Ethics and the Law: A Medical - Case Study Example

Ethics and the Law: A Medical Case The Scenario In my scenario, Dorothy is an 86 year old female with terminal cancer. Her past medical history includes Hypertension, Diabetes and a CVA which left her with slight left sided weakness, she was hospitalized on this occasion for a chest infection. Dorothy has a large family of adult children and lives with her eldest daughter on a full time basis, she has carers coming in 3 times per day, these carers were there primarily to care for her personal hygiene, aid with eating and drinking. The daughter then takes care of Dorothy in the evening. Dorothy had no cognitive impairment, and was an individual with a strong personality. A do not resuscitate form (DNR) was in place for this patient. From admission Dorothy refused to eat, the dietician had assessed her to rule out any physical limitations, for example Dysphasia. The daughter explained that her mother had been refusing to eat for some time prior to her admission and that she herself had been forcing Dorothy to eat and requested that the nurses do the same. On this particular day I was looking after Dorothy which meant it was my responsibility to feed her. Dorothy made it clear that she did not want to eat her lunch, I attempted to encourage Dorothy to eat and explained that it was in her best interest however she was not persuaded. Ethical and Legal Concerns within the Scenario The basic legal concern within this scenario is that the nurse should do when a patient refuses to eat even though it is in her best interests. The most basic law covering a nurse within his/her duties is that of a “duty of care” (Diamond, 2006). This has been defined by the NMC as “a responsibility to deliver safe and effective care based on current evidence, best practice, and where applicable, validated research.” (NMC, 2004). Further, a “court of law could find a registrant negligent if a person suffered harm because they neglected to care for them adequately” (NMC, 2004) (my emphasis). The questions that need to be raised here are the following. How can negligent be defined? This definition depends upon whether the patient is suffering harm, and whether that harm is occurring because I neglected to care for them adequately. Perhaps this issue may be explored through posing a similar although vitally different scenario. If I had just forgotten to give the patient her meal because I was on the phone with my boyfriend, and she had not stated that she did not want to be fed, then this would appear to be negligence. If I deliberately did not fee the patient on a regular basis because I had some reasons to hate her that would move beyond negligence into probable homicide if she subsequently died of starvation. But in the scenario as given what is adequate care defined as? It would seem that it was giving the opportunity for the patient to have her meal and also giving her the opportunity to refuse it. She is clearly in a position to refuse to eat as she has the DNR in place. The decision not to eat can be regarded as essentially analogous with a decision to refuse care, something which is an absolute right of any mentally competent, adult patient (Beauchamp, 2001). In recent years the idea that a patient has the right to refuse treatment, and in this case ‘care’ can be extended to the food that is being provided to the lady, in all cases. As the GMC put it in its 2002 Report; Adult competent patients have the right to decide how much weight to attach to the benefits, burdens, risks and the overall acceptability of any treatment. They have the right to refuse treatment even where refusal may result in harm to themselves or in their own death, and doctors are legally bound to respect their decision. (GMC, 2002) The question arises however as to whether concurring with the patient’s decision not to eat is in fact actually helping her to commit suicide, which is illegal under the provisions of the Suicide Act (1961). The relevant section of the Act (section 2.1) reads as follows: “A person who aids, abets, counsels or procures the suicide of another, or attempt by another to commit suicide shall be liable on conviction on indictment to imprisonment for a term not exceeding fourteen years". This is one of the strangest laws in existence, as it makes it a criminal offense to aid a person in doing something which the same Act made no longer a criminal offense. It is thus illegal to help someone to perform a legal act. The legal consequences for a nurse or doctor allowing a person to refuse treatment could be quite serious, but these were countered by Re B (Adult: Refusal of Medical Treatment) 2002, which stated that a patient could refuse treatment knowing that this would result in death. Indeed, the Court specifically drew a line between passively allowing death through omission and actively causing it through a purposeful action, as had been upheld as illegal in R v. Brown (1993). So in a legal sense it appears as though I should not pursue any more active methods to persuade, or even to force, the patient to take food. I have performed my duty of care through offering her the food and she has exercised her right to self-determination through refusing to eat. Ethical issues are also complex within this situation. A teleological analysis of the situation will look at the ends which an be predicted form the various ethical choices that are presented by the situation. In this case, if the I do not persuade the patient to eat, what is the likely outcome? My failure (or refusal) to persuade the patient to eat a single meal is unlikely to have far-reaching consequences. But if the patient regularly