42 results
Chapter 14 - Advance Care Planning and End-of-Life Decision-Making
- from Section 2 - Consultation
- Edited by D. Micah Hester, Toby L. Schonfeld
-
- Book:
- Guidance for Healthcare Ethics Committees
- Published online:
- 17 February 2022
- Print publication:
- 10 March 2022, pp 121-128
-
- Chapter
- Export citation
-
Summary
Mrs. Wilson’s case exemplifies one kind of disagreement about treatment near the end of life that occurs frequently in hospitals and often prompts a request for ethics consultation. There are several reasons for the frequent resort to ethics consultation in these situations. The values at stake, including freedom from suffering and disability and prolongation of life, are significant. In addition, treatment choices are often complex, offering uncertain benefits and burdens. Finally, as the long, public, and bitter legal battle over the care of Terri Schiavo made clear, Americans hold strong and divergent views about which life-sustaining treatments should, and should not, be pursued (Gostin, 2005). In this chapter, we explain that advance care planning and attention to goals of care can prevent or ameliorate much uncertainty and conflict over treatment decisions near the end of life.
Transplantation Ethics - Robert M. Veatch, Washington, DC:Georgetown University Press, 2000, 427 pp. US $65.00 cloth. ISBN 0-87840-811-8. Georgetown University Press, 3700 O Street NW, Washington, DC 20007, USA.
- John C. Moskop
-
- Journal:
- Politics and the Life Sciences / Volume 20 / Issue 1 / March 2001
- Published online by Cambridge University Press:
- 17 May 2016, pp. 97-98
-
- Article
- Export citation
Part III - Controversies in health care ethics: treatment choices at the beginning and at the end of life
- John C. Moskop, Wake Forest University, North Carolina
-
- Book:
- Ethics and Health Care
- Published online:
- 05 February 2016
- Print publication:
- 24 February 2016, pp 159-162
-
- Chapter
- Export citation
-
Summary
Health care options at the “edges” of life, near the dramatic events of birth and death, can reveal deep value differences among us and provoke intense moral conflict. Contemporary health care offers unprecedented choices about whether, when, and how birth and death will occur. Part III of this volume is devoted to examination of these choices.
The beginning of life
For a variety of reasons, reproductive decisions are among the most significant and controversial of human choices. Reproduction is, after all, a life-altering event for most of us. It creates a new human life, and it enables the joys and imposes the responsibilities of parenthood on those who choose it. Reproduction is almost always the result of sexual intimacy, one of the most valued and intense of human experiences. It raises the question, therefore, whether couples should be able to share this experience without reproduction as a consequence. Reproduction requires two people, but the major burdens of pregnancy, labor, and delivery fall on women, and that raises questions about the rights of women to make reproductive decisions. Finally, reproduction sustains, but may also threaten human societies. Western European nations with shrinking populations, for example, offer special benefits for their citizens who choose to have children. China, in contrast, for many years imposed penalties on couples who had more than one child, in an effort to control overpopulation.
Human reproductive values and desires vary across a wide spectrum. Consider the following three attitudes toward reproduction, for example:
For many people, reproduction and parenthood are highly valued and sought-after experiences. If these people have difficulty reproducing, they may seek medical assistance. Should technological assistance in fulfilling reproductive goals be available to all who desire it? Chapter 12, “Assisted reproductive technologies,” addresses this question, examining the scope and limits of reproductive freedom and the role of health care professionals and public policy in providing and controlling access to assisted reproductive technologies.
For many other people, reproduction is a highly undesirable event that they strive to avoid. Should abortion be available to all who desire it to prevent reproduction? Chapter 13, “Abortion,” explores this controversial question through a review of two representative positions on the morality of abortion, one pro-life and one pro-choice.
