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A Case Study

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An ethical dilemma is a conflict between two obligations. At times a health care worker may have an obligation to a patient that conflicts with his or her obligation to the employing facility or some other person. Sometimes neither choice can be made without sacrificing the other. This is a dilemma.  An example is in a situation where a pregnant woman is killed from injuries sustained in a car wreck, but the fetus may still be able to sustain life by keeping the mother on life support. The wife had always said she would not want to be kept alive on life support if there was no reasonable expectation of full recovery. Should she be put on life support when her family knew she did not want that and it would be at great expense to the family, and when the woman is already clinically dead?   

Prolonging life at the end of the lifecycle also presents ethical dilemmas. Should the child's college fund be spent on the grandparent's surgery bill when there is no reasonable expectation for a full recovery and the quality of life will include minimal functioning in a long term care facility?  The people in the middle have an obligation to care for both their child and their parent.

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 Health Care today has an abundance of ethical dilemmas such as assisted suicide, late term abortion, end of life decisions, and balancing for-profit health care delivery systems with humane and high quality patient care.

It is the society, community and individual that set moral standards that distinguish right from wrong. These standards are influences by the societal norms, philosophy, values and religious beliefs. An individual's personal ethics reflect these moral standards and direct his or her choices and behaviors. Respect for the needs and rights of the patient form the basis of ethical behavior in the health care field.

Each health profession has its own Code of Ethics; however they have some common general ideas. The following is a summary of typical commonalties:

  • The goal of health care is to promote optimal health, preserve life and support the transition through death when necessary.
  • The patient's religious and cultural beliefs and practices are respected.
  • Care is provided regardless of the patient's age, gender, race or type of illness or injury.
  • The practitioner performs within the defined scope of practice and avoids unethical or illegal acts.
  • Competence is maintained through continuing education.
  • The rights of patients are respected and confidentiality is practiced.
  • The profession is supported through participation in research and/or membership in professional organizations.

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The Code of Ethics for a given profession provides guidelines for ethical decision making. For example the National Association of Social Workers' Code of Ethic specifically identifies that having a sexual relationship with a client is unethical (even if consensual). A therapist from the social work profession who falls in love with a client would risk breaking the Code of Ethics to pursue a romantic relationship. If a therapist were to experience a desire to engage in a romantic relationship with a client, he or she will find clear guidelines for appropriate professional behavior in the Code of Ethics. An ethical decision made by a therapist would be to avoid pursuing a romantic relationship with a client.

This case comes before the court for the second time. In In re A.C., 533 A.2d 611 (D.C. 1987), a three-judge motions division denied a motion to stay an order of the trial court which had authorized a hospital to perform a caesarean section on a dying woman in an effort to save the life of her unborn child. The operation was performed, but both the mother and the child died. A few months later, the court ordered the case heard en banc and vacated the opinion of the motions division. In re A.C., 539 A.2d 203 (D.C. 1988). Although the motions division recognized that,  as a practical matter, it "decided the entire matter when [it] denied the stay," 533 A.2d at 613, the en banc court has nevertheless heard the full case on the merits. This is not a rehearing but an initial hearing en banc. The motions division heard only the application for a stay, which it denied and which is now moot. The en banc court, however, has before it the entire appeal on the merits, which no division of the court has ever considered.

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First, we must determine who has the right to decide the course of medical treatment for a patient who, although near death, is pregnant with a viable fetus. Second, we must establish how that decision should be made if the patient cannot make it for herself -- more specifically, how a court should proceed when faced with a pregnant patient, in extremis, who is apparently incapable of making an informed decision regarding medical care for herself and her fetus. We hold that in virtually all cases the question of what is to be done is to be decided by the patient -- the pregnant woman -- on behalf of herself and the fetus. If the patient is incompetent or otherwise unable to give an informed consent to a proposed course of medical treatment, then her decision must be ascertained through the procedure known as substituted judgment. Because the trial court did not follow that procedure, we vacate its order and remand the case for further proceedings. We observe nevertheless that it would be far better if judges were not called to patients' bedsides and required to make quick decisions on issues of life and death. Because judgment in such a case involves complex medical and ethical issues as well as the application of legal principles, we would urge the establishment -- through legislation or otherwise -- of another tribunal to make these decisions, with limited opportunity for judicial review.

It is also emphasize that their decision was the result of considerable deliberation and that they have enjoyed two luxuries unavailable to the trial court: ample time to decide the case, and extensive briefs and oral argument from the parties and several amici. The trial judge had no such advantage. He was called in during the worst of emergencies, with little time for reflection, to make a decision which under the best of circumstances is extraordinarily difficult. Although his decision must be set aside, we nevertheless commend him for the painstaking and conscientious manner in which he performed the task before him.

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Rather than protecting the health of women and children, court-ordered caesareans erode the element of trust that permits a pregnant woman to communicate to her physician without fear of reprisal all information relevant to her proper diagnosis and treatment. An even more serious consequence of court-ordered intervention is that it drives women at high risk of complications during pregnancy and childbirth out of the health care system to avoid coerced treatment. Second, and even more compellingly, any judicial proceeding in a case such as this will ordinarily take place like the one before us here -- under time constraints so pressing that it is difficult or impossible for the mother to communicate adequately with counsel, or for counsel to organize an effective factual and legal presentation in defense of her liberty and privacy interests and bodily integrity. Any intrusion implicating such basic values ought not to be lightly undertaken when the mother not only is precluded from conducting  pre-trial discovery (to which she would be entitled as a matter of course in any controversy over even a modest amount of money) but also is in no position to prepare meaningfully for trial.

The procedural shortcomings rampant in these cases are not mere technical deficiencies. They undermine the authority of the decisions themselves, posing serious questions as to whether judges can, in the absence of genuine notice, adequate representation, explicit standards of proof, and right of appeal, realistically frame principled and useful legal responses to the dilemmas with which they are being confronted. Certainly courts dealing with other kinds of medical decision-making conflicts have insisted both upon much more rigorous procedural standards and upon significantly more information. Ordinarily, when the factual record in a case is insufficient to support the trial court's decision, we remand for additional findings. In this case, however, a remand for supplemental findings would be inappropriate and futile because the caesarean has been performed and cannot be undone. The record is unclear as to whether A.C. was ever competent, after being sedated, to make her own decision, and the likelihood of marshaling further evidence now on this question is doubtful at best. If the substituted judgment procedure were to be followed, there is evidence going both ways as to what decision A.C. would have made, and we see no point in requiring the court now to make that determination when it can have no practical effect on either A.C. or L.M.C.

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Resource

rom Book Illingworth & Parmet: Ethical Health Care (pgs 127-137)  Title named: In re A. C., Appellant No. 87-609 District of Columbia Court of Appeals.

 
 


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