"Very simply, medical ethics are what we believe is good and bad, right and wrong about medicine," Robert L. Fine, a specialist in internal medicine and geriatrics and a frequent lecturer and writer on medical ethics , told the Reporter a Christian organization journal . Ethical Considerations of Moral Utility
in Medical TreatmentFurther Dr. Fine divided medical decision making into two types:
1. Technological imperative in which "we have a piece of technology and we must use it";
Then Dr. Fine went on to say in a most bottom line manner: "The big ethical questions are about the end of life and the beginning of life,"
2. Ethical imperative in which "it is not 'what can we do' but 'what should we do.'"
A. The moral issue ; Is it possible to have complete informed consent? In my experience the professionals of the medical community usually proceed as though they do have informed consent. Like salesmen assuming the sale, and taking the power of the gestalt between the patient and themselves, then decide what is "best" for a patient they may hardly know. An example of how this could go wrong, might be if the choice was between saving one hand in favor of the other and an assumption that the patient was right handed severely handicapped a lefty. Mechanically, a decision was made because statistically more people are right handed. So it may be seen, very often the physician bases decisions on data for the mean and the individual differences in people may confound them. So practically and philosophically speaking there can never be utter certainty that complete understanding of all aspects of the situation can be had even by trained professionals, and most especially by the lay members of the public E.G. most patients.
B. Explanation of both sides of the issue ; The medical community in deference to laws of malpractice and to satisfy the other legal requirements make efforts to inform and gain assent to treatment. Unfortunately, they are likely to proceed in the absence of clear informed consent in favor of life. In the Hippocratic oath that many doctors are required to swear to I find: "I will neither treat any patient nor carry out any research on any human being without the valid informed consent of the subject or the appropriate legal protector thereof..." Here there is an assumption made that the "valid informed consent" is in fact attainable. "From a medical ethics perspective, it is important to appreciate the issues involved in informed consent. First, the process ensures that the patient has been informed about the procedure, its rationale (and alternatives), and the related presence and frequency of risks. This information is essential for a patient to make an informed decision regarding the procedure. On the other hand, discussion of remote risks of serious complications may raise patient anxiety levels regarding the procedure. Increased anxiety may in turn have adverse consequences, such as increased complication rates, provocation of myocardial ischemia in patients with coronary artery disease, increased need for anxiolytic medications, and refusal to undergo medically necessary procedures." The decisions made under such circumstances may not be in the best interests of all concerned or even in line with expressed desires of the patient when not under such duress. If these expressions of lack of consent be not sufficiently well documented then the medical providers are bound to give heroic treatment. In extreme cases their resorting to measures that may sustain only organ health in patients that may have otherwise sub- minimal qualities of life and potential of improvement, constitutes an ongoing tragedy to all concerned.
"...in complex cases, problems will arise concerning
i) how to define best interests
Patients' best interests rest on the balancing of factors such as a low chance of survival with a high chance of severe disability. In such deliberations a reasonable goal of treatment may be more clearly seen by using "close up" ethics versus "distant ethics". This may result in different outcomes for similar ICU cases, but there is no inconsistency as long as ethical decision making is based on patient best interests. We must always avoid presenting a barrage of information to the family and then saying "let us know what you want us to do". The team must always recommend a plan to the family.
ii) who should define them for the incompetent patient, and
iii) how to resolve differences in opinion about the incompetent patient's best interests.
C. Explanation of why this issue is a moral issue and not solely an economic or political issue ; Prime to these investigations is the sheer human suffering of the patient and their loved ones. In the worst case scenario the patient with their discomforts in a body or mind incapable of even approaching a quality of life that any would consider minimal. Coupled with the loved ones that are unable to gain closure on what essentially is the passing away of the patient as they knew them and would like to remember them. Plus the bind of the medical professionals that are required to continue treatment in what amounts to a lost cause, must find such situations very discouraging. Is it in the moral best interests of utility beyond economics to permit the practices that promote such suffering in these extreme cases? I think not. Death is not always the worst option available to us. Ethically, I find it immoral to withhold this option when it clearly is in the best interests of few or none.
