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Case Scenario 1:

James, age 14, is afflicted with a
cleft lip and palate and needs a common operation that promises to improve both
his appearance and his speech significantly. Due to his appearance, James has
had tremendous difficulty finding acceptance among his peers and has few
friends. The boy’s father, a believer in mental healing, refuses to permit the
operation or even discuss it with the physician. The physician explains the
operation to James, who expresses a desire to try harder to close the cleft
palate “through natural forces.”

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Question 1: What ethical
principles related to autonomy, informed consent, beneficence, or
nonmaleficence lend support to James’s refusal of surgery? What ethical
principles override James’s refusal of surgery? Is James competent to consent
for or refuse treatment?

                  To fully
understand the ethical principles related to this situation, it is best to get
a clear understanding of what each ethical principle means. Autonomy can be
defined as the principle that one human being does not and should not have full
authority over another human being. Informed consent is expressed as when a
patient or a surrogate understands the medical situation and treatment options
completely, and is able to freely and with full capacity make a decision based
on the information given. Beneficence, on the other hand, is defined as a
health care professional acting with the welfare of their patient in mind.

Lastly, nonmaleficence is the health care professional has a duty to not make
the patient worse off than when they first asked for medical help (Baillie,
McGeehan, Garrett & Garrett, 2013). Now that each ethical principle is
clearly defined, it is appropriate to deduce that in James case the ethical
principles of autonomy, informed consent, beneficence, and nonmaleficence are
present. James has every right to be respected by the physician for his
decision to refuse treatment. The physician does not have the power over James
or his father to coerce James into proceeding with the treatment, even if that
is what the physician wants. Therefore, ethically, the physician must respect
James’ autonomy in his decision making. “The principle of patient autonomy
clearly implies that the patient or the surrogate has the right to refuse
treatment” (Baillie, McGeehan, Garrett & Garrett, 2013, p.53). The
physician also explained the operation to James, who in turn expressed a desire
to choose natural forces over the operation. James, in his full capacity,
understands the procedure, its risks and consequences, the benefits of the
procedure, and probable prognosis of his condition if he refuses the operation.

James has full information about the proposed treatment, and in his full
capacity is able to make a decision based on his treatment options. The
physician will treat James according to his wishes, because he/she will do so
on the basis that the he is respecting the principle of beneficence, in that
he/she is acting with the welfare of the patient in mind. The physician can
also propose alternative treatments that will do more good than harm,
respecting the principle of nonmaleficence. Therefore, they physician is not
making James worse off than before by not proceeding with the operation, since
James’ condition is not life threatening.

                  The ethical
principles of beneficence and the principle of double effect could override
James’s refusal of surgery only in certain situations. “The emotions seem to
dictate that the principle of benevolence “Do good” takes precedence over the
principle of autonomy and the necessity for informed consent” (Baillie,
McGeehan, Garrett & Garrett, 2013, p.51). However, since James is an
adolescent, he does not have the final say in what treatment to receive. On the
other hand, this situation could be seen as coercion on the father’s part.

Since James is choosing the treatment his father wants, he could be coerced in
doing so because it is his father’s say that is final. Thus, if James does have
a desire to improve his appearance and speech significantly, the principle of
beneficence can override the initial refusal. The health care provider would be
acting with the welfare of the patient in mind. Since this is a non-emergency
situation, informed consent must be attained before proceeding with the
proposed treatment. “The principle of double effect provides that a person may
perform an act that has or risks evil effects if all four of the following
conditions are verified: The action must be good or morally indifferent in
itself. The agent must intend only the good effect and not the evil effect. The
evil effect cannot be a means to the good effect. There must be a
proportionality between the good and the evil effects” (Baillie, McGeehan,
Garrett & Garrett, 2013, p.65). This principle is a subset of the principle
of nonmaleficence. According to this principle, if the physician proceeds with
the proposed operation, the physician would be doing more good than harm. The
answer to this question is not straight forward, as there is no clear picture
of what exactly is going on in this situation. However, treatment proposed by a
healthcare physician can be refused if the patient is competent and is informed
of all information regarding the medical condition. “Although the health care
provider is not ethical in forcing treatment on the patient or, with rare
exceptions, in treating without informed consent, the patient, like the health
care professional, must respect the principles of beneficence and
nonmaleficence” (Baillie, McGeehan, Garrett & Garrett, 2013, p.53-54).

                  In this situation,
if James is not being coerced by his father to refuse treatment, James can be
considered competent in his refusal of the operation. “In the context of health
care ethics, we mean the ability to make choices based on an understanding of
the relevant consequences of that choice on oneself and others” (Baillie,
McGeehan, Garrett & Garrett, 2013, p.35). James must understand the
consequences of his decision to accept or refuse the proposed treatment. In
particular, James should understand that he is refusing an operation that would
drastically improve his speech and appearance, which would help him find
acceptance among his peers. “The effects of the treatment on the patient’s
health, life, lifestyle, religious beliefs, values, family, friends, and
society are all factors that could bear on the ethical decision to accept or
reject treatment” (Baillie, McGeehan, Garrett & Garrett, 2013, p.35). Since
the physician explained the operation to James, which most likely included
risks, consequences, benefits, and prognosis if treatment is refused, and James
still refused treatment, then he can be considered competent in making the
decision to refuse treatment. “The fact that the patient makes a decision
contrary to that recommended by the health care professional or even contrary
to the general norms of society does not prove that the patient is incompetent
because of a lack of understanding” (Baillie, McGeehan, Garrett & Garrett,
2013, p.35).

Question 2: Based on your
above analysis, must the physician respect their refusal of the surgery? If
not, what ethically appropriate options are available to the physician?

Based on my above analysis, ethically the physician must respect James’s
refusal of the surgery. As quoted previously, “The principle of patient
autonomy clearly implies that the patient or the surrogate has the right to
refuse treatment” (Baillie, McGeehan, Garrett & Garrett, 2013, p.53). The
refusal of the surgery does not imply that James is ethical in refusing the
operation. The principles of autonomy specifies that the physician cannot treat
James without the informed consent of James or his father, except in narrowly
defined emergencies (Baillie, McGeehan, Garrett & Garrett, 2013, p.55).

Since James’s medical condition is not life threatening, the physician is
forced to respect James’s wishes and forego the operation. However, if the
physician did not have to accept the refusal of the surgery, there are a few
ethically appropriate options available to the physician. If the physician
finds that James is not competent to refuse treatment, the physician can seek
the help of the courts, who can then appoint a guardian ad litem. “The
court-appointed guardian is, then, the lawful surrogate who can consent to or
refuse treatment in line with the best interests of the patient or the rational
choice principle” (Baillie, McGeehan, Garrett & Garrett, 2013, p.51). This
pathway can also be used if the physician believes that James is being coerced
by his father to refuse treatment, and that his father is not acting in the
best interest of James. Another option the physician can choose is to consult
an ethics committee. The ethics committee is available to help in difficult
ethics cases (like the above scenario if it was indicated that James is being
coerced, or that his father is not acting in the best interests of his son).

The physician can consult the ethics committee to help resolve the conflict
about the correct action to take in patient care, especially with the refusal
of treatment. However, if the physician finds James competent in making his own
decision, ethically the physician does not have the power to proceed with the
proposed surgery treatment.



Baillie, H. W., McGeehan, J.,
Garrett, T. M., & Garrett, R. M. (2013). Health care ethics. (6thed.).

Boston, MA: Pearson.

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