- Muhammad Younas
Healthcare professionals often confront situations of ambiguity and uncertainty regarding patient’s treatment. Ethical issues arise when there is violation of ethical principles by the health care providers, more specifically when the patient and family leave the decision on physicians considering them dominant and body of knowledge. These issues also arise when physician takes decision based some personal interest and which is partially or not at all in favor of patient. In this paper I am going to comment on the malpractice which is defined as the form of negligence where by any professional misconduct, unreasonable lack of professional skills or the care provided not meet the standards and causes harm to the patient (Burkhardt & Nathaniel, 2008).
A 25 years old male patient diagnosed with subarachnoid hemorrhage after road traffic accident was kept on ventilator in intensive care unit (ICU). Patient attendants were relying for any decision on health professionals. The family was well established and was able to pay any cost to save their patient. Patient was progressing towards brain death and attendants were not informed about the situation. Patient remained on ventilator for the next seven days and then declared dead. Nurses failed to intervene as they were afraid of job insecurity. The doctor misused his authority and forced nurses to just follow the orders. The doctor was aware about patient’s condition, but kept the patient on vent to generate revenue.
In this scenario the doctor was aware about the subarachnoid hemorrhage and its poor prognosis as it was a traumatic brain injury leading towards brain death. Bullock et al. (2006) have classified subarachnoid hemorrhage as severe traumatic brain injury with twofold mortality rate and very poor prognosis. Despite the poor prognosis and no chances of survival of the patient the doctor kept the patient on ventilator because of his own, as well as institutional interest. The doctor kept the family unaware of this information and took decision based on his own interest as the family was well-off and was totally relying on the doctor for any action to be taken. Moreover, dignity of a human being was violated by keeping on prolong mechanical ventilation with brain death. Furthermore, the ICU bed and the ventilator could have been used for another critically ill patient as this was a case of brain death.
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Analysis of the ethical issue: Baskett, Steen and Bossaert (2005) have mentioned that the four ethical principles that are Autonomy, beneficence, non-maleficence and justice are crucial in making decision at the end of life care. In this particular scenario the four ethical principles have been violated as consequences of the malpractice that is keeping the family unaware of the patient situation and prognosis.
The term autonomy literally means “self-governance” (Burkhardt & Nathaniel, 2008, p. 54). As the patient was on ventilator, in this case the surrogate decision maker will be one of the family members. It is the doctor’s obligation to inform the family about the prognosis and chances of survival and also explain them the code options and then let them autonomously decide on behalf of the patient. By not informing the family and not involving them actively in the decision about code status of the patient, the healthcare provider violated the family autonomy and misused paternalistic approach. The principle of beneficence refers to an act for the benefit of others (Beauchamp & Childress, 2001). In particular to this scenario the specific beneficence has been violated as keeping the patient on ventilator with brain death is of no use for patient but only a false hope for family and financial burden. The element of veracity has been violated by not telling truth to the family about the patient’s condition and prognosis. One of the consequences of the malpractice by the doctor is violation of justice. The doctor was not fair in proper allocation of resources the ventilator and ICU bed could have been used for another critically ill patient which were occupied by this patient with brain death.
Ethical issue of interest and my position
Then main issues in this scenario are the decision taken by the physician based on his own interest and then keeping the family unaware of the whole situation and consequently the general ethical principles have violated through malpractice. My stance in this situation is that Parents are legitimate decision makers and must be involve in making decision on behalf of their children.
Autonomy of the legitimate decision makers has been violated. Emanuel and Emanuel (1992) suggested a four models approach based namely, (i) paternalistic model, (ii) the informative model, (iii) the interpretive model and, (iv) the deliberative model. Firstly, paternalistic model, the physician has adopted paternalistic approach but did not make sure that whether the interventions best promote health and wellbeing. Secondly, in the objective of the informative model, the physician did not provide legitimate decision makers with all the relevant information about the disease prognosis, the risk and benefits of the available interventions, but just decided on his own. Thirdly, in the interpretive model the physician did not elucidate the parent’s values about selection of the available interventions which realizes their values. Lastly, the deliberative model, the physician did not assist the parents to choose and decide for the patient the best health related values. All of the four models are focused on patient autonomy and stressed that autonomy of the patient should be taken care in any circumstances.
Malpractice by the physician reflects that he did not show adherence to his oath and accountability in taking decision for patient. It is the duty of the physician to bear in mind the preserving of human life and should owe his complete loyalty and resources of his knowledge for the patient (Pakistan medical and dental council, 2006). Furthermore, there was misuse of paternalistic approach by the doctor. Burkhardt and Nathaniel (2008) suggests that though based on beneficence, decisions taken are centered to patient wellbeing, however, the inherent supremacy in such a hierarchical arrangement may be abused and the decision taken may reflect the self-interest of the healthcare professional more than care for the patient (p. 270).
