Who is not worthy?
This being the start of a brand new year, I’ve decided to cease sounding like a broken record by taking a sabbatical from my past rants and raves on medical professionalism as the foundation of all ethical practice. Instead, I’m going to dust off my anthology of medical case studies, select some of the juiciest stories, and offer you all the opportunity to explore the "best” ethical resolution. Hopefully, my commentary will seed further discussion with friends, family, and colleagues; after all, there is nothing like a medical dilemma to spice up the conversation at a cocktail party.
Considering current news on healthcare policy changes around the world, I think it only fitting that we start with a classic case involving the ethical dilemmas that arise when patients must compete for limited resources:
Case-Study: Sue and Anthony are patients in the same medical center. Sue is a 48 year-old developmentally challenged woman who is recovering from a heart attack. She lives in a state mental health institution, without any family contact. The heart attack left her semi-paralyzed and incontinent. Anthony is a 55 year old married college professor with two teenaged children. Anthony is recovering from a stroke, and his prognosis is good. The hospital has a single crash cart and only one cardiac arrest team on duty and, as luck would have it, both Sue and Anthony have simultaneous cardiac arrests. Which patient, Sue or Anthony should the cardiac team resuscitate?
The knee-jerk reaction is to take a simple utilitarian approach to defend the decision to resuscitate Anthony, thereby serving the greater good by selecting the patient who scores highest in the "social worth” scale. Above meeting minimal medical indications for success, one patient will always be more suitable or "worthy” than another. Should patient competence, compliance, family status, capacity to contribute to society, and overall worthiness ratings influence an ethical answer to the question "Who should we let die?” If the decision were based on "social worth,” the patient whose life has lesser value to others (spouse, children, employer, friends and countrymen) would be excluded from treatment. One problem with decisions that are based on the patient’s value to others is that all too often, clinics, hospitals, and even doctors put themselves at the top of the patient’s list of valuable relationships, using a "FIRST PAID - FIRST SERVED” rule to justify patient selection. Personal bias inevitably enters into the equation. A fair and impartial appraisal of worthiness might take weeks (if such an appraisal can ever done), and the cardiac team stands the chance of losing both patients if it doesn’t respond quickly.
So, seeking to expedite the decision-making process, the cardiac team may rely on protocol – i.e., standards of quality care established through research and outcomes measurements. Statistical data can be used to support a decision; but one can’t help but wonder about the rights of the underdog. The temptation is to flip-flop from a utilitarian to a deontological approach, considering Sue’s right to live equal to Anthony’s; because if you were Sue, you would want to live; wouldn’t you? Most of us recognize equal access to emergency care as a fundamental human right. At the same time, bioethics is continually shaped by social, cultural and economical factors. The cardiac team’s decision defies a simple Kantian approach unless they can boil it all down to a single universal convention - such as, "FIRST COME – FIRST SERVED." If Sue is first in line, then, as long as she or her surrogate made no clear expression that life-saving care should be withheld, the morally "neutral” approach would be for the cardiac response team to select Sue. Recommendations have been made by the US Department of Health and Human Services to support the use of the FIRST COME – FIRST SERVED rule to help counter biased allocation of health resources. For example, the median transplantation waiting time for blacks is twice as long as whites (DHHS, 1998).
When facing a difficult medical decision, characterized by bias that is NOT related to the patient’s prognosis, then the most ethical approach may be to use the FIRST COME rule in order to neutralize unfair bias and promote equal access to limited health resources. But, when the disparity between patient prognoses is great, the FIRST COME rule may not be the best strategy to insure ethical distribution of limited resources. In such cases, bias (i.e., non-neutral judgments about "best” outcomes) is not only unavoidable, it is truly required for ethical decision-making. Or, as one my students put it, "In this case I don’t think it is ethical to use the FIRST COME – FIRST SERVED rule because the cardiac team has an ethical duty to provide limited resources to the patient who will get the most use and benefit: the youngest, the healthiest, the most robust.” Personal and professional biases will most likely influence the cardiac team’s assessment of which patient will receive greater benefit by being resuscitated. After all, biases are ways of expressing personal and professional values. The problem is that personal as well as professional values require periodic review and reformation.
Instead of taking a purely utilitarian or deontological approach, I want to focus on a single principle that weighs heavily into the decision between Sue and Anthony: respect for human dignity. History is filled with repeated attempts to reduce the value of individual dignity on behalf of the greater good or "social worth” (such as: Nazi experiments at Auschwitz; Unit 731 vivisection of Chinese and Korean prisoners; the Tuskegee syphilis study; South African research to remove homosexuality, Willowbrook experiments on mentally retarded children). There is no need for utilitarian, deontological or other theoretical elaborations to point out the difference between right and wrong in these cases.
The current case study deals with a choice that must be made between two patients. The decision raises universal questions about how we establish medical criteria, define quality of life, and deal with personal biases; more importantly, it raises questions about how we demonstrate respect for human dignity. Rather than lay claim to any "absolute" decision in this case, we are challenged as health professionals to demonstrate respect for human dignity. One way health professionals demonstrate respect is by offering hope: it all boils down to a social contract that guarantees health professionals are worthy of your trust. It certainly gives a whole new serious meaning to the bumper sticker I flaunted on my Alfa Romeo back in the 1980s, "Trust me, I’m a doctor.”
Respect for patient dignity doesn’t begin with the cardiac team’s decision; it starts when the patient first enters our care. Patient dignity is perpetually reinforced by every care provider, technician and ward clerk in a concerted effort to build faith - faith in care providers, faith in treatment. Faith requires hope, and hope is certainly not on the list of limited resources. Yet, medicine often overlooks its healing power. In Anatomy of an Illness, Norman Cousins describes how hope influenced his own recovery from a crippling disease saying; "I learned never to underestimate the capacity of the human mind and body to regenerate, even when the prospects seem most wretched.”
An automaton can dispense medication or respond to a code; people in the healing professions inspire hope: hope for patients who are deemed worthy simply out of respect for human dignity. Worthiness is expressed as an inherent property of humankind, not something that can be measured by the patient’s history or physical or rating of "social worth.” Each of us needs to feel worthy, and when we see the underdog uplifted we figure a good deed was done on behalf of all of us. Considering both patients met minimal indications for success, whether the cardiac team resuscitated Sue or Anthony is secondary to the goal of the entire hospital staff to keep patient dignity alive.
DHHS (1998). Testimony on organ donation by Mark R. Yessian, Ph.D. Assistant Secretary for Legislation (ASL). Retrieved from http://www.hhs.gov/asl/testify/t980408b.html
Holub P. Who is not worthy?. The Internet Journal of Allied Health Sciences and Practice. 2011 Jan 01;9(1), Article 3.