Answer to Q1:
The first ethical issue in the case is whether to keep the baby alive or not, following the realization that the initially predicted deformities were observed to be worse than anticipated. The doctor is faced with a dilemma of choosing between saving the baby from a future of pain and suffering and postponing the parents’ anguish if they lost the child at that particular moment. The prognosis led to the conclusion that the baby’s chances of survival were remote, and even with maximal life support, they were unlikely to leave the ICU.
Dr. Holbert’s decision to be compassionate to the baby leads to the second ethical issue, which is the approval of the slow code. Slow code practice is defined as a deliberate slow or incomplete response to a patient, particularly in situation where CPR is perceived to be non-beneficial. Slow code is controversial from an ethical perspective, which in this case refers to violation of the patient’s parents trust and right to be involved in all clinical decisions. The American Nursing Association (2012) in its position paper stated that slow code is an unethical practice.
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Answer to Q 2:
Resolution of the case is dependent on clear understanding of what is implied by congenital diaphragmatic hernia and severe cardiac anomalies. Clear presentation of these conditions would inform exploration of all possible medical and treatment alternatives that can be used to remedy the child’s condition. Only then can it be pronounced with certainty that there is currently no available option that can successfully be employed to save the child, which may justify the decision for the slow code.
In addition, the issue of slow code is a complex one because of varying opinions on its application among medical fraternities. Lantos and Meadow (2011) highlight the lack of consensus in application of slow code. For instance, The American College of Physicians castigates the practice in its manual for being deceptive hence; its half-hearted resuscitations should not be performed. Other stakeholders term slow codes as dishonest, crass dissimulation, and unethical. On the contrary, slow codes are believed to be appropriate and ethically defensible in cases where:
Cardiopulmonary resuscitation (CPR) would be ineffective
The family decision makers understand and accept the inevitability of death
Family members are distraught to consent or even assent to a do-not-resuscitate (DNR) order (Lantos & Meadow, 2011, p. 8)
Answer to Q 3:
Different aspects of biomedical ethics are applicable to the case from Vaughn (2016) perspective. To begin with, it can be observed that Dr. Holbert employs descriptive ethics, which refers to empirical facts of morality in openly discussing the abnormalities facing the baby with the parents. One can argue that the process was intended to inform application of normative ethics on both sides in relation to what ought to be done. The process facilitates reflection during the search for and justification of moral standards and norms. It is evident that the doctor and the parents reached different decisions because the latter opted to see through the pregnancy despite warnings from the doctor.
In the context of what followed the delivery of the baby, the role of applied ethics, which uses moral norms in resolving practical moral issues, is evident. The doctor’s decision to instruct the resuscitation team to apply slow code can be viewed from this perspective. The decision highlights contrasting application of moral objectivism, relativism, and subjective realism by the parents and the doctor. In relation to moral objectivism, the parents employ common morality in the assumption that moral standards are inherently true and apply to everyone. This is evident in their request to the doctors to do everything to save the child. One can argue that their belief that the child deserved to live their condition notwithstanding, is an outcome of moral relativism, which emphasizes in the relativity of moral values to beliefs in the absence of moral standards. This is closely linked to subjective realism where moral values are founded on some individuals believes. In the same vein, the doctor employs these ethical principles in deciding to apply the slow code because their judgment led to moral belief that it was the right choice given the circumstances.
Answer to Q 4:
W. D. Ross theory of prima facie is constructed on criticism of consequentialist moral theories. As a moral realist, a non-naturalist, and an intuitionist, Ross argued about the existence of moral truths. They emphasized that claims about something being good being true if that thing was good. In this respect, they advance the idea that ethical statements cannot be defined solely in terms of statements about the natural world, as doing so was equal to committing a natural fallacy.
Ross’s theory criticized ethical egoism, which advanced the belief of an action only being right if, in the long term, it served the interest of the individual performing it. Ross countered the theory by positing that duty is founded on respecting the rights and serving the interests of others regardless of the cost to the individual performing them. Ross also refuted the theory of ideal utilitarianism by positing that productivity of maximum good is not the justification of all actions as right. Ross argued that a moral theory should conform to the facts even if it simplifies it. Such facts must exist as the moral convictions of thoughtful and educated individuals. Where there are contradictions, those convictions that stand better the test of reflection should be kept and the others discarded. In this respect, Ross developed an incomplete list of prima facie duties that should govern ethics of morality: fidelity, reparation, gratitude, justice, beneficence, self-improvement, and non-maleficence (Ross, 1946) .
