Legal and Ethical Dilemmas in Medicine: What You Need to Know

Introduction 

Ethical dilemmas are common occurrences in the medical practice, particularly given the constant evolution of medicine due to the ever-changing technology. In most cases, ethical dilemmas emanate from the element of patient-doctor relationships. Current ethical concerns that arise in the field of medicine include patient autonomy, the role of health professionals in decision-making, the sense of wrong and right for the professionals in healthcare, and the idea of informed consent, which form a crucial part in the daily medical practice. Given the modern advancements in technology that have enabled healthcare professionals to help patients to prolong their lives, one of the most significant ethical dilemmas that professionals face pertains to the patients’ right to die. Moreover, advances in research have largely improved the capabilities of doctors, and they are therefore able to provide more advanced care that helps patients to live longer, including those suffering from terminal diseases. With these improvements, the issue of prolonging patients’ life against their will often emerges in the hospital settings as well as the legal systems. Several related cases have been presented to the justice system, therefore largely influencing how health professionals address the issue of end of life care. One of these cases is the Bouvia v. Superior Court of Los Angeles County, involving a 28-year-old woman using a California hospital and staff for applying preventive measures that she did not permit to, including a nasogastric tube that helped in prolonging her life. This paper explores the case from a legal and ethical perspective in a bid to establish its impact on the overall health reforms and provides recommendations as well as an action plan for managing issues relating to end-of-life in the present and the future. 

Description 

The plaintiff, Elizabeth Bouvia had arthritis and cerebral palsy that led to her body losing its functioning capacities, including those of the limbs. During her stay at the public hospital, she lived off government support. She also refused food and wanted to die. In addressing the case, Bouvia Elizabeth was declared mentally competent to make decisions about her health ( O’Dell, 2011 ). Bouvia was bedridden, in addition to depending on 24-hour care to help her with essential activities of daily living, which included feeding ( Orentlicher, Pope & Rich, 2014 ). Bouvia possessed a college degree, indicating that she was well educated; however, she was not in a position to support herself financially due to her inability to work but instead relied on assistance from the public, and she did not also have a permanent residence ( Orentlicher, Pope & Rich, 2014 ). 

In the first instance, Bouvia was 26 years old when she took herself to a California public hospital, stating that she aimed to die through starvation ( Orentlicher, Pope & Rich, 2014 ). She informed her attorney that she did not need a nasogastric tube to help in sustaining her life by providing nutrition. To emphasize on the same, she signed the relevant document stating her wishes using ( O’Dell, 2011 ). However, the medical staff in the hospital contradicted the patient’s requirements and inserted the nasogastric tube, which would prevent her from starving through force-feeding. As a result, she sought an order from a California court that would compel the medical staff to take out the feeding tube. However, her order request was declined after the team proved that since the patient was not terminally ill, she could survive for an additional 15 to 20 years under the nutrition ( O’Dell, 2011 ). 

Following two years of searching for state support and suitable housing with no success, Bouvia admitted herself again to a different public facility within California ( Orentlicher, Pope & Rich, 2014 ). As noted by O’Dell (2011 ), during this period, she was experiencing difficulties eating, which necessitated that she was spoon fed; however, she suffered severe nausea and vomiting after feeding. Again, the medical team at the hospital inserted the nasogastric feeding tube in opposition to the patient’s desires. In defending their actions, the staff maintained that they were acting in agreement with the best interests of the state, including prevention of suicide, preservation of life, and upholding the ethical standards outlined in the medical profession. In the first trial, the court denied Bouvia’s request, citing that the removal of the tube would indicate that the court would be abetting and aiding suicide since the plaintiff’s argument for eliminating the tube was that she wanted to die ( Orentlicher, Pope & Rich, 2014 ). 

The move led the patient to appeal the decision of the court decision, whereby the court of appeal stated that the medical staff and the hospital must withdraw the tube since it was inserted against the patient’s wishes. The court of appeal argued that Bouvia was an adult and her mental status was stable; hence, she had the right and capacity to fully exercise control over her body, including making decisions regarding her preferred medical treatment ( Orentlicher, Pope & Rich, 2014 ). Moreover, the court held that the rights of the patients surpass the interests of the state, noting that the quality of life that the patient was leading was a key and valid reason to consider withdrawing the tube. Further, the court argued that fulfilling the desires of the patient to refuse treatment cannot be equated to assisting suicide ( Orentlicher, Pope & Rich, 2014). The court explained that a patient's decision to accept or reject treatment only rests with the patient, provided he or she is an adult of sound mind, and the doctors and judges cannot second guess such a decision. Besides, the appeals court maintained that physicians and the hospital are responsible for relieving the patient suffering and pain as she proceeded with her desire to starve herself to death ( O’Dell, 2011 ). 

