There is conflicting interest between Jamilah and the son over what should be done. The social worker is aware of the demands of the patient but the ethics committee has not yet been involved in this case. It is therefore critical to determine the best course of action that should be taken by the hospital. Should the wishes of the patient be observed or should Bashir orders be maintained by the hospital? There is also a need to consider the legal implications of any decision made by the caregivers. This paper looks at the ethical issues arising in this case and the potential decisions that should be made by the hospital.
Background
The case of Jamilah, the son and the social worker is a classical one that needs ethical considerations in determining the best course of action. Jamilah has no advance directives in her file and Bashir who is the decision maker desires that the mother should have a Do Not Resuscitate order and no further interventions other than comfort care. The decision by the son does not reflect the wishes of the patient who wanted to live. She asked the social worker to help her when she visited Jamilah alone. The social worker is concerned about the relationship between the mother and the son which according to her is unsupportive.
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The emergency physician requested for a cardiology consultation. The consultant based the recommendations on the DNR order and due to the comfortable care clause and multiple comorbidities, the patient was to be managed medically. The report further recommended that additional interventions should not be instituted and cardiac catheterization should not be given. Similarly, coronary bypass surgery should not be considered. Halting other interventions will ultimately lead to the death of Jamilah in days. A clear understanding of this case can be obtained by addressing the principles of autonomy, beneficence, and non-maleficence.
Autonomy
The autonomy of the patient is sometimes very important that they should be allowed to decide on their own treatment irrespective of the position of the other parties who are in a better position to choose the best option for the well being of the patient. The autonomy of the patient can, however, be restricted if it is evident that there is a threat of a severe harm to the well being of the patient. Some philosophers accept no limit to the autonomy of the patient if there is no apparent danger of harming others. Autonomy is a notion of self-rule free from controlling interference from other people or being limited like inadequate understanding that prevents free decision making (Varelius, 2006). An individual who is autonomous acts freely according to a self-chosen plan in a similar manner to the way an independent government sets its policies and manages its territory.
An individual has diminished autonomy if they are controlled by others or is unable of acting or deliberating on the basis of their desires and plans. Such an incident is prevalent among prisoners or mentally retarded people. An individual's desires, beliefs, decisions, and choices are autonomous if they meet certain procedural criteria. The requirements should either meet one of the following requirements; the behavior of the person should result from issues like compulsion and weaknesses of their own will which is heteronymous and not autonomous.
The choice, beliefs, decisions, and desires of an individual are influenced by external forces like un-reflected socialization, coercion, and manipulation and therefore are not autonomous. If one's beliefs on a matter are inconsistent with each other, false or uninformed about the issue without their knowledge, they are not autonomous with respect to the issue. An autonomous person, in this case, may have false beliefs and other beliefs that are inconsistent with each other and are likely to be uninformed about an issue without their realization. An autonomous person can choose not to know some issues and may decide to take some risk or consider some of the decisions to be inconsequential for gathering information (Varelius, 2006).
Clinically, autonomy is a fundamental guideline for ethical practices. It is not all about allowing the patient to make their own independent decisions but the physician must create a conducive environment which is appropriate for autonomy choices by others. Physicians must, therefore, respect the rights of an individual for self-determination. They should also create the right condition for the patient to make an autonomous choice. Patients visit a physician for guidance on the best choice since they lack the necessary background or information useful for making informed choices (Bhanji, 2013). The physician should be able to educate the patient to enhance their understanding of the situation. They can also address fear and calm emotions that affect the ability of the patient to make the right decision.
Respect for autonomy includes seeking consent for medical treatment and procedures, confidentiality, the disclosure of patient's information and maintenance of privacy. The patient should, therefore, be presented with all the treatment options and explain the risks in an understandable manner and ensure that the patient understands the risk and agrees to all procedures (Bhanji, 2013). If a decision is to be made based on autonomy, Jamilah should be treated according to her wishes and the order of the son will be disregarded. The recommendations by the emergency physician will consider available options that can be used to address the condition affecting Jamilah. The consultant might consider options like cardiac catheterization or coronary bypass surgery or other interventions that are likely to enhance the life of Jamilah.
Beneficence
Beneficence is an action of kindness, charity, and mercy that involves doing good to the patient. It is an act that is performed from a position of obligation owned by the physician and is usually done from the perspective of more than what is owed. Ethical theories have embraced beneficence making it one of the foundations for contributing to the greatest benefits for all (Kinsinger, 2009). Patients have immutable rights to life and liberty and such rights need to be respected facilitated and nurtured. Practitioners should perform in a manner that contributes to the health and wellbeing of the patient and avoids any acts that could cause harm. Beneficence aims at the best care in addition to embracing practices that are not harmful.
