Role Of Family In Pakistan Law Medical Essay
Health care professionals, including nurses, often encounter scenarios where they question their decisions because their patients’ life and safety is at stake. At such instances, their strong grounding in the field of bioethics plays an important role to justify the decision taken and maintain a sense of contentment within them. Being thoughtful by applying various ethical principles, theories, and concepts, nurses can clarify the day-to-day occurring ethical conflicts and strengthen their skill of resolving them. The following case on end of life decision making will be the center of our ethical decision making in this article. This case is analyzed through the MORAL model, given by Patricia Crisham in 1985.
"Moral" is an acronym. Here, "M" means to massage the dilemma. Next step "O" is to outline the options. Then "R" means to "Review the criteria and Resolve" it. R is followed by "A" which means to "Affirm" the position and "Act", and finally, L means to "Look Back".
It is interesting to note that despite of knowing that all human beings are mortal and the time of death is uncertain, we carefully plan for our good living but not for our good death. If we would have planned for our deaths during our lives, then our deaths, to some practical extent, would be according to our desires. Our unmet businesses would have been fulfilled and we would have died in peace, contentment, and without suffering.
Early death-planning during our lives provides us an opportunity to decide on our own about all the decisions to be taken if our death results because of some disease or injury and when we might not be competent to think for ourselves. Pre stated measures to be taken at the end of our life or delegating the responsibility to some one to decide for us increases the chances that actions are taken the way we have wished.
This pre-planning leads to the concept of advance directives, which is defined as, "instructions that indicate health care interventions to initiate or withhold, or that designate some one who will act as a surrogate in making such decisions in the event that we lose decision-making capacity" (Burkhardt & Nathaniel, 2002, p. 213). Decisions seem to be easy for the dying person as well as his care givers when an advance directive is practiced. However, the situation becomes difficult when no directives are available. At that time when the patient is incompetent to verbalize his wishes, the role of his family becomes significant. The family members become the surrogate in deciding for their patient. However, situations turn out to be more difficult when there arises conflicts among the surrogates and the care provides; the health care professionals including nurses. Additionally, ethical dilemmas always arise when end of life issues revolves around medical futility since in such cases, preventing further harm, valuing life, and respecting the preferences of patients and families are to be considered (Schaffer, 2007).
Since, the responsibility of final decision making remains with the physician, taking irrational decisions will cause them carry the feelings of guilt throughout their lives (Carmel, Werner, & Ziedenberg, 2007). Nurses on the other hand, are the patient’s advocate and indirectly facilitate the physician to take appropriate decisions. Hence, they strive to take rational decisions.
Role of Family in Pakistan
Ethical dilemmas like such are very common in Pakistan. Pakistan is a family-oriented nation and the family structure is mostly extended. Here, most of the decisions are taken as a collective unit for the family. According to Khan (2012), nothing can be kept confidential in such extended family structures that prevail in Pakistan. Therefore immediate family members enjoy the right to take decisions on behalf of the patient by virtue of being the patient’s surrogate. Moreover, according to Khan (2012), since discussing about death is considered a taboo in this society, people do not talk about it and "there is no concept of advance directives" (p. 745). Hence, most of the decisions are taken at the end of life of patients.
An 80 years old male patient, admitted to Oncology ward, with metastatic cancer of stomach. After two days of his stay at the hospital, his conditioned worsened and he struggled for breathing. Since he had terminal illness, all treatment options seemed to be futile. The family, comprising of four sons, was with him at this crucial moment. His sons were well educated and were economically sound. At the time of deciding to provide mechanical ventilation to the patient or not, a discourse was generated between the health care professional team and the family. Two significant arguments emerged; to put the patient on the ventilator or not. The decision was taken and the patient was put on the ventilator. He survived for four days and died. The concern was about the end of life decision making for a terminally ill old patient and this article will analyze whether the decision taken was correct or not on the basis of the ethical decision-making MORAL model.
M-Massage the Dilemma
The first step is to "massage the dilemma" to identify important concepts. The following concepts emerged: advance directives, futile treatment, and the surrogate decision making.
An advance directive has two elements to consider; the living will and the power of attorney. According to Bukhardt and Nathaniel (2002), living wills are legal documents which direct to withhold or withdraw a life support if required. Besides, the durable power of attorney provides an opportunity to a competent person to designate someone to act as a surrogate while taking decision on his behalf, when he is no more competent to decide on his own (Bukhardt and Nathaniel, 2002, p. 214). Although in this scenario, the patient when was competent, has neither made the living will nor has assigned someone to act as his surrogate, all his sons were his surrogates who took the responsibility and unanimously decided on his behalf favoring to put the patient on the ventilator.
