Treating the Patient Simply for the Benefit of the Family: Is that Ethical?
It is not unusual these days for family members to insist that the healthcare providers perform tests and prescribe treatments that may be inappropriate or medically futile but for which the family will feel more comfortable that “everything was done” to improve or preserve the life of their ill loved one. This type of family behavior, if their requests are followed, despite the action may be inappropriate for the patient’s condition or futile, is said to contribute to the unnecessary increased costs of medical care, particularly in end-stage illnesses. And following the requests ends up only benefiting the psychologic uncertainties and anxieties of the family but providing no benefit or occasionally even unnecessary risk or harm to the patient.
Yet, one could also say that physicians should not just be treating the patient but, in fact, are also treating the family and those around the patient who have great emotional and perhaps other interests with the patient. But is this global responsibility really what patient care is all about? Isn’t the responsibility of the bedside physician only for the patient? Well, no. One could argue that physicians do have responsibilities to society and to the community particularly if one considers communicable diseases, hazards to others or (and this might be controversial outside of some disaster) consideration regarding the allocation of scarce resources. Should the physician also have responsibilities to a narrower domain such as the patient’s family? Is there a point, perhaps in the terminally ill and dying patient, where benefit to the family will trump any possible harm or benefit for the patient? And should that attempt to benefit the family be carried out by the physician?
I have tried to put an example of this issue in the form of a scenario and my challenge to my visitors is to answer the question: What is the ethical and most appropriate yet beneficent way the physician in this scenario should respond to the family’s request?
The hospitalized patient is elderly and is in the process of dying from an incurable illness. The patient is now comatose, unresponsive and clearly in no distress. An order has been written by the physician for an intravenous morphine drip administered on a regular basis to keep the patient comfortable. The family, sitting at the bedside, observes a respiratory irregularity that concerns them that the patient is uncomfortable. They request that the nurse provide the patient with additional morphine to what has already been administered. The nurse who has been following and observing the patient finds nothing in the patient’s respiration or responses to warrant additional morphine. She tries to explain to the family the basis of her conclusion. The family disagrees.
The nurse is concerned that to administer the morphine now would not be appropriate care for the patient but would risk that the patient would die prematurely from the morphine dose. The nurse is concerned that she might be causing the patient’s death not for the comfort benefit of the patient but simply for the comfort of the family sitting at the bedside.
The nurse refuses to administer additional morphine and the family calls the doctor.
If you were the doctor receiving the call how would you respond? Again the question “Is it ethical for a physician to treat a patient simply for the benefit of the family?” ..Maurice.
Graphic: Drawing from Washington Irving Rip Van Winkle (Philadelphia: Henry Altemus Company , 1900) 149 modified by me using ArtRage3.