In this situation there are three main stakeholders, Mrs. Jones, her family, and Dr. Rosenberg. The two conscious parties are in disagreement on how to treat Mrs. Jones while she is unconscious and unable to speak for herself as she approaches a possible end of life situation. The patient suffers from long-term heart failure and has been in the hospital three times this year already. Currently, she has contracted MRSA and is not responding to antibiotics and her kidneys are beginning to fail. Dr. Rosenberg would like to treat her with stronger antibiotics and dialysis but her children are worried that she is suffering too much and nature should take its course. The struggle here is that Dr. Rosenberg follows Jewish law and has taken a Hippocratic oath to do no harm to his patients and therefore believes he should take all measures to save her life before deciding to let go. This clashes with the family as they follow more of a Buddhist belief known as the first aspect of the Noble Eightfold Path, it “understands the true nature of existence as consisting of suffering, impermanence, and non­self”. Although it is not Dr. Rosenberg’s place to enforce his beliefs on his patients it does leave for a concerning moral dilemma.

In this situation neither party is being malicious or has intent to do harm but without an advance directive in place there is no way to know for sure what Mrs. Jones wishes are. This leaves the true ethical decision impossible to know for sure and the only way to assess the situation in the most ethical way possible is to look at the morally relevant facts. Mrs. Jones has had a long battle fighting these health issues so far but she is currently functional. She stands a great chance at full recovery on short-term dialysis and antibiotic treatment. To go against her family’s wishes of a voluntary euthanasia when they have legal control would be wrong, but to knowingly terminate someone’s life without their permission before their health became terminal on its own would be just as wrong. This is why Dr. Rosenberg’s proposed plan is the best possible outcome. First, Mrs. Jones should most definitely be treated and only then if her health continues to decline the family’s wishes should be honored. Who’s to say that after treatment Mrs. Jones wont wake up and be fully coherent in making her own decisions for the end of her life.

This family seems as though they are giving up too easily and that is the only reason why I question their morality. As much as I don’t want to believe it, I truly hope that their reasons for letting her go at this point are due to what they say, her suffering, and not because it is easier for them. Two days of being unconscious with a clear treatment plan to get someone back to normal is simply not enough time for anyone to ethically (and shouldn’t be legally) come to the conclusion to terminate someones life without that person giving consent.

2).        In the article “End of Life and Sanctity of Life” we see an ethical dilemma for a doctor and a family, who would be considered the stakeholders in this situation. The family’s ethical stance is nonmaleficence. The family believes that continuing treatment is only bringing harm and pain to their mother, Mrs. Jones. The treating physician believes he has a duty to practice beneficence and has a duty to manage a treatable condition. The values in conflict are the physicians duty to treat the patient and the family’s value to let their mother die a dignified death. In my opinion, the family’s choice to allow the patient to die by withholding a lifesaving treatment is not ethically justified in this situation.

In this case, the way we read it, is that Mrs. Jones’ condition is treatable with her being capable of returning to her prior level of function. Because of this, I do believe the doctor’s decision to treat is ethically justified and morally right. Not treating a patient can be considered killing a patient, if in fact there is a duty to treat the patient (Munson, p.112). Dr. Rosenberg felt a duty to treat the patient because he believed the patient’s life could be preserved with short term, relatively common treatment.

The family, knowingly or unknowingly, has chosen involuntary passive euthanasia for their mother, since the patient did not have a prior verbal or written living will (similar to the Nancy Cruzan case albeit different circumstances). The slides and videos in section three explain that involuntary passive euthanasia is withholding treatment from a patient who does not have the mental facilities to make the decision to continue treatment or end life or have prior know decisions on life-sustaining measures.

