Brain Death and Cultural Competence - Case Study Example

Brain Death and Cultural Competence Identification of salient facts Mr. Ahmed, who comes from a Shite Muslim Arab-American family, suffered a massive heart attack, and as a result, his brain activity is reduced to marginal. He is now in an Intensive Care Unit of the local community hospital and could breathe only with the assistance of a ventilator. Dr. Linda Hopkins, his treating physician, suggested the family to think on withdrawing the ventilator support, because Mr. Ahmed’s brain damage is irreversible. Nevertheless, Mr. Ahmed’s family member insisted on keeping the ventilator support. The doctor knew that the odds are against Mr. Ahmed. It is not possible to cure Mr. Ahmed. Under these circumstances, Nurse Janet Simpson suggested the family members to talk with Dr. Hopkins and the staff Imam from pastoral care sitting in a conference room. The Imam explained to Doctor Hopkins that according to their religious belief, cessation of brain activity is not considered as death of a human being. At the same time, the Imam explained the family members that according to the medical staff, very soon Mr. Ahmed’s brain would cease functioning. It would be considered as death, even though cardiovascular system might still function. As time passed, Mr. Ahmed became a brain dead person. Dr. Hopkins again approached the family with the same request, to turn off the ventilator. However, family members did not agree to it, and Nurse Simpson also reminded Dr. Hopkins about what the Imam said. Dr. Hopkins was in a quandary. She answered the Nurse; “By the death, we mean brain death and that is the law”. 2. Identification of Ethical Issues Shite religious beliefs do not consider that the cessation of brain activity is death of a human being. This is Mr. Ahmed’s familys religious belief. This is client’s autonomy. This is client’s family’s autonomy. Dr. Hopkins, as a physician understands that she has to fulfill her medical duty by turning off the ventilator, because the patient is a brain dead person. This is Dr. Hopkins autonomy as a physician. She cannot exercise this autonomy. Her act may be classified as malfeasance, or considered to be against the beneficences to Mr. Ahmed and his family. 3. Statement of Ethical Dilemma The dilemma is a situation in which the choices of one of two opposing decisions are equally difficult. Dr. Hopkins choice is to turn off the ventilator or stay with the Shite religious belief. She understands that Mr. Ahmed medically is a dead person. Keeping the ventilator on she cannot perform a miracle. At the same time, she understands she has to follow Shite Muslim cultural tradition. Dr. Hopkins is facing an ethical dilemma. An ethical dilemma is a state of moral choice, when one, no less important, destroys the realization of another moral value. Mr. Ahmeds family is also facing an ethical dilemma. There was a long pause among Mr. Ahmed’s family members, after the Imam explained that Mr. Ahmed would be considered dead, once the brain ceased functioning even though heart and lungs might function. This indicates that Mr. Ahmed’s family is also facing an ethical dilemma. When the family failed to resolve the dilemma among them, they referred to Mr. Ahmed saying, «He would say that we should keep trying.” This put additional pressure on Dr. Hopkins. As a doctor she fully understood that Mr. Ahmed would not make decision live years and years under ventilation support in an Intensive Care unit, but she could not prove it. She understood that by turning off the ventilator support, she would violet Mr. Ahmed’s autonomy. 4. Analysis according to Principles – including statement of recommendations for ethical resolutions. In assessing the conflict from the ethical point of view, one needs to identify all involved parties, and analyze the situation for a period of space of time. The issue here is to keep the ventilator support on, therefore, not violate Mr. Ahmed’s and his family’s autonomy and show beneficence to them. Let us analyze this situation from the view of all other present and prospective patients of the hospital. Mr. Ahmed is getting treatment in a local community hospital. Community hospital is paying for the treatment from their budget. Medical staffs know well that Mr. Ahmed’s biomedical process is irreversible. There is no way medical staffs can show beneficence to Mr. Ahmed, irrespective of whatever medical and human resources the hospital spends. The use of limited monetary fund will be a waste, if to consider that the same resources could be used for other patients, those who will recover. So what weighs more, showing beneficence to the family of a brain dead person or to the present and prospective patients? The local community medical staffs are facing an ethical dilemma. This is a professional ethical than a personal dilemma. When ethical dilemma is in the context of professional activities, one need to get the answer thru professional codes of ethics. 