Do immunization mandates sacrifice patient autonomy for the benefit of public health, and if so, is this a justifiable tradeoff?  Responsible governing bodies and healthcare providers are obligated to maximize a patient’s ability to make an informed, autonomous decision, while also promoting beneficence for both the individual patient and the group (i.e. overall population).  Immunization — generally achieved through vaccination — presents a challenging case for balancing autonomy with individual and group benefit.  This is further challenged by the fact that overall immunization efficacy is partly dependent on the percentage of the population inoculated, or herd immunity.  The benefits of immunization are not solely confined to the individual and thus it is in the interest of the government and healthcare providers to act on behalf of the collective group.  

In the past, immunization was mandatory by using it as a requirement for participation public education.  The mandating of certain childhood vaccinations reduces parental autonomy by creating an undesirable alternative to non-compliance.  Though this policy was once effective as making vaccination a de facto requirement for American children, state exemptions have made it relatively ineffective. 

Some states view vaccination as a procedure that conflicts with certain ideologies.  As a potential violation of religious freedom and patient autonomy, religious and personal belief (philosophical) vaccine exemptions were adopted in many states.  In fact, California, West Virginia, and Mississippi are the only states that do not have at least one of these exemptions for school enrollment (1).  These three states do however provide medical exemptions for rare instances of patients who have been deemed unfit for receiving vaccination.  While the religious and personal belief exemptions are designed to return greater autonomy to the patient, these laws have subsequently undermined immunization efficacy and the overall population safety.

After decades of effort to eradicate lethal communicable diseases, the government has seemingly abandoned its ability to enforce universal medical policy, rather choosing to prioritize maximizing patient autonomy.  The effects have been noticeable; measles, once thought to have been eradicated from the United States, has returned with the liberalization of patient autonomy policies regarding immunization (2).  Yet despite the return of some diseases, opponents to mandatory vaccination have been willing to challenge the underlying safety of vaccines as defense of their position.

These vaccination debates have persuaded some — with or without factually justifiable arguments — to utilize the vaccine exemptions for their children.  Past failures in vaccine synthesis and storage, along with egregious errors in administration protocol (i.e. Egypt’s Hepatitis C needle sharing and subsequent Hep C outbreaks) provide precedents for vaccine-skeptics to justify their stances (3).  While many of these arguments rely on straw man and falsely-equivalency fallacies, plenty of people are willing to disregard logical coherence for emotionally persuasive arguments.  While rhetorical strategy is not of direct relation to the dilemma of balancing autonomy with beneficence, the dissemination of such fallacious arguments poses as a threat to maintaining vaccine compliance when broad exemptions are available.  Safe levels of preservatives likes thimerosal will continue to be investigated, along with risk-benefit analyses of vaccination being included to challenge exemptions by demonstrating the collective risk induced from marginal gains in patient autonomy.  Sadly, absurd straw man arguments like “vaccines cause autism” detract from legitimate discussion regarding the government’s role in minimizing disease risk through compulsory immunization.  Vaccine exemptions as they currently exist have been abused and demonstrate the need for a revitalized focus on population health.

While I agree that it is the role of the government to enforce public health policies that seek to reduce and eradicate diseases from the population, the slippery slope of government involvement in healthcare continues to be of legitimate concern for many.  There are examples of medical procedures that have been deemed illegal on moral grounds, like abortion.  As popular opinion changes and politicians react to constituent demands, it does not appear to be unrealistic that hysteria regarding certain medical procedures could be used to defend either strict mandates or inappropriate exemptions that greatly sacrifice autonomy and beneficence, respectively.    

If there has ever been an example where a measured amount of individual autonomy can be curbed for the group benefit, mandatory immunization is certainly a defensible policy.  However, discourse indicates growing skepticism towards the pharmaceutical industry and the government’s intentions.  Growing resentment towards political lobbying — particularly against the villainized pharmaceutical industry — along with increased immunization exemptions present an unsettling trend in the government’s abdication of its authority over public heath policies.   