Some concerns for Mrs. Jones’ family is that she will be put through treatment that could harm her instead of making her well. The family, rightfully so, has concerns that the treatment may not cure the patient’s current health issues, therefore harming her instead of helping her. The physician is concerned because he truly believes the patient’s current medical issues can be resolved with dialysis and antibiotics. This means he has a duty to treat – but the family also has a right to have their wishes respected. The best outcome in this case is that the physician is able to make the family understand the course of treatment and that a positive outcome is likely to ensue. As healthcare providers, we will likely always hope that the physician and family come to an agreement, but that will not always be the case. Sometimes families seek ethic committees or even courts to help healthcare decisions and I’m sure there are times when physicians do the same.

Reading cases discussed in this section such as Bergstedt, Schiavo, and Cruzan really opens my eyes to the kinds of decisions families face when loved ones are incapacitated or have the desire to die to stop disease progression. In a New York Times article regarding the Cruzan case, it is noted that the Society for the Right to Die received almost 300,000 new requests for advanced directive forms. I found the article interesting in that the case led to what is now required of hospitals and nursing facilities. Every person admitting to a hospital or nursing facility must be given the option to discuss advanced directives, in a nutshell (but not as easy as I explain) gives the care providers directions on health care and treatment.

In the case of Mrs. Jones, I believe that because death was not imminent before this medical situation, not treating the patient is morally wrong. The patient did not technically have a terminal condition, therefore treatment should continue.

 

3).        In this last unit we deal with an incident that is very common among today’s practicing world of medicine. Often times, an elderly family member’s health starts to decline rather rapidly to a point of delirium or unconsciousness where they are not of sound mind. Some patients have no family members to help decide their next course of action, a few patient’s family members have no idea where to start, and others have every document and decision down to a tee in case something such as this were to happen. The “End of Life and Sanctity of Life” is a case argument that provides us with an ethical problem involving Mrs. Jones, an 82-year-old woman from a nursing home with a big family, and the attending cardiologist, Dr. Rosenberg who specializes in her current condition.  The article provides commentary and personal viewpoints from unrelated doctors to the case that further discuss the situation between the doctor-family relationship with an intended religious focus.

The readers find out that Mrs. Jones became unresponsive in the last two days due to a nasty MRSA infection in the hospital, she has no advanced directive in place and listed no religious preference or limitations to her hospital chart. The doctor does the next logical thing and calls the family in for a conference to discuss next steps in treatment. Dr. Rosenberg explains that while she may be in a terrible predicament right now, her symptoms are reversible with a bit of antibiotic treatment and temporary dialysis, but Mrs. Jones’ eldest son, Franklin, opposes any further interventions. It is from a previous experience that Franklin feels negatively about dialysis treatments, “My cousin was on dialysis for years, and, until he died, he was really miserable. I don’t want my mom to have to go through that at this age. I think enough is enough. She’s been in the hospital 3 times this year alone” (Reichman, Gadson, Wongsarnpigoon, Gooneratne, &Wickremaratne, 2005). Clearly the decision maker for the family, Franklin and Dr. Rosenberg share conflicting views. Franklin opposes any treatment for his mother, no dialysis and no antibiotics as he doesn’t “see any reason to pour more substances into her already tired body” stating, “it’s obviously her time to go. Can’t you just give her something to make her comfortable?” (Reichman). Dr. Rosenberg agrees that he will continue treating the pain, but as his commitment to being her attending, and an advocate for preserving life, he cannot stop treating Mrs. Jones because there is the ability to extend her life. On the foundations of his practicing, “According to the principles that guide my practice of medicine, I cannot withhold life-saving treatment from any patient- especially antibiotic therapy and temporary dialysis, both treatments with uncontroversial efficacy” (Reichman). The case makes a special point to include early on that Dr. Rosenberg is a practicing Jewish member, although I don’t see him making his religious affiliation apparent in his justification to help save Mrs. Jones’ life.

