Ethics:Treating a Patient for the Benefit of Others (1)
A decision by a physician about any medical treatment of a patient should be based on a risk vs benefit assessment. The possible risks and chance of risk may be fully or just partially known. The benefit can be a known patho-physiologic benefit (directly affecting the underlying disease) or it may include a quality of life or life goals or values consideration that is usually poorly known by the physician but best determined by the patient. When the patient is unconscious and/or does not have the mental capacity to inform or decide, then the physician will look to a surrogate. But the physician must make some degree of assessment before the medical treatment is offered or carried out.
How does one look at a clinical scenario where there is no direct benefit of treatment to the patient? And what if, in addition, there are physical or emotional risks? Why would a patient be treated without benefit? Well, one answer would be that the treatment of the patient was primarily to benefit others. One example in which the act doesn’t involve a drug or medical procedure would be the isolation of a communicable disease patient so that others would not be exposed to the disease. Another might be the current consideration regarding isolation of known pedophiles beyond the period of punishment again for safety concern for others.
Beyond these custodial treatments, there are medical pharmacologic or medical procedural treatments which occur which again do not medically benefit the patient but primarily benefits others. Treating those who have committed sexual crimes by castration or hormone injections in an attempt to protect others might be an example. Another which has been carried out in the past was the castration or tubal ligation of a mentally defective female to prevent her from becoming pregnant. Some of the sedation or tranquilization of Alzheimer’s patients might be prescribed by physician primarily to try to make the patient easier to manage by the caregiver and perhaps ease the emotional burden suffered by the caregiver. In this example one might argue that this patient therapy may be beneficial to the patient by hoping to prevent injury but also it might not.
A good example of the kind of treatment which occurs in medical practice which one can wonder about the ethics and the medical propriety is that of administering increasing doses of a narcotic such as IV morphine to a patient who is nearing the end of life from a serious illness such as strokes or cancer and who is already unconscious and clinically not in pain or in discomfort in order to satisfy the concerns of the bedside family. In terminally ill patients, occasional respiratory or muscular behavior can occur which will frighten the observing family members but clinically does not represent a comfort issue for the unconscious patient. If further morphine is administered, for example, the respiratory rate may be slowed to the point where respiration stops and the patient will die as a consequence of the administration. If the patient had been conscious or stuperous and was in frank discomfort, then the benefit of treating such a terminal patient with morphine would be medically and ethically appropriate despite the risk of death from the drug. Ethical support for this conclusion would come on the basis of the “double effect” principle.
The principle balances the good effect of the act (benefit) against the bad effect (risk). For an act to be ethical it must meet all 5 parts of the principle: 1) The act must be good or morally neutral, 2) Only the good effect is intended, 3) The good effect is not achieved through the bad effect, 4) There is no alternative way to achieve the good effect and 5) There is a proportionally good reason for running the risk. The question becomes is it ethical for an unconscious patient who clinically appears comfortable and in no distress be treated with a narcotic to further depress the patient’s nervous system to try to prevent a behavior which is unsettling only for the unsophisticated family watching and to provide them comfort while at the same time possibly risking and causing the premature death of the patient? More on this issue in a later posting. ..Maurice.
posted by Maurice Bernstein, M.D. @ 5:18:00 PM
4 comments
4 Comments:
It is interesting to me that in this article on treatment of a patient for the benefit of others, that no mention is made of the practice of maternity care in the U.S., which annually affects more than 4 million women. With all the technological bells and whistles quite literally in place in U.S. hospitals to "manage" the labor and deliver "process" which has successfully been marketed as a medical procedure rather than a natural function of the human body, we as American women are expected,as a matter of course, to submit to many procedures and protocals which do not have any health benefit to us and are scientifically shown to pose considerable threats to us and our children.
The benefit of these systematic practices clearly lies with the physicians and the hospital staff in meeting their time constraints conveniently and for drawing the most revenue out of the insurance companies as is possible. Doctors are most often seeing prenatal care patients at the same time as their term patients are giving birth, thereby requiring speedy deliveries so that they can be free to return to the clinic. Procedures to augment labor such as induction and amniotomies are meant to "get this show on the road" as was stated in one of my personal experiences with hospital maternity care. It is so common place that no thought is given to adverse effects by the average woman who has been indoctrinated to see the OB/Gyn as her deliverer from a condition which she surely cannot alleviate or be relieved of on her own. Another, more concerning practice is that of immediate cord clamping, which in nature is instinctively unheard of,and now is being linked to the cause of anemia, which in turn necessitates the need for blood transfusions ,asphyxia, which causes brain lesions as seen in autistic children, as well as the marked rise in all forms of brain function depletion from dyslexia to ADHD cases. These are of no apparent consequence to the attending OB for the simple fact that what kept him or her on time for their afternoon golf game does not show up as a significant birth trauma until the child begins school. How is it ethical to require a woman to leave her most natural environment , take away all of her sensation of labor through administration of drugs, place her legs in stirrups for the doctor's view, tell her when she is to push, deprive her baby of much needed blood and oxygen , not to mention the immediate nurturing , coaxing , attention of it's own mother, and subject both mother and child to an onslaught of hurried postpartum and postnatal confusion. This is such a violation of "human dignity" and respect that it is particularly fascinating to consider how I, myself, and millions more like me have been completely duped.
