Final Exam
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Philosophy
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December 14th, 2021
PHIL 2030 Final Exam
Essay A
When understanding ethics, it is important to listen to other people’s experiences
with oppression, and injustices. Specifically for ethics in healthcare, known as bioethics,
people need to listen to first-hand experiences of patients who have themselves
experienced the effects of an illness or disease, and inherent medical interventions and
policies in which they endure. From personal experience, Misak proposes that the
principle of respect for patient autonomy, although important, should not be deemed
with the same importance when assessing patients in critical care. Misak argues that
patients in critical care are not properly and thoroughly tested for mental distress
because commonly their competency is assumed to be intact when in reality, this is not
the case. Critics of her position have declared this creates a dangerous precedent for
ICU patients who are not competent enough to make their treatment choices, as well as
non-ICU patients. Through Misak’s position, she can manage the impact of these
objections by arguing that for patients in critical care this is in fact the route that will
benefit them most in the future, which will essentially minimize the risks of overall
unhappiness following their discharge.
The principle of respect for autonomy refers to the duty to respect a patient's
decision about their treatment despite possible disagreement. After her experience, she
argues that respect for autonomy needs to be reevaluated in the context of patients in
critical care. Misak suffered from ARDS, a severe lung injury that requires mechanical
ventilation or some type of life support for most patients. Misak herself spent weeks
experiencing various organ failure and drug-induced comas, leaving her with little to no
chance of surviving. (Misak 2005) It is common for patients with ARDS who are in
critical care to experience episodes of psychosis, extreme hallucinations, which can
result in patient-physician relationship consequences leading to the question of why
patients are granted authority in the decision-making process when they may be
incompetent. (Misak 2005) Misak acknowledges the importance of patient autonomy,
drawing on her own experiences of feeling alienated in the hospital, simultaneously
acknowledging the persistent desire to be extubated and released by most patients
which is a conflict of interest in their health and well-being.
In most cases, patients in critical care are not adequately assessed for
competency, which they usually measure through determining the patient's present
abilities and capacities, ie; do they have the capability to answer questions and engage
in thorough conversations? (Misak 2005) The complicated and difficult aspect of this
process is patients who seem to be okay, may, in reality, may not be. Misak draws on
her stay in the ICU; she was able to answer who and where she was, the names of her
children, and was therefore deemed mentality stable when in actuality she remembers
being a “psychological mess”. (Misak 2005) These informal tests are essentially
granting patients the power to make decisions about their treatments when they are not
in fact able to make ones that are beneficial to their physical and mental health. Most
patients in the ICU are ventilated which is a barrier in assessing their physiological
status, as most patients in critical care become agitated from the intubation, and will
likely do and say what it takes to not be. (Misak 2005) Furthermore, it is clear that not all
ICUs contemplate psychological well-being as a serious issue, and subsequently do not
test for it, which directly should impact the patient's autonomy.
Misak developed a two-step practical measure, that is simple and inexpensive
and could be used to manage the impact of critics' objections of a dangerous precedent
being set by not respecting patient autonomy in critical care. In this, she highlights the
duty to minimize the trauma patients experience following the ICU, as well as not to
completely cut the patient off once they have been released. First, the hospital she was
staying at was assembling a critical care transitional team to reduce the alienation and
mental instability which should be made available to all patients. Second, patients are
often unaware of what is to come in their recovery process and should be provided with
an explanation of what is to come in days, weeks, months, and years, as this is now
their life. If this practical measure could be implemented for all ICU patients, they could
eventually be deemed mentally stable, and make rational choices about their treatment
options and processes. Patients need healthcare professionals to conduct research on
being released from the ICU, and the mental distress that can seem invisible but is
clouding their judgment to make rational choices. If this was better understood and
there were critical care transitional teams accessible to all critical care patients, they
could be provided with the support to think logically about their treatment options.
To conclude, the critics of Misak’s objection do so because they fear it will set a
dangerous precedent regarding patients and respect to their autonomy. This concern is
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valid, however, Misak’s reason to delay respecting autonomy in critical care patients is
to preserve their physical and mental health, until they have reached a state where they
can be assessed and granted control over themselves again. She is not arguing that
patient autonomy should be completely disregarded, or that it is unimportant because
she makes it clear that this is not the case. She is arguing for this from her personal
experience with ARDS and staying in the ICU, and as a patient who was granted
autonomy and deemed to be mentally stable in making major choices about her
treatment. As she reflects on her own experience she has been able to realize that this
was not beneficial to her overall physical and mental health. When discussing ethics in
healthcare it is essential to draw on patient experiences, as this can help shape future
physician-patient interactions, and can provide all sides with a better understanding of
what is required. Through Misak’s position, she can manage the impact of these
objections by arguing that for patients in critical care this is in fact the route that will
benefit them most in the future, which will essentially minimize the risks of overall
unhappiness following their discharge.
References:
Misak, Cheryl. (2005). “ICU Psychosis and Patient Autonomy: Some Thoughts from the
Inside”.
