ETHICS AND END OF LIFE CARE Rashida Shenaille Andrew Mr. Miller is a 60 year old African American Nursing home patient. Diagnosed with colon cancer. CASE SUMMARY “MISTRUST, RACISM, AND END- Oncologist withholds chemotherapy due to functional status. Family resists constructing advance directive. OF-LIFE TREATMENT” BY: ERIC L. KRAKAUER AND ROBERT D. TRUOG Mr. Miller presents to the E.R. with pneumonia, bed sores, and a bladder infection. Although, no advance directive the ER staff decided to withhold treatment from Mr. Miller citing its futility. The oncologist takes control of Mr. Miller’s care and respects the wishes of Mr. Miller’s son in giving him treatment. ETHICS OF JUSTICE · There are multiple issues surrounding this case: ETHICAL ISSUES · 1. Racism · 2. Medical Mistrust · 3. Denial of Dignity · 4. Socioeconomic status Was Dr. Schuler's refusal to respect the son's request for life support justifiable? ETHICAL QUESTIONS Was Dr. Bonhom's concern about the issue of mistrust an appropriate con- sideration in his treatment decision. To what extent can racism and other societal injustices be addressed in the care of individuals? JOHN STUART MILL’S DIGNITY VS UTILITARIANISM · “All systems of morals agree in prescribing to do that, and only that, which accords with self-respect. it. In the best, with the sympathy of those they respect and a just regard for the good of all” (Mills, 1854 Diary Entry) · In this sense Mr. Miller was robbed of his dignity and his family by proxy. · In essence the ER doctors acted in an unethical way by denying the self respect and dignity of Mr. Miller. They did not respect his dignity to change the course of his treatment. · Similar to Rawl’s Veil of Ignorance. The doctors should have dispensed the care with the idea that they themselves or someone they know may one day be in that situation. · Utilitarianist perspective supports the actions of the doctors in that withholding care reserves medical resources which may provide wider benefit within society. What works to service the majority is just. “The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so, because it will make him happier, because, in the opinions of others, to do so would be wise, or even right” (Mills, 1863) MILLS & THE RIGHT TO A DNR Central Question: If dignity can be used to establish a right to refuse medical treatment for the individual, why can’t the same principle be used to establish a right to receive medical treatment? ETHICS OF CARE Why didn’t Dr. Bonhom ask for the family’s reasoning for refusing to prepare an advance directive initially? ETHICAL QUESTIONS Why did the emergency room resident and Dr. Schuler discuss Mr. Miller's treatment in front of the family? Why didn’t Dr. Schuler answer Mr. Miller’s son questions concerning his father’s condition and the purpose of the machinery in the emergency room? Hammington’s Social Readiness · · · Empathetic Ideation Example from Text: Dr. Bonhom recommended to not provide the patient with extensive treatment after diagnosing him with metastatic colon cancer. Dr. Bonhom told the patient's family who “appeared” to agree with the treatment and disagreed with preparing an advance directive each time Dr. Bonhom brought up the topic. Willingness to learn Example from Text: Dr. Bonhom learned of Mr. Miller’s family’s mistrust in the medical care system, which is why the family did not want to consider advance directive initially. Willingness to take action Example from Text: Dr. Bonhom moved forward with the son’s request to begin aggressive life support despite the emergency resident and Dr. Schuler’s recommendation not to “intubate, conduct CPR, and transfer Mr. Miller to ICU”. “However, when someone takes the time and effort to learn more about someone and actively listen to their circumstances, opportunities for deeper care may emerge. That depth of care is correlated to the time and amount of effort devoted to learning about the other. Such efforts are choices that individuals can decide to make.”(Hammington, 2017, p. 241) Ethics of Care Recommendation The hospital should create a program that designates representatives to each family after the first diagnoses. The representative will explain medical treatments and medical terms to the families who are in similar situations. This representative can serve as the liaison between the family and the doctors/medical staff. ETHICS OF CRITIQUE Shapiro & Stefkovich (2016) “Ethics of critique at its heart is based on critical theory which seeks to analyze social class and it’s inequities.” DuBois (1919) “How may we justly distribute the world's’ goods to satisfy the necessary wants of the mass of men?” Freire (Ghosh, 2019) “Creating opportunities for oppressed people to have agency and voice, reflecting on their experiences and realities of exploitation is a means of liberation.” Nuridden, et. al (2020) · · “The history of medicine and health care in the USA is marked by racial injustice and myriad forms of violence.” This includes: equal access to healthcare, segregation of medical facilities, exclusion of African Americans from medical education, use of bodies of color as “anatomical material” These are all forms of structural violence which seeks to explain how the organization of a society puts certain individuals and populations in harm's way. Was structural violence upheld by the actors with power in this case? ETHICAL QUESTIONS Was medical care given justly and satisfactorily? Were the voices of the actors with less power/agency elevated? “Creating opportunities for oppressed people to have agency and voice, reflecting on their experiences and realities of exploitation is a means of liberation.” (Ghosh, 2019) Ethics of Critique Recommendations Hunt for & gather data on patterns of discriminatory practices noticed by hospital staff and patients of color Implement a new policy in the emergency room – All patients requiring end of life care conversations are presented with an option to meet in a private meeting room or schedule an appointment for a longer, more focused conversation Hospital training of scenarios where when the medical opinion of a doctor and the wishes of a patient conflict, nuances of marginalization must be elevated and added to the doctor-patient discourse (With patient volunteers sharing their stories of effective discussions) Thank You! · Du Bois, W.E.B. (1919). Of Work and Wealth. Darkwater: Voices from within the Veil. (pp. 27-29). New York. · Ghosh, R. (2019). Juxtaposing the Educational Ideas of Gandhi and Freire. (pp.275-282).Hoboken, NJ: John Wiley & Sons. · ]Hamington, M. (2017). Social readiness: Care ethics and Migration. In S. W. Bender & W. F. Arrocha (Eds.), Compassionate Migration and Regional Policy in the Americas (pp. 237– 252). https://doi.org/10.1057/978-1-137-55074-3 · Nuriddin, A., Mooney, G., & White, A. I. (2020). Reckoning with histories of medical racism and violence in the USA. The Lancet, 396(10256), 949–951. https://doi.org/10.1016/s0140-6736(20)32032-8 · Shapiro, J. P., & Stefkovich, J. A. (2016). Ethical leadership and decision making in education: Applying theoretical perspectives to complex dilemmas. New York: Routledge.