For still others, reproduction may be a matter of relative indifference.[…]
References
- John C. Moskop, Wake Forest University, North Carolina
-
- Book:
- Ethics and Health Care
- Published online:
- 05 February 2016
- Print publication:
- 24 February 2016, pp 336-366
-
- Chapter
- Export citation
7 - Truthfulness
- from Part II - Moral foundations of the therapeutic relationship
- John C. Moskop, Wake Forest University, North Carolina
-
- Book:
- Ethics and Health Care
- Published online:
- 05 February 2016
- Print publication:
- 24 February 2016, pp 90-100
-
- Chapter
- Export citation
-
Summary
Case example
Twenty-two-year-old Annie was brought by friends to the ED of a small Virginia hospital. She fell while horseback riding, was kicked by her horse, and lay in a field for several hours. Despite initial IV therapy, her blood pressure remains very low, and an abdominal tap reveals that she is bleeding very rapidly into her abdomen.
Though she is in shock, Annie remains awake and alert. She asks Dr. Smith, the emergency physician caring for her, “Is it a serious injury? Will I live?”
Dr. Smith responds, “Everything will work out, Annie. It may be a little rough for a bit, but it will work out.”
“Are you sure?” she asks. “Please, tell me honestly.”
Dr. Smith is very concerned about Annie's unstable condition, and he is unsure how she will do. What should he say to her?
Past and present
In twenty-first-century Anglo-American societies, truthfulness is widely acknowledged as a central professional responsibility of physicians. Professional standards regarding truthfulness have, however, undergone significant change over the past century, and what constitutes truthful communication is still a matter of some controversy. Other cultures, moreover, endorse somewhat different approaches to communication between physicians and patients. This chapter will examine the meaning and justification of truthfulness in the therapeutic relationship.
In an article published in 1903, physician Richard Cabot states the “rule for truth-speaking” he was taught as a Harvard medical student: “When you are thinking of telling a lie, ask yourself whether it is simply and solely for the patient's benefit that you are going to tell it. If you are sure that you are acting for his good and not for your own profit, you can go ahead with a clear conscience.” As this rule illustrates, the medical profession of that era condemned self-serving lies, but approved lies told for the benefit of patients. Notice that the rule authorizes the physician to judge whether truthful or deceptive information will do more good for the patient, and to base his or her disclosure on that judgment.
This rule Cabot cites appears to have persisted well into the twentieth century. In a survey of 200 Chicago physicians published by Oken in 1961, almost 90 percent of the respondents reported that they generally withheld information about a cancer diagnosis from their patients.
20 - The genetic revolution
- from Part IV - Ethics in special contexts: biomedical research, genetics, and organ transplantation
- John C. Moskop, Wake Forest University, North Carolina
-
- Book:
- Ethics and Health Care
- Published online:
- 05 February 2016
- Print publication:
- 24 February 2016, pp 285-306
-
- Chapter
- Export citation
-
Summary
Case example
Twenty-three-year-old Ms. Alice Kemper seeks treatment in the ED of University Hospital for abdominal pain and bloating that has gotten progressively worse over the past week. Ms. Kemper reports that she had abnormal liver function tests during an uncomplicated pregnancy one year previously and that several members of her family have had cirrhosis or hepatitis. This information, along with her physical examination and the results of initial blood tests and urinalysis, suggests severe liver disease, and she is admitted to the hospital for further diagnostic testing. Based on a liver biopsy, eye examination, and genetic testing, Ms. Kemper is diagnosed with an advanced case of Wilson disease, a rare inherited disease in which excess copper accumulates in the liver, brain, eyes, and other organs. Because her liver damage is severe, Ms. Kemper is evaluated for a liver transplant. She meets the criteria for transplantation and is placed on the hospital transplant program's waiting list for a liver transplant.
