Legal and Ethical Issues in Healthcare - Case Study Example

Legal and Ethical Issues in Health Introduction Mr. Carini was an old patient suffering from a long-term chronic respiratory disease and therefore on palliative care. The patient was admitted to the local hospital in critical condition after overdosing on benzodiazepine tranquiliserstranquilisers. This was not just a normal accident case because evidently the patient had planned a suicide and ingested 100 tablets of the medication. Evidence of this was a suicide note and tape recording found with him. By the time he got to the hospital, the patient was facing certain death unless medical intervention was provided through drugs and intensive care for respiratory support. Carini’s daughter indicated that the father be accorded medical intervention because he was probably too confused to understand what he was doing. However, the son indicated that it was the patient’s wish to die and this was evident from the fact that this was the third suicide attempt. While the daughter wanted her father’s life to be saved, the son insisted that his father should be left to die with dignity as he had wanted for a long time. While the family could make decision on behalf of the patient, the medical professionals were faced with a legal and ethical decision which could put their professionalism into question. Legal and Ethical Implication of Intervention of Healthcare Professionals in Carini’s Case Mr. Carini’s case is a typical example of an end-of-life decision through the intention of the patient to take his own life (Seale, 2010; Kennedy et al., 2009; Dennis, 2009). Evidence suggests that this is an act that had been well planned and executed and that several attempts suicide had already been made in the past. According to Wheat (2009), self-harm is a manifestation of emotional distress. It is usually as a result of personal circumstances such as prolonged pain, trauma, or a mental disorder (Burglund, 2007; DoH, 2012). In this case Carini’s suicide attempts could be linked to prolonged pain and the desire to escape this condition. In legal and ethical terms, suicide is considered under mental health because although the circumstances leading to suicide may be physical, the decision is usually guided psychological factors (Nicholson et al., 2008; Dennis et al., 2010). The Human Rights Act (UK) provides that individuals have a right to life and that it is the duty of public officials (including health service providers) to respect human rights in everything they do (Wicks, 2009; Hodgson, 2009). Article 5 or the Human Rights Act provides for the right to liberty, this would include the liberty to make decisions about someone’s own life like in the case of Carini. Intervention by the health professionals in this case would need to be in a manner that those rights are not infringed upon. The Human Rights Act provides a foundation for all other laws in the UK that govern the psychological wellbeing of individuals including mental health law (Samanta&Samanta, 2009). All legislation on mental health has to be created and applied in a way that respects and protects human rights (Dimond, 2008), this has been particularly accomplished in the creation of Mental Health Act 2007 and Mental Capacity Act 2005. The Mental Capacity Act (MCA, 2005) was created to protect people who are not in a position to make decisions for themselves (Walters, 2009). The Act was created with human rights principles in mind so as to ensure people’s human rights were respected. The first guiding principle of the MCA is presumption of capacity; the principle recognizes the right of a person to make his or her own decisions as long as they have the capacity to do so (MCA, 2005; Department of Constitutional Affairs, 2009). In this case, it is clear that before the suicide attempt, Mr. Calini had the capacity to make the decision to take his own life by overdose. This was evident in the fact that he left a suicide note and a video. Therefore before intervening, the health professionals had to understand this decision and the right to it. The second principle is the right to make unwise decisions (Miola, 2009). According to the MCA (2005), people have the right to make decisions that others might think are unwise. Therefore the decision for Carini to commit suicide through by overdose might or might not be wise but only the patient would understand it fully and this needs to be respected before any intervention.The next principle of the Act is that any action or decision carried out on a patient’s behalf must be in their best interests (Gillon, 2003; Allmark et al., 2010). In this case, it appears that the patient’s interest was to ‘die in dignity’ as his son pointed out, the health professionals would therefore need to consider this in their intervention. By letting him die peacefully or helping him through euthanasia, his best interest would have been served. Another piece of legislation related to the Human Rights Act is the Mental Health Act 2007 (MHA, 2007). The Act is an updated version of the 1983 Mental Health Act and provides patients with the right not to be detained for treatment of a mental health disorder or related issues (Griffith &Tengnah, 2008). Although Mr. Carini was not exactly suffering from a mental disorder, his suicide attempts may be linked to psychological effects of his long-term respiratory ailment (Crawford et al., 2012). As a result, an intervention that would necessitate his detention in hospital until he recuperated would have to consider this legislation. It is unlikely that the patient would