Decision-making is a vital engagement within all organizational contexts. Decisions, in the medical field, hold more significance given the inherent seriousness of various impacts on the patient’s health and mental wellbeing. The decision-making processes require adequate consideration of both patient autonomy and physician recommendations (Quill 763). The case under review focuses on the moral and ethical aspects of decision-making by a new physician, Dr. B.
Dr. B has counseled that the patient be discontinued from the current medical regimen (current plan of terminal extubation) and instead adopt a new treatment that could possibly enhance his longevity. The medical counsel has grave repercussions since the patient, John, is critically ill with stage IV non-small cell lung cancer, and requires mechanical ventilation for respiratory support. The analysis incorporates a theoretical framework – moral theory and principles of ethics in evaluating the issue of concern – the new physician’s medical counsel. An in-depth moral assessment of the issue delves deeper into the matter, analyzing and rating the moral standing of the new physician’s counsel, in light of the serious repercussions on the patient’s health.
Argument: Patient autonomy and physician involvement in decision making are critical within clinical settings and hence, the new physician’s opinion to incorporate John, who is terminally ill, into a novel clinical trial while discontinuing the current medical regimen, has little moral standing and lacks support by the principles of medical bioethics.
Case Study: Dr. B’s Medical Counsel and Its Moral Standing
Dr. B counsels that the patient (John) to discontinue the current medical regimen (current plan of terminal extubation) and instead adopt a new treatment that could possibly enhance her/his longevity. Dr. T is the medical intensivist in the (ICU) intensive care handing over her patients’ care provision to a fellow intensivist, Dr. B. As Honiden and Jennifer inform, Dr. T takes great care when relaying each patient’s case details, partly gathered from various meeting times with the patients’ family relations, thereby sufficiently augmenting existing patient medical records. John, a 65-year old patient, has state IV non-small cell lung cancer. He was diagnosed half a year earlier, and underwent various rounds of radiation and palliative chemotherapy.
John’s case is unique, as he is considered to be a good candidate for a potential new clinical trial treatment. The treatment, utilizing a novel regimen, has portrayed a number of positive preliminary results. It is in the human-stage trial phase, having quite outstanding effects in dealing with refractory Stage IV disease. As presented, “due to his previously very high level of functioning”, John is a good candidate for the novel clinical trial (Honiden and Jennifer).
However, two weeks prior to beginning trial, John becomes critically ill and is admitted into the ICU, having suffered from acute respiratory distress syndrome (ARDS), besides the septic shock as a result of pneumonia. His critical case requires a highly delicate regimen involving multiple medications that stabilize his high blood pressure. John significantly recovers and is on minimal ventilator settings. However, his case is deteriorating due to the combination of severe deconditioning, inability to be successfully weaned from ventilation, and the prevailing metastatic disease.
Although medically stable, John is incapacitated, and unable to actively participate in decision-making. Dr. T reasons with Lisa, John’s wife, explaining that John has limited chances of attaining meaningful recovery. Dr. B, as the new intensivist, proposes the trial treatment procedure of tracheostomy as a result of the lengthy intubation and the advanced disease. However, Dr. T is against the “against the tracheostomy in favor of transition to hospice care” (Honiden and Jennifer). The agreement reached by John’s family is to put him on terminal extubation – the gradual withdrawal of the vital mechanical ventilation system, as John is unlikely to survive without respiratory support. The favored option is to slowly transition him to hospice care.
Patient Autonomy and Physician Involvement in Decision-making
Patient autonomy is increasingly a major issue of concern within current healthcare systems. Existing complex technology used in healthcare creates situational contexts whereby difficult decisions require both patient and family consent. Tariman, et al. input that physicians are vital participants in the decision-making process. Decision making is a continuous cognitive process focused on reaching a decision through consensus. It often incorporates the balance of both benefits and risks within multiple options, in John’s case: either tracheostomy or transition to hospice care.
