MED ETHICS DEBATE
docx
keyboard_arrow_up
School
University of Scranton *
*We aren’t endorsed by this school
Course
212
Subject
Medicine
Date
Apr 3, 2024
Type
docx
Pages
7
Uploaded by ConstableNeutronNewt3
A surrogate decision maker may refuse medical treatment for an incapable patient. This may be done by means of an advance directive, typically a living will and/or a durable power of medical attorney. In a living will, the patient specifies the treatment wanted or not wanted at the end of life. A durable power of medical attorney names a person who is to make informed-
consent decisions in the event that a patient becomes incapable, even if temporarily. If the surrogate has a durable power of medical attorney, the surrogate cannot override an existing living will but may otherwise speak for a patient. All of that sounds clear, but in reality a variety of circumstances can lead to doubt about whether a surrogate appropriately speaks for a patient. For example, a living will or a durable power of medical attorney might be from another state, and states have their own requirements for advance directives. Or a surrogate may be invalidated if the surrogate is not speaking in the interests of the patient. Furthermore, surrogates must themselves be capable of making medical decisions. This case is about doubt
arising partly due to the seemingly clouded judgment of a surrogate decision
maker, the patient’s wife, and a family dispute about which treatment the patient previously indicated he desires. CASE PRESENTATION AND DISCUSSION Mr. John Fayette is a 68-year-old former construction worker. Two years ago he suffered a stroke, and his health has been declining ever since. His kidneys are failing and he is now on
dialysis. He wrote a living will, stating as plainly as he could that he did not, under any circumstances, want resuscitation or to be on a ventilator. He named his wife, Harriet, as his power of attorney for health-care decisions. She completely understood both his desires and the fact that she was not to go against his wishes. However, she did not think he was making a good decision, and she therefore tried to talk him out of it. Recently, John had a major heart attack. He was taken to the emergency department at the nearest hospital. John’s wife told the physician that he did not want CPR or to
be on a ventilator. She did not have the power of attorney or living will with her. The emergency physician, Dr. Sudbury, thought that a ventilator would probably be needed but agreed not to use it. Two of John’s sons, both of whom John worked with for several years, arrived that evening and demanded that aggressive and full treatment begin immediately. They said that John would have wanted aggressive treatment and that they had had many discussions with their father at their work site about aggressive treatment should an accident occur. They work in a dangerous occupation and witnessed the deaths of two co-workers; another five went to emergency
departments with serious injuries. So they assured the physician that they knew their father’s wishes. Their mother was confused, they said. Harriet did not interfere, and Dr. Sudbury soon put John on a ventilator. Dr. Sudbury was placed in a difficult position. Although he was clearly informed by Harriet that
John did not want to be placed on a ventilator, he soon faced conflicting information about John’s desires. Under emergency conditions, he did not have the time or resources to get to the bottom of the conflict. It seems that
his best course of action was to treat John in a way that was called for by the standard of care, including ventilator support. Afterwards, issues about John’s
wishes might be resolved. John was moved to the medical intensive care unit, where the attending physician was told about the disagreement among family. The attending requested help from the bioethicist, Dr. Sonya Haddam,
on call that day at the hospital. Dr. Haddam quickly set up a meeting among all the concerned parties. At the meeting, Harriet produced a living will that followed the guidelines of their state. She still could not find the power of attorney she claimed to have. Dr. Haddam informed her that a living will does not take effect until the patient is judged to be terminal. Harriet seemed confused but said little more. When her sons said she was confused, she seemed to accept that, based on a nodding of her head. The sons again insisted that their father would never want to give up the fight, at least while
he had a chance. They assumed he understood that the living will would apply only if he were terminal. The sons agreed that under those conditions, a terminal situation, it would make sense to stop aggressive treatment, but not now when he had a chance of recovery. Dr. Haddam thought it was clear that based on her information, she would recommend continuing treatment. Nothing in this case is as clear as we would like it to be. We are told that John
