An 87-year-old Mr. Johnson with several critical health issues, had spent the past nine months in and out of healthcare facilities. Before that, Mr. Johnson had lived alone in a small South Carolina town. After his wife's death two decades ago, Mr. Johnson loved spending time with his three adult children. Other times, he spent in the company of a bubbly woman who lived a few meters from his house. Mr. Johnson always complained that life was not enjoyable owing to his health problems, and on several occasions, he requested his physician to stop the little device that always gave him painful electric impulses. The pacemaker was part of a CRT-D, required to be on the patient's body all the time. Mr. Johnson had severally complained that the CRT-D was causing him untold pain through its electrical impulses, and he was ready to have it stopped forever. Further, the patient did not want to be booked in a nursing home or placed under any medication. Deactivating the CRT-D was tenable, but the request to stop the pacemaker placed the doctor in a dilemma. Stopping the device would kill the patient within a few minutes and cognizant of this information, Mr. Johnson was ready for it.
Definition of CRT-D and Pacemaker
Cardiac resynchronization therapy defibrillator (CRT-D) is a device implanted in a patient's chest to aid their heart's chambers in contracting in an organized and efficient manner. The CRT-D uses a pacemaker that helps control abnormal heart rhythms and relies on electrical pulses to make the heart beat at the standard rate. Thus, the pacemaker is critical in ensuring that a patient's heart pumps out blood from their heart because it is placed in the lower heart chambers ( Cardiac Resynchronization Therapy, 2019 ). Through the help of this device, Mr. Johnson has had a prolonged life that had turned in an unbearable ordeal in recent months in recent months due to the painful electric impulses.
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Analysis of the Conflict Involved in the Dilemma
From the above dilemma, two conflicts arise that create a professional-familial values controversy. The first pertains to the professional consequences that would befall the physician if he heeded to the request by the patient. According to the physician’s assessment, it was apparent that stopping the pacemaker would result in the death of the patient. In such a scenario, a doctor must uphold professionalism by being honest in all their interactions ( American Medical Association, 2016 ). Professionalism dictates that the physician respects the patient's autonomy by including an informed consent process that would educate the patient and his family on the repercussions of their request. An informed consent process would serve to protect the doctor from conduct appraisal by their supervisors. This is because the ethical code of conduct requires that doctors issue their clients with informed consent forms before embarking on critical operations or granting to requests such as withdrawing crucial treatment ( LeBaron, 1993 ). The doctor should also protect the confidentiality and privacy of the client who has requested for medically-assisted death (A NA Center for Ethics and Human Rights, 2019 ). Confidentiality and privacy of a client are protected by law, and any attempt to breach either of them can have severe repercussions for the doctor's career.
The other conflict revolves around the issue of whether Mr. Johnson chose his request rightly. Although one can argue that it was his right to have his autonomous decision respected, it is reasonable to scrutinize if Mr. Johnson’s request was wrong. The patient had family, and it would have been better if he tolerated suffering for a while longer. This could have given him time to rethink what matters to have a quality life, spending time with his loved ones. Thus, one can, therefore, question Mr. Johnson's value. Nevertheless, one should not judge by merely raising these concerns because the position of the patient's family is not known. Llamas (2018) writes that a patient should have the discretion to choose the timing and manner of their death, and suffering can affect a patient's ability to reason constructively. The author's argument on the patient's discretion is reflected by Mr. Johnson’s level of willingness to avoid further pain by sanctioning death.
The chosen topic involves conflicts between professional and familial duties, with the former having more weight because it requires the physician to make the right decision. It was not the doctor's responsibility to question the patient's family values but their mandate in granting Mr. Johnson his request. Therefore, the most moral thing that the medic could have done in this dilemma was to consider the ethical constraints involved in the request. As professionals, doctors are required to dedicate their service to preserving life (Henry, 2018). The duty to protect the life of a patient is the foremost principle that guides professional decision making and, thus, the conduct of all physicians. Thus, in Mr. Johnson's case, the physician was required to ensure that the patient had the pacemaker's support, which was prolonging his life.
The pacemaker could have been withdrawn after assessing and ascertaining that they can issue such a request. Mr. Johnson had the required decision-making capacity and had the right to request that the pacemaker be stopped. Hence, the most moral course of action was to stop the functioning of the pacemaker. It is important to understand that there is no ethical difference in withdrawing and withholding medical intervention ( American Medical Association, 2019 ). If the doctor could have opted to have the pacemaker remain in place, he would have facilitated the patient's prolonged suffering. The physician was obligated to honor the patient’s request and remove the pacemaker because it would set the patient free from further pain while his family and close friends would grief for a while and latter have closure. Therefore, the decision to stop the functioning of the pacemaker would be for the greater good of the majority.