With extensive peer-reviewed research, FDA trials, and concrete examples of the risk imposed by non-medical immunization exemptions, the government should not feel compelled to expand parental autonomy over childhood vaccination.  Empirical evidence supports strict immunization laws; hysteria and fallacious arguments promote exemptions. With solid empirical support and clear examples of risks, it is the responsibility of our political leaders to stay informed and act in accordance with the best policies for their constituents. We can only hope that the many such cases of empiricism and reason lead our discussion, and not fear-promoting, fallacious arguments.

https://twitter.com/realdonaldtrump/status/449525268529815552

Sources

1.States with Religious and Philosophical Exemptions from School. NCSL. Online. Accessed 22 March 2017 <http://www.ncsl.org/research/health/school-immunization-exemption-state-laws.aspx>

2. Mnookin, S. The Return of Measles. Boston Globe. Sept 29 2013.

3. Miller, FD. Elzalabany MS, Hassani S. Cadres D. Epidemiology of hepatitis C virus exposure in Egypt: Opportunities for prevention and evaluation.World Journal of Hepatology. 2015. 28: 2849-2858.

Background:

Current Federal law requires that any drug on the market needs to be approved of application before it is transported or distributed to the patients. However, there are earnest patient who are looking for experimental drug for their untreatable disease. Due to their sickness, there has been demand to enter the clinical trial in order to get a head-start of the cure.

Harald and Jim have been a loving couple together for a consecutive 10 years. During that time period, Herald have been experiencing sickness easily, having ulcers in his mouth and starting to lose weight. Worrying about his condition, Herald went for a physical exam and it turned out he has AIDS. Herald was really earnest in trying the experimental drug, but he was screened out because he was not diagnosed early and was then incompatible because of his health condition. Although Herald got treatment in the end through his persuasion to the group, he died shortly after the treatment.

But the question still remains, should clinical trial open arm to those who are trying to guide their self-autonomy?

Ethical challenge:

One perspective to look at this problem is from the ethical challenge it faces in this situation. Harold and Jim questioned the authority: “if there was a drug out there that showed promise, and if the alternative for harald was certain death, why shouldn’t he be given a chance to try it?” It is always better to have something over nothing. Especially when on a shortage of beneficial clinical medicines, a patient should choose on his own, whether or not to give up his spot for someone with a bigger chance of being cured.It is about defending self-autonomy. By leaving Harald in a situation which he could only be treated by symptoms appeared, physicians are acting against their ethical responsibility to perform for the wellbeing of their patient.  

In the case patient is screened out of a clinical trial, and physician has total control by law of whether to add the patient, his choice set changes, and therefore his autonomy does not include taking the trial anymore. On another note, an incurable disease has never been cured before, thus it cannot be certainly concluded that such a trial would not work on specific groups of patients. Taking away patients’’ opportunities to participate, especially based on severity of their conditions, poses the same question as whether to run over four people on the train track and save the one on another, or change the direction save the four people and sacrifice that one person.

Research Challenge:

Many might argue that in this situation, because of the unequal in knowledge and vulnerability, physicians should have the upperhand of deciding whether patients should be included in the trail. There are much more aspects to consider in order to enter the trail. It is important to access the gained knowledge. Without accessing the known knowledge, there could be little improvement over the trail. Furthermore, fair methods to protect privacy and confidentiality should be set in the rule book. Changing the selection of sample, like in Harald’s case, can gradually cause a lose of focus on research purpose. -because researchers and investigators are unequal in knowledge and vulnerability. Patient’s beneficence over the risk shall be measured and controlled by researcher in order to justified its purpose of determining whether this investigational therapeutic alternative is the better alternative than existing one. Only by fulfilling the criteria above, the trail could be justified. After all, experimental medicine was not about one single human being, but it is about benefiting the greater human society to have a better cure.
Therefore, If serving the patient’s best interest is against the purpose of promoting social goal of accumulating knowledge and benefiting future generation, the patient’s self autonomy should not be defended.