Professionals must do right. They are obliged to act in a fiduciary manner and work towards the interest and wellbeing of the patient. They should, therefore, deal with the issues that constitute a conflict of interest in addition to addressing any issues of the relationship. Practitioners should appreciate the fact that they should conduct a risk-benefit analysis and inform the other parties. They should pursue the good, avoid harmful issues and embrace beneficence, therefore, producing more benefit than harm (Kinsinger, 2009).
Beneficence is practiced at the position of power and the professional must make choices authoritatively based on their specialized skills, training, and experience. They should, therefore, use their power for the good of the patient (Kinsinger, 2009). Practitioners have a moral obligation to act in the interest of the patient and their benefits. It removes or eliminates potential harm. They should engage in actions that prevent or reduce such harm while producing a positive good over the harm that was inflicted.
According to authors like Edmund Pellegrino, beneficence in medical practices is oriented exclusively to healing and does not include any other benefits. The author, for example, does not include issues like the provision of fertility control, performing purely cosmetic surgery or assisted death or effecting a merciful death by actively hastening such death. Pellegrino, therefore, considers beneficence as providing healing and related activities like caring for and prevention of diseases or injuries. The propositions of Pellegrino, however, receive significant criticism given that physicians offer different forms of benefits and their hands should not be tied to healing.
Professionals, for example, prescribe pharmaceutical products, provide cosmetic surgery for aesthetic reasons, help patients to draw wills, and comply with terminally ill patients request for assistance in dying. According to the Cruzan case of 1990, it is a moral violation to withdraw or withhold a validly refused treatment. Hastening death in this manner through the omission or actions of a physician can be viewed as merciful and benevolent. Jamilah, in this case, did not refuse the treatment and was, in particular, asking the social worker to help her live.
Physicians depending on beneficence are likely to consider other options that will enhance the life of the patient. They are to consider the wishes of Jamilah and institute appropriate actions including resuscitation which is against the will of the son. The clinicians will consider the cost and benefits of their initiatives and whether it is worth initiating such actions (Guido, 2010). They should also consider the risks involved in their decision and how it will affect the patient. The physicians should make their decision on what is best for the patient irrespective of the interest of the sons who according to the social worker are none supportive.
Non-maleficence
It is an ethical principle that requires professionals not to inflict harm intentionally. Caregivers must ensure that acts are not intrinsically wrong and are intended for the good of the receiver. The good should not be as a result of a bad effect and the good should outweigh the bad. Healthcare providers should ensure that the decision taken does not harm Jamilah. They should evaluate what is best for her and make a decision on a course of action that is good for the patient.
Legal Implications of the Ethical Dilemmas
Individuals have equal rights to seek health care and engage in a plan of care. The patient has a right to information in order to make an informed decision. it is, therefore, the obligation of the healthcare providers to ensure that they avail all the information required by the patient. It is also the responsibility of the service providers to provide the information transferred to the sons (Guido, 2010). Following instructions of Bashir is not only against the wish of Jamilah but also illegal since the hospital can be charged for negligence or causing the death of Jamilah. Disregarding the wish of Bashir can lead to legal issues if the sons refuse to pay the hospital bill arguing that the hospital disregarded their decision. The court, however, can compel them to pay the bill given that the hospital was working in the best interest of the patient.
Resources
A provider order for life-sustaining treatment (POLST) or a medical order for life-sustaining treatment (MOLST) can be filled by the doctor prescribing the desired instructions from Jamilah on the preferred treatment. The document can then be placed near the patient's bed. The doctor fills the form according to the instructions of the patient and the discussion on the likely outcome of the illness as well as the treatment preference. The doctor will include the treatments that are not to be used the conditions under which some forms of treatment can be used and the duration in which the treatment can be used including when it should be withdrawn. The doctor will include issues like resuscitation, use of antibiotics, and transfer to emergency rooms, pain management and tube feeding (Kahn, Liverman & McCoy, 2014).
Another important resource that Jamilah can sign is a living will which is a directive to the healthcare providers. She will state her wish for the end of life medical care if she is unable to communicate her decision in the future. It gives guidance to the doctors and the brothers if Jamilah cannot express her wish and ensures that they are not left guessing what Jamilah prefers. It ensures that future disputes are avoided if the sons decide to launch a case against the hospital. The forms for advanced directives can be used to indicate the wishes of the patient using few details as possible for example use of palliative care and extraordinary measures. The living will, in this case, meet the requirements of the state regarding witnesses.