The health care professional team was opposite to this option because by doing so, no benefit will be provided to the patient as supported by Beauchamp and Childress (2001), "treatment is not obligatory when it offers no benefit to the patient because it is pointless or futile" (p.133). In one of the similar scenarios, Carmel, Werner, & Ziedenberg (2007) mentions that health care professionals prefer not to use life sustaining treatments particularly for metastatic cancer patients, than any other condition like mental illness or being bed-ridden, since chances for their survival are less and there are less benefits.
The next step in the Moral model is the letter "O" which refers to outline options and outcomes.
O-Outline the Options and Outcomes
In this scenario, there are two positions and two agents acting. The first position is of the surrogates; the family, who wanted to put their patient on the ventilator. The second position is of the health care professionals including nurses, who wanted not to put the patient on the ventilator.
The consequences of the first position (putting the patient on the ventilator) are that the family’s wish will be fulfilled and the patient will be given a chance to prolong his life. Since the family had strong emotional bonding with the patient, putting ventilator to the patient will give them a sense of satisfaction and they would be relieved from the psychological trauma. Besides, the duration while which the patient will be on the ventilator will prepare the family to accept the fact that their patient will not survive for long. However, by doing so, rights of all potential patients waiting for the ventilator will be violated.
On the contrary, the consequences of the second position (avoid putting the patient on the ventilator) are that the health care professional’s wish will be considered, the patient will be provided with an opportunity to die a natural death without artificial equipment of prolonging life. Besides, one of the potential patients will receive the ventilator. However, by doing so, the patient might die earlier. Making the patient die early will take away the opportunity from the family to complete some of their unfinished businesses.
Therefore, the issue is whether to fulfill the family’s wish, keep the patient on the ventilator, and prolong his life or listen to the health care professionals, withhold the life sustaining treatment to the patient and let him die.
After the situation is well stated and the positions are clearly outlined, the moral model mentions to review the criteria and resolve the situation.
R-Review the Criteria and Resolve
While reviewing the criteria, two principles are found to be in conflict; the principle of autonomy vs. the principle of justice. Besides, two theories are also found in conflict which are the theory of care vs. utilitarianism. These principles and its relevance to this particular scenario are discussed as under:
The Principle of Autonomy
The principle of autonomy supports the position of surrogate decision maker in this case. Autonomy is defined as "the ability to govern oneself, make decisions and exercise freedom of choice" (Blondeau, Valois, Keyserlingk, Hebert, & Lavoie, 1998, p.328). According to this principle, the person has a choice to be aware about the situation, available options, its consequences, and is given the right to implement the chosen decision. Here, the patient’s surrogate should be provided with their right of autonomy and the value of their self respect should be considered.
Besides, according to the independent choice model of autonomy, health care professionals, though having strong alternative opinions about a treatment option, should not be biased and avoid influencing the patient and family to take one specific decision. Rather, they should communicate and share all possible options. Once the decision is taken by the surrogates, the health care professionals have to abide by them by all means (Quill & Brody, 1996). Additionally, the substituted judgment standard holds that if such is the case, then, the surrogate’s decision would mirror the decision of the patient (Beauchamp & Childress, 2001). In this situation, the sons had intimate affiliation with their father. They were aware about all the options and consequences. Since they were near to the patient, they knew about the patient’s preferences and values; therefore, they considered their option to be the best for him. Hence, the surrogate’s decision is correct. Considering these points, it can be stated that autonomy of the surrogate should be respected and the patient should be put on the ventilator.
Contrarily, it can be argued that autonomy should only be respected if the decision making is related to any simple decision about ordinary treatments; however, in this case, the decision was about a futile treatment option. The education that the health care professionals possess would go in vain if a medically futile treatment is implemented because the burden of all decisions has to be taken by the patient only (Quill & Brody, 1996). Since the purpose of medical education is to facilitate patients to live healthy and peaceful life; therefore, treatment options that would create suffering rather than alleviating it, always remains a concern for health care professionals. For this reason, the concept of autonomy is rejected by the opponents.