Thomas, John E., Wilfrid J. Waluchow, and Elisabeth Gedge. “Case 7.4: Access to Experimental Drugs in Catastrophic Circumstances.” Well and good: a case study approach to health care ethics. Peterborough, Ontario: Broadview Press, 2014. Print.

Vaughn, Lewis. Bioethics: Principles, Issues, and Cases. New York: Oxford University Press, 2010. Print.

Case 7.4 describes Jim and Harald, a couple who had been together for an extended period of time before Harald was diagnosed with an HIV infection that had developed into AIDS with indications of encephalopathy (Thomas 256). Unfortunately, due to Harald’s severe diagnosis he was rejected as a participant in a clinical trial for AZT and was simply treated for symptoms. Harald and Jim, together with their friends who were also not qualified to participate in the ongoing trial and who didn’t want to be subject to the bribery and lies that other HIV patients had resorted to decided to enroll in an open arm in which they would consent to receiving the drug and be monitored for outcomes (Thomas 257). While Harald did eventually receive the drug, it didn’t save his life.

In his case discussion, Thomas et al. presented two questions: “does the principle of autonomy mean that very ill people should be able to access any drug they wish if they accept the risk and is cheating the system in order to gain access to a drug ethically acceptable if the alternative is death?” (Thomas 258).

According to Beauchamp et. Al. moral status does not equate to respect for autonomy. “Obligations to respect autonomy do not extend to persons who do not act in a sufficiently autonomous manner–and who cannot be rendered autonomous­–because they are immature, incapacitated, ignorant, coerced, or exploited” (Beauchamp 108). They then argue that infants, irrationally suicidal individuals, and drug dependent individuals fall into this category. I would argue that Jim and Harald’s complete disregard for authority, and decision to take a harmful drug proves their ignorance and therefore disregards their right to autonomy. That being said, people do unconscionable things for people they love.

This brings me to the second question. The sheer force of love has given mothers the necessary strength to protect their babies, has made people make utter fools of themselves as they coordinate mass flash mobs and parades in order to express their love for someone, and has caused individuals to abandon all moral reasoning to fight for those they love. While Jim and  Harold’s decision to organize and open arm, in which they would administer unapproved drugs, it undeniably unethical, in a case where death is the only alternative, it is justifiable.

What do you think? Would your decision be different if it didn’t involve obtaining a drug, rather a loaf of bread? For those of you who are unfamiliar with the reference, in the play Les Miserables, the protagonist, Jean Val jean, is initially imprisoned for stealing a loaf of bread to save his starving nephew.

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York: Oxford UP, 2016. Print.

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

Case 7.4: “Access to Experimental Drugs in Catastrophic Circumstances”

Introduction

The role of the government in regulating access to drugs and the ethical norms governing clinical trials have been challenged and debated in bioethics and legal circles. Certain assumptions about the ethics of running clinical trials were brought under scrutiny especially during the late 1980s when AIDS was assuming epidemic proportions and pressure was building to find effective therapies.

In this case, Harold has AIDS and is rejected as a candidate for a clinical trial of an antiretroviral drug because his health status is poor. “[He] had everything to lose by accepting the rules and nothing to lose by trying to get around them” (Thomas, Waluchow, and Gedge 256). Harold forms a group of advocates that offers an open arm alternative to the double-blind clinical effect; participants consent to receiving the drug and are monitored for outcomes.

The Question / Discussion

Having an open arm offers patients an opportunity to exercise a high degree of autonomy in assuming a significant risk; it also enhances the autonomy of those entering the clinical trial as well, since they now have the option of either arm as a way of accessing the experimental therapy. Does the principle of autonomy mean that very ill people should be able to access any drug they wish if they accept the risk?