Assessment 

Ethical 

In making any decision about providing healthcare services, the values and rights of patients, which are outlined under the principle of patient autonomy, must be respected. According to O’Dell (2011), freedom is defined as the right of a patient to exercise control over their bodies. Based on the case, Bouvia is seen to be exercising the right to autonomy in determining what she considers appropriate for her body by refusing forced feeding through the nasogastric tube. Since Bouvia is of sound mind and a capable adult, she has the right to determine her decisions about her healthcare based on the principle of autonomy ( Gillon , 2015). In this context, Bouvia sought to end her pain and suffering through starvation but gave medical professionals consent to give her medications that would ease her pain as she waited to die ( Orentlicher, Pope & Rich, 2014 ). 

All healthcare professionals are guided by two fundamental ethical principles, including non-maleficence and beneficence ( O’Dell, 2011 ). Beneficence refers to the element of pursuing anything that can help patients to achieve better outcomes while non-maleficence refers to the aspect of not doing any harm ( O’Dell, 2011 ). From this perspective, the healthcare team attending to Bouvia argued that they were observing the principle of beneficence when they inserted the feeding tube to provide the patient with nutrition to prolong her life. On the other hand, they implied observing the principle of non-maleficence since their approach sought to prevent harm to the patient through the preservation of life, protecting third parties who were innocent, and preventing the patient from committing suicide by starvation (Lian & Lin, 2005). 

However, when Bouvia highlighted her treatment decision, it was the responsibility of the physicians attending to her to observe transparency in the process of making decisions and providing the vital information instead of trying to convince the patient to accept treatment measures that contradicted with her wishes ( Bell, Dubljevic & Racine, 2013). Such an approach would have played a vital role in ensuring that the healthcare team did what best suited the interests of the patients by understanding her thought process, which would have allowed for the establishment of a patient-medical staff relationship based on trust. 

One of the key issues that the court highlighted is that quality of life is a key and valid factor that the medical staff should have considered in deciding on whether to grant the patient her wishes or not (Martinez & Frank, 2014). In considering granting Bouvia her wishes, the court relied on such factors as the fact that she was bedridden at 28 with no hope of getting better, she was in constant and severe pain, and she relied on spoon feeding which exposed her to continual nausea and vomiting. With these factors expected to worsen as time passed by, Bouvia’s quality of life was projected to worsen. Hence, granting her wish to die was the most appropriate and ethical approach to relieve her of the pain and suffering that she was going through. 

Legal 

Bouvia's decision to sue the hospital staff was based on the requirements of the consent laws, which mandate that a person must be informed about the benefits, risks, and available treatment alternatives and one retains the right to reject treatment measures if they do not resonate with their interests and desires ( O’Dell, 2011 ). The informed consent laws outline four key requirements that patients must satisfy so that they can be allowed to make decisions regarding their treatment options ( O’Dell, 2011 ). The requirements include; one must be of sound mind, the patient must make his or her wishes known either informally or formally, and they must be proved, the physical condition of the patient should be considered, and the treatment approach that the patient rejects should be considered. 

Bouvia’a case indicates that the patient satisfied all the four requirements, since she was an adult and mentally stable, she expressed her wishes formally through writing and signing the paper with the help of her lawyer, she was extensively handicapped, and as a result, she was forced to take nutrition through a nasogastric tube, which she refused as she could not withstand suffering for another 15 to 20 years. 

From the position of a physician and hospital or healthcare facility, it is crucial to obey the directives that a client who satisfies the four requirements provides, particularly regarding the treatments that consider appropriate for their situation. When Bouvia's case emerged, none of the states in the U.S. supported physician-assisted suicide, commonly known as PAS. Hence, health professionals involved in managing Bouvia's condition feared to lose their licenses or being sent to jail if they abided by the patient’s wishes ( O’Dell, 2011 ). 

Regulatory compliance 

The increasingly continuous modifications of healthcare laws, as well as emerging reforms in the sector, continue to make it difficult for players in the sector to comply with the laws and reforms (Ness, 2011). Several bodies require that healthcare facilities implement ongoing programs on compliance, such as the office of the Inspector General, the Department of Health and Human Services, and the Department of Justice (Ness, 2011). The requirement is crucial in ensuring that the facilities are committed to upholding the state and federal government regulations and laws, in addition to the promotion of proper and ethical approaches in executing business activities (Ness, 2011). The facilities are required to observe prudence in their level of understanding state and federal laws and policies as they may be different in the perspective of the allowed practices. 

State governments have the power of promoting safety, public health, and welfare of their populations using police power, while the federal government demonstrates power over the healthcare sector from the perspective of interstate commerce ( O’Dell, 2011 ). The federal government is also responsible for the regulation of the quality of care across states through the application of relevant government regulation and self- regulation ( O’Dell, 2011 ). 

