Ethical Reasoning

The chief difficulty in making a decision in this situation is the absence of information about consent elements [Items 1-5]. One can question why this information was not obtained from the patient earlier, but the fact remains that at this point it is too late to gather any information about the patient’s wishes, nor is there time to discuss the matter with the staff of the unit to reach a consensus judgment.

Judgments about the patient’s quality of life are obviously an important factor in the decision. But notice that, absent a discussion with the patient, quality of life must be judged from the standpoint of an observer [Item 7] rather than from the patient’s own assessment [Item 6].  A reliable judgment on this basis would require a much closer relationship with the patient than the staff of this unit had experienced in the brief time they had cared for him.  Furthermore, the state of life of this patient immediately prior to the arrest was not obviously below the threshold of a worthwhile quality of life. He was conscious, alert, and capable of communicating with those around him. He appeared to have been reasonably mobile. Although his pain was considerable, it was not so severe as to cloud his consciousness or to prevent meaningful mental activity.

Determinations of the efficacy of the treatment [Item 12] and the reversibility of illness [Item 13] will vary depending upon the basis on which the judgment is made. Resuscitation and embolectomy offer a fairly good prospect of reversing the cardiac arrest. However, even if they are successful in achieving this limited objective the patient’s underlying cancer and heart disease will not be reversed. Thus, from a perspective of the overall condition of the patient, the proposed treatments must be ruled ineffective and the conditions irreversible.

A standard-medical-care policy [Item 15] or a medical-indication policy [Item 16] faces similar difficulties. Determinations of “standard” care or medical “indication” are often made from the limited perspective of efficacy regarding the immediate medical crisis, with little attention to the overall life prospects of the patient. Overcoming the immediate problem benefits the patient little if the life situation to which he is restored is painful, hopeless, and/or unwelcome.

In this situation little is known of the patient’s family or other social relationships, so the other regarding elements [Items 22-24] cannot be ascertained sufficiently to make them a major factor in the decision.

None of the conceptual elements [Items 30-40] appears to offer a decisive basis for choice in this situation either. One might argue that refraining from resuscitating this patient would be an “act of mercy” [Item 34] that would provide a “good death” [Item 35] and avoid prolonging the dying process [Item 38]. However, without any indication from the patient that he finds his condition intolerable, to make such a judgment would be an extremely presumptuous exercise of paternalism.

The application of the distinctions in [Item 30-33] does not entail one conclusion rather than the other. Resuscitation might be classified as an ordinary measure (and thus perhaps as morally obligatory), but a case might be made for considering the emergency embolectomy as an extraordinary measure.  If resuscitation is foregone, the patient would have been allowed to die rather than killed [Item 32], and his death would have resulted from passive rather than an active death-dealing measure [Item 33]. These factors might indicate that foregoing resuscitation would be morally permissible, but they do not provide a decisive reason for or against this choice.

Most of the moral principles listed (with the possible exception, in this case, of [Item 42] dictate sustaining life, but they would be challenged by many people in precisely this sort of situation. The factual appeals [Items 49-50] seem clearly misguided if applied to this situation: the diagnosis has been thoroughly confirmed, and the patient’s medical problems are so overwhelming that the possibility of a cure is virtually nonexistent.

The law [Item 41] leaves decisions in such situations to the discretion of the physician present (wisely, in our judgment), but this means that it cannot be looked to as a basis for decision.

On what basis, then, is a decision to be made in this situation? Without decisive indications of the patient’s wishes or other consent elements and decisive negative quality of life judgments, the most reasonable basis for choice is to invoke what the President’s Commission describes as a “presumption in favor of sustaining life”. This presumption, in turn, is rooted in the principle of the value of life [Item 45].

Thus, we conclude that resuscitation is morally obligatory in this situation. And that, indeed, is the decision that was made in the actual case, as you shall now see.

Part II



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