Autonomy

In Bioethics: Principles, Issues, and Cases, Vaughn argues that the heart of the modern doctrine of informed consent in Kantian. I agree with Vaughn that because persons are autonomous, rational agents, they must be allowed the freedom to make choices and to have them respected; they may give or withhold their consent to medical treatment and the risks of research—consent that is valid only if informed, competent, and voluntary (Vaughn252). Autonomous agents have the right to decide for themselves whether to expose their persons to the rigors and risks of clinical investigations.

Ethical Justification of Having an Open Arm

Access to the open arm, an ethical alternative to doing nothing for those like Harold who are catastrophically ill, has an ethical justification; although it is not designed to produce the kind of generalizable knowledge that issues from a clinical trial, it will provide clinical information on a case by case basis, which may in time reveal useful commonalities or surprising individual results worth developing into a further research question. Further, it is often considered compassionate, since it offers the possibility of a cure to those in very dire circumstances (Thomas, Waluchow, and Gedge 257).

Application: The Tuskegee Tragedy

https://www.youtube.com/watch?v=-JP3Qa32IPw

The shocking revelations about the Tuskegee Study came decades after the research had been conducted. When finally told, the story provoked outrage, moral debate, and an apology from President Bill Clinton (Vaughn 241).

The Public Health Service, working with the Tuskegee Institute, began a syphilis study in 1932. Nearly 400 poor black men with syphilis from Macon County, Ala., were enrolled in the study. They were never told they had syphilis, nor were they ever treated for it. According to the CDC, the men were told they were being treated for “bad blood,” a local term used to describe several illnesses, including syphilis, anemia, and fatigue (Vaughn 241).

At the start of the study, there was no proven treatment for syphilis. But even after penicillin became a standard cure for the disease in 1947, the medicine was withheld from the men. The Tuskegee scientists wanted to continue to study how the disease spreads and kills. Dozens of the men had died and many wives and children had been infected. It wasn’t until 1997 that the government formally apologized for the unethical study: “What was done cannot be undone. But we can end the silence. We can stop turning our heads away. We can look at you in the eye and finally say, on behalf of the American people: what the United States government did was shameful” (Vaughn 241).

Connection and Conclusion

Unlike in Case 7.4, moral principles were not upheld during the experiment conducted in this historical case. Autonomy (respect for persons as autonomous agents) beneficence (doing good for and avoiding harm to persons) and justice (treating equals equally) were violated. By inference, a very ill patient like Harold should be able to access an experimental drug as an autonomous person if he accepts the risks; he must be competent and consent must be both voluntary and informed, while autonomy, beneficence, and justice have to be weighed out and upheld.

Works Cited

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

Thomas, John E., Wilfrid J. Waluchow, and Elisabeth Gedge. “Case 7.4: Access to Experimental Drugs in Catastrophic Circumstances.” Well and good: a case study approach to health care ethics. Peterborough, Ontario: Broadview Press, 2014. Print.

Vaughn, Lewis. Bioethics: Principles, Issues, and Cases. New York: Oxford University Press, 2010. Print.

Paternalism and Autonomy are two topics that are highly discussed in the field of Bioethics. Often times, there is a juggle between which should be considered to be the most important factor to recognize and whether that decision can be justified. The following case deals with these topics. Harald and Jim are a couple. Harald has AIDS. Around the time, researchers were conducting clinical trials with antiretroviral drugs on individuals with the disease, but they were only accepting those with early diagnosis, and screened out those who had a poor health status. Harald was screened out of the clinical trial and found out people who also got screened out were finding ways to still access the drugs (Well and Good, 256). In looking at this case, should the principle of autonomy have priority or the researchers correct in making the decision for the people?

