Doctor ethics question

  1. A person needs to undergo surgery. Someone shot him. He will die in three hours. No one knows him. He has no family. He comes to the hospital and his mental situation is bad. He seems to be crazy and says irrational things. He can't think or make decisions for himself. You are a medical doctor. Do you go in surgery to try and save his life even if the patient says he doesn't want it (you clearly understand that the choices he makes are not necessarily logic)?

    So, I basically came up with this question. What does the doctor have to do? Does he have any consequences if he doesn't follow the patient's desires? Does he have to consult someone? What would happen if this situation wasn't urgent (say he will day in three months because of cancer)? What do you do?
     
  2. jcsd
  3. Your confusing an ethics question with a legal question. The legal issues vary from state to state as far as mental competence and decision making as far as I know. So let's leave those legalities out for my post and focus on the ethics question. I would say sedate the nutcase, do the surgery, and when the patient "comes around," do a mental evaluation from there.
     
  4. True, but the legality part is also part of the situation. They are very closely linked. I think your option makes sense. You take the basis of being a doctor, saving lives, and you apply it while knowing the patient can't think.
     
  5. berkeman

    Staff: Mentor

    In California (and many other states), the patient has to be a mentally competant adult in order to refuse care. In the situation you described, the field EMS personnel (Paramedics & EMTs) and the doctors and nurses in the hospital would not accept this patient's refusal of care.
     
  6. bobze

    bobze 652
    Science Advisor
    Gold Member

    From a doctors standpoint you would do the surgery. You are given legal leeway when the matter is concerning emergent situations. So long as you document properly, what led you to make these decisions then you should be okay. This is called implied consent--for when a patient is delusional, intoxicated, mentally unfit or otherwise incapacitated to make a medical decision and prolonging the delivery of a procedure to properly consent a next of kin could result in a poor prognosis.

    This extends to parental/child relationships as well. For example, suppose you had a mother and her newborn and you as the doctor had reasonable suspicion the child had Hirschsprung disease. You went to talk to the mother to explain your concern and the need for a barium enema to confirm the diagnosis and treat it accordingly. The mother refuses because she doesn't believe anything is wrong. You would do the procedure anyway in this case and go to probate court later, because the consequence of forestalling the procedure, diagnosis and treatment is grave.

    Situations that are not emergent are handled differently. As a provider you have to determine competency. If people are competent they are allowed to make stupid decisions, there is nothing you can do about that as a doctor other than provide them with informed consent. In areas where competency is sketchy or you are uncomfortable in determining it you can request a competency evaluation (in most states handled by a psychiatrist, but some states psychologists can do this assessment as well). If the patient is not competent to make medical decisions you go to court and probate them. The judge usually places the patient's medical decisions in the care of family, the medical team attending to the patient or the state (which usually just follows the medical recommendations the attending doctor).
     
  7. Bobze, the mother in your case is aware of the situation and the risks since you went to explain it to her. She finds that nothing is wrong according to her. Why wouldn't you accept her choice as she becomes competent by your informing her? The disease the you mentioned, how long will it take it to hurt the baby? (I'm no doctor so I don't know.)

    EDIT: According to a website, it could kill in two days if the mother ignores vomiting of the child and dehydration etc. But, wouldn't you still have time to rexplain the implications of the mom's decision to her and inform her adequately? I don't think you the mother would let you do the procedure if she was the one with the disease. in this case, she is the baby legal responsible, and she doesn't want it.
     
    Last edited: Jul 1, 2013
  8. bobze

    bobze 652
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    Yes, even if you explain the risks of hirschsprung disease and she refuses you do the barium enema anyway. Most states in the US have laws that protect children form negligent decisions on the parts of their parents, and health care practitioners as well in emergent situations. Hirschsprung's disease, untreated, would be considered an emergent situation. Depending on the health of the baby and severity of disease you could have serious consequences, like death, in a day. Even if it turned out to be less severe and the baby could live, for say a few weeks without intervention, you could still have long term sequelae that you'd (as the doctor) potentially be held responsible for.
     