did not want aggressive treatment and that he was growing tired of his condition. This was first expressed by Harriet, but she failed to be consistent or at least to reaffirm that view. She could not produce the appropriate document, the power of attorney, and a living will takes effect only under a terminal condition. Dr. Haddam was faced with the sons’ statements, who presented their views clearly, and his wife, who seemed to vacillate. Understanding that it was a life-and-death situation, Dr. Haddam decided, with good reason, to recommend continuing treatment. Nevertheless, she probably should have questioned Harriet without her sons being present. This may have led her to a different conclusion, perhaps more in keeping with John’s actual desires. The sons knew about their mother’s original statement and about the living will. Even though a living will takes legal effect only when a person is diagnosed as terminal, it may have moral standing, showing a person’s desires for or against treatment. The sons, however, interpreted it in the legal sense, claiming their father would have thought of it as coming into effect only if he were dying. Their mother’s silence probably also indicated to them that they were right. Under these conditions, it is difficult to fault the sons. Five days later, John was anxious to leave the hospital. He understood that he faced the likelihood of death, but he survived. He thought that he would recover, in the weeks ahead, enough to return to life as he knew it before this incident. He was happy with that. He mentioned his living will to a nurse, saying that he regretted writing it and
did so only because he was depressed. Now that he had defeated death, as he said, he would recant his living will and instruct his wife and children to fight for him unless he was facing a futile situation. Six weeks later, John did recover more or less to his former condition, and he rewrote his living will. People have a right to change their minds. This is clearly stated in legal
documents related to living wills. If they do change their minds, and assuming they are capable, then typically that should be honored. However, until they change their minds, their prior expressed wishes should be followed under the substituted judgment standard of proxy decision making. Substituted judgment means making a medical decision for an incapable patient is to be done in the way the patient would have made the decision for himself. In this case, the fact that John changed his mind is not relevant to prior decision making. If this were factored into decision making, then advance directives would lose all of their impact. Some bioethicists might believe that the possibility of a change of mind shows that advance directives are often, maybe even typically, not a good thing, but we believe that most bioethicists would claim that advance directives should be honored
in typical circumstances because this is a keyway to preserve patient autonomy.
Should the patient have received care? NO
1)
Beneficence and non-maleficence: the principles of medical ethics include beneficence the obligation to do good and non-maleficence the
obligation to do no harm. In Mr. Fayette’s case the initial living well specified that he did not want aggressive treatment including resuscitation and ventilation. Given his health condition stated wishes providing aggressive treatment could be seen as a violation of non-
maleficence principles as it could subject him to interventions that he explicitly wished to avoid. It also a deviation from beneficence since it may not align with his best interests as perceived in his initial wishes.
2)
Patient autonomy: respect for patient autonomy is a fundamental principle of medical ethics. For Mr. Fayette’s living will is a clear expression of his autonomous decision regarding his medical care period deviating from the living will without a clear and consistent evidence of change in his wishes can be viewed as a breach of his autonomy. This may undermine the trust patients have in healthcare systems to honor their autonomous decisions.
3)
Informed consent: the principle of informed consent requires that patients have adequate information to make decisions about their care. Mr. Fayette’s living will represented his will considered an informed decision about the treatments he wanted to receive. Deviating from this document particularly in the absence of new documented wishes raises concerns about the adequacy of informed consent for his treatment.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
4)
Minimizing emotional distress: Changing the treatment course against Mr. Fayette’s living will lead to emotional distress for the patient and his family. Upholding the living will minimizes the distress by ensuring that patient’s wishes are protected. 5)
Respecting advanced directives: advanced directives such as living wills are legally ethically binding documents that express a patient’s wishes for their medical care when they are unable to make decisions. Respecting these directives is not only an ethical obligation but a legal one. In this case the initial living will if valid and applicable to his condition should have been the guiding documents.