Although differing, both sides are equally and ethically justified in their thoughts on Mrs. Jones. Franklin’s decision on no dialysis is clouded by his cousin’s experience that passed away while on the treatment. He probably did not want to continue to see his mother suffer, maybe, although not prefaced, he also thought about the medical bills that the family could or could not afford. Dr. Rosenberg, however, feels it is within his rights as a physician to care for his patient. In Gert, Culver and Clouser’s theory of “An Alternative to Physician-Assisted-Suicide,” they ask “Is the Doctor killing the patient?” Gert’s response is, “not treating counts as killing only when there’s a duty to treat; in absence of such duty, not treating doesn’t count as killing.” (Munson, p 112). Rosenberg probably believes that providing her with the proper treatments and eliciting no further harm to her, especially if he can make her outcome better with sustainable measures will benefit both him and Mrs. Jones as this is his duty to her, and in any case, puts him out of being a moral agent to her death.

Doctor Sandra Gadson’s commentary elicited the best response for me on this case. Her idea to explain the situation down to what’s best for the patient to one deciding family member and possible courses of action the doctor can take is the best way to interact with the family. Doctors valuing their Golden Rule to develop and practice with a “sense of compassion, a sense of concern, and empathy,” with the underlying message of treating others how you would want to be treated (Reichman) is the most favorable way to address the family in hopes that they would understand the doctor’s choice. Gadson shares the physician’s creed on the value of life. There are challenging factors that may hinder a doctor’s decision to no longer treat the patient, she proclaims that, “life is sacred and important, and our mission as physicians is to give the best possible care to our patients without judgement of race, financial background, education or gender,” (Reichman). With these statements in mind, and combining all the characteristics that entail being a physician following their mission, their decision on how to help the patient should be weighed heavily against the family’s wishes.

What makes this case controversial is that there is no advanced directive put in place, none of her family members are the legal power of attorney. Franklin, among the family’s unspoken consensus, is the direct decision maker for Mrs. Jones but the mother did not herself label him to speak for her when she was fully competent and in situations like this. Nobody knows if she didn’t want to be further treated, nobody knows if she did. Does this incident mirror some aspects of Terri Schiavo’s case? (Munson, p. 146) Did the family have personal gain or self-interest from the mother’s death such as Terri’s husband according to Terri’s parents? Would Terri have eventually gotten better with time as the family initially thought was occurring just as Mrs. Jones had the possibility to get better following available interventions are risks the supporting sides are willing to take. This scenario also has an underlying correlation with another case we studied in class. The Cruzan V. Director trial in 1990 where the family lacked ““clear and convincing” evidence that Nancy herself desired not to be maintained in a persistent vegetative state, her parents lacked authority to carry out a request to remove nutrition and hydration” (Munson, p. 140); although differentiating circumstances, both instances lacked any direct evidence or directives of what either patient wanted in terms of additional care. It was only after the proceedings that the Cruzan family were able to get co-workers to testify that Nancy verbally stated her wishes to be removed from her feeding tube. The court allowed this oral statement to serve as her advanced directive. Unfortunately, for Mrs. Jones, no family member ever expressed any verbal testimony Mrs. Jones may have provided when she was competent enough to do so.

Should the decision be made that Dr. Rosenberg stops all further treatment and provides palliative care via keeping her comfortable by treating her pain, it would be non-voluntary euthanasia. According to the “Kinds of Euthanasia” Slide and presentation, Mrs. Jone’s fits the lower right quadrant, she is non-competent, and the doctor is withholding the issuing of antibiotics and procedures needed to sustain her life, as well as the lack of permission from the patient. In the Euthanasia and Suicide Review Sheet, Mrs. Jones technically doesn’t fall into the passive category because she did not verbalize her intent to have her life-supporting measures withheld. The fact that she has a longstanding history of cardiac failure, one could say death was imminent and continuing with treatment would be futile past palliative care. The fact that there is two opposing sides in how she should be treated raises concerns on what she would have wanted and ultimately which was the right decision.