Journal of Medicine and Philosophy
, 30:4, 411-430
Essay B
When a medical dilemma occurs, and there is a disagreement between a patient
and a physician regarding treatment plans, how does one find the most ethical solution?
To help make decisions when these situations arise, there has been a ‘four principle
approach’ conducted for health care ethics. This approach was originated and
conducted by Tom Beauchamp and Jim Childress in their textbook Principles of
Biomedical Ethics. Rules for ethics in healthcare are often in regard to the four
principles, as well as moral considerations. Essentially, these principles are ‘rules’ to
ensure ethics in healthcare are prioritized, with a focus on what is overall most
beneficial to the patient's health and wellbeing. In the difficult case of Madame Brossard
refusing to provide consent for the life-saving operation, the surgeon ethically cannot go
against her medical wishes as she is competent and continuously rejects the surgery.
Despite the previous surgeon's mistake causing her to be in this position, the hospital
and doctors are not allowed to perform the surgery if following a model of moral
responsibility and ethics.
The four principles of bioethics include beneficence which is the duty to provide
benefits to the patient while balancing benefits against risk, nonmaleficence which is the
duty to avoid creating harm for a patient, respect for autonomy which is the duty to
respect patients right to make decisions about their treatment, and justice which is the
obligation of fairness in the distribution of benefits and risk to the patient and society.
(Beauchamp 2006) Some principles arose from historic roles, and some from modern
problems, but all principles connect to models of moral responsibility. However, often
the solution is not simple nor straightforward and so specification and interpretation are
required to reach an outcome. They are starting foundation points in health care ethics,
which can be looked at as abstract rallying points for reflection, meaning they do not
merely suggest a final or adequate appeal. (Beauchamp 2006) These principles are
significant as they highlight the fact that important parts of morality have been neglected
in the past in health care ethics, and need to receive more attention and prioritization.
When looking at the case of Madame Brossard I am going to apply each of the
principles. The principle beneficence says the surgeon should not operate if she has
made it clear that not doing so will benefit her, however logically this surgery would
benefit. Next, the principle of nonmaleficence says that the surgeon should operate
because without it she will most likely die and the surgery would be actively preventing
further harm from her in the future. Next, the principle of respect for autonomy would
say that it would be ethically immoral to operate as Madame Brossard has repeatedly
made it clear she does not want the surgery. Lastly, the principle of justice says the
surgeon should operate because it would produce the most fairness in the distribution of
benefits and risk to the patient, by saving her life, and her family too. Although multiple
of the principles say ethically the operation should be done, the fact that Madame
Brossard herself is definitively rejecting the surgery cannot be ignored, as it would be an
infringement of the physician's respect for her autonomy.
In recent years the belief that the correct model of a physician's moral
responsibility should not be understood as traditional ideals to medical benefit, but
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emphasizing the rights of the patient, which includes an autonomy-based right to the
truth, confidentiality, privacy, disclosure, and consent. (Beauchamp 2006) It is now
common to see the beneficence-based model of health care ethics which is the
autonomy model being practiced in clinical encounters. The principle of respect for
autonomy stems from the liberal Western belief of how important individual freedom is
for political and personal development. (Beauchamp 2006) This can be associated with
several contemporary ideas including privacy, voluntariness, choosing freely, and
accepting responsibility for one's choices. (Beauchamp 2006) Recent social history has
prompted health care ethics to highlight autonomy rights, as well as justice-based rights.
Issues raised by minority rights, women’s rights, and various others include health care
components which can include the right to health care information, access to care, and
rights to be protected against unwarranted human experimentation, among many more.
(Beauchamp 2006) This is why I argue that the principle of respect for autonomy should
be given practical priority in health care ethics.
To sum up, the four principle approach allows us to work through our moral
dilemmas in a way that supports and creates a method of context-expansion into
additional distinctive normative rules, as opposed to a system stratified in terms of
priorities among rules. (Beauchamp 2006) The ethical conflict, in this case, stems from
not knowing which model of healthcare ethics to use; both respects for autonomy and
beneficence are important moral principles and are both prioritized in the highest
importance for health care ethics. However, at the end of the day, Madame Brossard is
competent enough to make this decision for herself, and her autonomy needs to be
respected by the physician. I understand that some may object to this position, however,
unless she is showing signs of mental instability and or displaying irrational behaviours
the decision lies in her control. For example, if they were to ignore her request and
perform the surgery saving her life, she could very well wake up and be furious that her
autonomy was infringed upon, she could pursue legal action against the surgeon.
Therefore in the difficult case of Madame Brossard refusing to provide consent for the
life-saving operation, the surgeon ethically cannot go against her medical wishes as she
is competent and continuously rejects the surgery. Despite the previous surgeon's
mistake causing her to be in this position, the hospital and doctors are not allowed to
perform the surgery if following a model of moral responsibility and ethics.
References:
Beauchamp, T.L. (2006). The ‘Four Principles’ Approach to Health Care Ethics. In
Principles of Health Care Ethics (eds R.E. Ashcroft, A. Dawson, H. Draper and
J.R. McMillan).
https://doi.org/10.1002/9780470510544.ch1