Autonomy and terminal illness
Ethical dilemmas especially those due to a conflict with the principle of autonomy are bound to arise in the management of patients with terminal illness. This essay will discuss the case of Sally a patient with terminal breast cancer. In particular, it will address the issue of whether Sally’s attending physician should write a “Do Not Resuscitate Order” (DNR) if she experiences respiratory arrest during thoracentesis. It will explore the issue based on the rights and responsibilities of the various stakeholders involved.
Discussion
Sally has the right to autonomy that is to make decisions about her condition freely and without compulsion (Smeelter & Brunner, 2004, p.57). In this respect, information about the risk for going into respiratory arrest which is associated with the thoracentesis to be performed under the guidance of ultrasound should be explained to her by the physician in a compassionate manner. In light of the right to autonomy, the decision on whether she should be resuscitated or not should be left to her. Sally has the responsibility to help the health care team members in the provision of her own care (Smeelter & Brunner, 2004, p.58) something which she is evidently not prepared to do because she refuses to discuss her condition or its prognosis and opts to pile the blame for her distress on the physicians attending to her. Sally’s husband being the principle relative is obligated by the law to provide psychological, material and financial support to the patient.
Meanwhile, the attending physician has the responsibility to provide the patient with all the information pertaining to her condition in a compassionate manner. Further, he/she has the duty to adhere to the ethical principle of beneficence that is the duty to perform only those actions that will be beneficial to the patient (Hope et al, 2005, p.23). In this light the “Do Not Resuscitate Order” (DNR) may be interpreted as being beneficial to the patient since it will relieve the undue suffering she otherwise has to bear. In addition to the duty to uphold good, the attending physician also has a duty to adhere to the principle of nonmaleficence and hence ensure that his/her actions do not pose any harm to the well being of the patient (Hope et al, 2005, p.23). For this particular case, an ultrasound guided thoracentesis poses some degree of harm to the patient as does the shortness of breath. Therefore, it is the responsibility of the attending physician to carefully weigh the potential harm posed by the shortness of breath against the potential harm posed by the thoracentesis procedure before invoking the DNR order.
Similarly, the oncologist has to adhere to the ethical principles of beneficence and nonmaleficence as the attending physician. Having weighed the risks posed by chemotherapy in patients with co-morbid bone marrow depression and congestive heart failure against the risks posed by the cancer itself, the oncologist had decided that of the two, chemotherapy was the greater evil since it posed more risk to the patient’s well being.
The patients’ right on autonomy is applicable in conditions whereby the patient is competent to make decisions regarding their own management. However, this patients’ right is superceded situations whereby patient is not competent to make his/her own decisions in regard to their management for example, in emergency situations. Decision making for the latter scenario is left to relatives or the physician if relatives are not available (Swartz, Preece & Hendry, 2002, p.5).
The ethical dilemma in this particular case study is as a result of a conflict between the ethical principles of autonomy, beneficence and nonmaleficence. Based on the deontology theory of ethics, the DNR order is unethical because this theory places emphasis on the morality of an action regardless of the potential benefits or harm of the action. Based on the utilitarian ethics theory, the DNR order is ethical because it is for the good of the patient and the husband, the two people majorly affected by the patient’s condition (Schwartz, Preece & Hendry, 2002, p. 5). If respiratory arrest occurs during the thoracentesis and the patient is not resuscitated, the patient will be relieved off the suffering incurred due to her condition while the husband will be relieved off the discomfort of having to endure seeing the patient suffering.
In conclusion therefore, after having examined the responsibilities and rights of all stakeholders in Sally’s case and applying ethical theories, the attending physician should write a DNR without informing Sally. However, the physician should explain to Sally the risk for arrest during thoracentesis in a clear and compassionate manner before she goes for the procedure.
References
Hope, R.A., Savulescu, J. & Hendrick, J. (2005). Medical ethics and Law: The core curriculum
(3rd ed.). London, UK: Elsevier Limited.
Schwartz, L., Preece, P.E. & Hendry, R.A. (2002). Medical ethics: A case based approach.
London, UK: Elsevier Science Limited.
Smeelteer, S.C. and Brunner, B.G. (2004). Brunner & Suddarth’s textbook of medical-surgical
nursing (10th ed.). Philadelphia, PA: Lippincott Williams and Wilkins.