Now, as to the economic factors at work here, maternity patients represent a quarter of inpatient services in U.S. hospitals, clearly a very lucrative market, and also a very pleasant means by which hospitals can advertise their facilities, thereby, increasing the likelihood of repeat business when there is a real medical condition. So many procedures are carried out as standard practice that are often the cause for further intervention. Of course, no one is going to educate the patient concerning these issues before they arise. That would eliminate the need for many cesarean sections and NICU stays which can quadruple the fees charged to the insurance companies which pays for the anesthesiologist, neonatologist, and all of that state-of-the-art equipment necessary to carrying out that,aforementioned, extravagant advertising campaign.
All of this and much, much more contribute to a substandard care in America that is responsible for a less than stellar infant mortality record of about 23rd, I believe, in the world , among developed nations. Those that rank on top in that area have maternity care protocals that routinely leave well enough alone in dealing with normal healthy low-risk pregnancy, which constitutes the greater majority of upwards of 90% of the population. They have access to midwives who teach that diet is a fundamental factor in creating a positive outcome in pregnancy, that women are designed to give birth, that it is no more a pathology than are our other bodily functions under ordinary circumstances, and that we have physiological processes built into the system that automatically transfer both systems of mother and child from the symbiotic state to independence if left alone.Since midwifery has been so marginalized in the U.S., it seems like a diabolical situation that is persisting to benefit the greedy and to place our children in a most vulnerable position within the very first seconds of life. It flies completely in the face of good science, knowing that the medical community is aware of the detriment caused by its practices, but just as the government would have the general public believe that it has our best interest at heart, so are we , the ignorant masses , asked to just trust the authority figures and all that they do.
It has been my experience also that the more informed I become and the more my decisions reflect my actual "informed consent" the more apparent it becomes that I really must " comply with the recommendations if I want to have my baby here" as was told to me by two different OBs in my current pregnancy. I was also told that I had no right to refuse routine tests even though I could show completely reasonable evidence for my position.
So, in conclusion to this extensive comment that is so near and dear to me, I will state that I have been given but two choices. I can have access to immediate emergency facilities if I will submit to the treatment prescribed by a physician that has her own interests at the heart of my "care" or be denied that immediate access and take back my sovreignty over my body and my child by leaving the institutional situation altogether. I truly believe the second option is safer than the first and so am willing to take the matter into my own hands. I hope that this raises some eyebrows in the obstetrical community because I am not the first nor the last to take this stand on this basic life event and each of us who have come to this conclusion are speaking out to anyone who will listen about the need for choices in this country. It is ludicrous that such a fundamental human event is seen as a potential pathology across the board and that they that see it as natural are being conditioned to fear it and are treated as if they were neglectful child-abusers if they do not.
Alabama Mama, all your pointe are well taken. Unfortunately for the patient, there is much treating of the patient for the benefit of others and that includes the physician and the function and ?financing of institutional systems. These unprofessional and unethical behaviors should be recognized and broadcast as you have attempted in your commentary. Thanks. ..Maurice.
Dr Maurice B
I fell across your bioethics blog as I was looking for an answer to my question. I'd really like to know what you think after reading your blog "Ethics:Treating a Patient for the Benefit of Others..." very thought provoking I have printed it to share with my colleges at work.
I am a RN working in the Palliative field now for a long while and my question is: Can an unconscious and/or medicated patient feel respiratory distress ?
This question arises for an order left by one of our doctor as follows:
Scopolamine 0.4mgs s/c q 4-6 hrs prn for resp distress.
I felt unsure re this order because clinically the patient had received previously a dose of Scop for highly audible congestion and distress and appears relaxed, flask : no muscle resistance. Facial expressions calm and devoid of any pains or discomforts. Hence no outward signs of "felt" distress... However audible congestion persists.
I left a note for the doctor the next morning asking "If patient is congested +++ but no distress don't give scopolamine?"
She wrote back "unconscious + secretions/congestion = respiratory distress"
Is this a case of is the glass half empty or half full? Is distress in the eye of the beholder?
Lloyd RN
Lloyd RN, when a patient is unconscious and "relaxed, flask : no muscle resistance. Facial expressions calm and devoid of any pains or discomforts. Hence no outward signs of 'felt' distress" then the conclusion that the patient is in distress is in clinical error since really the true distress is simply in the emotions of the beholder. To treat the patient to reduce this emotional distress of the healthcare provider would be appropriate if that is the goal of patient-oriented healthcare. Yes, there should be attention to the mental health of healthcare providers but administering a drug to the patient is not an ethical nor even a necessary way of doing that.
Now, the situation would be different if the doctor wrote the scop order based on the attempt to resolve a pathophysiologic process which if left untreated could lead to patient distress. Such an order in your case would read "Scopolamine 0.4mgs s/c q 4-6 hrs prn for demonstrated rales, ronchi or tracheal abnormal sounds." If these conditions were met, then the treatment would be for the patient and not the nursing or physician staff. ..Maurice.
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