  9. Thanks! Seems logical. What are your thoughts on theweb link?
     
  10. bobze

    bobze 652
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    Gold Member

    I'm not familiar with the laws in the UK. However, in regards to ethics a living will provides the patient with autonomy if filled out when a patient is competent to make medical decisions. It states what kinds of interventions a patient would like to receive from medical professionals. If she filled it out and was competent then a practitioner is ethically obligated to follow those advanced directives irregardless of how a patient ends up in a hospital.

    Whether she had capacity to issue those directives is another issue. From the article it appears that the treating doctor, as well others called in for second opinions stated she had capacity. In which case, legally and ethically you are bound to follow the patients wishes. Like I said above, if a patient has capacity you can't stop them making bad decisions--You can only inform them of the consequences of those decisions and what options (medically) are available to them. Intervening when you shouldn't would violate patient autonomy, one of those ethical values found in that oath we all take.
     
  11. If the mother had the disease and she refused, would you consider her negligence and give her the procedure? Being a doctor sure is a hard job :eek:
     
  12. bobze

    bobze 652
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    In the second link I provided above if you scroll down the section titled "conflicts between autonomy and beneficence", they do a pretty good job of summing up how Western society, or at least particularly in the US those values are "ranked". Normally we give greater weight to a patient's wishes if they have capacity to make their medical decisions than we do to beneficence (acting in a patient's best interest).
     
  13. Very informative article. The term "mentally competent" is very vague though. How could you classify a depressed person?
     
  14. bobze

    bobze 652
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    No. An adult that has capacity to make their medical decisions can make bad ones. Even at the cost of their life. If you have consented them and informed them and they still choose to refuse a life saving procedure there is nothing you can do, but respect their decision.

    A child (in the example I provided above) is different. They cannot have capacity to informed consent and informed consent is made by proxy--their legal guardians. In most case that will be respected, however if a decision is made that could cause grievous harm or loss of life that guardian decision can be ignored (in an emergent situation) or taken away from the guardian if not immediately necessary (through the court).

    The basis of that is; while a guardian makes the medical decisions for someone without capacity (a child in this example), the law and ethics dictates that when the child comes of age to have capacity what would they choose? Most "reasonable" (legal jargon) people would choose to have a life saving or morbidity reducing intervention. Ergo, you as a physician, act in the best interest of the patient (beneficence), not the guardian.
     
  15. bobze

    bobze 652
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    You're telling me. You go to medical school thinking its all going to be science, medicine, rainbows and unicorns, only to discover a significant portion of your class load your first two years is given over to ethics and legal topics :smile:
     
  16. bobze

    bobze 652
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    Its is, something more akin to ambiguous legal jargon than medical jargon. I've run out of time for the evening though and unfortunately need to be back at the hospital in 8 hours (after a 16 hour day :frown:) which means I need to get some shuteye!

    However, this is a pretty good article on determining decision making capacity:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181079/
     
  17. BruceW

    BruceW 3,598
    Homework Helper

    The entire issue is one big grey area. Even if the person is determined to be capable of making rational, sane decisions, then their wishes are not necessarily going to be listened to. For example, if they chose not to undertake surgery that would save their life, I'm pretty sure that they will be forced to undertake it anyway, right? Or maybe I misunderstood this?
     
  18. bobze

    bobze 652
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    Gold Member

    I think you misunderstood. If someone has capacity to make a medical decision nothing is going to be forced on them. You can choose not to have a medical procedure done to you, even if it life saving.

    If a person is unconscious, there are no advance directives on file, there is no easily available surrogate decision maker or someone doesn't have capacity, then normally doctors would do an intervention on the grounds that is what most reasonable people would choose.
     
  19. BruceW

    BruceW 3,598
    Homework Helper

    really? I don't think so. Maybe I'm wrong though. I don't know much about it.
     
  20. bobze

    bobze 652
    Science Advisor
    Gold Member

    You are. :biggrin:

    I'm not sure where you got the idea that medical procedures are forced on people, but that is incorrect. Like I said, anyone with capacity can refuse any kind of medical intervention they wish. Even if that intervention is required to save their life. Can't really be more clear than that.
     
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