Besides, “older patients with cancer often suffer from poor physician-patient communication” (E70). This case scenario can result in poor judgment and understanding of treatment risks and benefits within clinical settings. Furthermore, older patients are affected by distinct gerontological issues like frailty, polypharmacy, and multiple comorbidities; all which further complicate existing decision-making on patient treatment. The case under review is presents a number of ethical and moral concerns that ultimately place the Dr. B’s suggested incorporation of John (terminally ill) into a new clinical trial. From a theoretical perspective, as Furler and Victoria indicate, the medical responses to various health inequities, when “framed within a justice orientation tended to implicitly draw on such a regulated and highly specified vision of clinical care…”
Often there are varied limitations to existing use of care and justice orientations as guides for medical action. The limitations are related to how individuals interpret the four principles of bio-ethics: non-maleficence, patient autonomy, respect for justice, and beneficence. Patient autonomy is a bio-ethical right that promotes individual capacity to overcome various social limits. It frame subsequent medial engagements on the physician’s provision of full information that promotes access to quality clinical care. In the case under review, the ethical concern is incorporating John into a new clinical trial, despite his grave medical condition. This consideration does not take into account the patient autonomy bioethical principle, whereby John’s family have already given consent to the current plan – transition to hospice care.
Moreover, the medical counsel to incorporate John into a clinical trial is also unethical as it does not consider the Beneficence principle of bioethics – providing the best available clinical care to all patients within an empathetic, caring, and compassionate context (Furler and Victoria). Moreover, the consideration does not take into consideration the bio-ethical principle of non-maleficence. According to the principle, doing harm to the patient entails changing current care provision based on the social position of the person, in this case, John’s terminal illness. In terms of theoretical perspective, the Communication model of shared decision-making (SDM) proves quite important.
Tariman, et al. expound that the model “explicitly identifies the communication process as a vehicle for decision making in cancer treatment” and is applied to decision-making in all treatments of patients with cancer (E72). The model puts into perspective the importance of communication in presenting all factors of consideration before proceeding with new treatment regimen (E72). It is an important theoretical framework that is encouraged in John’s case context.
However, Dr. B’s actions are also anchored on the Doctor as agent model where the physician is responsible for providing complete information, eliciting patient preferences, and subsequently making decisions founded on existing patient preferences. More importantly, the conflict theory model of decision-making is useful in understanding the prevailing case context where decisional conflicts often lead to stress and associated coping patterns (Tariman, et al., E72). This framework is quite useful in emergency case contexts, influencing various consequential decision-making procedures.
Case Analysis: Moral Assessment
Decision-making is framed within both ethical and moral value contexts. As Madison K., and Steven engage, the contemporary patient-physician relationship is significantly influenced by the eventual rejection of medical paternalism. Patient autonomy is more favored, whereby the patient is expected to make the final decision, or in the case of John, who is terminally ill, by his family/relations with vital input from the physician’s medical expertise. In regard to the case context, Dr. B is new to the case but feels as though there is another alternative to John’s current regime but is unsure whether or not to share his other idea with the patient and family.
This is an example of the rejected medical paternalism, which favored the assumption because of existing medical expertise and knowledge, physicians know best what is most important to the patient. The ethical and moral issue of concern is that Dr. B. offers John’s case as an ideal candidate for the clinical trial, without the actual consent from John. Moreover, John’s proposed participation in the trial lacks the necessary ethical considerations for John’s wellbeing, specifically the ethical principal of patient beneficence. Specifically, concern revolves around the lack of adherence to the bio-ethical principles of patient autonomy and beneficence. (Quill 763). This medical counsel by Dr. B does not hold moral ground, since there is little consideration of bio-ethics in relation to John’s medical condition – terminal illness. Besides, the event is controversial since it does not consider John’s prognosis, as provided by Dr. T, nor John’s family wishes that he be transitioned into hospice care.
The ethical issue of concern focuses on the moral and ethical standing of the decision-making process of Dr. B, as a new physician handling John’s medical case. Dr. B is more oriented towards tracheostomy, and signals the possibility of John becoming a trial candidate. Dr. B further counsels that the transition to tracheostomy is based on the uncertainty of John’s respiratory prognosis. This decision-making process is explored through the Behavioral decision making model where the physician frames a decision-problem in a manner that affects the patient’s or relations’ medical preference. More often, the physician attempts to over-emphasis the proposed treatment’s benefits, while downplaying the risks (Tariman, et al., E72).
