Three Studies in Bioethics, Case Study Example

Casse 9: “Make Me Live: Autonomy and Terminal Illness”

The case brings to lights issues regarding the potential acquiescence to patient autonomy in situations where a medical decision is at odds with the decision of a patient. In other words, the case underscores a certain tension regarding whether the rights of decision should be conferred to patients or to medical staff.  As Crigger describes the specifics of the tension in this case, the problem is if: “the physician should write a do-not-resuscitate (DNR) order, because M.G. might arrest during the procedure and be placed on a respirator and taken to the intensive care unit.” (Crigger 102) In essence, the medical personnel are forced to make a decision as to whether their decision is more rational than the decision of the patient.

The decision in favor of the physicians’ writing of the DNR order suggests that medical physicians should be allowed to perform their duties according to how they best see fit. By continually thinking about the patient’s desires, the physician’s ability to make informed professional decisions is compromised. The physician, therefore, by underscoring the terminal nature of the case, does not see any medical benefit to the patient in resuscitation; furthermore, this would only lead to more suffering for the patient, as M.G. will be confined to a respirator and intensive care unit. This argument essentially emphasizes the autonomy of medical staff to use their expertise and training to do their job.

In contrast, by ignoring the wishes of the patient, an argument can be made that this approach is a violation of the patient’s autonomy: Should the patient not be allowed to decide her own fate regarding what kind of care she wants to receive, and challenge the medical decisions in the affirmation of her own rights and autonomy? By forbidding the writing of the DNR order, this is an affirmation of the patient’s ability to determine his or her own future, and would appear to satisfy her own ethical rights.

The tension between the practice of medical professionals and the doctor-patient relationship is crucial in this case. The doctor is not only committed to providing medical treatment, but moreover has a healthcare relationship with the patient. It is according to the latter that the ethical dimension of the case surfaces: the question is not one of the professional expertise of the physician, but rather of the ethical rights of the patient. Thus, respecting the autonomy of the patient must be adhered to, insofar as this is the central ethical issue of the case: if autonomy is taken seriously as an ethical principle, then it follows that a patient’s wishes must be taken seriously and not merely be dismissed by the medical establishment. Moreover, there was no indication in the case that the doctors had any evidence for the mental incompetence of the patient. If the doctors were to argue against the wishes for the patients, in order to maintain an ethical commitment to autonomy they would have to prove via a psychiatric evaluation that the patient suffers from mental incompetence and is unable to make rational decisions.

Case 37: The Tracheosectomy Tube

The case recalls the question of decision-making authority in the medical environment, as a conflict in medical procedure is presented in terms of the patient’s wish not to re-insert a tracheosectomy tube, whereas the hospital intern judges this necessary to prolong the life of the patient. Moreover, issues of temporality complicate the questions of decision-making authority and autonomy in this case, to the extent that the intern is forced to react immediately to preserve the patient’s health.

In this case, the decision in favor of the patient’s wishes would be an ethical endorsement of the individual’s autonomy in determining their own healthcare. That the patient does not wish the tube to be re-interested–after having already gone through the same experience– indicates their desire to not repeat what was obviously a trying experience. Thus, the argument to respect the wishes of the patient would indicate that the patient is competent to decide their own fate, and furthermore, has a right to decide.

To re-insert the trachesectomy tube would appear to directly violate the patient’s autonomy. However, there is a clear temporal dimension at stake in this case: has the patient had enough time to reflect on the pros and cons of this procedure in order to properly make a decision regarding his healthcare?; Or is his decision to be considered uninformed and thus, should the overruling of his decision be considered as an act committed to the patient’s benefit in the case of an emergency situation? This argument supports the medical community’s ability to make decisions in which questions of action are of paramount importance; furthermore, an argument could also be made that Joe displays mental incompetence by refusing treatment, as brought upon by a sudden and trying situation.

While the case does not overtly suggest some “mental incompetence” that may be attributed to the patient, it nevertheless recalls questions of treatment, and in this regard, it can be crucial, as Ridley notes, that the “physician’s first step should always be encouragement or persuasion.” (Ridley 240) As such, the possible complications that could occur to the patient because of any delays in treatment requires a suspension of the ethical autonomy of the patient at this juncture, in order to allow the medical staff to perform medical procedures that they deem necessary. Thus, the case demonstrates that in certain situations the significance of the absolute right of individual autonomy must be deferred to a particular context, such as cases in which time is prescient, so that medical personnel may perform its duties effectively and efficiently for the benefit of the patient.

Case 40: Preterm Labour and Prenatal Harm

The case represents a certain complication of the fundamental ethical issue of autonomy, insofar as what is at stake in the doctor’s decision are essentially two respective competing autonomies: the autonomy of the mother and the autonomy of the unborn fetus. The physician is forced to decide between the autonomy of the two. The options presented in the case, moreover, also reveal a third ethical decision: the physician’s own inability to reconcile his personal ethics with the autonomous decision of the mother.

From the perspective of an ethical position that emphasizes the absolute respect of the autonomy of the mother, the only option is to accede to her wishes and not ascribe the same ethical autonomy to the unborn fetus. As Marquis notes, “Dr. C is considering taking action that would deprive Ms. W, of her liberty and override her right to control her own body.” (Crigger 197) In this argument, the proper course of action would therefore be found in the doctor’s decision to send the mother to a colleague who would have no objections to perform this procedure. Nonetheless, in this case it is clear that the doctor finds that it is ethically untenable on a personal level to respect the autonomy of the patient.

From the other perspective, while the mother has made her wishes explicitly clear, the doctor questions her individual competence to make autonomous, rational decisions. Clearly, the doctor questioned the mental competence of the patient, as he sent her for a psychiatric evaluation in order to determine her ability to make a rational decision regarding the life of the unborn fetus. This itself evinces a commitment of the doctor to the autonomy of the fetus; moreover, the doctor attempts to support his decision with an objective analysis of the case. The pursuit of a court order would thus be the doctor’s attempt to legally recognize the insufficiency of the mother’s decision making and would not violate her autonomy, while also protecting the fetus.

In the pursuit of a court order, the doctor is making no individual claims about any possible status of personhood that could be attributed to the fetus. Evidently, he personally believes that the mother is endangering the fetus, as demonstrated by his pursuit of the psychiatric evaluation and the court order. Yet whereas the doctor’s own personal ethical commitments may be construed as the impetus for pursuing these courses of actions, the doctor nonetheless defers his own opinion to these professional bodies. In essence, the doctor is pursuing a course of action that is consistent with respecting the ethical obligations and legal obligations of personhood. Thus, although motivated by what may be termed personal ethical convictions, the doctor’s actions remain consistent not with his personal inclinations, but rather with objective sources that intend to gauge both the woman’s mental competence and the possible rights of the fetus in this case.

Works Cited

Crigger, Bette-Jane. Cases in Bioethics: Selections from the Hastings Center Report. New York: St.Martin’s Press, 1998.

Ridley, Aaron. Beginning Bioethics: A Text with Integrated Readings. New York: St Martin’s Press, 1998.