Question

Mary was a 40-year-old mother of two with a history of tumor and hospital visits; however, her last doctor’s visit in October left her and her family with shattering news. Doctors diagnosed Mary with metastatic inoperable tumor. Since Mary last visit, her conditions worsened due to malignancy and she became a victim of nausea, vomiting, intestinal obstruction and slothfulness. When Mary came to know of her medical conditions, she became stubborn and denied treatments the hospital offered her: exploratory laparotomy, insertion of a urinary catheter, and insertion of nasogastric tube.

The matter of refusal of treatment between the medical staff and Mary put her family in a hard situation. They encouraged Mary to agree to take the hospital’s treatments; on the other hand, they also wanted to respect and honour her autonomous wishes. In due course, the medical team established a terminal diagnosis for Mary and informed this to her family. Afterwards, the family asked the consultant to keep this information from Mary. The consultant agreed and Mary sustained her stay in the hospital with the trust that she was suffering from tumor which can be cured.

A week later, the holidays approached Mary and her family conversed plans for Christmas as well as her discharge from the hospital. Though Mary’s family and doctors were well aware of her prognosis, both groups willingly concealed the truth and let Mary believe her health condition was not terminal. This created an uncomfortable situation for the involved health care professionals involved in this tough conflict of interest. Eventually, Mary’s disease took control of her life and she unknowingly passed away one week before her expected Christmas holiday.

Questions:

1. What advice do you think Ackerman would offer to Mary's doctors about navigating the conflict between beneficence and autonomy?
2. What advice do you think Goldman would offer to Mary's doctors about navigating the conflict between beneficence and autonomy?

Answer 1

BENEFICENCE

Beneficence is the action which is done for the benefit of patient. Beneficent actions can be taken to help, prevent or remove harms or to improve the health situation of the patient. Physicians are having the obligation protect their patients by providing any means of aid and causing less damage to their physical and mental health through the course of treatment. Whenever they provide the treatment to a patient he should weigh and balance possible benefits against possible risks of an action.

AUTONOMY

Autonomy is the right of a person to make their choices without any force or interference by others. One of the fundamental clinical ethics is respecting autonomy of others especially patients. Autonomy is not only allowing patients to make their decisions but the physicians have to create awareness in patient to make the right and meaningful choices.

In the above mentioned case study, Ackerman and Goldman would offer Mary's doctor regarding the conflict of beneficence and autonomy .

According to Ackerman , the principle of autonomy is related with informed consent . According to him , all the relevant information should be communicated to the patient and help the patient to take the right decision. Also get an informed consent from them whatever they decide or choose. Even if it's the continuation of treatment or withdrawal from treatment an informed consent should be obtained. In the above case study , even though the relatives requested it was the doctor's responsibility to inform mary about her terminal illness and he should have obtained an informed consent from her because the physician is considered as an information provider. So the principle of autonomy was not respected in the case. When it comes to beneficence , Ackerman says that weak paternalism can be justified which means that , if the doctor doesn't reveal the information with the purpose of benefit for patient and it really benefits them then it can be justified. But the actor doctor in the above case cannot be justified because mary was not benefitted at the end. But instead of telling her she is going to die and make her emotionally upset , she was happy in planning her vacation and hoping that she will be fine . So the doctor could make her happy till the end of her life. So it an be justified according to him.

According to Goldman, the patient himself should have access to information vital to his own wellbeing which means the right to be told the truth about his condition, and the right to accept or refuse or withdraw treatment on the basis of adequate information. As per him, self determination is a primary right. Lying in the context of medical decision making is more critical than not telling the truth. When you do like that it is interfering with the patient’s right of self
determination. In the above case study , Mary has all the rights to know that she is terminally Ill but as per the relatives request the doctor kept it hidden . It is unethical. She has the right to choose the treatment or deny it. But she was not informed about her terminal illness and because of that she planned her vacation in an impression she is going to get cured. She was not prepared to die even though she was terminally Ill because she was unaware about her condition. Here the doctor didn't follow the principle of autonomy.

The principle of beneficence is also not followed in this case because mary was not benefitted with the proper treatment or care which reduces her physical and emotional distress. In the present case, the doctor was concerned about her reluctance to treatment and the relatives requested because thinking that she may completely deny hospitalization. So thinking about her health and long life , they wanted her to stay in hospital and that is the reason they didn't reveal the truth . But according to Goldman , health and long life are less fundamental values than self determination. So Mary had all the rights to deny the treatment after knowing the condition . Doctor should have explained her about the terminal illness what she is suffering and tried to make her understand the situation and make right decision. Also he should have respected her choice of decision so that she could have mentally prepared and had the time to say farewell to her loved ones.