Ethics in Clinical Practice

In a hospital in New York City,  a Chinese native quadriplegic patient, Charlene, who has been relying extremely on a ventilator for her breathing function, had some of his relatives wanting the ventilator removed, and she be served regular food as normal in any event, against the doctor’s stand. In both Charlene’s and her proxies’ view, the ventilator  is not helpful anymore and at best, just burdensome, because it is more likely that Charlene would die anyway because apart from her breathing problem, she has been suffering terminal illness of Cancer. The doctor, predominantly citing futility of their request, has refused subject to the Hospital’s Ethics Committee regulations, and Charlene’s family has moved to court besides vowing never to bring any of their patients to the medical facility again! This is an ethical problem. Is the problem based on lack of clear or inadequate distinctiveness of medical ethics and health-care choices of patients and their representatives? This is what this paper aims to address.

Overview/Background of the Problem

Increasingly, doctors and other medical practitioners are faced with the dilemma of honoring their oath and the powers of the attorney, while at the same time responding to the wishes of patients and their proxies, as well their medical interpretation (Amir & Brody, 2007).  Mildred (2010) reckons that in many countries including the United States, people are progressively holding the belief that they should be allowed to make choices about food, fluids and life support measures for themselves or family members who are ill, a position of choice they believe should be respected by the medical practitioners. This should be, in their view, granted regardless of doctor’s opinion which may be on the contrary. A number of studies have been conducted to expose the intricacies of this ambivalence (Higgs & Dahlgren, 2004). In a survey conducted by Research Technology (RT) in February 2007, many people always want their wishes regarding food and fluids for their patients respected even when the doctor makes it clear that the patient’s body strength and medical condition cannot adequately support such measures (Amir & Brody, 2007).  One may be attempted to ask, what the dilemma or the problem is all about. On the whole, the challenges that medical practitioners face as tight spots in dealing with Patient’s Living Wills and Durable Powers of the Attorney seem to be tied to two issues: Lack of Clear or Inadequate distinctiveness of medical ethics and health care choices by patients and their representatives!

Undeniably, lack of clear or inadequate distinctiveness of medical ethics and different orientations of patients and their representatives, is to blame for the selective application or ‘unrealistic’ decisions regarding Patient’s Living Wills and Durable Powers of the Attorney (Doukas & Reichel, 2008). One the whole, the wish for life-saving measures remains predominant among the American population. Almost everyone wants all available treatment measure used  to rescue seriously suffering patients, while a few have accepted removal of life saving measures when a patient’s situation seems irreparable and burdensome (Kleinberg, 2010). A study that was published in the Journal of American Association (JAMA) for instance, reveals that most gravely ill individuals in the Veteran Administration hospitals have the desire for all means to be employed to regain their health. Regardless of these bare facts, doctors and other health-care providers are today and increasingly so, denying Life Preserving actions and measures, even if both the patient and family members direct otherwise (Robert Powell Center for Medical Ethics, 2011). This can be directly associated with lack of clarity or oneness in the application of various ethical codes of the medical profession and sometimes due to different cultural parameters of both patients /or the proxies, and the physicians themselves (Doukas & Reichel, 2008).

Literature Review

There are a number of models, theoretical orientations and recent happenings through which the decision predicaments and ethical policy gaps facing the medical profession in regards to patient’s wills, and durable powers of the Attorney, can be examined in the context of Charlene’s case.

Denial (or Granting) of Care as ‘Futile’ is in Most Cases grounded on ‘Quality of Life’ and Not Physiological Reasons

 To begin with, a number of recent cases particularly in America seem to echo these dilemmas. The case of Terri Schinder-Schiavo which has been dubbed ‘’Advance Directive+ is the clearest way to give directions on fluid/food usage’’, is one such (Robert Powell Center for Medical Ethics, 2011).  While the laws of most states in the United States have provisions for such advance directives, doctors and medical practitioners, and the health-care facilities, often times controlled by Ethics Committees, have been authoritatively denying these patients such measures because by some ethical default, they’re obligated not to (Robert Powell Center for Medical Ethics, 2011). This is more compounded by an increased percentage of family members of patients (even in a-not so obvious situation) demanding such actions unlike in the past. In  a study capturing 26 health-care facilities in California, two hospitals were found to be dictating specific terms and conditions under which life preserving measures must not be obligated regardless of any such appeal by the patients or their representatives. In this category, were those suffering irresistible dementia, and Alzheimer’s disease! The study reports that doctors, even after refusing such, increasingly insist that their action (in-action) is in line with the medical professional codes of conduct (NMC, 2008).  Indeed, arguments have since been fronted by human rights crusaders and media representatives including journalists that such in-action by doctors contravenes the very fundamental medical ethics to preserve life (Higgs & Dahlgren, 2004). This appears ironical.