However, in the case under study, it is notable that the John (the patient) and family have already established a relationship with Dr. T, and were ready to implement the plan that he had proposed to them. In regard to the case aforementioned, it is vital to understand and acknowledge the importance of both patient autonomy and physician involvement in decision making. Significant and life-changing decisions, especially concerning medical cases, often require: patient consent, in-depth knowledge of the patient’s medical history, a cultivated long-standing inter-personal relationships, and a positive patient-physician-relatives association (Thomasma, 243).
Dr. T, having seriously discussed John’s case with his wife Lisa, presents the best possible treatment option – transitioned into hospice care. These actions are moral and ethically justifiable as explored through the shared decision-making (SDM) model. Communication was the main vehicle that was utilized in conveying vital information and eventually aiding in the decision-making process of John’s cancer treatment. Dr. B’s counsel is not morally grounded as it does not entail full and concise communication with Lisa, as John’s wife and immediate relation.
Moreover, the model stresses the importance of clearly and effectively communicating all consideration factors prior to proceeding with new treatment regimens. Besides, his decision-making process is better understood through the conflict theory model of decision-making, whereby decisional conflicts can lead to stress, of both the patient and family members during emergency medical treatment. Dr. B’s counsel would inevitably mean that John’s incorporation into the new clinical trial would elevate already existing stress levels in the patient, which would significantly impact his wellbeing. Besides, John’s family is more prepared for the transition to hospice care, as opposed to new clinical trial involvement that can lead to increased stress levels.
Patient autonomy and physician involvement in decision making are critical within clinical settings and hence, the new physician’s opinion to incorporate John, who is terminally ill, into a novel clinical trial while discontinuing the current medical regimen, has little moral standing and lacks support by the principles of medical bioethics. In John’s case, who is terminally ill, the medical counsel by Dr. B as the new ICU medical intensivist fails on both moral and ethical grounds. It is notable that patient autonomy is a bio-ethical right promoting individual capacity to overcome social limits and which frames subsequent actions due to physician provision of full information that promotes access to quality clinical care. Moreover, the bioethics principle Beneficence expresses the need for providing the best available clinical care to all patients within an empathetic, caring, and compassionate context. When considering Dr. B’s medical counsel, it is evident that it falls short of these major moral and ethical considerations.
- Furler, John S. and Victoria J. Palmer. “The ethics of everyday practice in primary medical care: responding to social health inequities.” Philosophy, Ethics, and Humanities in Medicine: PEHM vol. 5, no. 6. 3 May. 2010, doi:10.1186/1747-5341-5-6.
- Honiden, Shyoko, and Jennifer Possick. “Should Physicians New to a Case Counsel Patients and Their Families to Change Course at the End of Life?” Journal of Ethics | American Medical Association, 1 Aug. 2018. Web. https://t.co/FDE1Lc98ar
- Kilbride, Madison K., and Steven Joffe. “The New Age of Patient Autonomy.” Jama, 2018. doi:10.1001/jama.2018.14382.
- Quill, Timothy E. “Physician Recommendations and Patient Autonomy: Finding a Balance between Physician Power and Patient Choice.” Annals of Internal Medicine, vol. 125, no. 9, 1996, p. 763. doi:10.7326/0003-4819-125-9-199611010-00010.
- Tariman, Joseph D., et al. “Physician, Patient, and Contextual Factors Affecting Treatment Decisions in Older Adults With Cancer and Models of Decision Making: A Literature Review.” Oncology Nursing Forum, vol. 39, no. 1, Jan. 2012, pp. E70–E83.
- EBSCOhost, search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=70081817&site=ehost-live. Thomasma, David C. “Beyond Medical Paternalism and Patient Autonomy: A Model of Physician Conscience for the Physician-Patient Relationship.” Annals of Internal Medicine, vol. 98, no. 2, 1983, p. 243. doi:10.7326/0003-4819-98-2-243.