While Ms. Kemper is waiting for a transplant liver to become available, she is referred to Mr. Quinn, a genetic counselor, to give her more information about her condition. Mr. Quinn explains to her that Wilson disease is caused by multiple mutations in a gene that enables production of a protein that transports copper within the body. Without this protein, excess copper accumulates in and damages multiple organs. Because Wilson disease is an autosomal recessive disorder, patients with this condition have inherited gene mutations from both of their parents. If both parents are carriers of this gene, each of their children has a one-in-four chance of inheriting the mutations from both parents and developing the disease. Mr. Quinn explains that Ms. Kemper's siblings are also at risk for this life-threatening genetic disease. Ms. Kemper informs him that she has two younger siblings, a 16-year-old brother and a 14-year-old sister, but that she does not want to inform them about her condition or communicate with them in any way. She explains that she was abandoned by her parents and her family years ago, and she refuses to have anything to do with them. She does, however, ask whether her 1-year-old daughter can be tested for the genetic markers for Wilson disease, so that she can be on the lookout for signs of the disease.
Acknowledgment
- John C. Moskop, Wake Forest University, North Carolina
-
- Book:
- Ethics and Health Care
- Published online:
- 05 February 2016
- Print publication:
- 24 February 2016, pp xi-xii
-
- Chapter
- Export citation
Part I - Ethics in health care: role, history, and methods
- John C. Moskop, Wake Forest University, North Carolina
-
- Book:
- Ethics and Health Care
- Published online:
- 05 February 2016
- Print publication:
- 24 February 2016, pp 1-2
-
- Chapter
- Export citation
-
Summary
The five chapters in Part I of this volume provide a general introduction to the field of health care ethics, including its purpose, history, methods, and relation to the domains of law and culture. The account of the nature, scope, and limits of health care ethics provided in these chapters is designed to set the stage for examination of the multiple specific topics in ethics and health care in the subsequent chapters of the book.
Chapter 1, “The role of ethics in health care,” begins with a description of several concepts of ethics, common sources of moral guidance, and methods for resolving moral disagreements. It then considers the relation of ethics and health care, arguing that ethical issues are especially prominent in health care. This prominence is a result both of the importance of the human interests at stake and of the complexity of many treatment decisions. Ethics can guide difficult choices in health care, but decisions also depend on factual information, and even the most careful moral reasoning may not produce a unique and definitive “correct” solution.
Chapter 2, “A brief history of health care ethics and clinical ethics consultation in the United States,” describes the emergence of health care ethics as a new field of inquiry and practice in the latter half of the twentieth century. This review highlights major changes in the US health care system during this period. It also identifies three high-profile events that called public attention to moral issues in medical research and practice: investigative reports condemning the decades-long Tuskegee Study of Untreated Syphilis in poor black men, the US Supreme Court abortion decision in Roe v. Wade, and the New Jersey Supreme Court Quinlan decision on rights to refuse life-sustaining medical treatment. Chapter 2 also outlines the development of the practice of clinical ethics consultation in US health care facilities. From its origins in the 1970s, clinical ethics consultation has become a widely available service designed to help health care professionals, patients, and families make difficult moral choices about medical treatment.
Chapter 3, “Methods of health care ethics,” summarizes a variety of different approaches that scholars have proposed for moral reasoning in health care settings. These approaches recommend different theoretical tools and strategies to guide moral deliberation, including basic principles, paradigmatic cases, moral rules, and moral virtues. This chapter also describes a simple, step-by-step procedure for analyzing health care ethics cases.
18 - Aid in dying
- from Part III - Controversies in health care ethics: treatment choices at the beginning and at the end of life
- John C. Moskop, Wake Forest University, North Carolina
-
- Book:
- Ethics and Health Care
- Published online:
- 05 February 2016
- Print publication:
- 24 February 2016, pp 252-262
-
- Chapter
- Export citation
-
Summary
Case example
Dr. Quill has recently given his patient Diane some very bad news; a bone marrow biopsy shows that she has acute myelomonocytic leukemia. Diane owns a successful business, is married, and has a college-aged son. An oncologist informs her that treatment for her leukemia involves two courses of chemotherapy followed by whole body irradiation and stem cell transplantation, with a projected five-year survival rate of about 25 percent. Without treatment, life expectancy is less than six months. The oncologist recommends that she begin the chemotherapy immediately. To the surprise and dismay of her physicians, Diane refuses aggressive therapy for her condition, saying that the one-in-four chance of five-year survival is not good enough for her to undergo so difficult a course of therapy. Despite their efforts to persuade her to begin chemotherapy, she persists in her decision to live the rest of her life outside the hospital and to accept only palliative and hospice care.