Moreover, many cases have erupted at the appellate level regarding disagreements between patients and their representatives wanting life preserving measures on one hand and medical practitioners and health-care facilities who do not sanction such on the other hand.  Further, there are today a number of Ethics Committee agreements, with most of the committees writing and ‘ratifying’ futility guidelines (Robert Powell Center for Medical Ethics, 2011).  For instance, the Society of Critical Care Medicine’s Task Force on Ethics provided an agreement report supporting refusing ‘a foregoing life sustaining treatments in the critically ill’’ This report authoritatively asserts that: ‘’If a requested treatment entails, according to the norms of medical practice, loss of function, mutilation, or pain disproportionate to the benefit, the physician and nurses are not obligated to provide it’’ (Johnson, 2010.pp18).  This means that both the quality of life and the preservation must be evaluated to warrant advancing and withdrawing life preserving measures.  This seems pegged on the belief that treatment of patients must be arrived at vis-à-vis the broad medical situation of the patient, to the extent that even patients who are terminally ill are denied the provision. Also, the American Thoracic Society (ATS) asserted that provision of life saving measures cannot be provided when such measures is likely futile, where ‘futile’ means that the measure would in the highest probability not lead to the patients survival (Johnson, 2010). Interestingly, following these views, a research finding published in the Archives of Internal Medicine in the year 2004 found 65% discrepancies with the cases against such directives (Johnson, 2010).

Inherently, whereas the refusal by medical practitioners to grant life saving measures is mostly grounded on ‘futility’ of the chosen measure or treatment, this paper sees it crucial to differentiate the specific use of the concept and the broad implication of it.  Hawley (2007) reckons that some medical doctors believe a measure or treatment to be ‘futile’ when such is not effective or does not postpone time of a patient’s demise. Others, however, conceptualize the concept ‘futile’ in an expansive sense, such as implying ‘not tendering quality of life’’ (Hawley, 2007. pp6). For instance, most doctors are in consensus that in a case of a high level demented Alzheimer suffering patient, then Cardio-Pulmonary resuscitation, is not appropriate, and that the doctor ought to employ DNR status tailored on his own medical assessment. The same principle should be followed on patient’s discretion. For example, doctors having the right to choose a patient’s quality of life initiative and not the patient him/herself (Johnson, 2010). However, in another study conducted in 1991 by the American Medical Association’s Council on Ethical and Judicial Affairs discredited ‘quality of life’ expanded viewpoint as ground to refuse affected patients and family members actions which are life preserving (American Thoracic Society,1991).

A case involving, Larry McAfee, in Georgia who was Quadriplegic and exclusively reliant on a ventilator, because in his estimation it did more harm than good, is an example to consider as partly a replica of Charlene’s case. Like inn this, the family went to court to seek endorsement on the removal proposition.  According to Hawley (2007), some people read and reported this differently as ‘approved suicide’.  He then processes that distinctions should thus be made in regard to terminal illness, quality of life, Euthanasia (passive or active), ordinary and extra-ordinary ways to life extension among others (Hawley, 2007).

Ethical Codes and its Role: Broad Focus in Medical Context

Ethics refers to the acceptable code of conduct upon which the behavior of an individual can be evaluated as acceptable or not acceptable, or as either right or wrong. The means of setting up a universally acceptable code of conduct has, however, had controversies with different thinkers coming up with various theories to attempt to develop the standards. This has led to diverse views on what is ethical and what is not ethical among different communities or social groups. Philosophy and religion, and not necessarily medicine, have been major ways of attempting to establish the generally acceptable principles in these settings (Wright, 2000).

In the field of in Medicine, the conception of ethical codes can be traced to the days of Hammurabi, even though it is Hippocrates who coined medical oath as we know it today (Kelly, 2007). Despite this, debates and discussions on the role and need for ethics code in respect to their application have heightened due to increased tasks and social interactions of medical practitioners with members of society. This has further been justifiable on a number of dilemmas regarding health-care choices and the lack of distinctiveness in the application of the codes. In psychology which is a twin to medicine, ethics arose due to need for interaction before and after the Second World War. In this epoch, the psychology as a field was increasingly expanding, and thus come the year 1947, the American Psychological Association (APA) appointed a committee for the ‘Ethical Standards’’ and the mandate of the committee was to establish code of ethics for psychologists, with the specific aim of changing human behavior (Wilson, 2010).  One might however want to ask the role of ethical codes and norms in medical practice and how then it applies to the current dilemmas being faced in the context of this paper.

Broadly, ethical code is indicative of moral norms underlying the values of medicine as a profession. As in many professions, ethical norms in medicine are geared towards achieving morality associated with ‘doing good’ causing no harm, respecting others and their dignity, and being fair and honest with everyone. Norms in a profession refers to the ideals of that profession and defines distinct behavior types (dos and don’ts) that guide the professionals as they conduct their business. In a sense they guide the conduct of the individuals involved and provide the ground upon which the codes are assessed (Harrison et al. 2010).

The specific roles of these norms and codes of ethics include the following: One is the establishment of the professions integrity. This role is largely associated with creation and maintenance of the professions capability based on societal norms of respect and responsibility. (Wright, 2000).This role separates and makes the field of medicine unique as a ‘’community of common purpose’’ and forms a unitary agreement among the members of the profession and thereby by extension supposedly boosting the confidence of other members of society in it (Harrison et al. 2010). Further, the integrity of the profession is anchored on ethics code streamlined for the members to focus on the activities and the duties they have for the entire society (Humphrey, 2008).