Regardless of the above mentioned argument, the role of health care professionals is weak because only medical futility does not support their decision to hold the life sustaining treatment for the patient. There are a number of reasons for which surrogates do not believe in the concept of medical futility. These include being skeptical that physicians might be incorrect in assessing the prognosis of the patient, wanting to assess on their own about the patient’s condition for improvement, asking for second opinion, and strongly believing in miracles (Zier, 2009). Moreover, for the family, the quality of life of their patient is not limited to his socio-economic worth only. For them, the patient’s added four days of life would have given them a sense of satisfaction that they have cared for their patient till the end and that the life of their patient is something to be valued rather than taken away. Hence, based on these arguments, the principle of autonomy is strengthened and a strong case can be made to put the patient on the ventilator.
The Principle of Justice
The principle of justice supports the position of health care professionals in this case. This principle urges upon fair and equitable distribution of health care resources (Burkhardt & Nathaniel, 2002). Besides, the egalitarian theory holds that not only goods and services, but also, opportunities should be equally distributed including health care (Beauchamp & Childress, 2001).
"Justice may demand that one patient is not given what is individually optimal because another patient has a greater moral entitlement to a scarce resource" (Quill & Brody, 1996, p. 767). In this case, the scarcity of resource can affect the potential patients in need of the ventilator. Scarce health care resources do not affirm that only a few fortunate will receive it; rather, it is unjust to those who can not enjoy the provision of required goods and services (Beauchamp & Childress, 2001). Based on this concept every patient, irrespective of having wealth or position, has a right to be put on the ventilator if he needs it. Therefore, at certain times, this principle overrides the principle of autonomy.
Besides, there are a few different arguments that support the concept of justice for someone more in need. While considering age, it is argued that young people should be given priority over the elderly with respect to life sustaining treatment because it is assumed that older people of the society have already enjoyed various opportunities. On the grounds of fairness, young people deserve to live additional years which the older people have already lived (Beauchamp & Childress, 2001). Further, even if the old person is given a chance to live a few more years, he might not be productive to benefit the society in general; therefore, spending resources on him would just be a mean to spend cost without any outcome.
Justice for all other potential patients in need is to provide them with the opportunity to be kept on ventilator, which would bring a new and productive life for them to come in future, rather than keep the ventilator for the old man who would survive for few more years only.
It can be stated that since there was no apparent patient to request for the ventilator, it could have been given to the old patient. However, it is important to consider that there are a number of potential patients who might not have reached to the medical facility and if the ventilator is already given to the old patient, then, their right of minimum health care for survival would have been violated. Therefore, according to the principle of justice, putting the old patient on the ventilator is not wise.
In addition, the family was emotionally attached to their patient and was taking decision on the basis of their internal feelings only; which was only one aspect. The other aspect insists to consider the notion of justice, distribute resources equally and in fair means, and forget the emotive side. Therefore, in this situation, if the theory of justice is applied then, as rightly mentioned by Botes (2000), "through the impartial and objective application of universal rules and principles, it is hoped to ensure fair and equitable treatment of all people, even if it means relegating certain aspects such as emotions" (p. 1073). Consequently, all patients in need will be given equal importance, based on rules rather than emotions alone.
Theory of Ethics of Care
The theory of ethics of care supports the position of the surrogate. Appropriate motive is essential while performing a morally acceptable act. This is true for emotions also since emotions have a moral role (Beauchamp & Childress, 2001). It is defined as the ethics of care which aims to value relationships (Gilligan et al, as cited by Botes, 2000, p.1072). This theory focuses on valuing relationships more than only fulfilling rights and principles. It proposes that principles should not be rejected; rather, used in a way that relations and moral judgments are not neglected (Beauchamp & Childress, 2001).
The basic aim is to emphasize on the traits such as personal relationships and emotions including sympathy, empathy, compassion, fidelity, discernment, and love. In this scenario, the family, out of the feeling of affection and love, was not considering the need of other deserving patients. The family cared for their patient and did not want their patient to die. Hence, family decision is justified according to the theory of ethics of care.
Also, since the patient was vulnerable; therefore, this theory holds that for vulnerable population, one can disregard respect for rights and obligations, but consider needs, wants, care, love, and empathy (Beauchamp & Childress, 2001). Furthermore, based on the virtue of kindness and compassion (Beauchamp & Childress, 2001), in this situation, this theory would completely disregard the importance of medical futility and strongly affirm that caring and considering other’s needs and wants is a prime obligation to perform than to blindly consider lives of the loved ones to be useless and worthless.
