Some Issues Raised:
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Advance Directives
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Decisional Capacity
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Informed Consent
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Right to Refuse Treatment
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Self-Determination
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Withdrawing Treatments
Rita M., a 78-year-old female, has suffered from COPD for about
20 years. She comes to the hospital in crisis about once a year and spends
some time on a respirator. Currently, she is a resident of a nursing home
where there is decent care for residents but little in the way of diversionary
activity. Rita M. says that she is bored there most of the time. She seems
appropriately attached to her son, but he cannot visit her frequently because
he lives some distance from the nursing home. Another crisis has occurred
and she is admitted to the hospital. This crisis, however, is worse than
usual, and Rita M. is told that she will have to remain on a respirator
for the rest of her life. The attending physician, Dr. E., informs her
that a tracheotomy can make the respirator dependency more comfortable
and that she can then return to the nursing home to live out the rest of
her life. After several days, Rita M. informs Dr. E. that she does not
want to have the tracheotomy and that she wants to be removed from the
respirator and allowed to die. Dr. E., who is concerned about this decision,
has developed the following options in consultation with the house staff
who accompany him on rounds: (1) the patient could have the tracheotomy
and return to the nursing home; (2) the patient could be removed from the
respirator, and nature would take its course; (3) the patient could be
removed from the respirator and receive morphine injections to alleviate
pain when it occurs; (4) the patient could receive a morphine injection
prior to removal from the respirator and subsequent injections as needed.
Dr. E. presented these options to Rita M. and she chose the fourth one.
She was subsequently given the injection and extubated. She died 20 hours
later.
Some Discussion Questions:
1. Does the principle of autonomy allow Rita M. to make this decision
even though she is not "terminal."
2. How does Dr. E. maximize his patient's autonomy?
3. In what way is Dr. E. being beneficent toward his patient?
4. How does Dr. E. avoid being paternalistic toward his patient?
5. Is Dr. E. following the principle of fidelity in the way he is
dealing with Rita M.'s decision-making?
6. How does this case reflect the strengths of virtue ethics and
feminist ethics?
7. What principle(s) of bioethics [autonomy, beneficence, justice,
paternalism] do you think should govern this case?
8. What strategies would you implement to bring this case to a resolution
which maximizes the well-being of the patient?