Introduction
The paper is dedicated to the analysis of the case of Jamilah Shah, a 90-year-old woman of Turkish origin. She was brought to the hospital’s emergency department from an extended care facility where she resided after collapsing due to a heart attack. Because of communication difficulties and the absence of the patient’s advance directives, healthcare providers contacted her sons. The youngest one, Bashir, announced that he is a decision-maker and his mother does not need resuscitation or any other interventions except comfort care. At the same time, according to the social worker, Jamilah articulated clearly that she wanted medical help and she wanted to live. At the same time, due to the family’s request, she could not receive the cardiac catheterization or coronary bypass surgery necessary for her life.
Ethical Dilemmas
On the basis of the provided information, three ethical dilemmas related to autonomy, beneficence, and non-maleficence may be observed. In medical ethics, autonomy refers to a patient’s self-determination, self-rule, independence, dignity, freedom of will, integrity, responsibility, individuality, and self-knowledge. In other words, it is a person’s right to make decisions concerning his health and medical interventions free from others’ influences (Olejarczyk & Young, 2022). In the current case, the ethical dilemma of autonomy arises from Jamilah’s wish to live, which contradicts her son’s decision to reject any treatment that may prolong his mother’s life.
Another ethical dilemma is connected with the ethical principle of beneficence. In medical ethics, it relates to health care professionals’ moral obligation to act in a patient’s interests to ensure his well-being. On the one hand, the social worker aims to help Jamilah, especially knowing that she asked for help. In addition, the hospital’s staff is responsible for the provision of health care delivery and medical treatment of the highest quality to ensure the patient’s most appropriate outcomes. On the other hand, Bashir’s decision violates the ethical principle of beneficence and demonstrates unsupportive relationships in the patient’s family.
At the same time, the principle of beneficence frequently conflicts with the principle of “do no harm,” or non-maleficence. The latter presupposes a healthcare provider’s responsibility to avoid harm to a patient, however, the most necessary medical interventions may be the most harmful ones as well. In this case, it is essential to evaluate all potential variants in order to preserve the balance between beneficence and non-maleficence. In the case of Jamilah, the principle of beneficence prescribes the necessity of medical assistance, including cardiac catheterization or coronary bypass surgery. However, considering her multiple comorbidities and age, these interventions may cause unintended but serious complications.
Legal Implications
All identified ethical dilemmas are associated with particular legal implications. First of all, there are patient rights on the basis of ethical principles and universal human rights that should not be violated by cultural norms, values, and beliefs. Thus, according to the law, Jamilah has the right to refuse treatment even if this decision contradicts the principle of beneficence or receive proper medical assistance (Olejarczyk & Young, 2022). However, while she articulated her wish to live, there are no legal documents that approve it. In addition, according to the law, healthcare professionals are obliged to take life-saving measures in the case of an emergency to stabilize a patient’s state guided by the principle of beneficence (Olejarczyk & Young, 2022). While the physician started Jamilah on anticoagulants, he required advance directives, the patient’s informed consent, or the family’s request for further actions. Finally, executing the patient’s right to be treated justly, healthcare providers should evaluate all potential risks associated with medical interventions and their absence and inform both the patient and her family members in order to pursue the principle of non-maleficence and define the course of further actions.
Courses of Action
In response to Bashir’s decision, the following three courses of action may be identified:
The course of Action 1: Bashir’s wish will be regarded as the family request. In this case, the ethical principles of the patient’s autonomy and beneficence will be violated. Jamilah’s wish to live will be ignored as she will likely die within several days due to the absence of necessary interventions.
Course of Action 2: The principle of autonomy and beneficence will be prioritized – thus, Bashir’s wish not be followed. In this case, Jamilah will receive medical assistance, including cardiac catheterization or coronary bypass surgery, however, the risks of complications that may be harmful to the patient will not be assessed.
Course of Action 3: Any decision will be delayed in order to evaluate various perspectives and gather additional information. In particular, Jamilah’s wishes should be recorded, her other sons should be asked as well, the risks of interventions within the framework of the existence of severe chronic obstructive pulmonary disease and diabetes mellitus om the patient should be evaluated, and the patient and her family members should be informed about potential complications.
From a personal perspective, the third course of action may be regarded as the most appropriate one, as it allows one to act on the basis of all three ethical principles. First of all, the patient’s autonomy will be respected as her wishes related to her health will be considered. Moreover, healthcare providers will receive an opportunity to avoid the conflict between the principles of beneficence and non-maleficence. In other words, due to delayed decisions, they will evaluate whether interventions will be reasonable or harmful for Jamilah, considering her multiple comorbidities and respectable age that may impact the process of recovery. Finally, all information should be provided for the patient and her family members, and on this basis, the further course of action will be determined.
At the same time, the first course of action seems the most inappropriate one as it violates all principles of medical ethics. First of all, Bashir’s wishes are not well-informed – instead, they simply demonstrate misunderstanding and a lack of support in Jamilah’s family. In addition, the family request should be considered when a patient is unable to speak for himself or incapacitated while advance directives are absent. However, in the case of Jamilah, although the woman does not have a living will prepared in advance, she is educated enough and can speak for herself to express her wishes related to her health and interventions.
Resources of Jamilah’s Wishes
The main source that could have made Jamilah’s wishes clearer is advance directives. It could be either a living will or a durable power of attorney for health care (“Advance care planning: Health care directives,” n.d.). A living will state a patient’s directives dedicated to treatment or its absence if he is unconscious or cannot make sensible decisions. In turn, a durable power of attorney for health care names a health care proxy who will make decisions related to a patient’s health in the case of his unconsciousness or inability to speak (“Advance care planning: Health care directives,” n.d.). In this case, Jamilah could have communicated with healthcare providers in advance and filled out legal forms in order to detail her wishes.
However, as her advance directives are absent, another source for the clarification of her wishes, which is still available, is informed consent. According to 42 The Code of Federal Regulations (CFR) § 482.13, “patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment…” (Olejarczyk & Young, 2022, p. 10). Thus, for Jamilah and her sons, the rationale of medical interventions and potential risks should be explained in order to receive the patient’s recorded informed consent that will determine whether interventions should be made or only comfort care will be delivered.
Conclusion
In order to handle similar situations in the future, certain policy recommendations for the facility’s medical staff and other employees should be made. First of all, advance directives should be promoted, especially among patients with multiple comorbidities and senior patients. In this case, healthcare providers will know the course of action, being sure that the ethical principle of a patient’s autonomy is followed. Another recommendation is the establishment of a clear algorithm related to the clarification of a patient’s wishes. In other words, healthcare providers should ascertain that a patient is in consciousness and can speak for himself. In the case of communication difficulties, an independent translator should be invited. These procedures are essential to avoid acting on the basis of the family request that contradicts a patient’s will. Finally, in the case of absent advance directives, medical staff should initiate the evaluation of the advantages and disadvantages of medical treatment in order to balance the necessity to help with the avoidance of harm. In addition, a patient and his relatives should be informed about all potential risks to ensure that all decisions will be well-considered.
References
Advance care planning: Health care directives. (n.d.). National Institute of Aging. Web.
Olejarczyk, J. P., & Young, M. (2022). Patient rights and ethics. StatPearls. Web.