change his mind after recovery and therefore might have to be detained unwillingly. It is clear from the details of the case that the patient did not want any further medical treatment for his chronic respiratory condition but instead wanted to die. Thus any medical treatment based on advice from the daughter or otherwise would be against his wishes. Intervention to save the patient’s life without his consent (Being suicidal, the patient would not have given any) would potentially breach his rights (Fry & Johnston, 2008). According to Allmark and Tod (2009), imposing medical treatment on a protesting patient without consent could be potentially inhuman and degrading. It could also be in violation of the right to respect for private and family life and in this case the medical practitioners will have to prove that such treatment was really a ‘medical necessity’ (Burnard& Chapman, 2004; Hughes & Walter, 2008). In the case of Herczegfalvy v England, 2009, the courts ruled that “the position of inferiority and powerlessness which is typical of patients in intensive care calls for increased vigilance in reviewing whether there has been compliance with their rights”. But as a general rule, a measure that is therapeutic will not be regarded as inhuman or degrading (DoH, 2009). This in this case, since the patient is unable to consent or reject, intervention by the medical professionals to save his life will not necessarily be inhuman, degrading, or taking away his right to ‘die in dignity’. While this would preserve the ethical integrity of the medical practitioners because they will have saved a patient’s life, on the other hand the ethical thinking behind it may be questioned because recovery would take the patient through unwanted difficult physical and psychological pain (Cavanaugh, 2010). Legal and Ethical Implication of non-Intervention of Healthcare Professionals Non-intervention in Carini’s case would mean letting the patient die from the medicine overdose. This may have various ethical and legal implications. First from the medical ethics point of view, any patient that is admitted in a life-threatening condition deserves treatment to save his or her life (Chappell, 2012). Lack of intervention or deliberate withholding of treatment would be negligence expose the medical staff to professional conduct investigations (Hoy et al., 2007), this is particularly if the Patient’s daughter thinks that her concerns of her father’s confusion had been ignored. In the case of Blyth v Birmingham Waterworks Co. (1856), the judge defined negligence as “omitting to do something that a reasonable man would do, or the doing something that a reasonable man would not do; in either case causing, unintentionally, mischief to a third party”. If the doctors failed to act to save life in this case, it could be construed as negligence. Respect for human life and best interest are the main guiding ethical principles in medical practice. Doctors and other medical practitioners have an ethical obligation to respect human life, protect patient’s health, and to make their patients’ best interest their first concern (Wainwright & Gallagher, 2007). This implies that the practitioners should withdraw treatments where there is no net benefit to the patient (Tingle &Cribb, 2007). In the case of Mr. Carini, all indication is that any medication offered at this stage to save his life would have no net benefit to him as it would not take away from him the desire to die in peace or lessen the pain he has to suffer in fighting with chronic respiratory diseases. From this point of view it can be argued that withholding treatment would be a good decision. According to the good practice General Medical Council (2000), the responsibility in the decision making process must be clearly identified and the amount of weight given to each participant determined. In another case, Re D [1997]38 BMLR 1, the defendant suffered long-term psychiatric illness and spent a lot of his life attending psychiatric care. The patient also suffered chronic renal failure that required regular dialysis. The hospital fund applied to the court to make it possible for it not to impose haemodialysis on the patient for his own best interests even though he could not be able to consent or refuse treatment. It was held that the court grant the request on the best interest of the patient and treatment not be imposed in circumstances where the doctors found it reasonably impractical. This case can be related to Mr. Carini’s case in two ways, in both cases the patients did not have ability to accept or refuse treatment and it was in the best in the best interest of the patients not to impose treatment. Withholding of treatment to Mr. Carini would therefore be legal in these circumstances as it is largely true that having wanted to die, he would not choose to accept treatment were he to be in a position to make the decision. The decision to withhold treatment may only be illegal if the patient truly was confused about his actions as the daughter had pointed out and there was sufficient proof of this kind of confusion, of which there was not. Ethical Principles and how they relate to the Case A number of ethical issues have to be considered in decision making and good practice in relation to this case; Respect for Human Life and best interest for patients It is a well-established ethical obligation for all medical practitioners to show respect for human life and protect the health of their patients (Pugh et al., 2009). This would imply that medical practitioners should offer treatments whereby possible benefits are