Ethical Issues
Autonomy – The ideal of self-determination is the basis for autonomy. It is important that a patient be allowed to decide what should be done to his or her own body. In other words, nobody else has the right to assert their power over another. Likewise, a physician should be allowed to decide not to perform a procedure if doing so would conflict with his or her values. In the Cruzan case, Nancy’s autonomy by way of her parents’ substituted judgment was overridden in favor of the State of Missouri’s policy to preserve life. Although the Supreme Court did not deny that Nancy had the right to refuse nutrition/hydration, there was not enough clear and convincing evidence to know that refusal was what Nancy truly wanted. Also, the autonomy of the hospital staff was taken into consideration because they did not feel it was right to withdraw treatment without a court’s consent. At first glance, it may seem that Nancy’s autonomy was not taken into consideration because her parents had to wait so long for the courts to agree to withdraw nutrition/hydration. However, the courts were actually erring on the side of caution because there was no advance directive indicating refusal of treatment as an option. Once Nancy’s parents found three more witnesses to attest to her wishes, the Supreme Court agreed that Nancy would have wanted refusal of treatment.
Beneficence/nonmalificence – Physicians strive to do what is good for the patient while avoiding doing harm in the process. In the Cruzan case, the definition of good may be debatable. Some may see preserving life as doing good, while others may argue that using life-sustaining interventions that have little or no benefit is doing more harm than good. Moreover, there is a question of who is to decide what is considered “good” for a patient when the patient is incompetent. Is it the physician, the family, State, or Supreme Court? The physician has medical knowledge of what will sustain life while the family has knowledge of the patient's wishes. The State of Missouri has a policy emphasizing preservation of life that intends to protect the citizens of that State, while the Supreme Court has a duty to do what is good according to the Constitution in order to protect the rights of American citizens. In the end, the decision to withdraw nutrition/hydration could be seen as an act th...
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...dgment as to how that very patient would act if he or she was competent. The surrogates in the Cruzan case were Nancy’s parents. The surrogate, whether he or she has received written documentation, oral communication, or no communication at all by the patient, gives or declines consent to recommendations for treatment from the physician. If the patient has documented or orally communicated his or her wishes for treatment prior to the onset of incompetence, the surrogate should use substituted judgment. In the Cruzan case, the state of Missouri (like many other states) required clear and convincing evidence concerning Nancy’s feelings about consenting to treatment. The state required clear and convincing evidence because they did not want to impinge on Nancy’s autonomy; they also believed that in considering her autonomy it would be better to err and keep her alive than err and end her life. A surrogate decision maker is needed in place of an incompetent patient to accept or refuse consent to treatment in end-of-life issues, but they are only efficient in using substituted judgment when clear and convincing evidence exists concerning the wishes of the once competent patient.
Autonomy is a concept found in moral, political, and bioethical reasoning. Inside these connections, it is the limit of a sound individual to make an educated, unpressured decision. Patient autonomy can conflict with clinician autonomy and, in such a clash of values, it is not obvious which should prevail. (Lantos, Matlock & Wendler, 2011). In order to gain informed consent, a patient
There are many ethical paradigms through which humans find guidance and justification for their own actions. In the case of contractarianism, citizens of a state are entitled to human rights, considered to be unalienable, and legal rights, which are both protected by the state. As Spinello says, “The problem with most rights-based theories is that they do not provide adequate criteria for resolving practical disputes when rights are in conflict” (14). One case that supports Spinello is the case of Marlise Munoz, a brain-dead pregnant thirty-three year old, who was wrongly kept on life support for nearly two months at John Peter Smith Hospital in Fort Worth, Texas. Misinterpretation of the Texas Advance Directives Act by John Peter Smith Hospital led to the violation of the contractarian paradigm. Although the hospital was following the directive in order to maintain legal immunity for its hospital staff, the rights of the family were violated along with the medical fundamental principle to “first, do no harm.”