One side of the argument is that the principle of autonomy should govern at all times. Harald and all the other subjects who were rejected should have been given the chance to make an autonomous decision knowing what the risks are. They have the right to decide what should be done to their bodies. The fact that the researchers screened them out without allowing them to decide for themselves is a violation of their rights. Beauchamp and Childress talked about anti-paternalism and how proponents of anti-paternalism argue that paternalism treats autonomous agents as “less-than- independent determiners of their own good,” and “if others impose their conception of good on us, they deny us the respect they owe us, even if they have a better conception of our needs than we do” (Beauchamp and Childress, 220). By deciding for them in the clinical trial, the researchers were undermining the capabilities of Harald and the others to decide what is best for them. In addition, people were already find ways around the trials by getting the drugs from those who were already in the trial. Essentially, the people were going to do what they needed to do get the drugs so there was no point in denying them access in the first place.
On the other hand, it can argued that the researchers were correct in making the decision to screen out those who do not fit the criteria. In other words, the paternalistic approach should have priority. The goal of paternalistic actions is to provide benefit and avoid harm. Researchers of this clinical trial had to think about the risks and the harms that could be done to the subjects. Beauchamp and Childress talked about hard paternalism and the conditions in which it can  be justified. One of the conditions is “the paternalistic action will probably prevent the harm” (222). In this case, perhaps the risks of this clinical trial could have caused even more harms and other negative health outcomes in addition to the disease. As the old saying goes, “better safe than sorry” By choosing to reject them, the researchers were saving them from even more problems. In addition, the mindset of these individuals must be examined. Some of the individuals were catastrophically ill so they were desperate to find any means that will get them well. If that was the mindset of some, then they would have been choosing to participate in a trial that could have detrimental effects on them because they did not care about the risks. In this case, it can be said that the paternalistic action was justified.

Cites:

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

Thomas, J. E., Waluchow, W. J., & Gedge, E. (2014). Well and good: a case study approach to health care ethics (4th ed.). Peterborough, Ontario: Broadview Press.

Clinical trials are constantly viewed with scrutiny due to seemingly controversial methods including the use of placebos as well as experimental drugs with unknown effects. As referenced by Beauchamp and Childress, there has been a shift in the way in which society views clinical trials from being primarily concerned with protecting participants from “the burdens and risks associated with research” to now trying to make participation in clinical trials more accessible (Beauchamp and Childress 234). Although there has been an increase in participant interest, it brings about its own problems with regards to who should be illegible and what means are ethical in the name of research.

In Case 7.4, Thomas, Waluchow and Gedge present three main ethical considerations with regards to clinical trial participation and procedures, but for the purpose of this post, I will only focus on one. The ethical dilemma questions if “the principle of autonomy means that very ill people should be able to access any drug they wish if they accept the risk” (Thomas, Waluchow and Gedge 258). In the specific hypothetical case presented, Harald discovered that he was HIV positive and due to his advanced case and poor health status he was rejected from a clinical trial. Although it was unclear exactly how the drug worked and what the outcomes would be, Harald had no better solutions to his rapidly deteriorating health condition. I agree with the approach Harald and his partner Jim pushed for in the case: enacting an open arm alternative where infected individuals who were too sick to be involved in the research aspect of the clinical trial could still receive the drug in the hopes that it would treat or maintain the disease. In this scenario, researchers can continue to explore potential risks, benefits and side effects in otherwise “healthy” individuals while still providing potential treatment to the more “unhealthy” infected patients. While having unknown risks and side effects may appear to violate the principle of nonmaleficence, the fact that the drug is in a clinical trial implies that there is reasonable belief that it has beneficial effects.