greater than the burdens of risks going along with treatment. On the other hand they have to avoid treatments with no net benefit to patients. The most important factor however is that the benefits and burdens of treatment should not be limited to purely medical considerations but should also take into account the circumstances of the patient (Rhodes &Alfandre, 2007). However, this would not mean that the patient has the right to die and the medical team should withhold treatment at the risk of making them negligent. This is demonstrated by the case of Pretty v UK (2002) where it was ruled that the right to life guaranteed by Art.2 (European Convention on Human Rights 1950) could not be interpreted as conferring a right to die, and also that the concept of a private life under Art.8 was a broad term not capable of precise definition.In the case of Carini, withholding treatment seems to be the most ethical decision in the patient’s interest because apart from keeping him alive, the treatment would not provide private benefit. However, as illustrated by case of Pretty v UK(2002), Carini had no right to be assisted in dying not could such a decision be supported under the concept of private life. Decisions for patients without competence to decide The ethical principal in this case is that where adult patients have no mental capacity to make decisions for themselves and have not expressed their wishes in advance with a statement then the decision must be made for them by the doctor, with the patient’s authorized responsibility (DoH, 2009; Mc Hale, 2009). Consultations should be made with the patient’s family members, or partner, or a caregiver that should be able to offer an opinion of the patient’s best interests or opinions (Varcoe et al., 2004). It is noted in this case that a doctor cannot be bound to make a decision on the word of a third party and can seek further clarification from the courts where the circumstances allow. In the case of Mr. Carini, the medical practitioners could make a decision on behalf of the patient because he is unable to do so as he is unconscious. However, the patient had left a suicide note that carries some weight in this case. The two family members present cannot agree on a single decision because the son supports the father’s wish to die and insists that it has always been in the best interest of the patient. However the daughter argues confusion on the part of the patient, albeit without proof. In this case it would be advisable for the doctors to take the safer decision of saving the patient’s life on the basis of the decision by the daughter. This is demonstrated by the case of Paton v UK(1981) where failure to consult a child’s father before abortion was determined as not being denial of respect for family life. In Carini’s case, failure to take the son’s advice would equally not be denial of respect for family life as he was consulted and his sibling took an opposite decision. This scenario would have been better decided by a court of law but since it is an emergency an immediate decision should be made. It is upon the medical practitioners to decide whether the suicide note and the son’s advice form sufficient basis to decide to withhold treatment or not (Nicholson et al., 2008). Accountability Medical practitioners are ethically responsible not only to their patients but also to society at large. However, they are individually accountable to the General Medical Council (GMC) for decisions about treatment and care of patients (Dimond, 2008). In this case, it can be argued that the patient was under prescription of powerful sedatives without good supervision although he had a history of suicide attempts. Accountability here rested with either the family or the doctor prescribing the medicine depending on whether the latter was aware of the patient’s suicide attempts. As illustrated in the case of Donoghue v Stephenson [1932], the hospital treating the patient of respiratory illnesses had a duty to the patient to ensure that any medication was prescribed and taken under supervision because the patient had attempted suicide before. Conclusion The first issue in this case is that the patient is elderly and has suffered a chronic respiratory for long, this could be one of the factors that informed his decision to attempt suicide for the fourth time. Although suicide is not punishable by law in the UK, assisted suicide is criminal (Cairns, 2011). As it is, without medical intervention the patient will certainly die as per his wish. The doctors could let this happen and still be free of criminal conduct on the basis of negligence (Walters, 2009). The disagreement between his two children as to what is the right option between trying to save his life and leaving him to die as he wished certainly raises issues of responsibility and decision-making for a patient not able to decide. However, the medical practitioners may decide that on the basis of the suicide note and video message, the patient has made the decision to die. This would be within legal limits although it would still raise a question of ethics. Finally, the medical personnel handling the patient have an obligation to make an immediate decision on whether to save the patient’s life or let him die by withholding treatment. References Airedale NHS Trust v Bland [1993] AC 789 Allmark, P., & Tod, A. (2009). End of life care pathways: ethical and legal principles. Nursing Standard (Royal College Of Nursing (Great Britain): 1987), 24(14), 35-39 Allmark, P., Cobb, M., Liddle, B., & Tod, A. (2010). 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