Shortly thereafter, Diane tells Dr. Quill, who has been her primary care physician for the past eight years, that she dreads the thought of a lingering and painful death and very much wants to maintain control and dignity in her final days. She says that, when her condition gets worse, she wants to take her own life in the least painful way possible. She adds that she has discussed this at length with her husband and son, and they believe that they should respect her choice. Diane then asks Dr. Quill if he will help her take her life when her discomfort, physical deterioration, and dependence become too great. She tells him that having the means to end her life will free her from the fear of a lingering death and enable her to enjoy the time she has left.
How should Dr. Quill respond?
Key concepts
For more than half a century, the potential role of physicians in aiding the death of their patients has been one of the most controversial issues of health care ethics. Because “aid in dying” includes several different practices, and because commentators do not always use the terms that describe these practices in the same way, it is important to begin with definitions of suicide, physician-assisted suicide, and euthanasia. I define these concepts as follows: Suicide is the act of taking one's own life voluntarily and intentionally.
Part IV - Ethics in special contexts: biomedical research, genetics, and organ transplantation
- John C. Moskop, Wake Forest University, North Carolina
-
- Book:
- Ethics and Health Care
- Published online:
- 05 February 2016
- Print publication:
- 24 February 2016, pp 263-264
-
- Chapter
- Export citation
-
Summary
Parts I, II, and III of this volume have examined the roles, history, and methods of health care ethics, the moral foundations of therapeutic relationships, and moral issues at the beginning and at the end of life. Part IV will consider complex moral questions encountered in three specific health care contexts: biomedical research on human subjects, health care for genetic conditions, and organ transplantation.
Chapter 19, “Research on human subjects,” begins by recognizing the importance of biomedical research for achieving the beneficent goals of health care. It also recognizes the potential for grave harm to research subjects, illustrated in the Nazi medical research on concentration camp inmates and the Tuskegee syphilis study conducted by the US Public Health Service. The chapter goes on to examine basic criteria for morally defensible research on human subjects: informed consent, assessment of risks and benefits of the research, confidentiality, and equitable selection of subjects. It concludes with a discussion of who bears what responsibilities for the protection of human research subjects.
Chapter 20, “The genetic revolution,” describes both the great promise of the emerging practice of “personalized genomic medicine” and the great peril of misunderstanding and misuse of genetic information evidenced in the morally abhorrent eugenic sterilization and extermination programs of the twentieth century. The chapter examines moral questions in three domains of genetics activity: biomedical research, health policy, and clinical medical care. The discussions in this chapter focus on the use of genetic testing and the disclosure of genetic test results in various settings, including prenatal care, care for newborn infants, pediatrics, and adult medicine.
The volume's final chapter is Chapter 21, “Organ transplantation.” This chapter describes the emergence and growth of transplantation as a life-extending intervention for patients with a catastrophic medical condition, end-stage organ failure. The success of transplantation has stimulated great demand for this treatment, and the available supply of transplant organs has not kept pace with the increasing demand. Faced with the growing scarcity of transplant organs, transplantation advocates have proposed, and societies have implemented, a variety of strategies to increase organ supply. The chapter reviews and evaluates several of these proposed strategies, including presumed consent to organ donation, financial incentives for organ donation, revision of neurologic criteria for the determination of death, abandonment of the “dead donor rule,” animal-to-human organ transplantation, and bioengineering of human organs.