In addition there was violation of social justice by the physician in the allocation of resources and budget for other deserving candidates. After the brain death the physician new that further treatment is futile and of no benefit for the patient yet he ordered to continue the treatment. The ICU bed and ventilator could have been used for other deserving candidates. If a patient is dead and still on ventilator in this case the cessation of treatment will not provide harm (Beauchamp & Childress, 2001). It clearly indicates that the doctor kept the patient after brain death longer for own and hospital interest.
Ethics of care
In the light of ethics of care being a nurse the nurse personally feels that that the patient was on ventilator and was in a vulnerable state and though he failed to intervene but what possible he could have done? The theory of ethics defined by Tronto (1993) as cited in Lachman (2012), there is a pre-existing moral relationship between people and he further stated that there are four phases in patient care that are (i) caring about, (ii) taking care of, (iii) care giving and (iv) care receiving. In “caring about” phase the nurse noticed that the physician violated the legitimate decision makers’ autonomy by not involving them in decision making. In the phase “taking care of” he realized that he could have taken the responsibility and empathize what the parents were experiencing. Therefore in the “care giving” phase he could have advocate for the patient and family that they must know about the patient’s prognosis and thus take their own decision. Finally in the “care receiving” phase then he could have got the success of the interventions done in the previous three phases.
Though the survival rate was low but there was still hope and the physician just wanted to give chance to this young blood and was hopeful that there might be a small chance. Occasionally miraculous recoveries from comas are reported widely (Swinburn, Ali, Banerjee and Khan, 1999). As the family was very anxious and the patient’s father was a cardiac patient, in this situation the doctor did not want to inform the family promptly. (Literature support with statistics) (We should not give up).
The family gave the rights to the physician to decide for the patient, so he claims that he was just doing for the benefit of the patient. Moreover, the doctor did not misinform the family but just kept them unaware of the situation because he thought that telling the truth may increase their anxiety level. The physician may support him through Mill’s autonomy which talks about the obligation to persuade others when they have false or views (Beauchamp & Childress, 2001).
Justification of my Position
Even if the doctor was right in his position he still should have not taken the decision by himself. The decision to withhold or with draw is made by the physician in consultation with family members (Burkhardt ansd Nathaniel, 2008). Moreover, burden of the treatment outweigh the benefits. The reasons for continuing the futile treatment are primarily based on physician emotions, guilt, concerns about family and fear of legal consequences (Jox, Schaider, Marckmann & Borasio, 2012).
How the scenario could have changed
The family should have informed about the patient situation, prognosis, possible interventions along with risk benefit ratio. Thus the physician would have remained loyal to his oath and obligation by not providing false assurance to the family, and also the family was to suppose face the grief anyway. After the brain death the patient should have weaned off form ventilator and by announcement of death the dead body should have processed with dignity. Thus there would have less financial burden on the family and also justice have maintained by providing chance to other critically ill patients.
There should be a clear policy at institutional level regarding patients with brain death. Moreover, health care provider should show adherence to the implementation of such policy. The nurse as an advocator should advocate on patient’s behalf and also involve hospital ethical committee. It should be responsibility of the hospital ethics committee to investigate such cases and consider further necessary action accordingly. Patient and family education is an utmost duty of healthcare professionals, specifically physician should involve family in the decision making process.
Being health care professionals we face ethical issues in patient care and treatment more often, when we are dealing with critically ill patients when they are at their most vulnerable. The situation of uncertainty and ambiguity is always there, but health care professional should be more accountable and sensible and should take decisions that are ethically and legally sound and should meet the patient and family values.
Beauchamp, T. L., & Childress, J. F. (2001). Principles of biomedical ethics. (5th ed.). New York: Oxford University Press.
Burkhardt, M. &Nathaniel, A. (2008). Ethics and Issues in Contemporary Nursing (3rd ed.) Australia: Delmar.
Bullock, M. R., Chesnut, R., Ghajar, J., Gordon, D., Hartl, R., Newell, D. W., … & Wilberger, J. (2006). Surgical management of traumatic parenchymal lesions. Neurosurgery, 58(3), S2-7-S2-62. doi: 10.1227/01.NEU.0000210363.91172.A8
Emanuel, E. J., & Emanuel, L. L. (1992). Four models of the physician-patient relationship. Journal of the American Medical Association, 267(16), 2221-2226.
Jox, R. J., Schaider, A., Marckmann, G., & Borasio, G. D. (2012). Medical futility at the end of life: the perspectives of intensive care and palliative care clinicians. Journal of medical ethics, 38(9), 540-545. doi: 10.1136/medethics-2011-100479
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Swinburn, J. M., Ali, S. M., Banerjee, D. J., Khan, Z. P., Cranford, R. E., & Jennett, B. (1999). Discontinuation of ventilation after brain stem death. British Medical Journal, 318, 1753- 55.
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