Some Issues Raised:
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Benefit of Treatment
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Communication
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Life-sustaining Treatments
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Oral Advance Directives
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Ordinary/Extraordinary Means of Extending
Life
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Quality of Life
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Self-Determination
Shirley W. is a 26-year-old female, unmarried with no dependents.
She has reached the end stage of leukemia, has accepted her impending death,
and has told her physician that she wishes to have no heroic measures used
to preserve her life. Although she also wishes to be kept comfortable.
Her physician, Dr. Q., wants to honor her request but is concerned with
her rapidly falling platelet count. The lower the platelet count, the greater
the chance of hemorrhage. The physician does not know whether to interpret
possible platelet transfusions as "heroic measures." On the one hand a
hemorrhage would cause Shirley W. to die soon, and a transfusion would
extend the dying process. On the other hand, if the hemorrhage occurred
in the mouth, the death would be very uncomfortable because the patient
would choke. If the latter were allowed to happen, Dr. Q.'s promise to
keep the patient comfortable would be broken. Not knowing quite how to
proceed, Dr. Q. consults with the staff and as a result offers the patient
the following mode of treatment. If a hemorrhage were to occur in the mouth,
the patient would be given platelets as a comfort-producing measure. Thus
the platelets would be seen as serving a palliative function in keeping
with the patient's desire to be kept comfortable and would not be seen
as a heroic measure whose primary function is to prolong life. However,
if the hemorrhage were to occur in some other part of the body, the priorities
would be reversed, the platelets would be seen as heroic measures, and
they would not be given.
Some Discussion Questions:
1. What virtues is the physician practicing in this case?
2. Is Ms. W. causing her death?
3. Is Dr. Q. causing Ms. W.'s death?
4. How does the issue of Ms. W.'s dignity arise in this case?
5. Would you consider this to be an acceptable exercise of the patient's
right to self-determination in the refusal of treatment?
6. What ethical principle(s) [autonomy, beneficence, justice, paternalism]
should govern this case?
7. What strategies would you implement to bring this case to a resolution
which maximizes the well-being of the patient?
8. How might an ethics consultation
be helpful in resolving the disputes in this case?