8 - Informed consent to treatment
- from Part II - Moral foundations of the therapeutic relationship
- John C. Moskop, Wake Forest University, North Carolina
-
- Book:
- Ethics and Health Care
- Published online:
- 05 February 2016
- Print publication:
- 24 February 2016, pp 101-113
-
- Chapter
- Export citation
-
Summary
Case example
Fifty-seven-year-old Mr. Evans arrives at the Emergency Department of a large teaching hospital complaining of chest pain, cough, and shortness of breath. Chest x-rays are obtained, and they reveal a large pleural effusion (a buildup of fluid between the layers of tissue that line the lungs and the chest cavity). Mr. Evans is admitted to the hospital and is assigned to a general internal medicine inpatient team. The team concludes that a thoracentesis (removal of accumulated pleural fluid with a needle inserted between the ribs) should be done to allow Mr. Evans's lungs to expand more freely, making breathing easier, and to obtain a fluid sample for testing. The senior resident asks Dr. Collins, the first year resident on the team, to perform the thoracentesis, and she agrees. Dr. Collins has observed this procedure on multiple occasions, but she has never performed a thoracentesis before. In obtaining Mr. Evans's consent, must she inform him that this will be the first time she has performed this procedure?
Origins and moral grounds
First introduced in the United States more than half a century ago, informed consent to medical treatment is now generally recognized as a fundamental moral and legal right of patients. This chapter will examine the origins, moral grounds, and essential elements of informed consent. It will also describe recognized exceptions to the professional duty to obtain the patient's informed consent.
The concept of informed consent has its origins in medical law. Early twentieth-century cases in the United States recognized a right to consent to proposed treatment, articulated in a classic statement by Justice Benjamin Cardozo in 1914: “Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient's consent commits an assault, for which he is liable in damages.” Cardozo refers to assault, and early consent cases relied on legal concepts of assault and battery, understood in this context as the intentional, nonconsensual, and offensive touching of a patient by a physician.
In a series of cases beginning in 1957, US courts expanded the established duty to obtain a patient's consent into a duty to obtain an informed consent, that is, to obtain consent after providing specific information about the proposed treatment to the patient.
10 - Professionalism: responsibilities and privileges
- from Part II - Moral foundations of the therapeutic relationship
- John C. Moskop, Wake Forest University, North Carolina
-
- Book:
- Ethics and Health Care
- Published online:
- 05 February 2016
- Print publication:
- 24 February 2016, pp 126-137
-
- Chapter
- Export citation
-
Summary
Case example
Dr. George Gayle has just completed the final stage in his formal medical training, a fellowship in medical oncology, and has joined a local multispecialty medical practice. He is a devoutly religious man and is a leading member of a large Christian congregation. Because his religious faith is such a central part of his life, Dr. Gayle would like to incorporate his spiritual beliefs into his professional practice.
Dr. Gayle informs his physician colleagues that he intends to address spiritual issues with his patients in several ways, including asking all of his patients about their own spiritual beliefs and practices, inviting patients to pray for healing with him, encouraging patients to take advantage of the health benefits of prayer and of other religious practices, inviting patients to visit the Sunday school course he teaches, and helping patients with serious illness understand that there is meaning in life and hope for the future. May he engage in these activities with his patients?
Over the past two decades, professionalism has become a major topic of discussion in medicine and health care. Commentators warn that the increasing commercialization and bureaucratization of health care is undermining the professionalism of physicians and other health care professionals. In response, professional associations have adopted formal statements pledging support for principles of professionalism, and professional schools have expanded professionalism instruction for their students. This chapter will examine the concept of professionalism and consider its moral significance in health care. It will then focus on one specific application of the concept of professionalism, namely, the identification and enforcement of professional boundaries.
Conceptual issues
Despite general agreement about the importance of professionalism in health care, there is considerably less consensus on the meaning of this term. In its most general sense, ‘professionalism’ is defined as “the conduct, aims, or qualities that characterize or mark a profession or a professional person.” As this definition indicates, understanding what is meant by professionalism requires a prior understanding of the concepts of a profession and a professional. But these latter concepts have many meanings, and they are associated with many kinds of “conduct, aims, and qualities.”
