California Physicians, Clinical Ethics and the Law (Part 1 of 3)
Dr. William Osler described clinical medicine as "a science of uncertainty and an art of probability." What are the goals of a clinician? Reduce uncertainty? Do no harm? Beneficence and nonmaleficence? Listen to the patient in the efforts to maintain patient autonomy while being sensitive the multicultural framework of today's society? The answer is yes. But, how does a clinician adhere to the central ethical maxims of medical practice as stated in their Hippocratic Oath and reduce uncertainty, while maintaining patient autonomy?
Today, the physician-patient relationship occurs in a complex context: the social, legal, economic and institutional paradigms. The process of consistently good decisions in the face of uncertainty is called clinical judgment. Ideally, the physician's recommendation for a particular patient should be based on the physician's knowledge of both the best available clinical data and the patient's values. Advocates of evidence-based medicine state that even though the physician's recommendations are based on sound evidence, the patient should be the final decision maker, because only patients can assess the risks, benefits, goals, and costs of treatment in their own lives. Physicians must serve as critical interpreters of information and foremost, as reliable guides toward reasonable decisions.
Case: Rights and Duties. A 72-year-old male was admitted to the intensive care unit. He suffered a massive myocardial infraction. He has yet to recover consciousness and has had irreparable brain damage due to anoxia. He is married and has three sons. His eldest son works as a radiographer in the hospital. His second son is an evangelist with the Pentecostal church. His youngest son is living abroad. The ICU has a family room that has been taken over by patient's family. It is also constantly filled with well-wishers from the church who hold prayer and song meetings around the clock. Relatives of other patients are complaining about the lack of access to the family room and the noise levels. However, when the senior staff nurse asks them to keep the noise down, the evangelist son threatens the hospital with legal action for religious discrimination. He also says that the hospital is impeding the chances of his father's recovery because if they cannot hold a prayer meeting then no miracle can take place. Despite full active medical treatment and round-the-clock-prayers the patient makes no improvement over the next 6 weeks. The medical team decides to discuss the possibility of allowing the patient to pass in peace by withdrawing supportive medical intervention. He has multi-organ failure and has not regained consciousness. Patient's wife and evangelist son refuse to allow this and insist that everything be done to save him, including resuscitation. The unit staff are becoming upset that patient is not being allowed to pass with peace and dignity. The radiographer son agrees with the medical team and tries to convince his family. However, the mother and other son threaten legal action and believe that patient is not being cared for properly. No joint decision is ever made and there are no "Do Not Resuscitate" orders on file, Advance Directives, or Estate Plan in place. After 11 weeks patient passes during a 60-minute cycle of resuscitation.
What are "right" and "duties"? What is the difference between positive and negative rights? Who has "rights" in this case? Blog 2 of 3 will continue with this discussion. Contact Kolah Law for assistance with Clinical Ethics issues in your practice/organization.