Additionally, ethical codes and norms function in creating public trust (Kelly, 2007). This is achieved by showcasing the profession as and its members as responsible and in a functional high standard profession in relation to societal universal beliefs and expectations. It is thus seen as a social agreement or a covenant that the profession has with the larger members of the society. Whether the codes of medicine or at least their application, keep to this ideals is what ought to be examined (Steven, 2000). Humphrey (2008) notes that the  Hippocratic Oath itself  does not spell or enforce punishment to Medical Practitioners, but primarily only gives medicine as a profession a sense of duty to humanity.   According to him, the oath does three things: ‘’protection of the patient’s rights, appealing to the instincts of the medical practitioner, and spells the norms of association between patients and doctors’’ (Humphrey, 2008. p.36).  Specifically, however, the medical practice has some ethical tenets. O’Rourke (2000) recounts that practitioners should:

‘’not harm the patients,  must obtain informed consent from the patient or the patient’s proxy, must respect human life and bodily integrity, must tell the truth, maintain confidentiality, especially concerning harmful facts and information, respect the spiritual path of the patient, not use patients in research projects without their consent, allow patients in research to die if life-prolonging therapy is ineffective or imposes an excessive burden, and offer health-care because people are in need and not because they can pay for it’’ (O’Rourke pp. 67)

Ironically, in applying these norms, there is often the need to resolve conflict regarding the norms. O’Rourke (2000) believes that because human beings can predict about the future, acting should be based on issues and actions which enhance a patient’s well being.  This is what he calls ‘‘reasoned analysis’’ or capability of human beings. He, else how, notes that while reasoned analysis should be tailored around moral norms, this morality should not entirely be the factor for some decision making.  He wonders why different medical practitioners arrive at different decisions even if they start with the basic ethical facts about medicine. This is what prompts others to agreeing that a nutritional or hydration system be removed while others insisting it must be maintained (O’Rourke, 2000).

It then follows that sometimes the role in which societal norms come in handy is predominantly on education and professional enculturation. This socialization role is based on societal values and the professional standards defining what professionals should expect of themselves and others in the profession as well. Karen (200) observes then that a code in this sense should be perceived as a document that facilitates supports and provides a roadmap on how physicians and nurses should use their judgment and make decisions as they practice. The other role is in the enforcement of values. The norms are important for offering a basis of a checklist and a monitoring tool.  Wright (2002) shares the same assertion and adds that ethics code defines the types of behaviors considered as violations or the ones that go against grain, and provides a roadmap and guide for medical professional to avoid such behaviors, besides helping the clients in making complaints about such violations (Wright, 2000)

Problem Analysis

A part from the literature analysis, contextual analysis of the whole issue requires a look at some theories of ethics to come up with possible course of action. Utilitarianism theory, which has its origins with Jeremy Bentham, holds that in making ethical decisions, whether medical or otherwise, one must not always just center on actions, but must be mindful of the penalties or the impacts as well. At the core of this theory, is that actions must be assessed with values, and that values (for instance pleasure) ought to be fully exploited. In this, Utilitarianism holds the view of ‘‘the pleasure principle’’: that any action is morally acceptable, if it brings pleasure or does not cause harm to others, but repugnant when it brings about pain or harms others. In deciding a case for family members who want their patient to be removed from a life saving machine or not for example, this theory is applicable. While their want is aimed at the noble aim of satisfying him/and his family or preventing further burden, the doctors inaction can be based on giving the patient a possible chance to live or to die.  Overall, Utilitarianism has weaknesses and this is noticeable in this context, ranging from the difficulty in determining the amount of ‘‘pleasure’ one gets (how much a patients proxies may be rewarded, or how well the doctor applies medical practice measure regardless of how it affects others among others (Geirsson & Margaret, 2002).

Virtue ethics is equally important here. The central idea about virtue ethics is that actions must be tailored around the right virtues which model people to be moral and responsible. One must find a balance in the extremes of the virtues. For instance, doctors must at all time protect and preserve life, but also do this with the context of medical interpretation in mind (Geirsson & Margaret, 2002).

Possible Solutions

Accruing from the foregoing discussions, the solutions  would be  pegged on policy change intervention and harmonization of such while also thinking through educating the public to understand the ethical standards of medical practice. Specifically, this paper recommends the following: One, the medical profession should review their ethical codes in a manner that they are not vague or ambiguous: In this these regard, there should be a universal uniting laws in each state and country regarding the wills of patients and powers of the attorney.

The best strategy to achieving this would be to conduct research in all the states, with a view to arriving at a consensus and pushing for policy consensus through state agencies for legalization. In the meantime, the doctor dealing with Charlene’s case might want to transfer her! Further, as policy intervention framework, legal distinctions should however be made in regard to terminal illness, quality of life, active and passive euthanasia,  as well as ordinary and extra-ordinary means to prolong life’’.