Although it is true that many drugs never make it from clinical trials to the market, in this case, as with many other cases we look at, patient autonomy must be taken into consideration. If a patient is fully competent and understands that the risks and benefits of a drug are not explicitly known and still wishes to continue, I believe that the patient should be allowed to try the trial drug if he or she wants to. In Harald’s case, he didn’t appear to have any other options. If his symptoms were worsening, no other treatments were helping and he thought he had nothing else to lose, why not give him the drug? Is it possible that the drug will have harmful effects and make his condition worse? Yes. Is it also possible that the drug could alleviate some of his symptoms or at least maintain the course of the disease? Also yes. I believe that as long as there is a possibility of benefits along with the possibility of harms, and there is no other viable treatment available, the use of trial drugs should be a legitimate option for terminal patients. While there is concern in the research community about how including certain types of participants may skew the results or imply false outcomes, I believe it to be unethical to refuse potentially life-saving drugs from individuals who are deemed to be “too sick” to provide useful information in the name of science. While breakthroughs in biomedical research are extremely important for future patients, physicians have an obligation to their current patients to respect their autonomy, prevent harm and try to alleviate suffering. If continuing without or with useless treatment would inevitably lead to death, offering a drug that could potentially prevent harm, in this case being death, is an act of beneficence as well as respect for autonomy.

On a slightly different note, would the situation change if the risks, benefits and side effects of a drug were all known and the drug was found to be associated with high risks? While recreational marijuana is still illegal in most of the United States, many states have legalized the use of medical marijuana for certain patients in order to alleviate pain. On a similar note, high dosages of morphine are prescribed to many patients in hospice to reduce suffering and keep such terminal patients as comfortable as possible (“Hospice Patients Alliance”). In these cases, the risks and side effects are known, yet still prescribed as viable treatments for certain patients due to the potential benefits. What makes the case of medical marijuana and high dosages of morphine different from a drug on a clinical trial? All three cases exhibit potential risks and benefits. Is it acceptable to prescribe patients drugs with high risks as long as the risks are explicitly known?

References

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

“Hospice Patients Alliance – When It Is Inappropriate to Have PRN Medical Orders for Morphine.” Hospice Patients Alliance – When It Is Inappropriate to Have PRN Medical Orders for Morphine. Hospice Patients Alliance, n.d. Web. 23 Mar. 2017.

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

Dr. Anne O’Byrne gave a rather interesting lecture regarding kinship and belonging. Essentially, humans are inherently drawn towards both understanding and discovering bonds of blood. Our society constantly seeks to answer the questions—where am I from, and who do I come from? These two questions are becoming deeply intertwined, as humans have a tendency to associate their identity with a location, rather than a human lineage. This shift has emerged due to both a decrease in the usage of oral histories and the increasing complexity of family trees.

In my opinion, the discussion of linguistics was the most interesting aspect of the lecture. The word genocide is derived from the Greek word génos, meaning kin, and cide, the act of killing. The concept of kin emphasizes belonging to a particular group, while simultaneously provoking separation within the world. Essentially, we cannot belong to all worlds and social groups.

After the discussion of belonging and kin, I thought that it was interesting to tie the topic back to health. Often times, physicians are encouraged to maintain appropriate boundaries with patients—this practice may diverge with the concept of kin relationships (Pilgrim 2001). Essentially, the patient may lack the proper medical knowledge to fully understand and navigate the healthcare system without proper assistance. Therefore, the patient may perceive a lack of belonging within the complex healthcare sector. Should it be up to the physician to build stronger relationships with patients to foster a sense of belonging within the healthcare system? Or should they strive to maintain the existing boundaries? In my opinion, I think it is important for the physician to emphasize with the patient—however, the development of a stronger patient-physician relationship may slightly impinge on the patient’s autonomy.

References:

Pilgrim, David, Floris Tomasini, and Ivaylo Vassilev. Examining Trust in Healthcare: A Multidisciplinary Perspective. Basingstoke: Palgrave Macmillan, 2011. Print.

O’Byrne’s Lecture on Kinship

O’Byrne brings up her lecture by talking about the idea of “where you come from is who you are”. Henceforth, to know who you are is to know where you come from. There is a sense of belonging or solidarity that comes from kin. O’Byrne brings up many questions in her talk.

What really is kin? How much do we really know about where we come from? Why are we so committed to having a connection with those who share the same blood? How is kinship related to injustice?