A living will be more appropriate in this case given the nature of the case and the potential for future lawsuits if Bashir decides to launch a case against the healthcare providers.
Courses of Action
Following Bashir’s Wishes
Bashir is the decision making and would like the mother to have a Do Not Resuscitate (DNR) order with no other form of interventions apart from comfort care. According to the consultant, if nothing is done to Jamilah, she will die in days which is what Bashir desire. Taking this course of action will violate ethical principles of autonomy, beneficence, and non-maleficence. The professionals, in this case, will not have acted according to the interest of the patient. Jamilah asked the social worker to help her live. Any other course of action that goes against her wish will be a violation of the ethical principles. According to the discussion above, patients have a right to decide the medical treatment as long as the hospital provides adequate information for such a decision.
The intentions of the brothers and in particular Bashir should also be considered in this case. The social worker noted that the relationship between the mother and the sons was non-supportive. Bashir might have a hidden agenda which is against the wishes of the mother. If the intentions of Bashir and the brothers are good then the principle of beneficence and non-maleficence will apply. However, beneficence requires that healthcare workers should treat Jamilah in a way that provides maximum benefits. The second principle ensures that the professional does not cause harm to Jamilah (Kahn, Liverman & McCoy, 2014). Healthcare professionals should, therefore, protect their patient and should not allow the wishes of Bashir to override the Jamilah desire to live.
Refuse to Follow the Wishes of Bashir
Healthcare professionals can decide to disregard the wishes of Bashir and continue administering the medical interventions that will extend the life of Jamilah and probably lead to the improvement of her health. The professionals, in this case, will be acting according to the wishes of Jamilah who requested the social worker to help her from the current condition because she wanted to live. According to the principle of autonomy, Jamilah is free from any controlling influences of the sons and should be able to make informed decisions as to what her wishes are.
If the healthcare providers choose this course of action, they will be truthful to Jamilah and show respect to her decision. The patient is free to decide by themselves what should be done by the health care providers as long as they receive accurate, complete and comprehensive information that will help her make an informed decision (Kahn, Liverman & McCoy, 2014). The healthcare providers will be observing the principle of autonomy. Availing all the information will ensure that Jamilah can choose from different options the best course of action. Selecting this course of action will also ensure that the health care providers will provide maximum benefit to the patient and will ensure that there is no harm.
Delaying the Decision
The healthcare professionals can delay any actions to gather more information and perspectives that will help them choose the best course of action. Such a move could be appropriate where there are no constraints of time and the health of Jamilah was not put in jeopardy. The scenario, in this case, is that any delays are likely to lead to the death of the patient in days. Urgent actions need to be taken if the patient is to continue living. Delaying the decision might lead to the deterioration of the health of the patient which can ultimately lead to death. It is, however, necessary to consider the period in which the decision can be made.
Delaying decision making is not the best course of action. Healthcare professions must consider the impact of such delays on the health of the patient. If the delay is for hours to allow the ethics committee to make their decision then such delays can be accepted as long as the patient is to put at risk. However, if such delays are likely to affect the outcome of the entire process then they should not be allowed it is common for example that delaying the decision and later deciding to disregard the wishes of Bashir will require the inputs of the consultant. Such actions might expose the patient to more harm. Similarly, medical interventions result from such delays will not incorporate the wishes of the patient which will be a violation of the autonomy principle.
Policy Recommendations
Avoid causing harm to the patients by practicing a duty of care. Provide benefits to the patients by promoting actions that offer benefit to the patient. Consider the risk and benefits of your actions and ensure the benefits outweigh the risk. Respect for the autonomy of the patient by creating a conducive environment that will enhance their decision making (Kahn, Liverman & McCoy, 2014). The policy recommendations ensure that the staff is guided by the principles of autonomy, beneficence, and non-maleficence. It ensures that conflicts and legal issues are avoided in the future. It enhances decision making and ethical practices in the hospital.
References
Bhanji, S. (2013). Health Care Ethics. Journal Of Clinical Research & Bioethics , 04 (01), 1-2. doi: 10.4172/2155-9627.1000142
Guido, G. (2010). Legal & ethical issues in nursing . Boston: Pearson.
Kahn, J., Liverman, C., & McCoy, M. (2014). Health standards for long duration and exploration spaceflight . National Academies Press,
Kinsinger, F. (2009). Beneficence and the professional's moral imperative. Journal Of Chiropractic Humanities , 16 (1), 44-46. doi: 10.1016/j.echu.2010.02.006
Varelius, J. (2006). The value of autonomy in medical ethics. Medicine, Health Care And Philosophy , 9 (3), 377-388. doi: 10.1007/s11019-006-9000-z
