Some Issues Raised:
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Autonomy
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Decisional Capacity
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Patient Virtues
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Patient Vulnerability
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Professionals
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Quality of Life
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Right to Refuse Treatment
John Q. is a 56-year-old male with a wife and two grown children.
He has just suffered his third heart attack in five years, and his cardiologist,
Dr. Y., has told him that he must have bypass surgery if he is going to
live. Dr. Y. has also told him that because of the already existent damage
to the heart muscles he will be a semi-invalid for the rest of his life
even with the surgery. John Q. had been an active businessman until his
first attack as well as an avid golfer, and he has resentfully had to cut
back on his activity since that attack. Now the possibility of extensive
surgery and living as a semi-invalid is too much for him to bear. He goes
into a depressed state and refuses the surgery, saying that he is "tired
of being sick" and that life holds no meaning for him any longer. He is
adamant about not having the surgery. The family asks for a psychiatric
consultation, and Dr. Y. supports the idea because he believes that the
psychiatrist might be able to talk John Q. into the surgery. Upon examination,
the psychiatrist agrees that the patient is depressed but he determines
that the patient is not so depressed that he cannot make a rational judgment
about the surgery. However, he also agrees that Dr. Y. and Mr. Q.'s family
should bring to bear whatever pressure is necessary to coerce Mr. Q. into
having the surgery.
Some Discussion Questions:
1. Describe the patient's vulnerabilities in this case.
2. How could Dr. Y have addressed his vulnerability more directly?
3. Is Mr. Q. a candidate for a paternalistic intervention?
4. Would you consider Mr. Q. to be lacking in decisional capacity?
5. Is coercion appropriate in this case?
6. How should depression be interpreted in cases like Mr. Q. when
the patient refuses treatment?
7. Assess the path of Mr. Q.'s practice of self-determination in
light of his "virtue narrative."
8. What ethical principle(s) [autonomy, beneficence, justice, paternalism]
should govern this case?
9. What strategies would you implement to bring this case to a resolution
which maximizes the well-being of the patient?
10. How might an ethics consultation
be helpful in resolving the disputes in this case?