Health Reform 

Changes emanating from the state and federal governments largely contribute to the ever-evolving changes in the healthcare law. The differences also arise from the outcomes of medically related court cases. The concept of death with dignity has been a subject of debate for several decades, dating back to the 20 th century ( Shepherd, 2013). In the past, the two main cases that have been made concerning the idea of dignified death, including Vacco v. Quill and Washington v. Glucksberg , which were both decided at the Supreme Court. The arguments presented in the cases demonstrate that states that forbid the idea of PAS or death with dignity violate the U.S. Constitution's 14 th Amendment (O’Dell, 2011). However, the Supreme Court rejected the claim, citing that the states are not in violation of the Amendment (O’Dell, 2011). From this perspective, the government largely discourages the idea of PAS, which prompted the body to pass the Assisted Suicide Restriction Act that prevents the use federal resources in procedures about assisted suicides, indicating that the government cannot pay for related physician services or lethal drugs through the Medicare program (O’Dell, 2011) 

For a long period, the U.S lacked constitutional rights that would allow for PAS or death with dignity, which gave states the freedom to establish if they would implement policies to support the practice or not (Simmons, 2018). Oregon State was first in passing the death with dignity laws in 1997, which allow PAS, and since, other states have followed in the implementation of the laws, including California, Vermont, Washington, and Colorado ( Shepherd, 2013). The laws allow patients declared to have less than six months of living to commit suicide with the help of a medical professional (Simmons, 2018). Through the provisions of the law, patients are allowed to request physicians for prescriptions of lethal doses, which then the patients administer on their own (Simmons, 2018). As the year's progress and more individuals embrace the idea of dying with dignity, more states are expected to pass the laws that support PAS, an element that further and fully grants patients the autonomy right as explained in 1914 by Justice Cardozo (O’Dell, 2011). 

Recommendations 

Implementing a plan that seeks to attend to the ethical and legal issues that arise daily in the practice of medicine is crucial for all healthcare facilities. Based on the above analysis the key recommendations that the writer would recommend comprising of three major strategies for addressing ethical and legal concerns as they arise, controlling the concerns, and in some cases, preventing the issues from arising. The first strategy focuses on ensuring that healthcare facilities have fully functional ethics committees made up of competent staff. These committees constitute important avenues for managing ethical and legal problems arising in healthcare facilities, which include hospitals. These kinds of committees did not exist before the 1960s; however, by around the 1990s, approximately 90% of hospitals consisting of 400 beds or more provided services about ethics consultation, which forms the basic function of the committee (Aulisio, 2016). 

The key functions of the committees include providing consultations on issues of clinical ethics, revising or developing hospital policies that address ethical concerns, and providing learning opportunities concerning different areas in the field of clinical ethics. The members of the committees are derived from diverse non-clinical and clinical fields, such as social workers, religious leaders, psychiatrists, and physicians among others. It is also recommended that such committees include at least one person who is competent in ethical matters as well as a lawyer ( Taljaard, Weijer, Grimshaw & Eccles, 2013 ). The major goals of the committees include advocating and promoting the rights of patients, sponsoring and creating fair procedures and policies to enhance better patient outcomes, promoting joint decision-making between care providers and patients, and enhancing the ethical atmosphere for all individuals working within the healthcare facilities ( Taljaard, Weijer, Grimshaw & Eccles, 2013 ). 

The second recommendation pertains to the need for healthcare organizations to implement strategies for promoting and enhancing the connection between the primary care providers and the patients. The physician-patient relationship is crucial, as it plays a vital role in influencing positive health outcomes. Studies have increasingly demonstrated that effective collaboration between patients and the care providers plays a vital role in improving the patients' health status as well as the quality of life. Trust is the key factor in such relationships since it prompts patients to openly express their thoughts, ideas, and wishes with the physicians. From this dimension, care providers are responsible for informing and recommending the best treatment alternatives for the patients as well as conducting accurate diagnosis; however, this can only be achieved if patients are honest with the providers. Traditionally, healthcare providers were largely regarded as authority figures, and they were granted the sole responsibility of making treatment decisions. In the traditional context, the concerns and wishes of the patient were disregarded, however, in the recent years, this idea has changed, and the relationship between patients and care providers has become a vital element in making crucial treatment decisions, thus the emergence of the shared decision model. The model is based on the idea that patients are autonomous beings with rights; hence, they deserve to be informed about the recommended treatment alternatives, advised about the benefits and risks of the different alternatives, and given freedom to select the alternatives that they consider most suitable ( Taljaard, Weijer, Grimshaw & Eccles, 2013 ). 

