subject to further mental distress should be enough to justify his autonomous decision to refuse of treatment.

References

1. Beauchamp, Tom L., and James F. Childress. “Respect for Autonomy.” Principles of Biomedical Ethics. New York, NY: Oxford UP, 2001. 101-40. Print.

2. Gagné, G. G., M. J. Furman, L. L. Carpenter, and L. H. Price. “Efficacy of Continuation ECT and Antidepressant Drugs Compared to Long-Term Antidepressants Alone in Depressed Patients.” The American Journal of Psychiatry 157, no. 12 (December 2000): 1960–65.

3. Rehor, G., A. Conca, W. Schlotter, R. Vonthein, S. Bork, R. Bode, M. Hüll, et al. “[Relapse rate within 6 months after successful ECT: a naturalistic prospective peer- and self-assessment analysis].” Neuropsychiatrie: Klinik, Diagnostik, Therapie Und Rehabilitation: Organ Der Gesellschaft Österreichischer Nervenärzte Und Psychiater 23, no. 3 (2009): 157–63.

4. Jelovac, Ana, Erik Kolshus, and Declan M. McLoughlin. “Relapse Following Successful Electroconvulsive Therapy for Major Depression: A Meta-Analysis.” Neuropsychopharmacology 38, no. 12 (November 2013): 2467–74. doi:10.1038/npp.2013.149.

 Background In Case 5.4: Protecting an “Unborn Child,” a young 22 year old girl named “G’ is revealed to be addicted to having a glue as well as other solvents sniffing addiction. “G” addiction has made her incapable of raising children as she has had to relinquished her parental rights for three of her children to family services (Thomas, 201).   The case study describes that the Manitoba Court of Appeal ordered that “G” be released from a treatment facility she was placed in by doctor recommendation. Due to “G’s” doctor’s belief that it was in the unborn child’s best interest to place “G” in a treatment facility and monitor “G” ’s activity on the grounds that every individual has the right to well-being of the individual.

Dilemma  In this particular case the dilemma seems to be rooted in autonomy, which would be whether or the mother’s right to self-determination outweighs the non-maleficence argument which would site that it is the doctors professional job to make sure that the unborn child is protected.  From the autonomy standpoint the mother has the individual ability to govern herself, her body and her choices independent of her place in a metaphysical order or her role in social structures and political institutions (Christman, John) . From the non-maleficence standpoint the choices made by the mother will impact the health of her offspring possibly compromising its health. Understanding both standpoints brings about conversation about a variety of important moral principles, which need to be considered.

Reflection I recognize that my decision may come from my ability to relate to “G” ’s situation, but I would have side with “G” on the matter. Being a feminist the minute I read the case I began think about the issue of women’s autonomy and being able to make decision based on body ownership. “G” owns her physical body and it is completely up to her to make all the decision regarding it.  The author mentions in the case study that women’s rights activist contend that it is a human right more importantly a woman’s right to govern her own bodies will and that she must be offered the strongest possible protection (Thomas, 201).To often in the society we live in insurance companies, husbands, religions, etc. try to control the ownership of this sacred entity that belongs to no one but the physical person. And for these reasons I believe it is only right that “G” make the ultimate decision about the situation at hand.

 Work Cited

Christman, John. “Autonomy in Moral and Political Philosophy.” Stanford University. Stanford University, 28 July 2003. Web. 02 Feb. 2015.

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

The dilemma presented in Case 5.4 in Well and Good called “Protecting an Unborn Child” is whether or not a mother’s right to self-determination is more important than her unborn child’s rights and health. Should she be forced into rehab for her drug addiction for the health of her fetus? This question comes down to an issue of autonomy vs. non-maleficence. In one respect, the mother’s choice to continue her drug-abusive ways should be respected because it is her body and her right to control it. On the other hand, the decisions she makes during her pregnancy will mostly likely (due to the experiences of her previous pregnancies) affect the child in a negative fashion in the long run. According to Beauchamp and Childress, both are important moral principles that must be considered in the final decision. There have been many cases in which these two important moral principles fall into conflict.

One example of a similar situation is Case 3.5 in Well and Good called “Religious Conflict over a Life-Saving Blood Transfusion,” which we discussed in class. This case involves a Jehovah’s Witness father who wants to refuse a life-saving blood transfusion for his daughter in order to save her immortal soul from hell while possibly condemning her to a physical death. In this case, we also discovered a conflict between autonomy and non-maleficence, where respecting the decisions of the father (and possibly even the daughter) on behalf of his child had the possibility of harming her physically. In this case, we discussed a “standard” used by courts in which doing no harm to the patient outranks the parents’ choices on the care of their child. It is the doctor’s obligation to do everything he can to help the patient, even if it means not respecting decisions of the parents that are potentially harmful to the patient.

Another conflict of moral principles in the case of the unborn child is autonomy and justice. The mother’s right to self-determination directly violates the unborn child’s rights (if he or she has any) to a healthy life in the future. While it is true that an unborn child technically does not have the same legal rights granted to human beings, the decisions being made about the unborn child’s health will affect him or her for the rest of his life when he or she is born. Therefore, is it right to deny rights to an unborn child when the consequences won’t be evident until he or she is born and has rights of their own?

By choosing to carry the pregnancy to term, she is choosing a life for her child. Assuming she wants that child’s life to be easy and free of complication, her decisions to continue in her drug-abusive ways are almost guaranteeing a hard life for her child with respect to her past pregnancies. With that decision, I believe “G” is morally obligated to protect the well being of her child even before he or she is born since these decisions will affect her child only after they are born. However, I would have to agree with the courts that legally, you can’t force the mother to end legal actions that may or may not harm a fetus with no legal rights. In a perfect world, I would love to see women choosing to be mothers by making the decision to carry their pregnancy to term make decisions to not do drugs, smoke, drink, and do other activities with specific, known negative effects on a fetus. If a mother’s moral obligation is to care for her child, then why should that begin just once the child is born?

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 5th ed. New York, N.Y.: Oxford UP, 2001. 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.