Preface
- John C. Moskop, Wake Forest University, North Carolina
-
- Book:
- Ethics and Health Care
- Published online:
- 05 February 2016
- Print publication:
- 24 February 2016, pp ix-x
-
- Chapter
- Export citation
-
Summary
My goal for this book is to provide an engaging and concise introduction to the expanding field of health care ethics. The volume is designed to be accessible to university undergraduates, but detailed enough for graduate and professional school students and health care professionals in practice. Because it is an introduction to health care ethics, I have avoided stating and defending my own position on controversial moral issues and complex case examples. Rather, I have attempted to provide essential conceptual and factual information about the issues discussed, a fair statement of commonly held positions, and a review of central moral arguments. This approach, I hope, will enable readers to understand why the issues and cases are challenging, to engage in careful moral reasoning and deliberation about them, and to formulate and defend their own conclusions.
The book is divided into four parts. The five chapters of Part I offer basic information about health care ethics. These chapters provide an account of the role of ethics in health care, a brief history of health care ethics and clinical ethics consultation in the United States, a review of leading methods of moral reasoning in health care, and an examination of the relationships between law and ethics and between culture and ethics in health care. Part II examines the moral foundations of the therapeutic relationship between patients and health care professionals. Each of the six chapters in this part focuses on a central moral feature of that relationship, including privacy and confidentiality, truthfulness, informed consent to treatment, surrogate decision-making for patients who lack decision-making capacity, respect for professional boundaries, and responsible stewardship of health care resources. Part III is devoted to ethical issues in health care at the beginning and at the end of life. The seven chapters in this part explore the topics of assisted reproductive technologies, abortion, maternal-fetal conflict, advance care planning and advance directives, moral conflicts in end-of-life care, medical futility, and aid in dying. The three chapters of Part IV examine three additional areas of major interest and attention in health care ethics: biomedical research on human subjects, human genetics, and organ transplantation. Each of the four parts of the book begins with a brief introduction that includes a summary of the content of its individual chapters.
21 - Organ transplantation
- from Part IV - Ethics in special contexts: biomedical research, genetics, and organ transplantation
- John C. Moskop, Wake Forest University, North Carolina
-
- Book:
- Ethics and Health Care
- Published online:
- 05 February 2016
- Print publication:
- 24 February 2016, pp 307-327
-
- Chapter
- Export citation
-
Summary
Case example
The clinical staff of the liver transplantation program at a major US academic medical center is having its monthly meeting to determine which of the candidates recently evaluated by the program will be added to the program's waiting list for liver transplantation. Among the patients under consideration today are the following three:
Mr. Hale is an 18-year-old university student who suffered acute liver failure as the result of an overdose of acetaminophen (thirty-seven tablets within one hour). He states that he took the tablets for an unrelenting headache and had no suicidal intent. He has a history of attention deficit disorder, depression, and cannabis use. His parents appear to be quite willing to support his medical care.
Mr. Irving is a 32-year-old inmate of Central Prison. He was convicted on a murder charge at age 19 and has eight more years to serve on his sentence. He has liver failure due to cirrhosis, and his cirrhosis is a result of juvenile hemochromatosis, a rare genetic condition causing severe iron overload in the liver and other organs. Mr. Irving also has ascites (fluid accumulation in his abdomen) and encephalopathy (loss of brain function due to liver failure). He has a history of drug abuse prior to his incarceration. His father has petitioned the Governor for early release due to his illness.
Mrs. Nguyen is a 73-year-old Vietnamese immigrant with cirrhosis caused by chronic hepatitis C infection. Her condition was stable until she took a Chinese herbal remedy that resulted in acute liver failure. She has no other illnesses and, until the present acute illness, worked full-time in a clothing store. She is a widow, but has a large and supportive family.
Which of these patients, if any, should be added to the program's waiting list for a liver transplant?
