23 April 2012

Clinical ethics II

I expand upon the case I relate in my previous post. It brings up several rich ethical topics.

My outline of the relevant theory:
Medical care should be beneficent and nonmalfeasant: it should strive to serve the patient's best interest and to avoid harm. Harrison's points out that medicine and business possess distinctly different philosophies: "do no harm" on the one hand, and "buyer beware" on the other.

Physicians should have respect for patient autonomy, a respect for the patient's wishes regarding what is done to his body. This does not mean that the doctor needs to do everything a patient demands. If a patient requests an inappropriate surgical procedure or an improper drug, the physician need not comply. However, if the patient is of sound mind and has reasonable justification, the patient is entitled to decline medical interventions. The physician is obliged to ensure that the patient is well-informed (and educate him if he is not) and to verify that the patient is capable of making a reasoned decision.

In addition, the physician has an obligation to people beyond just the patient. If a physician learns that a patient intends to murder to another person, he is obliged to act, perhaps by notifying police. If a physician diagnoses a patient as HIV-positive, he is obliged to report it to the local public health department and to ensure that the patient's sexual contacts are notified that they have potentially been exposed to the disease.
With the help of the concepts above, we can reason through this case:
The patient is of sound mind and has a coherent justification (religious beliefs) for refusing blood products. What complicates matters, though, is that there are children involved--one in utero and five of them born. The doctors must ensure that these children will not suffer the harm of being left without a caretaker.

According to Massachusetts law, the mother would be allowed to decline blood products so long as someone had agreed to become the children's legal guardian in the event of her death. In this case, the patient was married; by default, the husband would have to take responsibility of the children. Therefore, the patient was entitled to decline products, independent of her husband's wishes.
The case is interesting not only from an ethical standpoint, but from a medical one. In a coup of extensive planning, advanced technology, and skilled execution, the surgical team delivered the child, performed a hysterectomy (removal of uterus), and sealed off the arteries before the mother lost a dangerous amount of blood. Mother and baby both lived. Since the mother elected for a hysterectomy, which sterilized her, she will never again have to make the same wrenching decision about her pregnancy.

Again, the original case, as related in the New England Journal of Medicine, can be found here.

In a future post: what are the consequences of the dearth of training in clinical ethics for budding physicians?