The central idea of the concept of "autonomy" according to the context of this article is that an able-minded, relatively rational thinking person makes an informed decision concerning his/her health. In the case of forty-nine year old Monica with a form of terminal cancer, the author seems to ask if the medical team should truly allow Monica autonomy in what appears to be a no win situation for her, or if in their definition of compassionate care, the team should step in to make the determination on how Monica would be best off. I agree with the commetary offered by Elger when she notes in her conclusion "in the abscene of written or oral directives, not waking Monica would be an unjustifiable form of hard paternalism."
How can a physician assume total responsibility for how a patient chooses to live (or die)? Is that the role of a physician? If the issue is strictly on providing care, then Monica's team of physicians have done their jobs to the extent that she is as stable as her condition will allow. Because it seems possible to "wake" Monica from her sedative state, even though she may be in pain by doing so, why shouldn't she at least be allowed to have her voice heard? If Monica had no chance of resusitation or the ability to regain conciousness then wouldn't the physicians be required to contact any known next of kin to see if they could speak on behalf of the patient's wishes? It certainly seems unethical and perhaps illegal for a physician to take a patient's life into his/her hands soley on the basis of what he/she believes is right when there is the opportunity to let the patient (or patient's family or friends) make such an important decision. Afterall, that doctor may have just met Monica for the first time when she was admitted into the hospital. Each person is an individual in that we don't all view life and death issues the same way. Why would the physicians even want the burden of assuming that for a complete stranger when the decision is probably twice as difficult when it's made for oneself?
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What, then, is the role of the physician? Because if it is strictly “providing care,” does defining the role of the physician so narrowly border on confusing patient autonomy with noninterference, as Ackerman points out? Do doctor’s only need to be “honest and good technician[s]”?
ReplyDeleteMore importantly, what defines “patient care”? Where is the line drawn between patient care and unjustified paternalism? Have Monica’s physicians truly completed their jobs, or do they have a greater responsibility to both Monica and the society they serve?
We, as a society, ask more from doctors than simply mechanical tune-ups, which was what Monica asked for by seeking out their knowledge and abilities. The medical team is worried that she would no longer be able to make an informed, autonomous decision. If she is not able to make that decision, why shouldn’t the people who’s medical advice she sought in the first place?
"If monica had no chance of resuitation or the ability to regain conciousness then wouldn't the physicians be required to contact any know next of kin to see if they could speak on behalf of the patients wishes?"
ReplyDeleteThis was the exact difficulty I was grasping with when reading the article, she has the ability to regain consciousness, unlike many unfortunate people, so she deserves the right to at least be able to say goodbye to her loved ones and make any arrangements. If the doctors believe there is an ethical dilemia with asking her to chose a treatment option then simply dont ask her to make that decision. They could restrict information provided to her if they found she was not in a rational state when she awoke but at least provide her with the right to say goodbye if she can.
Wallace, your question is essential and I believe has different meanings to different people. (Doesn't everything?) When you asked, "what is the role of the physician", I think you hit the nail on the head. For me, it does mean to provide care in terms of "fixing the problem" (if possible) that brought the patient into the physician's office to start with. It also means to provide guidance to what medical experts consider "health" as predeterminded by standards based on age, weight, sex and other factors. Different specialties offer different perspectives on the approach used to "fix" the problem. In the process though, I expect my doctor to offer advice, and answer any questions that I have related to my health. I do not however expect him or her to take it upon himself or herself to do what they think is right to "fix" my problem without my consultation. That, to me is hard paternalism and seems to trample on my individual rights.
ReplyDeleteAs an example, if I complain that it hurts to breath through my nose, I would expect my doctor to investigate the reason behind it, and offer solutions to me to solve the problem. If the solutions make sense to me, I then decide which solution I want to pursue (or not. I may then decide that the procedure is too invasive, expensive, may take too long to recover or whatever and live with the pain). I wouldn't expect a doctor to then take it upon himself to correct my large or crooked nose just because he thought it would make me happier to have a smaller or straighter nose in addition to taking the hurt away.
I don't mean to trivialize my point, just that I want to make clear that I do appreciate your question of a doctor's role, because I think besides "fixing the problem" anything else is left to individual determination. That blurred line can go for anything - certainly any profession. Do we expect our teachers to be counselors, babysitters, providers, friends, role models, investigators or what? Some would argue that it could depend on the situation, and surely because few things in life are cut and dry that would be true, however when we ask our doctors to wear these many hats and relinquish responsibility (except in the case of an emergency where time is a factor) for ourselves, it is a choice that we make for ourselves. At least, that's how it should be, not an assumptive role that the doctors take upon themselves when there is the opportunity to find out the patient's goals for his/her health.
Wasabi, you and I agree - or perhaps we're both confused. Because she(Monica)can regain conciousness, that's where I am at a loss, too. When an ambulance is called upon a scene where there is a serious injury and the patient's/victim's vital signs aren't stable, I don't question or doubt that the paramedics get right to work to stabalize the patient. I'm sure they don't ask the patient or wait to hear from the patient's family if it's ok to proceed to provide what they believe to be care to at least get the patient/victim to the hospital to receive further care - but that's an emergent situation. If the paramedics are called to a scene and a person is able to refuse treatment, the paramedics probably make sure the police are aware of the refusal and go on their way, but they don't then decide that they will care for someone who refuses it anyway. Why should it be any different when the discussion involves a concious patient and a physician? Doesn't that present a case of some sort of liability on the part of the doctor? Isn't that a breach of trust in the whole patient-doctor relationship if nothing else?
ReplyDeletePresence, I read your initial post after reading the case study and commentaries about Monica, and, at the time, completely agreed with you. Then I read Ackerman's article and I'm not so sure I fully agree.
ReplyDeleteAckerman's points about the constraints that can impede autonomous behavior are very valid, and, as he illustrates in examples, true. I think there are many situations where our ability to make the decision that fits with our long term goals is constrained. And if this is the case, then doctors should be able to make those decisions for us.
Now the question is, is Monica constrained severely enough so that she will not make the proper decision? I think not, and like Wasabi says, the mere fact that she has the ability to regain consciousness is almost reason enough. How can we expect doctors to know exactly HOW severe the constraints are? I think they would vary from person to person. And in a situation like this, it's just too hard to tell, so the only reasonable option is letting Monica make the decision herself.
So now I've come full circle and I'm back to agreeing with you, Presence.
I debated in my head about what options the doctors would best choose for Monica. Then I put myself in the patient's shoes, thinking, would I want the physicians to make the decisions about my health, or would I want to be brought to consciousness in order to make my own decision? I agree with Presence when she asks, shouldn't the patient be allowed to let her voice be heard since it is possible to 'wake' her from her current state?
ReplyDeleteMaybe from a physician's point of view, it's really hard not to put yourself in the patient's shoes. Rather, only think what is best for the patient and not yourself. I think a physician's goal is to take every measure possible to keep the patient alive, and knowing that there is a chance for the patient to have a say so with regards to her health, then by all means, bring her back to the conscious state and let her make her own decision.