Success and scarcity
Success
On December 23, 1954, surgeons in Boston performed the first successful human organ transplant, transplanting a kidney from a healthy identical twin into his dying twin brother. Since that time, surgeons have developed techniques for transplantation of multiple organs, and investigators have discovered effective therapies to prevent immune system rejection of transplant organs. Many nations have developed sophisticated systems for recovering transplant organs from patients after death and distributing those organs to waiting patients.
11 - Resource stewardship
- from Part II - Moral foundations of the therapeutic relationship
- John C. Moskop, Wake Forest University, North Carolina
-
- Book:
- Ethics and Health Care
- Published online:
- 05 February 2016
- Print publication:
- 24 February 2016, pp 138-158
-
- Chapter
- Export citation
-
Summary
Case example
Dr. Moore is a gastroenterologist working in a large multi-specialty private medical practice. One of his long-term patients is Father Nolan, a 54-year-old Episcopal priest with chronic hepatitis C virus (HCV) infection. Father Nolan contracted this infection more than twenty-five years ago, probably through a blood transfusion, and he has had slowly progressive liver injury over the past two decades. Until very recently, the only available drug treatment regimen for HCV infection was lengthy, arduous, and only partially effective. Father Nolan began this treatment regimen five years ago, but suffered severe complications and had to discontinue the treatment.
A new drug, sofosbuvir, has just been approved for the treatment of HCV infection. The early evidence suggests that this new drug is a genuine medical breakthrough. Treatment with a combination of sofosbuvir and other medications is short in duration, is well tolerated, and has a more than 95 percent cure rate. Dr. Moore would prescribe the new drug for Father Nolan right away, but for one stumbling block – the cost of the treatment regimen is about $140,000. Father Nolan has private health insurance; his parish provides this insurance to its staff through a non-profit insurer that specializes in health insurance plans for small religious institutions. In an attempt to control its costs, the insurance company has placed strict limits on who can be reimbursed for this drug, reserving it for only those patients with severe liver disease who need immediate treatment. The company has decided that its many other chronic HCV patients can wait until competing drugs now being developed by other manufacturers enter the market over the next few years, and the subsequent competition drives down drug prices.
Father Nolan does not meet his insurer's strict conditions for receiving the new HCV treatment. He is not acutely ill, but he does have continuing symptoms caused by liver damage, including fatigue, loss of appetite, and swelling in his lower body. Dr. Moore believes that his patient would clearly benefit from receiving the new treatment as soon as he can. He is considering several options. He could report exaggerated symptoms to the insurance company in order to make Father Nolan eligible to receive the new treatment.
Contents
- John C. Moskop, Wake Forest University, North Carolina
-
- Book:
- Ethics and Health Care
- Published online:
- 05 February 2016
- Print publication:
- 24 February 2016, pp vii-viii
-
- Chapter
- Export citation
9 - Surrogate decision-making
- from Part II - Moral foundations of the therapeutic relationship
- John C. Moskop, Wake Forest University, North Carolina
-
- Book:
- Ethics and Health Care
- Published online:
- 05 February 2016
- Print publication:
- 24 February 2016, pp 114-125
-
- Chapter
- Export citation
-
Summary
Case example
Ms. Tina Cartrette is a 28-year-old woman with severe intellectual disability (also known as cognitive disability or mental retardation). Ms. Cartrette also has cerebral palsy and a seizure disorder. She has been a resident of a long-term care facility since she was 5 years old, and has never been able to sit up, walk, talk, dress, or bathe herself. Ms. Cartrette is fed through a tube inserted directly into her stomach. She has been hospitalized five times in the past year for urinary tract infections, which, in her case, cause high fever and seizures.
When Ms. Cartrette reached the age of 18, she was declared legally incompetent, and her mother, Ms. Diane Arnder, was appointed to serve as her legal guardian. Ms. Arnder lives in a distant city; she calls the residential care facility regularly to check on Ms. Cartrette and visits her daughter about twice a year.