The best outcome for this patient is different for each individual. If I were in Franklin’s shoes, based on the supporting evidence, I would try the initial treatments of dialysis and antibiotic regimens. Who are we to say what she does or doesn’t want when not in sound mind? Yes, she does suffer from previous health conditions that have hospitalized her, but that doesn’t mean she doesn’t want the right to continue living. Her frequent health concerns and hospitalizations, especially to the cardiac ICU should have been brought to the attention of the family before where an advanced directive could have been set in place for future events such as this.  Her problems did get more complicated in the hospital but she is not a resident there. The sole intent of her entering the hospital was to alleviate her symptoms and try to fix her so she could continue on living. If the problems presented are reversible she is able to leave the hospital with the intended goal she had entering it, even if there were obstacles along the way.

 

4).        In the “End of Life and Sanctity of Life” article, Mrs. Jones’ stakeholders are her children and Dr. Rosenberg. Since Mrs. Jones has no advance directives and is in a non-voluntary state, she is unable to make her own medical decisions. The children and Dr. Rosenberg are stuck in an ethical disagreement. Should Mrs. Jones undergo treatment in hopes of curing her MRSA and kidney infection or forgo treatment and die? The family and doctor have different values and reasons behind the best course of action for Mrs. Jones.

The children think their mother should not be treated and believe she can be comfortable with pain medicine until death takes its course. They are concerned because she is 82 years old, dialysis can be miserable, and she has already been hospitalized several times this year. In other words, she should not have to suffer. “Enough is enough,” said the oldest son Franklin. The family’s moral values have been shaped through their cousin’s past experiences with dialysis so it seems burdensome to put their mother through the same misery. In my opinion, the Jones family was not ethically justified with their requests to Dr. Rosenberg. The doctor clearly stated that he has a reasonable course of action and the mother’s health will likely get better with treatment.

Dr. Rosenberg values the principles of medicine and the life of his patient. He believes in the physician’s duty to provide beneficence, justice, &nonmaleficence for Mrs. Jones. In the Washington v. Glucksberg case, the court expresses the State’s responsibility to protect and preserve all human life. Dr. Rosenberg is concerned that if Mrs. Jones is not treated soon with antibiotics for MRSA, then it could spread. He went on to say that if her potassium imbalance is not corrected, then she will have a fatal arrhythmia. Callahan talks about medicines proper role of promotion and preservation of health. Dr. Rosenberg does not wish to withhold life-saving treatment which he is ethically committed to continue for Mrs. Jones.

Callahan agrees with the AMA’s distinction between active and passive euthanasia because natural causes or withholding treatment does not kill. If Dr. Rosenberg does not treat Mrs. Jones, she will die by the natural course of the disease. Choosing to not treat Mrs. Jones would be unethical. Gert and his colleagues conclude that not treating when there is a duty to treat is also killing. If Mrs. Jones is denied the treatment recommendations of Dr. Rosenberg, then non-voluntary passive euthanasia would occur. Although non-voluntary passive euthanasia is legal, there is no advance directive, written or verbal, that Mrs. Jones would want to rationally refuse treatment. In Cruzan v. Director, the court at first supported the Missouri Supreme Court’s denial of approval to remove Nancy’s life-support because of no ‘clear and convincing’ evidence that Nancy herself did not want life-sustaining treatment.   They have to go into the stride to get in

The best outcome for this case is for Dr. Rosenberg to continue reassuring the family members that the antibiotics and dialysis treatment will likely be successful for their mother. He should go ahead and treat Mrs. Jones even if the family does not agree. Denying Mrs. Jones treatment would be immoral simply because the family is afraid for their mother.

5).        In this fictional case study, Mrs. Jones is an 82 year old woman who was hospitalized in the cardiac ICU and is now unconscious with line sepsis MRSA and acute renal failure. Her attending cardiologist, Dr. Rosenberg, has recommended more aggressive antibiotics and dialysis as a treatment for Mrs. Jones because he thinks there’s a strong possibility that the patient will pull through. Dr. Rosenberg informs Mrs. Jones’ family of the treatment plan and prognosis, but Mrs. Jones’ eldest son, Franklin, doesn’t think that she should be treated any further and wants the doctor to give her something to make her comfortable because it’s her time to go.