does not eat meals, thus if becomes the policy of the hospital to allow her not to eat, then the terminal nature of her illness may be speeded up. In the long-term, as the cancer is terminal, the patient’s refusal to eat will not have a great effect upon her prognosis. She may or may not die somewhat sooner through not eating, but she cannot be said to be “killing herself” by refusing to eat. A utilitarian perspective, that is, the “greatest happiness for the greatest number” is not really relevant here, because the patient’s actions only directly effect herself. True her family will be effected if she starts to suffer more than she is currently doing, but this must be regarded as a subsidiary effect of only minor importance. A deontological focus on duties suggests that there are two conflicting duties present here. First, the nurse has an absolute duty to care for a patient and relieve her pain/symptoms as much as possible, and yet at the same time there is second duty, which may also be regarded as absolute, to see that the right to self-determination implied within British Common Law and codified within European regulations is adhered to. In this case the duty to relieve pain and suffering may actually counter the duty to preserve the patient’s right to self-determination and autonomy. Within this particular scenario it seems as though the patient’s right to self governance needs to be preserved because she has been found to be competent enough to sign a DNR form and she has “no cognitive impairment”. This would suggest that she has the right to refuse to eat. Indeed, as death is an inevitable part of the process of living, and as she is terminally ill, then it would seem utterly illogical not to allow her to stop eating. In many ways her decision might be seen as a kind of proactive DNR (Freeman, 2001). An existential point of view would also point towards allowing the patient to stop eating. Existentialism, at least within this context, deals with the innate uniqueness of every human situation and the need to make moral choices based upon that uniqueness. It is perhaps the opposite of the deontological point of view as it suggests that there are no absolutes. In this scenario the woman is terminally ill with cancer, she already has a DNR and has apparently decided to stop eating and perhaps thus to hasten her inevitable death. The patient has made an existential decision based upon the facts available within her unique circumstance. She has made the basic right to self-determination through deciding to die. Both the legal and the ethical considerations seem to point towards the validity of allowing the patient to stop eating, but this does not mean that the process for either myself as a nurse or the woman or her family or other medical personnel will be any easier. If she continues to refuse food but will allow herself to drink water, the slow process of weakening due to lack of sustenance will be quite agonizing to watch. While the pain of her cancer may be far greater than any she will be feeling from lack of food, and thus act as a cover for it, it is likely that she will somewhat suffer. As a nurse I feel my instinctive responsibility is to care for a patient and to relieve their suffering as much as possible. The fact that I would be concurring, and in a way “collaborating” with a patient’s attempt to die as soon as possible, which might in some ways be regarded as helping her commit suicide, will be very difficult for me in a personal and professional sense. While patient clearly has strong cognition and a strong personality, she should be given every opportunity to change her mind and to start receiving food. Indeed, those aspects of her character may make her more stubborn and less likely to admit that she has made a mistake. In some ways she might see a decision to start eating again as a final loss of autonomy. A caring, nurturing environment should be provided in which such pressures do not occur. In the future of my career may similar situations may be faced. As medicine advances at an almost exponential rate and many people live to very advanced old age and survive for long periods diseases/conditions that would have previously killed them quickly, such situations are likely to recur. The old medical adage of the Hippocratic Oath to “do no harm” may need to be interpreted as not “doing the harm” of keeping someone alive when they want to die in a dignified manner. If some patients decide to hasten their deaths through what amounts to starving themselves then they should be allowed to. My task will be to enable them to be as comfortable as possible while the results of their decision are playing out within their bodies. Allowing a person to kill themselves through starvation, or at least not intervening to provide sustenance forcefully, will be a difficult experience. I imagine it might get easier with time and repetition, although paradoxically I hope it will not. The emotional reaction to such an experience should be a part of the caring duty, indeed, it is almost impossible to care if it is not present. ________________________________________________ Works Cited Beauchamp, T. and Childress, J. (2001) Principles of Biomedical Ethics 5th ed. New York: Oxford University Press. Dimmond, B. (2005) Legal Aspects of Nursing. 4th ed Harlow: Pearson Longman. Freeman, JM. McDonnell, K. (2001) Tough Decisions: Cases in Medical Ethics. Oxford University Press General Medical Council, “Guidelines”, May, 2002. Nursing and Midwifery Council (2004) The NMC Code for Professional Conduct. Re B (Adult: Refusal of Medical Treatment) 2002. 2 AER 449. R. v. Brown (1993) 2 AER 75. Suicide Act, 1961. Read More