Bioethics Flashcards
Midterm exam
Decisions of ending life or hastening death for cases of incapacitated patients
An incapacitated patient is one who is temporarily or permanently unable to make decisions due to acute medical conditions, such as being in a coma or suffering from an acute mental health crisis. The distinction between incompetence and incapacitation is important because the incapacity may be reversible, and the patient’s ability to make decisions might return.
End-of-Life Decisions for Incapacitated Patients:
Temporary Nature of Incapacity: In cases where the incapacity is temporary (e.g., due to anesthesia or a coma), the patient’s preferences cannot be known during the period of incapacity, and decisions are made based on their previous wishes (if documented) or best interests.
Family or Medical Team Decisions: For patients who are temporarily incapacitated, the healthcare team may provide the necessary life-sustaining treatments until the patient regains capacity. If a decision must be made in the interim (such as withdrawing life support), the family or a surrogate decision-maker would typically be involved.
Ethical Considerations: There is tension between the preservation of life and allowing natural death. While life-saving treatments are generally given, when the prognosis is poor, some argue that forcing life-sustaining treatment on an incapacitated patient may violate autonomy.
Decisions of ending life or hastening death for cases of incompetent patients
- Incompetent Patients
An incompetent patient is unable to make their own medical decisions, often due to conditions like dementia, mental illness, or severe brain injury. When a patient is incompetent, they cannot express their preferences regarding end-of-life care.
End-of-Life Decisions for Incompetent Patients:
Substitute Decision-Makers: If a patient is incompetent, decisions about hastening death or end-of-life care typically fall to a surrogate decision-maker (often a family member, legally designated agent, or healthcare proxy). The surrogate is expected to make decisions based on the patient’s best interests or, in some cases, based on what the patient would have wanted (i.e., substituted judgment).
Advance Directives: If the patient has previously expressed their wishes through an advance directive, living will, or durable power of attorney, those documents guide decision-making. These documents may specify the patient’s desires regarding life-sustaining treatments or instructions about euthanasia or withdrawing life support if they become incompetent. If the patient had previously expressed a desire to end their life in a specific way (such as no CPR, or refusal of life support), the surrogate should honor those wishes, as long as they align with the legal and ethical standards in place.
Ethical Dilemmas:
What if an incompetent patient’s prior wishes conflict with the surrogate’s judgment of what the patient would want in the current situation?
Should surrogates be allowed to make decisions that hasten death or withdraw life support when there is no clear, previously expressed wish from the patient?
Decisions of ending life or hastening death for cases of competent patients
End-of-Life Decisions for Competent Patients:
Autonomy and Informed Consent: A competent patient has the right to make decisions regarding their end-of-life care, including the choice to refuse life-sustaining treatments or request euthanasia or physician-assisted suicide where legally permitted.
Right to Refuse Treatment: Even if a treatment is life-saving, a competent patient can choose to refuse it if they believe that the burden outweighs the benefit, or if they wish to avoid a prolonged dying process. The right to die with dignity is grounded in the principle of autonomy.
Physician-Assisted Suicide and Euthanasia: In jurisdictions where physician-assisted suicide (PAS) or active euthanasia is legal, a competent patient has the right to request assistance in ending their life. In PAS, a physician provides the means (usually medication) for the patient to self-administer, whereas in euthanasia, the physician actively administers a lethal dose. Ethical considerations: Is it ethical to honor a request for euthanasia? This brings up questions about the moral obligation to preserve life versus respecting a patient’s autonomy.
Examples:
A terminally ill patient with unmanageable pain and a poor prognosis chooses to undergo physician-assisted suicide.
A competent patient suffering from chronic illness chooses to stop receiving life-sustaining treatment, such as a ventilator, because they believe it prolongs suffering without a meaningful improvement in their quality of life.
Be prepared to critically evaluate a case study pertaining to… IVF
Psychological and Social Considerations
What were the emotional and psychological impacts of IVF on the individuals or couples involved? IVF can sometimes lead to significant stress, disappointment, or emotional strain, particularly if multiple cycles are needed or if the procedure fails.
Were the potential social implications considered, such as family dynamics, the expectations of society, or stigma
Parental Responsibility and Future Considerations
What responsibilities do the intended parents have, both toward the child born via IVF and toward any embryos that may have been created but not implanted?
If the IVF resulted in a genetic child, was there a consideration of whether the intended parents were ready for parental responsibility, etc.