5. Counter argument entertained and refuted Ethical dilemmas arise every day, but, as a rule, we decide to use «the principle of least resistance». Local community medical staffs are questioning about spending their limited resources on a brain dead person. The medical staffs are not paying attention to malfeasance. Local community staff and Dr. Linda Hopkins are speaking of using professional ethic codes. However, a situation should not be excluded, when the postulates written in the professional conduct code, may conflict with some of the principles of universal ethics, regardless of one’s professional affiliation. The situation may be complicated by internal moral conflict, because every man has a set of moral criteria, which are valuable, but may be contrary to the prevailing rules and the norms of professional ethics. We live in a multiracial, democratic society, and every member of the society has the same right towards his or her own religion. Shite Muslim religion belief does not consider termination of brain activity as death. What about paying respect to the religious belief of Shite Muslim community? There are other Shite Muslims in the community, who may not like Dr. Hopkins decision. How will they accept Dr. Linda Hopkins’ decision? This is true that, not a single professional code of ethics may consider, the diversity of situations, which a professional faces. A professional needs to resort to the norms of universal ethics, when faces a situation like this. The norms of universal ethics are justice. Professional ethic codes are part of the justice too. However, in this case professional ethic codes cannot answer about how to resolve a medical issue by not hurting someone’s religious faith. What should the local hospital community staffs, and especially Dr. Linda Hopkins do to solve the ethical dilemma? Neither Dr. Linda Hopkins, nor the local community medical staffs can solve this ethical issue by using the ethical code only. The solution of this problem should be found thru the justice system, if Mr. Ahmed’s family opposed to turning off ventilation support. 6. Conclusion This case has two principal ethical issues; whether Dr. Linda Hopkins should turn off the ventilator against Mr. Ahmeds family members will and whether Mr. Ahmed’s family members should understand that a brain dead person would never recover. This section will analyze these issues to determine which ethical principles are at stake, how to resolve it giving the value to the weightiest principle. A physician’s responsibility is to provide proper treatment so the patient can recover. Mr. Ahmed is breathing on a ventilation support system. Ventilation support system is not a treatment method. Hospitals use it for a brief time, which will allow the out-of town relatives to get to the hospital and say goodbye. Is there any other treatment that medicine can offer to Mr. Ahmed? Mr. Ahmed is a brain dead person. As one cannot feed a dead person, so medicine cannot offer any treatment to Mr. Ahmed, once he is a brain dead person. Is Mr. Ahmed’s autonomy at stake? The answer is no. Is Mr. Ahmed’s family’s autonomy at stake? Mr. Ahmed’s family members autonomy is not at stake, but the medical option of turning of ventilation support contradicts their religious belief. Can we keep the ventilation support on forever, and if we do so, whose autonomy is mostly at stake? The other clients’ autonomy is at stake because hospital will not be able to use a part of their resources. Would Dr. Hopkins deprive Mr. Ahmed and his family of having beneficences by withdrawing the ventilation support? There is no unequivocal answer to this question. If we think the answer from the medical point of view, the answer is no. If we think the answer from a religious point of Shite Muslims belief, the answer is yes. However, here is one unequivocal answer. By keeping the support, Dr. Hopkins will deprive others of having beneficences. Because, a part of hospital medical and human resources will be engaged to support the ventilation, which will never, cure the patient. Dr Linda Hopkins’ act will be justified, for the greater interest and long-term outcome, if she turns off the ventilation system. However, there is one challenge. Will her performance be considered non-malfeasance and deliver justice to the Ahmed family? The above analysis cannot give that answer. That is why; it is recommended that Dr. Linda Hopkins seeks assistance of the justice system. Individuals leaving in a society seek the answer from the justice system, when other solution fails to satisfy the society. Justice system will be able to answer, whether turning the ventilation support off by Dr. Linda Hopkins is a non-malfeasance move towards Mr. Ahmed and his family members, whether it will harm the religious belief of Shite Muslims. This is the only way; we will find the solution of this dilemma. Uniform determination of death act of the United States of America says; “§ 1. [Determination of Death]. An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.” On September 8, 1992, Justice MacKenzie, said at Michigan Appeal court "A person will be considered dead if in the announced opinion of a physician, based on ordinary standards of medical practice in the community, there is the irreversible cessation of spontaneous respiratory and circulatory functions. If artificial means of support preclude a determination that these functions have ceased, a person will be considered dead if in the announced opinion of a physician, based on ordinary standards of medical practice in the community, there is the irreversible cessation of spontaneous brain functions. Death will have occurred at the time when the relevant functions ceased." The above case study clearly shows that Dr Linda Hopkins’ decision of turning off the ventilation support system to Mr Ahmed, once he is declared brain dead, will not be wrong, and will not prevail against the religious belief of Shite Muslim in accordance with the existing law of the country. This act will deliver justice to all parties in a broad sense and for a long-term outcome. At the same time Mr. Ahmed’s family member should pay respect to the law of the country. References Death Defination. (n.d.). Legal Reference. Retrieved from http://www.duhaime.org/LegalDictionary/D/Death.aspx In re Rosebushm 491 NW 2d 633 – Mich: Court of Appeals 1992. (n.d.). Michigan Court of Appeals. Retrieved from http://scholar.google.ca/scholar_case?case=8098579616030293515&q=543+nw+2d+321&hl=en&as_sdt=2,5 Uniform Determination of Death Act. (n.d.). National Conference of Commissioners on Uniform State Laws. Retrieved from http://www.law.upenn.edu/bll/archives/ulc/fnact99/1980s/udda80.htm. Read More