The final recommendation involves improving the palliative care alternatives for patients who are terminally ill. The form of care refers to specialized care for persons from the terminal or extremely serious illnesses. The care focuses on relieving the patients of the disease symptoms and the stress associated with the disease, rather than curing the illness. The major role of palliative care is improving the quality of life among the affected patients. The model of care was intended to effectively meet the needs of individuals in need of end of life care; however, in most regions, it remains ineffective in meeting the patients’ needs. The main issues that contribute to the inefficiency of palliative care include the undiagnosed and unrecognized emotional distress among individuals with terminal illnesses, an element that contributes to the undertreatment of such conditions as severe depression, anxiety, and existential fear, which largely affect the patient’s health outcomes and quality of life. Inefficiency in palliative care emanates from several factors, including inadequate research in the field, and incomplete information on what the system of care is capable of achieving due to lack of sufficient training of health professionals. From this perspective, it is essential for facilities that provide healthcare to invest sufficient resource in palliative care units to achieve improved patient outcomes (Higginson & Finlay, 2003). 

Action Plan for Prevention 

In preventing such cases as the Bouvia v. Superior Court of Los Angeles County case , education would play a vital role. In this case, education would cover such areas as advance care planning, which would involve patients once they are admitted to a healthcare facility. Education would also focus on encouraging care providers to hold critical conversations with the patients in such settings as the offices. Moreover, hospitals need to develop protocols or policies using complete patients' electronic records. The staff would then be trained using the developed protocols and policies, which is a vital aspect in ensuring that they are updated in any changes in healthcare, in addition to enabling them to understand and document the wishes of the patients. 

Further, education is required to encourage healthcare professionals to recommends palliative and hospice services to terminally ill patients. Hospices allow for end of life patient management through palliative sedation intended to relieve patients who are terminally ill of their suffering and pain through providing them with comfort care. The hospice company would them focus on the provision of end of life choices education to the patients’ families and the patients. Presently, the implementation of PAS would be the most challenging decision to implement since the state in which the facility operates is yet to pass laws permitting the practice. Currently, the much that can be done is lobbying state governments that are yet to pass the laws to consider changing the rules. Implementation of the PAS laws would then necessitate further education of the care providers to understand the process and practices surrounding the procedure. 

Conclusion 

Ethical dilemmas are inevitable n healthcare, and they often inspire discussions that further necessitate changes in healthcare laws. About the concept of death with dignity, which is also supported by the principle of patient autonomy several cases, including that of Bouvia, have played a vital role in implementing policies that insist on a patient's quality of life over the number of years that one is to live. Bouvia's case played a vital role in the implementation of the right of patients to decline treatment. In this context, it is essential for care providers to re-examine the approaches that they apply in the provision of care services. The three fundamental approaches that the providers can apply in ensuring competence in managing the dilemmas include setting up ethics committees, enhancing palliative care treatment for terminally sick patients, and improving the patient-physician relationships. 

References 

Aulisio, M. P. (2016). Why Did Hospital Ethics Committees Emerge in the US?. AMA journal of ethics , 18 (5), 546. 

Bell, E., Dubljevic, V., & Racine, E. (2013). Nudging Without Ethical Fudging: Clarifying Physician Obligations to Avoid Ethical Compromise.    The American Journal of Bioethics,13 (6), 18-19. doi:10.1080/15265161.2013.781714 

Gillon, R. (2015). Defending the four principles approach as a reasonable basis for good medical practice and therefore for good medical ethics. Journal of medical ethics ,  41 (1), 111-116. 

Higginson, I. J., & Finlay, I. G. (2003). Improving palliative care for cancer. Lancet Oncology , 4 (2), 73. 

Martinez, R., & Frank, C. (2014). End-of-Life Decisions: Who Decides and the Role of the Psychiatrist.    Psychiatric Times . Retrieved from http://www.psychiatrictimes.com/login?referrer=http%3A//www.psychiatrictimes.com%2Fend-life-decisions-who-decides-and-role-psychiatrist 

Ness, R. (n.d.). Integrity in Action. Retrieved February 26, 2017, from http://www.trusteemag.com/articles/543-integrity-in-action 

O’Dell, R. (2011). The Bouvia Case Revisited: An Introduction to the Bioethical Topics of Individual Rights, Acts of Conscience, and the Right to Die.  Online Journal Of Health Ethics ,  7 . doi: 10.18785/ojhe.0702.05 

Orentlicher, D., Pope, T. M., & Rich, B. A. (2014). The changing legal climate for physician aid in dying.  JAMA ,  311 (19), 1961-1962. 

Shepherd, L. (2013). The end of end-of-life law.  NCL Rev. ,  92 , 1693. 

Simmons, K. M. (2018). Suicide and death with dignity.  Journal of Law and the Biosciences ,  5 (2), 436. 

Taljaard, M., Weijer, C., Grimshaw, J. M., & Eccles, M. P. (2013). The Ottawa Statement on the ethical design and conduct of randomized cluster trials: precis for researchers and research ethics committees. B MJ, 346 , f2838.