Submitted to Joshua Evans, PhD. in partial fulfillment of
HCE 430 Applied Ethics in Health Care
August 3, 2019
Sarah is a mother of four and she is suffering from a massive stroke. The stroke left her with major complexities and she cannot eat, speak or move the left side of her body. Health practitioners are giving her artificial nutrients and hydration with the help of a nasogastric tube. Sara is being irritated by the tube and she is continuously pulling that out. As a result, she got aspiration pneumonia. The caregivers were terrified whether to continue giving her ANH using the NG tube or should insert PEG tube. But one of her sons, Josh told the caretakers not to move forward with a PEG tube as it will create more complications. The doctors were going to follow what Josh said until one of her daughters reveal that Josh is not willing to help their mother and doctors must not listen to him. Josh is not interested in saving her mother’s life and he had even shifted her to a nursing home. Maria requested that possible treatments should be used to save her mother’s life and ANH must be given by inserting a PEG tube.
This situation created a dilemma because Sarah was widowed and it was not clear that which child is responsible for her and should be making decisions for her. This case raises questions that whether the caretaker should be continuing the treatment or should listen to John and do not insert the PEG tube for giving her artificial nutrients and hydration. In this essay, I will be arguing that Sara should be given medical treatment taking into account the role of autonomy, liberty, and choice of caretakers in terms of medical ethic that can prove best in the interest of patient
Patient’s autonomy is the central tenet in medical law and it gives a chance to the patient to make a decision regarding the care they are going to receive. Autonomy is related to self-governance and maximizes the capability of patients to make decisions for them. As a legal principle whether the expression of the will should be allowed to a patient who does not understand what treatment procedure is good for him or an autonomous decision should be considered as a regulatory tool and the patient should be allowed to act freely (Coggon & Miola, 2011).
However, medical law suggests that “doctor knows best” is very clear and in order to give the autonomy of decision making to a patient he or she should be briefed regarding the treatment options. Medical law says that if the patient is competent enough to make decisions then consent should be given to him or she before started the treatment processes (Coggon & Miola, 2011). Dunn and Foster (2010) say that if an adult is not able to make decisions then decisions should be made for him or her and those decisions will be considered as lawful if that involves the best interest of the adult patient.
However the principal of Welfare talks about the safety of an individual and it emphasizes the moral implication of keeping a person away from any sort of harm (Dunn & Foster, 2010). Best interest standard is more like an underlying platform that defines the goals and objectives of healthcare. In the subject case study, the overall approach to be applied should adhere to the Best Interest Standard because it is the responsibility of healthcare providers. Taking into account other relevant aspects of this case study it is asserted that the power of moral welfare should be exercised in the case of Sara because she needs quick treatment and the decision making of his son might cause a risk to her life. It would not be wrong to say that the course of decision making completely relies on healthcare providers because all dimensions of the son's decision are negating the core principles of Medical Ethics. Moreover, if the son is against treatment, the daughter is equally in favor of medical services for Sara that highlights the significance of principles of Healthcare department because in the end, what matters is the best interest of the patient.
The conflict can be solved with the help of the principle of proportionality (Dunn & Foster, 2010). This principle states that the moral sense or the sense of a justice of a person cannot be justified if it is creating any kind of harm. Thus following a decision that causing harm is unjustifiable and should be avoided (Luy, 2015).
The wellbeing of an adult should be analyzed in a broader term before making any decision. Risk management is such a case might be contradictory between harm prevention and best interest of the individual. In the case of Sara, the thinking of both the children are not the same regarding their mother but her daughter is thinking to minimize the risk factors and also wants the quick recovery of her mother. It reveals from her behavior that Sara might agree with her not with John as he says not to process any treatment procedures.
In the given case, the decision making of Sara’s son might have a bad impact on the health of his mother. As she cannot eat drink or move and she needs artificial nutrients and hydration to be alive. If the PEG tube is not transmitted then she will not be going to get something to eat. I think that ANH is a moral obligation in this case because it is a source of nutrition for Sara and it is not doing any kind of harm. Although it is quoted that the patient continuously pulls the tube and it might cause infection still, life seems a major priority when compared with infection, At least ANH has the ability to keep the patients alive and it is the prime focus of healthcare. Moreover, refusing to do the PEG tube would automatically cause harm to the patient as she would be starving and dehydrating.
In some cases, the autonomy of the decision making of an individual may be waived in favor of the values and need of the family group and such cultural contact of decision making cause dilemma for the care providers.