On the contrary, the kantanian view would question the theory of ethics of care in favor of not to put the patient on the ventilator. Since the decision was emotion-oriented rather reason-based, Kantianism would consider it morally incorrect, (Beauchamp & Childress, 2001). Additionally, since the other patients in need would be under similar condition, and their families possessing similar emotional affiliations, then Kantianism would insist to decide rationally rather emotionally, about those patient who would require ventilator the most. In such a situation, the theory of ethics of care does not justify this patient’s individual need.
However, the nurses are committed to safeguards the interest of patients; whether it be individual, family, group, or community (code of ethics for nurses, 2001 as cited by Bukhardt & Nathaniel, 2001). Nursing professionals have taken pledge to respect the patient’s preferences, values, and wishes. Therefore, if nurses neglect the family’s wish, then on the one hand, they would not be respecting their pledge; whereas, on the other hand, while blindly following principle-oriented tasks, they will neglect the complexity in human nature which values emotions and relationships. Ultimately, the concept of holistic care will be neglected. Hence, in order to consider the sufferings of others, ethics of care should be considered and it is justified in this situation.
The theory of utilitarianism favors the position of the patient and surrogate when it signifies the concept of the advance directives. "Utilitarianism is the moral theory that holds that an action is judged as good or bad in relation to the consequence, outcome, or end result that is derived from it (Burkhardt & Nathaniel, 2002, p. 28). Though the theory of utilitarianism can be related to the concept of advance directives in various significant ways, we will limit utilitarianism to this scenario only.
Considering this particular issue, health and respect of the decision of a large number of people who would be in need of a ventilator at the end of their lives is the utility that is aimed. This will be ensured if the concept of advance directives is utilized within the societies. In contrary to the ethics of care which persuades us to care for the ones to whom we have intimate associations; the theory of utilitarianism convinces us to care for those patients also, who are distant from us but who might require more of our care and empathy.
The theory of utilitarianism is not only consequence-focused, but also is beneficence-focused (Beauchamp & Childress, 2001); therefore, providing the option of advance directives will benefit a number of patients. Since in this scenario, advance directives was not available and the surrogate decision making was functional; therefore, this particular patient has the right to be placed on the ventilator.
Religion is regarded as a fundamental aspect when making any decision making in Pakistani society because the country was founded on religious grounds. The patient belonged to a Muslim religion. According to the Islamic point of view, life is provided by God Almighty and He is the only one who will decide how and when to take one’s life. In addition, the time for death is already decided by God and no one will die before the pre-determined time. Therefore, human beings should not take any measures that might end the patient’s life. Hence, all such measures should be taken to prolong the patient’s life till the patient’s final day arrives as per God's will.
Conversely, there are certain contrary views related to the religious support. If the treatment option is withhold, then the patient might die of natural death; whereby his body functions will deteriorate. However, if the patient is placed on the ventilator, then whenever the patient will die, it would be because of unnatural means (Beauchamp & Childress, 2001).
Despite of this argument, it is emphasized that even if the patient is placed on the artificial breathing device, his life is prolonged by artificial means and he does not die by natural means, this was also because of the God’s will. If and only if God wanted, then the patient would have died when on ventilator. Therefore; here, putting this patient on the ventilator is justified by the Muslim's religious norm.
These are some of the arguments in conflict. Evaluating them on the grounds of ethical principles elucidate one final position that should have been taken in this scenario. The final position chosen for this scenario was to fulfill the wish of the surrogate and put the patient on the ventilator.
This leads us to the next step of the moral model; the letter "A" which refers to affirming the position and acting accordingly.
A-Affirm the Position
This affirmation of the final position is guided by three more actions, abbreviated by the term "ACT". The three letters refer to the following: "A" depicts anticipating the objections and obstacles to the action, "C" holds to clarify own’s position and plan actions to respond to the anticipated objections and obstacles, and "T" maintains to test the choice by acting on it (Crisham, 1985).
A-Anticipate the objections. When anticipating the objections, a number of issues arise. Firstly, it is important to reflect on the duration while the patient will remain upon the ventilator. Since death is uncertain, once the patient is put on the artificial device for survival, one is unsure whether the patient will revive from the poor condition or not, and for how long he has to remain in the same state. This is a huge constraint that keeps us away from deciding. Secondly, it can be objected that once the patient is provided with life sustaining treatment, it might take long for him to revive and at that time questions might be raised about withdrawing the treatment. During the whole process, a lot of time, effort, cost of treatment, and other resources will be utilized and the burden of such a decision will remain not only upon the patient, but also upon his family, the health care professionals, and the health care system. Thirdly and most importantly, the decision of keeping the patient on the ventilator will violate the rights of other deserving patients.