Legal Considerations
Were all legal requirements followed? IVF may involve complex issues related to parental rights, especially if donor gametes (sperm/eggs) were used, or in cases of surrogacy. Was there clarity regarding who has legal rights to the child (e.g., biological vs. intended parents)? etc.
Be prepared to critically evaluate a case study pertaining to… IVF
When critically evaluating a case study related to In Vitro Fertilization (IVF), several ethical, legal, medical, and personal factors must be considered. These include issues related to patient autonomy, accessibility and fairness, embryo rights, parental responsibility, and social implications.
Patient Autonomy and Informed Consent
Was the patient fully informed about the IVF process, its success rates, risks, and potential complications?
Did the patient provide informed consent after understanding the medical, psychological, and financial implications of IVF?
Consider whether the patient was free from any coercion or external pressures
Medical Considerations
Were the medical indications for IVF appropriate? For instance, IVF is often considered when there are issues with fertility, such as blocked fallopian tubes, low sperm count, or unexplained infertility.
What were the medical risks for both the mother and the baby, including the likelihood of multiple births (twins, triplets) and associated complications like preterm birth, low birth weight, or birth defects? etc.
Ethical Issues Related to Embryo Handling
How were embryos handled? IVF often involves the creation of multiple embryos, some of which may not be implanted. Ethical concerns arise regarding the disposition of unused embryos. Were they frozen, donated for research, or discarded? etc.
Access to IVF and Social Justice
Was the IVF process accessible to the intended parents in a fair and equitable manner? Consider whether IVF was affordable, especially in cases where insurance or public funding was involved.
Did the case address potential issues of accessibility for people from different socioeconomic backgrounds, ethnic groups, or countries? Is there fairness in access to reproductive technologies?
What does non-futile medical care refer to?
Treatments that are likely to produce meaningful benefits for the patient.
What is involved in determining whether care is futile?
Clinical judgment, which may include consultations with ethics committees or discussions with the family.
How can futile care conflict with patient autonomy?
If the patient or their family insists on continuing treatment that is clearly ineffective.
What ethical concerns may arise with futile medical care?
It may violate principles of beneficence (doing good) and non-maleficence (avoiding harm).
What is an example of high burden, low benefit treatment?
Administering chemotherapy to a patient with advanced terminal cancer who is near death.
What does high burden, low benefit mean in the context of futile care?
The treatment may cause harm or discomfort without providing any measurable improvement.
Give an example of futile medical care.
Continuing life-sustaining interventions like mechanical ventilation in cases of irreversible organ failure.
In what situations is futile medical care commonly seen?
In cases where patients are at the end of life or suffering from a terminal condition where recovery is impossible.
What is a key characteristic of futile medical care?
Lack of therapeutic benefit, meaning the treatment does not improve the patient’s condition.
What does futile medical care refer to?
Treatments or interventions that are unlikely to produce any meaningful benefit for the patient.
What is the distinction between futile and non-futile medical care?
It pertains to the effectiveness of treatments in achieving intended outcomes, especially in terminal illness situations.
What is a concern regarding the interpretation of advance directives?
Advance directives may be misinterpreted or misunderstood by family members or healthcare providers.
How can rigid adherence to prior directives undermine patient autonomy?
It may not respect changes in a patient’s preferences, especially as they near the end of life or experience new insights.
What does Dresser say about the changing nature of patient preferences?
Dresser critiques the assumption that a patient’s previous testimony or written directives should be held as sacred or unchangeable, emphasizing that values can shift over time.
Why might advance directives not reflect a patient’s evolving sense of dignity or quality of life?
Medical circumstances can vary greatly, and what seems acceptable at the time of writing the advance directive might not feel right when faced with a new reality.
What is the issue of contextual inflexibility in advance directives?
Advance directives can’t account for the contextual nuances of a particular situation, leading to misalignment with the patient’s current wishes.
How might a patient’s preferences change regarding life-sustaining treatment?
A patient who, when healthy, expresses a desire to refuse life-sustaining treatment may change their mind if they experience a terminal illness.
What is Dresser’s critique regarding the predictability of future decisions in advance directives?
Dresser argues that it’s challenging for individuals to predict how they would feel or what they would choose when faced with specific medical circumstances in the future.
What ethical limits does Dworkin recognize in patient decision-making?
A patient’s decision must not undermine the well-being of others, and the provider’s duty to minimize harm must be balanced with respecting the patient’s wishes.