Application of Ethical Theories
Aristotle’s Golden Mean
The golden mean philosophy by Aristotle illustrates the extremes that form an ethical dilemma. On the one end is the excess, while at the other lies the deficiency. At the center of the dilemma is the moral behavior that informs one’s decision ( Duffy, 2009 ). Concerning the excess aspect, the physician could have opted to grant the patient their request while the deficiency side could have been marked by the physician not granting Mr. Johnson's wish. The middle ground between the two extremes could have been the doctor's reasoning with the client on his decision. This could have nevertheless given resulted in the physician breaching the autonomy of the patient to decisions. The ground for the golden mean is that the patient has a close-knit family, including the woman friend whom they spend quality time together.
Utilitarianism
Unlike the golden mean by Aristotle that finds a position that benefits the two sides, the utilitarianism theory differentiates right from wrong in an ethical dilemma by focusing on the outcome. Utilitarianism provides that the most ethical decision is the one that will have the best impact on the majority ( Jordan, 2017 ). Applying this theory to Johnson's case amplifies the dilemma because if the doctor fails to grant Mr. Johnson's request, it will prolong his suffering, which implies that the patient's family will also be affected. Similarly, if the physician stops the pacemaker, the patient will die within a short time, and his death will also affect the family. However, the family will not feel pain for a long time after the death of Mr. Johnson, they will grief him for some time, and life will go back to normal without the strain occasioned by a person with a terminal illness.
Natural Law Ethics
The natural law ethics is a theory that posits that individuals have intrinsic values that inform their reasoning and behavior. Therefore, the rules of morality are inherent in people and not determined by society or institutions ( Paterson, 2017 ). The physician is given the leeway to interrogate his values on what constitutes right or wrong (Hajar, 2017). Because natural law ethics means that humans base their decisions on past experiences in making choices, the doctor is left to rely on their belief system. Therefore, it follows that if from past engagements, the medical expert feels that it is not right to remove the pacemaker, then that is the right course of action.
Summary
Of the three ethical theories, utilitarianism works best for this case because it considers the controversy between professional and familial duties. The theory also gives the physician a leeway to interrogate both their personal values and professional ethical guidelines. Thus, one can conclude that utilitarianism widens the scope of the ethical dilemma. The natural law ethics seems to constrain the medic’s decisions on their personal values. Consequently, the decisions that one makes can be affected by personal biases informed by past experiences on similar moral dilemmas. Last, the golden mean application allows the physician to question the patient's decision, which means that the latter’s autonomy is affected. The reasoning behind the utilitarianism choice reflects the choice of the most moral course of action stated earlier. Both selections consider the needs of all the parties involved, including the patient, physician, and the former's family. Importantly, the choices allow the doctor to interrogate their personal values and ethical principles that guide the medical profession.
References
American Medical Association. (2016). AMA Code of Medical Ethics: AMA Principles Of Medical Ethics [Ebook] (1st ed.). Retrieved from www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/principles-of-medical-ethics.pdf
American Medical Association. (2019). CHAPTER 5: OPINIONS ON CARING FOR PATIENTS AT THE END OF LIFE [Ebook] (1st ed.). Retrieved from www.ama-assn.org/system/files/2019-06/code-of-medical-ethics-chapter-5.pdf
ANA Center for Ethics and Human Rights. (2019). The Nurse’s Role When a Patient Requests Medical Aid in Dying [Ebook] (1st ed.). Retrieved 4 August 2020, from www.nursingworld.org/~49e869/globalassets/practiceandpolicy/nursing-excellence/ana-position-statements/social-causes-and-health-care/the-nurses-role-when-a-patient-requests-medical-aid-in-dying-web-format.pdf .
Cardiac Resynchronization Therapy - Type - Mayo Clinic. (2019). Retrieved 16 August 2020, from www.mayoclinic.org/tests-procedures/cardiac-resynchronization-therapy/pyc-20385014
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Henry, T. (2018). AMA to Supreme Court: Doctor Participation in Executions Unethical . American Medical Association. Retrieved 4 August 2020, from www.ama-assn.org/delivering-care/ethics/ama-supreme-court-doctor-participation-executions-unethical .
Jordan, M. (2017). The Ethical Considerations of Physician-assisted Suicide. Dialogue & Nexus , 4 (1), 12.
LeBaron, Jr., G. (1993). The Ethics of Euthanasia . Quantonics. Retrieved 4 August 2020, from www.quantonics.com/The_Ethics_of_Euthanasia_By_Garn_LeBaron.html .
Llamas, J. (2018). The Moral and Ethical Dilemma of Physician-Assisted Suicide - Minority Nurse . Minority Nurse. Retrieved 4 August 2020, from minoritynurse.com/the-moral-and-ethical-dilemma-of-physician-assisted-suicide/.
Paterson, C. (2017). Assisted suicide and euthanasia: a natural law ethics approach . Routledge.