In this situation, the major stakeholders are Mrs. Jones, Dr. Rosenberg, and Mrs. Jones’ family. Mrs. Jones is unconscious, so she cannot have an ethical opinion on the matter because she is not autonomous at this time but she is a major stakeholder because it is her life at question. Dr. Rosenberg’s ethical position is that he cannot withhold this life-saving treatment from Mrs. Jones because he is doing what is best for his patient and there are reasonable courses of action that could preserve her life. Dr. Rosenberg is acting with beneficence towards his patient. Mrs. Jones’ family could arguably also be acting with beneficence towards Mrs. Jones because they are worried about how miserable she would be if she were on dialysis for the rest of her life.

The values that are in conflict for the parties involved in this fictional study are beneficence, autonomy, and natural law. Everyone just wants to do what they think is best for Mrs. Jones, Dr. Rosenberg wants to preserve her life and her children want to end her suffering. Mrs. Jones is unconscious so her she is not autonomous and cannot voluntarily decide whether or not she should have the life-saving treatment so her family is trying to use paternalism in this situation. The last value was natural law, Dr. Rosenberg thinks that Mrs. Jones can pull through with these treatments so it would be wrong for him to deny her of the treatments and ultimately kill her.

It can be argued that Mrs. Jones’ family is ethically justified in their requests to Dr. Rosenberg because they just want to stop her pain and suffering, but this would be non-voluntary passive euthanasia which is ethically wrong because the patient could very well pull through. Things might be different if Mrs. Jones were autonomous or if she had an advanced directive: in Cruzan v. Director, since there is no clear and convincing evidence that the patient wanted not to be maintained, the family lacks the authority to remove life-sustaining treatment. Dr. Rosenberg is definitely ethically justified in his proposed course of action because he believes there is a strong chance that Mrs. Jones will pull through and if she seems to be declining still, treatment can be withdrawn at a future time if necessary.

If Mrs. Jones is denied the treatment recommendations of Dr. Rosenberg, this would be non-voluntary passive euthanasia because Mrs. Jones is unconscious and is therefore a non-competent patient. Gert says that “it is part of the duty of a physician to make sure both that the refusal is rational and that it is the informed, considered, and non-coerced preference of the patient.” Mrs. Jones is unconscious and has not left an advanced directive so, according to Gert, it would be like killing Mrs. Jones if Dr. Rosenberg did not fulfill his duty to treat her because she has not refused treatment. Callahan would disagree with Gert in this regard because doctors are moral agents who require their own independent moral grounds to kill and natural causes do not kill.

The major factors and concerns for Dr. Rosenberg and Mrs. Jones’ family are the moral implications that the decision would have and what the possible results of the decision are. It would be morally wrong for Dr. Rosenberg to deny his patient this treatment because she will die if she does not get the antibiotics and dialysis, but the result could mean that she would be miserable on dialysis for a prolonged period of time or that she could just simply die of natural causes because his prognosis was wrong.

In my opinion, the best outcome for this case would be if Dr. Rosenberg could convince the family that his treatment plan would be in Mrs. Jones’ best interest. Despite what the family wants, Dr. Rosenberg should be the one who is ultimately making the decision in this scenario because there is no advanced directive for Mrs. Jones’ and it is morally wrong to deny her of her future because Dr. Rosenberg thinks she’ll survive.

References:

Munson, Ronald, et al. Bio-Medical Ethics: PHI 227, Northern Virginia Community College, ELI Distance Learning. Cengage Learning, 2013.

Reichman, Edward, et al. “End of Life and Sanctity of Life”, American Medical Association (AMA).  May 2005, Volume 7: 5. Web. Accessed October 24, 2016.