... others with decision making at the end of life through the Cruzan Foundation.The Cruzan case drew national attention, and the family was put under media throughout the process. Missouri now allows health care directives (though not living wills) to instruct that medically assisted nutrition and hydration be removed after a diagnosis of permanent or persistent vegetative state has been made. The Cruzan case became the first "right to die" argument ever heard by the United States Supreme Court.
Four doctors, three terminally ill patients, and a nonprofit organization called Compassion in Dying, came together to file a suit arguing that prohibiting PAS is against a person’s right to liberty (Illingworth & Parmet, 2006). This became known as the Washington et al. v. Glucksberg et al. case. This case went to the Supreme Court in January of 1997 and by that following June was ruled constitutional to uphold PAS as illegal (Washington et al. v. Glucksberg et al., 1997). The penalty for any assistance in a ...
A divergent set of issues and opinions involving medical care for the very seriously ill patient have dogged the bioethics community for decades. While sophisticated medical technology has allowed people to live longer, it has also caused protracted death, most often to the severe detriment of individuals and their families. Ira Byock, director of palliative medicine at Dartmouth-Hitchcock Medical Center, believes too many Americans are “dying badly.” In discussing this issue, he stated, “Families cannot imagine there could be anything worse than their loved one dying, but in fact, there are things worse.” “It’s having someone you love…suffering, dying connected to machines” (CBS News, 2014). In the not distant past, the knowledge, skills, and technology were simply not available to cure, much less prolong the deaths of gravely ill people. In addition to the ethical and moral dilemmas this presents, the costs of intensive treatment often do not realize appreciable benefits. However, cost alone should not determine when care becomes “futile” as this veers medicine into an even more dangerous ethical quagmire. While preserving life with the best possible care is always good medicine, the suffering and protracted deaths caused from the continued use of futile measures benefits no one. For this reason, the determination of futility should be a joint decision between the physician, the patient, and his or her surrogate.
The autonomy of a competent patient is an issue not often debated in medical ethics. Refusal of unwanted treatment is a basic right, likened to the common law of battery, available to all people capable of a competent choice. These fundamental rules of medical ethics entered a completely new forum as medical technology developed highly effective life-sustaining care during the 20th century. Several watershed cases elucidated these emerging issues in the 1960’s and 70’s, none more effectively than that of Karen Ann Quinlan. Fundamentally, this case established that a once-competent patient without the possibility of recovery could have their autonomy exercised by a surrogate in regard to the refusal of life-sustaining treatment. This decision had a profound effect on medical ethics, including treatment of incompetent patients in end-of-life situations, creation of advance directives, physician-assisted suicide (PAS) and active euthanasia.
The so-called ‘right to life’ debate has been beaten to death with no resolution in sight…but what of the ‘right to die’ issue? In California, legislation was passed last year that allows terminally ill patients, who are not expected to live more than six months, to request physician-assisted suicide. However, as with the other four states that have adopted similar legislation, the patient must be capable of administering the lethal drug to himself or herself, medical personnel are not required to participate in any way, and the relief does not benefit any others, such as quadriplegics or those suffering from chronic debilitating diseases("State-by-State Guide to Physician-Assisted Suicide"). Therefore, healthcare professionals can choose to follow their own moral values regardless of the patient’s wishes…and they do. The option to choose not to follow a patient’s wishes, or to deny assistance, steps squarely on the personal rights and freedoms of the
2. They may not refuse lifesaving care if there is a compelling state interest in requiring treatment for the common good (e.g., immunization to prevent the spread of communicable disease).
In the case of Cruzan by Cruzan V. Director, Missouri Department of Health “Right to Die” is the issue at hand. Nancy Cruzan twenty-five on January 11, 1983 was thrown from her car in a crash a few miles from her home. When police and paramedics arrived on the scene of the crash her brain had been deoxygenated for somewhere in between the time frame of twelve to fourteen minutes. Sadly
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