Twelve days ago, Ms. Cartrette was hospitalized once again with a high fever and uncontrolled seizures. She received IV antibiotics and medications to control her seizures, but the medications led to respiratory depression, and, with Ms. Arnder's consent, Ms. Cartrette was intubated, placed on a mechanical ventilator, and transferred to the Medical Intensive Care Unit (MICU). She remains in the MICU on ventilator support. Dr. Friedland, Ms. Cartrette's attending physician, has discussed her treatment options with Ms. Arnder. Dr. Friedland told Ms. Arnder that continuing ventilator support could make Ms. Cartrette permanently ventilator-dependent, but removal of the ventilator would probably result in her death. After discussions with her husband and her pastor, Ms. Arnder has requested that the ventilator be withdrawn, explaining that she does not want to see her daughter suffer any longer. Most of the members of Ms. Cartrette's treatment team (including Dr. Friedland, several nurses, and a social worker) are willing to honor this request, but one of the residents disagrees. He points out that Ms. Cartrette is neither terminally ill nor unconscious, and he asserts that she should not simply be allowed to die. How should the team proceed?
The moral issue, and the available options
As noted in Chapter 8, a patient's lack of decision-making capacity is a generally recognized exception to the legal and moral duty to obtain the patient's informed consent to medical treatment.
17 - Medical futility
- from Part III - Controversies in health care ethics: treatment choices at the beginning and at the end of life
- John C. Moskop, Wake Forest University, North Carolina
-
- Book:
- Ethics and Health Care
- Published online:
- 05 February 2016
- Print publication:
- 24 February 2016, pp 242-251
-
- Chapter
- Export citation
-
Summary
Case example
Dr. Tyson is a general pediatrician in private practice. He is caring for Gail, a 5-week-old infant who presented to his office three weeks ago when her parents became concerned about her decreased feeding and apparent weakness. The parents reported that they were told that Gail was normal and healthy when they took her home from the hospital. Gail is a pretty baby girl, but Dr. Tyson's initial physical examination three weeks ago revealed that she was seriously ill. She had an elevated respiratory rate and very poor muscle tone.
Dr. Tyson was concerned about a life-threatening infection and so began a course of antibiotics immediately and admitted Gail to the hospital. While in the hospital, her respiratory condition worsened, and she was intubated and placed on a ventilator. No infection was discovered, but a muscle biopsy revealed tragic news: Gail has a rare and incurable genetic disease called fatal infantile myopathy. This condition is caused by a genetic mutation in the mitochondria of the muscles that leads to progressive weakness and death, usually within six months. Dr. Tyson shared this diagnosis with Gail's parents and grandparents and grieved with them.
At a subsequent family meeting, Gail's parents and grandfather (who is a pastor at a local church) told Dr. Tyson that they were praying for Gail's recovery and believed that God would not allow her to die. Dr. Tyson replied that he wished that Gail could be cured, but that he believed that Gail's illness was incurable and that she would die soon, with or without the current treatment measures. He voiced his concern about the pain and suffering associated with artificial ventilation, needle sticks, feeding tubes, and other interventions required to keep Gail alive. Dr. Tyson recommended removing the ventilator, but the family rejected this recommendation. The family did seek the advice of a theologian from a nearby Bible college. The theologian listened to Dr. Tyson's and the family's views, and acknowledged the difficulty of the situation, but offered no solution. How should Dr. Tyson proceed?
The rise of the futility debate
As described in Chapters 15 and 16, a series of US court decisions in the 1970s and 1980s established patient rights to refuse life-prolonging medical treatment.
Further reading
- John C. Moskop, Wake Forest University, North Carolina
-
- Book:
- Ethics and Health Care
- Published online:
- 05 February 2016
- Print publication:
- 24 February 2016, pp 328-335
-
- Chapter
- Export citation
Dedication
- John C. Moskop, Wake Forest University, North Carolina
-
- Book:
- Ethics and Health Care
- Published online:
- 05 February 2016
- Print publication:
- 24 February 2016, pp v-vi
-
- Chapter
- Export citation