6)
Principle of veracity: principle of veracity relates to honesty and truth telling in medicine. Deviating from the living well without a clear and compelling reasons could be seen as a lack of transparency and honesty and decision making. It's ethically important to provide care that aligns with the patients expressed preferences unless there are compelling reasons to do otherwise.
7)
Equity and fairness: in cases where there are doubts and inconsistencies treating the patient in accordance with their initial wishes ensures equity and fairness. This approach avoids potential bias
disputes and conflicts that might arise when family members or healthcare providers attempt to interpret the patient's wishes without clear documentation.
8)
Resolution of conflicts: medical ethics encourages the resolution of conflicts through dialogue communication and focus of the best interest of the patient. In this case it would have been ethically sound to engage in open and transparent communication with all parties involved and seek consensus. Following the initial living will would be a
way to respect his wishes and potentially prevent family conflicts.
9)
inconsistent wishes: the primary reason for not following the living will in this case is the inconsistency in Mr. Fayette’s expressed wished. Initially, he clearly stated in his living will that he did not want aggressive treatment, including resuscitation or ventilator support. However, after experiencing a life-threatening event and perceiving a chance of recovery, he changed his mind and expressed a desire to
continue fighting for his life. This inconsistently raises doubts about whether the original living will accurately reflect his current wishes.
10)
Ambiguity: the living will itself will have created confusion. While it clearly expressed Mr. Fayette’s preferences, the sons interpreted it in
a legal sense, believing it only applied in terminal situations. Such ambiguity in the document and differences in interpretation contribute to the uncertainty surrounding the patient’s true wishes.
11)
Importance of Patient Autonomy: while advance directives and living wills are essential tools for preserving patients’ autonomy, they should not be rigidly followed incases where the patient’s best interests and current wishes are in doubt. In this case. My Fayette’s ability to change his mind and express a new living will underscores the importance of respecting patient autonomy and allowing them to make decisions that align with their current values and circumstances. 12)
Substituted Judgment Standard: the substituted judgment standard in proxy decision making suggests that decisions should be made in a way that the patient would have made if they were capable. In this case, the fact that Mr. Fayette changed his mind and rewrote his
living will reflects his actual desires at that moment, and these should be considered as the best reflection of his preferences. 13)
Lack of clarity in Advance directives the case highlights the potential shortcomings of advance directives and the challenges they can pose in decision-making. The living will, while clear in some aspects, failed to specify its applicability under non0terminal conditions. This ambiguity in the document makes it difficult to confidently assert that Mr. Fayette’s initial wishes apply in his current situation. 14)
Ethical duty to reevaluate: given the evolving circumstances and Mr. Fayette’s change of heart about his medical preferences, there is an ethical duty to reevaluate his situation. The attending physician, Dr. Sudbury, might have reasonably concluded that a reevaluation was warranted to ensure that the treatment aligns with Mr. Fayette’s current values and desires.
15)
Uncertainty regarding Harriet’s position: Harriet 's position was inconsistent and unclear during the decision-making process. Her initial
statement was that Mister Fayette did not want aggressive treatment which she later appeared to waver and did not produce the power of attorney document as evidence of her authority. This uncertainty raises
concerns about whether she was truly representing her husband's wishes.
16)
Legal and ethical responsibility of the physician: the attending physician Dr. Sudbury faced A challenging ethical and legal responsibility. When presented with conflicting information and legal uncertainties regarding the living will the physician may have felt compelled to err on the side of caution by providing aggressive treatment to avoid potential legal ramifications. The sleep will concern could have influenced the decision to deviate from the living will.
17)
Medical futility: the principle of medical futility comes into play when a treatment is unlikely to provide significant benefit to the patient. The attending physician may have believed that despite Mr. fayette expressed preferences in the living well aggressive treatment was not futile and had the potential to Improve his condition and quality of life.
18)
Legal implications: the absence of durable power of attorney and
the ambiguity in the living bill could have raised concerns about potential legal repressions for the attending physician period to protect
against legal challenges Dr. Sudbury may have opted for aggressive treatment as a precautionary measure.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help