Application of Ross’s theory of prima facie as decision-making tool is founded on the precipice that the duties are deterministic, of concretely, what an individual ought to do. A prima facie duty is one that is obligatory, other things equal, implying that it holds unless it is overridden by another duty of duties. In The Right and the Good , Ross, posited that a number of prima facie duties may apply to a single situation, and may even contradict where ethical dilemmas are involved. However, Ross also argued that there could never be a true ethical dilemma because one of the duties applicable to a given situation is always weightiest and overrules all the others. According to Ross (1946), this is the absolute duty or obligation in regards to the actions an individual ought to perform.
Answer to Q 5:
The prima facie ethical duties that presented Dr. Holbert are the decisions to balance between the good of the child and the emotional wellbeing of the parents. This is captured in Ross’s duties of fidelity, justice, non-maleficence, and beneficence. The doctor had a duty to prevent the child from the evident pain and suffering if left to live and the parents from the subsequent emotional burden. The prognosis after birth revealed the child to be severely deformed than early predicted. The fact that the child could be temporarily be kept alive under maximal support did not sit well with the doctor hence the decision to recommend the slow code. It is evident that the doctor believed compassionate death of the child overrode the need for the parents’ emotional wellbeing, which depended on keeping the child alive.
Answer to Q 6:
The parents also had a duty of fidelity because they wanted to fulfill their role as parents by letting their child live regardless of their condition. They also perceived themselves as having a duty of self-improvement in relation to their own childless condition. In this respect, it can be argued that the need to be parents, overrode all other duties. The decision to request the baby to be kept alive under all circumstances is strongly founded on the moral belief that they cannot afford to be childless by letting their baby die.
Answer to Q 7:
Ross’s theory as decision-making tool is evident in the case because it allows each party to present their case based on perception of which duties are supreme based on their standing. However, Ross’ agreement that there can never be an ethical dilemma in application of prima facie duties in decision-making is misconceived. It has been demonstrated that Dr. Holbert’s decision to employ the slow code is regarded as unethical by critics of the practice. Therefore, the decision goes against the wishes of the parents, who under the circumstances should be the ultimate decision makers.
Answer to Q 8:
It is important to reiterate that under Ross’s theory, Dr. Holbert is bound by prima facie duties of fidelity, justice, beneficence, and non-maleficence. Employing Ross’s theory as a tool for ethical decision-making, leads to the conclusion that the doctor’s order for the slow code can be justified. Despite the fact that the parents hold the ultimate say in the medical decision to be undertaken in the management of the baby, it is important to revisit the circumstances raised in Lantos and Meadow (2011) that related to when the slow code is perceived as ethically sound including where:
Cardiopulmonary resuscitation (CPR) would be ineffective and
Family members are distraught to consent or even assent to a do-not-resuscitate (DNR) order
In this regard, the doctor’s order is the most ethical sound because the parents could not come to terms with the fact that their child was facing an inevitable fete owing to their severe deformities. The doctor is better placed to make the decision not to subject the child to suffering and pain, which would cause parents to be even more emotionally distraught. In doing so, Dr. Holbert fulfils their duties of fidelity to medical ethics, beneficence and non-maleficence to the child and parents in terms of long-term outcomes.
Answer to Q 9:
Any practitioners who find themselves in Dr. Holbert’s position should endeavor to avoid making controversial decisions. It is important to reiterate that parents are responsible for their infant in all decisions, and their wish supersedes all else existing circumstances notwithstanding. A doctor who is faced by a similar case should explore all available alternatives to keep the child alive in accordance to the wishes of the parents. Therefore, they should never initiate the slow code no matter how compassionate they feel in relation to the baby’s chances of survival. It is important to perform all necessary protocols in accordance to standard procedures to avoid any controversies.
References
American Nurses Association. (2012), Nursing Care and Do Not Resuscitate (DNR) and Allow Natural Death (AND) Decisions. ANA Center for Ethics and Human Rights .
Lantos, J. D., & Meadow, W. L. (2011). Should the “slow code” be resuscitated? The American Journal of Bioethics , 11 (11), 8-12.
Ross, W. D. (1930). The Right and the Good (1946 reprint ed.). London: Oxford University Press. p. 21.
Vaughn, L. (2016). Bioethics: Principles, issues, and cases (3 rd ed) . Oxford University Press