C-Clarify own’s position and plan actions. We affirm our position on the basis of respecting the patient's and surrogate’s right of autonomy, the concept of care and empathy, and the patient's and family's-defined concept of quality of life.
By respecting the principle of autonomy, the family’s wish would be fulfilled. Also, the nurses' pledge would be respected which strongly emphasizes upon the patient’s right of self determination and empathy towards them. Concerning only about the beneficence and paternalism, and overruling autonomy, an environment of distrust would be created among the health care team and the family which is not desirable (Quill & Brody, 1996).
Since caring does not consider good or bad, rather focuses on the emotions; therefore, nurses shall remain attentive towards the vulnerable patient’s needs more than just focusing on rules and principles (Beauchamp & Childress, 2001).
Additionally, the decision is guided not only by considering the position of the health care professional who believed in medical futility, but also, on the concept that quality of life is not limited to medical futility alone and strong emotional bonding and valuing family’s perspectives and desires are also meaningful. Considering quality of life only on the notions of technological assessments and predictions provide a narrow view and nurses might neglect the complexity of human relationships that gives meaning to an individual’s life.
Furthermore, under treatment or over treatment might result because the care givers feel the treatment pointless; whereas, the patient and family relates the consequence of the treatment to bring good quality of life (Dreyer, Forde, & Nortvedt, 2009). Therefore, careful and clear decisions should be implemented while considering the patient’s and family’s perspectives. Also, one should not disregard the probability of miracles that are beyond the control of health care systems.
Though it appears that a lot of cost and resources would be spent upon this final position, these are considered trivial before sustaining life of a loved one. Once the options and the consequences are well explained and the surrogate decides to opt for one position, it should be respected. These are some of the crucial points on the basis of which we affirmed our final position.
T-Test your choice by acting on it. After taking the final stance, nurses will put the patient on the ventilator.
Finally, the last concept of the Moral model has to be analyzed; the letter "L", which refers to look back. This highlights the significance of evaluating the individual case and planning ways to resolve such conflicts if they appear again within the health care systems.
This case is resolved; however, some recommendations can be suggested for next time. Firstly, the option of advance directives should be made available and operationalized to everyone. This is because directives provide opportunities for individuals to have a certain control over their life; in particular to life sustaining treatments (Blondeau, Valois, Keyserlingk, Hebert, & Lavoie, 1998, p. 328). This degree of control can be meaningful and it ensures that rights including autonomy, beneficence, and non maleficience are respected. They can plan, pre-hand, about their end of life care and decide upon the aggressiveness of those treatment options. Besides, it also lessens the stress upon the health care team and the family while dealing with such difficult situations (Bukhardt & Nathaniel, 2002).
Secondly, it is vital for the health care team to discuss with the patient and surrogate, in detail, the phenomenon of end of life and the options available. So that issues such as withdrawing and withholding treatment are clear to them ahead of time and they can decide under full knowledge and with soundness of mind. Also, sharing of all possible options will help physicians to understand their own values and perspectives and these may guide those patients as well who would want to follow the decisions of their physicians (Quill & Brody, 1996).
End of life decisions are not easy to make. Who owns the authority to decide for other's life and/or death and which options to consider valuable, always remains a concern. Besides, an added concern is present when advance directives are not available and the patient is incompetent and indecisive. A complexity in arguments should be evaluated on ethical grounds to come to a relatively rational decision that would best fit in situations under consideration. Decisions should not depend upon a single principle or theory. Formulating decisions only on the concept of medical futility is questioned by surrogate decision makers based on various reasons mentioned above. Also, deciding only on the grounds of ethics of justice or of care does not solve the issue either. Only considering autonomy of patients or surrogates or finding options for benefiting a large number of people, also does not serve the purpose. A mix of all concerned theories and principles should be analyzed before placing a person’s life at stake.
Since individuals are unique, so are their needs and desires. Therefore, It is evident that ethical decision making should be done while considering each case scenario as an independent one. This would result in satisfying the individual in suffering as well as other persons who are concerned.
These scenarios are common among dealing with various terminally ill patients. Nurses work on the forefront when caring for their patients. Therefore, a number of times, they are in a fix to decide. Therefore, it is apparent that the nursing body emphasizes the need of preparing nurses for making decisions on ethical grounds. They should be well-versed in rationalizing and should be empowered to raise their voice when such ethical discourses arise. Not only this, but also, there is a need for an ethical-culture where all the health care professionals are knowledgeable and generate well-deserved arguments to reach to an ethically sound decision which is required.