Ethical decision by committee
The following case study is revised from Steinbock, Marquis, & Kayata (1989)1
Ms. W is a nineteen-year-old unmarried woman pregnant for the third time, having previously had an abortion when fifteen, and a daughter now ten months old. She was admitted to the hospital in the twenty-sixth of gestation and placed on intravenous medications (magnesium sulfate) to stop her preterm labor. Two days later, Ms. W asked her physician, Dr. C, to discontinue the medications because she was "tired of being in the hospital and the medications and the fetus were too painful and uncomfortable."
Dr. C explained that the potential risks of premature delivery include: respiratory immaturity, intra ventricular hemorrhage, neurologic handicaps, and even fetal death. He advised her to continue the medications for two to three more weeks to give the fetus more time to mature. These critical weeks would enhance the fetus's chances of survival (from 50 percent at twenty-six weeks' gestation to 90 percent at thirty week's gestation) and decrease morbidity, reducing the risk of chronic lung disease (from 50 percent at twenty-six weeks to 20 percent at thirty weeks' gestation) and neurologic handicaps later on in life.
Ms. W continued to refuse treatment, and a psychiatry consult was obtained. Ms. W was found to be extremely immature, emotionally labile and unrealistic, to have a very poor social situation (battered by family members), to have sometimes had suicidal ideas, to have used illegal drugs in the past (but not recently) and to have a longstanding personality disorder (histrionic personality). Meanwhile she continued to refuse the medication to stop labor and threatened to leave the hospital.
What should Dr. C do?
- Respect Ms. W's wishes and risk delivering a very premature fetus who may expire or may survive and be handicapped secondary to prematurity and its complications.
- Refuse to abide by her wishes, but transfer care to a physician who is willing to do so.
- Refuse to abide by her wishes and try to obtain a court order to force Ms. W to undergo treatment.
Whatever your choice, option #1, #2, or #3, the major challenge is to justify that decision on ethical grounds; i.e., one that is based on common principles of beneficence, nonmaleficence, common good, distributive justice, respect for human dignity and autonomy. In the medical dilemma facing Dr. C, principles of beneficence/nonmaleficence come into conflict with respect for patient autonomy, and the ethical solution must weigh benefits and consequences to arrive at an objective analysis.
For example, one may justify choosing option #3, refuse to abide by Ms. W’s wishes and obtain a court order, as the best decision based on weighing the facts, e.g., Jonsen’s 4-topic method of ethical analysis can be used to identify the facts relevant to medical indications, patient preferences, quality of life and contextual features.2 The 4-topic method provides "objectivity,” with an ethical decision that is based upon a lengthy and objective review of the patient’s diagnosis, prognosis, mental capacity, finances, and cultural and religious beliefs, as well as concern for public health and safety, institutional policies, and legal parameters – far too much information for Dr. C or any other single human to fathom. That is why we assemble ethics committees – in order to combine notes and pool information. Until someone develops a Watson for bioethics, the ethics committee provides the most objective analysis possible. (Watson is the supercomputer that crushed all opponents on the television game-show Jeopardy).
Weighing the objective facts and features from a variety of perspectives, an ethics committee might find that the third option, to seek a court order, is the best decision, as long as Dr. C does not use the threat of seeking a court order to coerce Ms. W to comply. One member of the ethics committee may suggest counseling to help educate Ms. W about the dangers to her and her fetus' health if she disagrees with medical advice. Another member of he ethics committee may stress the importance for Dr. C to "listen" to his patient and find out why she is unhappy in the hospital. All members of the committee might agree that it is important to reassure Ms. W that she has the right to make the final decision, while reminding her of the obligation she has to refrain from harming the child (an attorney on the ethics committee might warn all members that there are cases where children have sued parents for neglect and harmful prenatal conduct).
The collaborative approach taken in the ethics committee’s recommendation for Dr. C is "objective” only in the fact that it didn’t include Ms. W in the committee meetings – or, more practical, someone with the ability to "stand in the patient’s shoes” (like in the movie Freaky Friday, where the mother gains empathy for her daughter after seeing things from her perspective). In the training of doctors and other health professionals, high scores in empathy correlate to high scores in clinical care; and patients are more compliant with empathetic doctors than with detached ones.3
Whereas mechanistic schemes like Jonsen’s 4-topic method is a way to view the patient from the outside-in; standing in the patients’ shoes is a way to see them from the inside-out. There is no 4-part checklist for standing in the patient’s shoes; rather, it is a perspective that is gained from listening to the patient while surrendering the tendency to make any preconceived judgments. This is a skill that makes the ethical practice of medicine more of an art than a science. Along with scientific expertise, the ethical approach requires humanistic skills to better appreciate the ordeals of illness in order to act as the patient’s advocate.
The old adage, "No one ever built a monument to a committee,” shows that committees don’t get the credit they deserve. When a committee demonstrates the ability to "stand in the patient’s shoes” it is able to provide an empathic perspective to their decision. In these instances, the monument that is constructed on their behalf is a living, breathing one – the patient.
- Steinbock, B., Marquis, D. & Kayata.S. (1989). Preterm labor and prenatal harm [Case study and commentaries]. Hastings Center Report, 19(2), 32-34.
- Jonsen, A.R., Siegler, M., & Winslade, W.J. (2010). Clinical ethics (7th ed.). NY, NY: McGraw Hill.
- Hojat, M., Mangione, S., Nasca, T.J., Gonnella, J.S., Magee, M. (2005). Empathy scores in medical school and ratings of empathic behavior in residency training 3 years later. The Journal of Social Psychology, 145(6), 663 – 672.
Holub P. Ethical decision by committee. The Internet Journal of Allied Health Sciences and Practice. 2011 Apr 01;9(2), Article 2.