D. Possible costs (actual dollars, or changes in societal attitudes, behavior, values, etc.) of the "What if" decision to one or both sides of the issue ; Some of the enormous financial costs of these practices are as follows. The drain of resources from the insurance companies drives up the cost of insurance and places it out of the reach of many Americans. For those that have no insurance the financial burdens could be ruinous to their estate or the life savings of their family. In many cases the bills are picked up by Social Welfare or some other government agency when there are no other payers available. This places the burden on the tax-payer and consequently the funds are not available to alleviate suffering and promote social good in other areas. Finally, the equipment, drugs, and beds required in these hopeless cases may affect availability of these resources to patients that might stand a better chance of regaining health. Again the Hippocratic Oath speaks to this: "I will treat without exception all who seek my ministrations, so long as the treatment of others is not compromised thereby..."
E. Materials to back up above points are hot-linked with the quotes.
F. Assessment of strengths of these sources and why you chose to use them;
1.The Reporter- Interactive News "Informing your faith" I do not feel that information on this page which so closely is aligned with my own views, need be dismissed out of hand due to its religious affiliation. In general I would shy away from this sort of site, however. 2.MacLean Center for Clinical Medical Ethics at the University of Chicago oddly enough this resource is no longer available from them, and it is a official document that is probably available elsewhere formerly posted to an authoritative source. 3. Medscape an online journal that appears to be quite solid as well. It is open to peer review and I would catagorize it right in line with its' print cousins. 4. This quote from Dr Byrne who is currently an Associate Professor and the Director of the Neonatal Intensive Care Unit of the University of Alberta in Canada is solid. His narrative on the nature of issues involved in the ICU is most enlightening I recommend reading the entire webpage this was culled from. 5. Derek Parfit ("the philosopher's philosopher") from his book Reasons and Persons (Oxford, 1984). Being that this is in print and the author is accountable, we must assume that this was published in good faith. I love the quote and felt compelled to include it. 6. Likewise this quote from Lu Xiaohe 's dissertation on the University of Depaul site is right on in their itemization of values and to me quite clear.
G. Discussion of how one or more moral philosophies support your position on the issue and explanation of why that philosophy substantiates your position including a short summary of the applicable principles of the philosophy ; The following quote is from Derek Parfit ("the philosopher's philosopher") from his book Reasons and Persons (Oxford, 1984) who thinks there is a weighty consideration to all this, that may be seen in many philosophical debates. "Each side in the disagreement saw only half the truth. Each put forward as sufficient something that was only necessary. Pleasure with many other kinds of object has no value. And, if they are entirely devoid of pleasure, there is no value in knowledge, rational activity, love or the awareness of beauty. What is of value, or is good for someone, is to have both: to be engaged in these activities, and to be strongly wanting to do so"
"Value can have three dimensions:
(1) it may be that which meets the needs of subjects;
I am bearing in mind the above quotes on values when we examine this as I am wont to do from a Utilitarian standpoint. Which by way of definition I find in the work of John Stuart Mill, "Utilitarianism" the following quote that is a bit vague and for the purpose of this paper adequate: "The creed which accepts as the foundation of morals utility or the greatest happiness principle holds that actions are right in proportion as they tend to promote happiness, wrong as they tend to produce the reverse of happiness." It seems easiest and clearest to return to the worst case scenario of the incompetent and incapacitated patient. Where in cases like these by virtue of the minimization of unnecessary human suffering, alone would be a furtherance of this goal. Add in avoiding the costs incurred due to excessive treatment. Not to mention the use of available resources that might be better spent on ones that have a desire to, or find value in, continuance of life. Would, I think, make a clear case for every effort to create a flexible legislative structure and active involvement of medical care providers, to this end. Namely the peace, contentment, and ease of living and dying as well and as happy as is possible.
(2) it may be that which a subject wills or creates;
(3) it may be that which a subject appreciates or enjoys."
Lu Xiaohe
H. Concluding paragraph should comment on whether the practice being discussed will be allowed into our ideal community . In an ideal community there would, I think, need to be a clearly marked and wide avenue to all concerned paving the way to do our best to eliminate the possibility of prolonging life beyond it's reasonable limit. This might be best effected by gaining as close to an informed consent as is possible. As well, some means by which folks can predetermine what care they would be willing to undergo and under what circumstances they would not consent to further treatment. Perhaps even to require upon the application of a driver's license a living will, just like the check box for "organ donor" that is currently in place, in most states. In any case in light of the potential for miscarriages of just treatment of incapacitated and incompetent patients, it behooves us all to prepare for this eventuality, and put the instruments in place to forestall a situation that might come upon us suddenly without prior warning. Distasteful as we might find the process of creating these documents and making our wishes known to family and/or friends and our personal physician that could advocate on our behalf in case of incapacitation it needs to be done. I feel it very important to accept the realities of life which at some point will include infirmity and death.
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