The concept of Principlism can also be used to analyze the given situation of Sara. Principlism is based on four principles and these principles are effective until they are not creating any conflict with the other principle. These principles include respect of autonomy, taking into account the best interest of the patient, considering the risk factors, and taking care of what would be right and what would be wrong for the patient. These principles are used to make ethical decisions for an individual who is not in a condition to make decisions for himself or herself. All these principles should be checked, and it should be analyzed which principle has the highest weightage in that situation and the decision making should be made according to that (Falahati, 2014).
There are various critiques of decision making with the help of principlism according to which it is difficult to omit one principal and to identify the weight of the other principal. But in many cases, more of these principles are used in decision making and the highly weightage principle reveals itself (Falahati, 2014).
For instance, Sara cannot take her own decision but neither has she given any authority to her children to do that for her. One of her children is making a decision that is justifiable; it also reveals the best option for Sara for the time being and is also taking care of the risk factors. Sara’s son says that the treatment created a problem for her and the doctors do not need to process another treatment option as well. This decision is not feasible neither has it minimized the risk factors which are not justifiable (Falahati, 2014).
Moreover, in the field of medicine, a person is called autonomous if the individual is capable enough to make a decision that would be relevant. The decision is understood as non-autonomous if it is not fulfilling the criteria of provision that is set by medical laws. This law says that the adult should have an idea of what is good for him or her and what decision will minimize the health risks. To make the patient aware of what treatment would be suitable the physician must spend some alone time with the patient (Falahati, 2014).
If the doctor helps to make the patients understand their condition then it would also be helpful for the patient to decide what measures should be taken to provide adequate services and treatment to the patient, that can keep her alive. In the given case of Sara, she is not able to make the decision for herself so she needs the help of her children to make decisions on her behalf. The doctors need to brief her situation to her children so that they could come up with a rational decision. The decision making of the individual should not be affected by any kind of external factors like personal choices, belief or cultural system. The decision should merely base on minimizing risk and for a timely recovery. Generally, the person does not need to be completely autonomous because the involvement of a doctor is necessary to guide the patient. The decision of an autonomous person will always act on the basis of certain goals. In the case of Sara, her daughter is deciding on the basis of the fact that her mother should get better quickly. In accordance with the objectives of healthcare and the prime responsibilities, the best interest of patients is focused, in this case, the statement of a daughter also seems to prove effective in the long run. Sara's daughter asserts that her mother should be given required treatment and it would lead her mother to health if not, it will keep her alive and it is one of the best interests. (Falahati, 2014).
However, the decision of the patient has a great impact on the treatment procedure and the patients need to participate in the process that the recovery can be possible. Autonomy has an intrinsic value and the clinic is using the concept of autonomy to save peoples life. But some patients have an illness that do not let them make rational decision and patient refuse for treatments. Some restrained treatment on cultural or religious grounds and health practitioners do not challenge the beliefs of such individuals (Chubak, 2009).
However, in case of Sara, she has no issues of any religious or cultural beliefs that could restrain her from getting on-time treatment, but it is not confirmed that who will be going to make decisions for her. She is a widow and her children have a contradictory view regarding the treatment procedures. Her son says that the doctor should not be giving her the treatment and her daughter says that Sara needs accurate treatment to save her life. With respective of the laws of ethical autonomy is given to Sara whatever decision she is going to take but the given situation shows that she is unable to select the decision-maker for herself. It is, therefore, the caretaker should listen to her daughter decision because her decision is justifiable, rational and in the best interest of the patient. If Sara gets on-time treatment she will be able to minimize the risk factors and should be able to fight against her illness. The doctors need to take awareness session with Sara's son so that he would also be part of the decision making.
Chubak, B. (2009). Clinical Responsibility in the Age of Patient Autonomy. AMA Journal of Ethics, 11(8), 567–570
Coggon, J., & Miola, J. (2011). Autonomy, Liberty, And Medical Decision-Making. The Cambridge Law Journal, 70(3), 523–547. https://doi.org/10.1017/S0008197311000845
Dunn, M., & Foster, C. (2010). Autonomy and welfare as amici curiae. Medical Law Review, 18(1), 86–95
Falahati, S. (2014). What is the Scope of Autonomy in Medical Practice? Scottish Universities Medical Journal, 3(1).
Kockler, N. J. (2007). The Principle of Double Effect and Proportionate Reason. AMA Journal of Ethics, 9(5), 369–374. https://doi.org/10.1001/virtualmentor.2007.9.5.pfor2-0705
Luy, J. (2015). The principle of proportionality: the concept and its application to animal protection issues such as the ‘three Rs’ and the ‘harm–benefit analysis.’ ALTEX Proc, 4, 16–23.
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