Ethics Case Study No. 2:
Family Wishes and Patient Autonomy
Of the four scenarios presented to us, the option of Family Wishes and Patient Autonomy piqued my interest for two reasons: (1) A remark made by Professor Michael Burke in one of our earlier classes, “Introduction To Ethics”, specifically that (paraphrased) “…ethics and law are rarely akin to one another,” and (2) My own personal experience. In choosing this scenario I intend to offer the conclusion that it ought to be the patient’s right to decide. Adhering to the criteria provided to us: the use and observance of relevant facts that should be considered; an opposing argument; alternatives, and finally a comparison and contrast to both Kantian and Utilitarian approaches to this ethical dilemma. Interestingly, at least at first glance, it appears to me that my conclusion that it ought to be a patient’s right to determine his / her own fate in this scenario, ought not necessarily conflict with either a Kantian, or a Utilitarian philosophical perspective. Therefore, as charged at the outset, I feel I can defend my conclusion, using both Kant’s Categorical Imperative, and the Principle of Utility and view of the Hedonic Calculus approaches, respectively.
The questions posed are, “What is the physician’s responsibility in this case? Should the physician honor the patient’s request? If we assume the patient is legally competent to make medical decisions, on what basis, if any, can the physician refuse or postpone action the request to stop life support? How much weight should be given to the family’s wish to save the patient?” I will answer each of these questions, observing the paradigm of relevant facts first.
What is the physician’s responsibility in this case?
I am neither an attorney nor a doctor, but within the Hippocratic Oath are the words, “First do no harm”. By not keeping a person alive by artificial means, the physician is not necessarily breaching this principle. This is not the same type of ethical and moral dilemma as, say: Dr. Kevorkian’s practice of physician-assisted suicide. Here, Ralph Watkins, who is already seventy-five years old, is suffering, and he was given a twenty-percent chance of being successfully emancipated from the mechanical respirator that was essentially keeping him alive (and even here, his doctor said, “…maybe twenty-percent”), the doctor’s responsibility is to facilitate his patients’ healing. However, when this is beyond the scope of possibility, a physician’s responsibility is to minimize the patient’s pain, and provide comfort to the patient.
Should the physician honor the patient’s request?
Legally, the answer is quite clear. The physician’s responsibility in this case would be to both respect the patient’s directive of a DNR, provided of course, the patient in question is of sound mind, which according to the facts presented in this case study, he is. At least for this particular case, though it is true that litigious and ethics are on opposite sides of an axis, in this case, they certainly can occupy the same metaphysical space. Given the model of Categorical Imperative, the maxim of this patient is that it is not just ok, but preferable to him—to end his life. Can this be universalized? The answer in other philosophical sphere’s may be no, but in Kant’s paradigm—the answer is yes. Legally too, the answer is yes. It is already established in the United States’ courts of law (though I do not believe I’m qualified to assert with any comfort of conviction that all fifty states contain these statutes).
Considering the Principle of Utility, this is not quite as clear, though in the final analysis, though not necessarily providing the largest amount of pleasure to the most people, it can provide the largest amount of happiness. Further, it does meet the standard of maximized pleasure / minimized pain. ** Later in this case example, I will use this particular part (the one) to offer the counter argument, or criticism.
If we assume the patient is legally competent to make medical decisions, on what basis, if any, can the physician refuse or postpone action the request to stop life support?
Initially, the answer to this question was going to be to call out the keywords, “…if any…” in the question, and conclude there aren’t any. However, after giving this question a bit more thought, an argument could be made that the only basis that could be grounds for the refusal, or postponement of honoring the patient’s request, would be something that might fall under the umbrella of Hypothetical Imperative. In other words, IF <the condition>, THEN <the choice>. And so, IF the physician was aware of a potential cure, or, if the legal restrictions on stem-cell research were lifted, then those might be the only quasi-substantial argument. However, this cannot even be considered an ‘inferred fact’, and it certainly isn’t a ‘direct fact’.
How much weight should be given to the family’s wish to ‘save’ the patient?
I have taken some license in this essay, and have not adhered to the usual standard format of maintaining a third-person narrative for the case example paper. Mostly for this answer, I will perhaps speak in first-person completely, because I have had this experience, most recently—five days ago, and therefore, right at the forefront of my consciousness.
My initial response to this particular question was to essentially ‘borrow’ from my response to the second question: “Should the physician honor the patient’s request?”, because the question seems almost a reworded version of question 2, depending on what perspective the question begs. The cliché, “six-in-one, a half-dozen in the other” seems apropos here. But as just mentioned, I have had this personal experience as the family member for the patient (my mother), seven years ago. I did not like learning from the doctor that my mom had JUST signed a DNR, the day before. I initially offered quite a bit of resistance while at my mother’s bedside, upon learning for the doctor that this was in fact, something she had just signed the day before she slipped into a coma. Upon discerning my quite clear tone of resistance, the doctor informed me that he had a legal obligation to honor the DNR. In her case, she too, was mentally able to make this decision. That was one of the worst examples of feeling powerless that I ever felt, at that time in my life, because the doctor told us there was the option of intubating my mom, but that was considered extraordinary means.
Looking back, honoring the patient’s (my mother) wishes, was the right thing to do—whether speaking as myself in first person narrative; whether the metric being used is legally; or, whether the metric is either the parameters of Kant’s Categorical Imperative or the Principle of Utility. In other words, the standard for each of these metrics, is met.
Just five days ago found my family engaged in the exact same scenario with our father. This time however, the roles were reversed. My father was not of sound mind, an official DNR was not in place, and the family was cognizant of his wishes, especially upon his last turn for the worse. Here again, whatever the metric being considered, they do not breach either Kant’s Categorical Imperative (the universalization of my father’s individual maxim), nor the Principle of Utility (the least amount of pain), nor matters legal, nor matters moral.
Clearly list the alternatives. (What available action could be taken?)
A necessary, and completely legitimate question—however—given the charge to “…present all relative facts…”, if one is to adhere to the “spirit of the law”, then there really are no alternatives. That said, if a higher emphasis is placed on the “letter of the law”, then the alternative could be simply to disregard the wishes of the patient, in appeasement of the family.
Include one criticism of your position
** Perhaps the least onerous argument to make against all of the ‘pros’ that have been offered, is the justification using that part of the Principle of Utility, that which provides to most pleasure to most of the world. I concede to a nebulous understanding of this, with regards to if it is a Boolean proposition (an “and”, or an “or”). If BOTH conditions must be true (or exist), then a legitimate argument can certainly be offered against my conclusion—but only from the perspective of one claiming to follow a Utilitarian perspective. If it is only ONE (instead of both), the argument could still be made, but not as universally or consistently.