O’Byrne first starts off her lecture talking about the origins of belonging in a historical, scientific, and linguistic sense. What I found interesting was when she mentioned that our own DNA tests show that who we are as individuals is actually very blurred. A question that she made me ponder about was what a white supremacist would do if the white supremacist finds out that there is a small percentage of African ancestry in the kin. She then delves into an even deeper meaning of human lineage. She brought up the fact that we cannot appropriate our own lineages. One cannot “not have been born”. What was interesting was that she brought up the other point of on the other hand, the parent could not have known that the child would be “you”.  However, I found her talk on the types of belonging very difficult to understand. She mentions an oceanic, or earthly, type of belonging as well as a transcendence type of belonging.

In the second part of the lecture, she talked more about the idea of kinship and the injustices that are behind it. We as humans are all committed to our own “blood” and who we are is supposedly determined from where we came from. As a result, genocidal violence, and injustice spurns form this ideology. She also brings up the question of becoming kin other than in blood? This question made me think about the connection between a really good friend and how a bond with a really good friend could be comparable to a bond between blood. O’Byrne also talks about how the alienation of a child from his/her parents a form of injustice. Her Fredrick Douglas example in which Douglas’ mother walked 12miles just to see her alienated child was very interesting.
Overall her lecture was very interesting and it got me to think a lot about kinship and it’s role it plays with us as individuals as well as with us as a society. O’Byrne ends off her lecture by talking about what we could do. She asserts that we should acknowledge both types of belonging. Belonging to belong as well as belonging to a pure belonging.

Terrence F. Ackerman argues that medical doctors have the responsibility to intervene in their patient’s decision-making if it is in their best interest. The reasoning behind his argument is that illness inherently diminishes the value of autonomy because people who are sick are not competent enough to make their own decisions. This may be due to physical, psychological, or social constraints, relating to their illness or medical situation, which influence their decisional capacity. “Decisional capacity is based on the patient’s ability to understand the choices, to deliberate about those choices, and to articulate his choice. Decisional capacity is dynamic—that is, a patient who had appropriate decisional capacity yesterday may not have it today.” (Marco) I agree with his argument in the sense that doctors should evaluate whether a patient is mentally sound enough to make competent decisions. However, if a patient is mentally sound, a doctor should not override their decision based on a notion of diminished autonomy. There will always be stressors affecting a patient’s decision-making capacity. However, if the patient is not psychologically impaired, they should be able to have final say in their medical treatment, regardless of their physician’s opinion.

The issue at hand is one of patient autonomy versus the principle of beneficence, in the sense of paternalism. Doctors must weigh whether their duty to help their patient is greater than the patient’s right to make autonomous decisions. Initially, this seemed like a simple decision. A doctor should always ensure their patient is making decisions that are in their best interest. However, the main deterrent to this is that sometimes patients do not agree with their physicians about what course of action is in their “best interest”. Should a medical professional be able to override a patient’s bad medical decision based on their knowledge of the patient’s best interest?

This idea reminds me of the issues we discussed in the beginning of the semester. For instance, Jehovah’s witnesses are forbidden by their religion to receive blood transfusions, even in times of immediate need. When treating a patient who is a Jehovah’s witness, would it be acceptable for a physician to override the patient’s decision to refuse a blood transfusion if it would save the patient’s life? Many would argue that the answer is no, due to the principle of autonomy.

In the end, I believe doctors must come to terms with allowing patients to make decisions that may not necessarily result in their best interest. This does not mean a physician is not entitled to express their professional opinion. In fact, I think the best course of action for a physician is to explain their reasoning to the patient and allow them to make their own decision. “In cases where the choice made will clearly adversely affect the patient, practitioners need not be so neutral that they cannot indicate what they consider to be the best choice. No effort at persuasion is tantamount to abandonment.” (Dunbar) Therefore, doctors should only intervene in patient decision-making by persuading the patient to proceed in one direction versus another. Patients have the right to refuse treatment, even if it is not the best course of action in the eyes of medical professionals. I believe the following quote by Dr. Steven Pantilat appropriately summarizes a physician’s obligations:

“a patient who has had bypass surgery may want to continue to smoke or a patient with pneumonia may refuse antibiotics.  In these situations the autonomous choice of the patient conflicts with the physician’s duty of beneficence and following each ethical principle would lead to different actions. As long as the patient meets the criteria for making an autonomous choice (the patient understands the decision at hand and is not basing the decision on delusional ideas), then the physician should respect the patient’s decisions even while trying to convince the patient otherwise.” (Pantilat)

References

Ackerman, Terrence F. “Why Doctors Should Intervene.” The Hastings Center Report 12.4 (1982): 14-17. JSTOR. Web. 18 Mar. 2017.

Dunbar, Terri. “Autonomy versus Beneficence: An Ethical Dilemma.” Primary Health Care. N.p., Feb. 2003. Web. 18 Mar. 2017.

Marco, Catherine A. “Does Patient Autonomy Outweigh Duty to Treat?” Virtual Mentor. Amer Med Assoc, 24 Mar. 2009. Web. 18 Mar. 2017.

Pantilat, Steven. “Autonomy vs. Beneficence.” Autonomy vs. Beneficence. UCSF School of Medicine, 2008. Web. 18 Mar. 2017.

The 1982 Hastings Center Report raises several important issues from across the spectrum of biomedical ethics that we have been discussing in this class. The most prominent issue raised in the article “When Doctors Should Intervene” by Terrence F. Ackerman is that of how autonomy is affected by illness. According to Ackerman, there are many ways in which illness diminishes autonomy. Illness can make a person mentally incompetent to make decisions, create social pressures that impact a patient’s course of decision making, or cause fear that also impacts a person’s decision making.

Ackerman then goes on to argue that a paternalistic intervention is justified in a situation where an illness impacts autonomy in some way. While I mostly agree with him, I do believe that there need to be some limits on physicians’ intervention in order to protect patients’ autonomy. While it is likely that illness legitimately affects a person in several ways, there is always the possibility that a patient has undergone a legitimate value change and truly, competently, and autonomously wishes to change his or her direction of treatment. Thus, physicians and surrogate decision makers need to be careful when dealing with issues of paternalistic intervention.

Ackerman suggests that the way to deal with these situations is to return control to the patients by explaining the relevant information in such a way that the patient can clearly understand what is going on and can make a decision based on that understanding. This is where I begin to take issue with his argument. One of the most dangerous things a physician can do for a patient’s autonomy is to explain information through different lenses. For example, a patient dealing with diminished autonomy as a result of severe anxiety may still legitimately fear a certain course of treatment even if he or she was not being under the influence of anxiety. However, if a physician was to emphasize the good aspects of the treatment and downplay the negatives to try to get the patient to do what the physician considers to be the best course of action, then in my view, this physician has performed a hard paternalistic intervention that is unjustified.

The framing effect makes it extremely difficult to get information to a patient in an unbiased manner, and it is almost impossible to do so if the information is transmitted verbally. In my opinion, the best way to give information to a patient is to write it out on a paper and give it to the patient to read, and then give the patient the opportunity to ask any questions about his or her condition and plan for treatment.

This whole discussion reminds me of the case of Dax Cowart, which we discussed in class this past week. Cowart’s case was a case of paternalistic intervention by his physicians that he did not want. While the case can be made that the paternalistic intervention was justified on the grounds that he suffered a severe injury that ultimately led him to have depression and unjustifiably want to commit suicide, this was clearly a case of a legitimate value change that coincidentally coincided with a severe medical occurrence that could diminish autonomy. In addition to not accounting for this possibility, Dax’s physicians also failed miserably with their presentation of the information, as they inflicted him with severe pain under the guise of making him better. I would argue that he was worse off due to all of the pain and suffering associated with the treatments for his burns. As Dax’s case makes very clear, physicians need to be careful with their own evaluations of a situation and how they present information to patients about their own situations.