Brian Parkins

Phil 314 - Case Discussion 2

12/15/2012
The Case of Mr. Carrera
Issue 1 - The Competency of Patients
Material
The respect for a patient's autonomy should be one of the most important factors when deciding
treatment options for a patient. Proper explanation of medical conditions to a patient is essential in
facilitating treatment decisions in the best interest of the patient. This requires that the physician divulge
the most significant, if not all, risks and benefits of a treatment to a patient, and clarifying any points that
the patient may not understand in increasing simplicity until comprehension is reached. While the side-
effects of a treatment may be extensive, it is important to itemize them and present the most relevant or
serious effects the patient may encounter during treatment. Legally, a patient is incompetent if they are
unable to respond knowingly and intelligently to questions about their treatment, participate in treatment
decisions by means of rational thought, and understand the items of basic medical treatment information.
Application
It is initially the patient's choice as to what treatment he or she may pursue. A physician is
required to give as much information as necessary, as the decision to pursue a treatment is ultimately left
to the patient. While many patients may simply side with the physician's recommendation, some patients
may object to certain side-effects and therefore reject the treatment option. In such a situation, the
physician must respect the patient's right to autonomy and present alternative treatment options, if
available. To ignore the patient's objections and provide the treatment regardless would be a miscarriage
of medical justice.
Objection
In this case, Mr. Carrera is cycling between stages of unconsciousness and disoriented confusion.
As a result, it is impossible to present the treatment options until comprehension is met. As Mr. Carrera
is incompetent to make decisions in the best interest of his own treatment, either a living will, his next-of-
kin or a surrogate decision-maker must be used.
Decision
Anything Mr. Carrera says in regard to his medical treatment at this point is unusable, even if he
should appear aware of his surroundings and situation.
Issue 2 - The Authenticity and Application of a Living Will
Material
When a patient is incapable of making informed decisions regarding his medical treatment, any
existing living will or advanced directive should be used. A living will is synonymous with an advanced
directive, and is a document signed in advance by the patient and either a witness or notary public
indicating the wishes of the patient in medical situations should he or she be deemed incompetent to
direct their own treatment. In these documents can be anything from whether a patient wishes to be
resuscitated to certain side effects of treatment the patient personally views would be unacceptable, such
as future complications in fertility or removal of certain organs or body parts. It is imperative, however,
that the patient be deemed competent enough to both communicate their wishes in the living will and sign
said document prior to its use. Some issues with living wills exist, however; the document may be vague
or unclear, or it may not include certain scenarios. Other issues with the document, such as how well the
patient was informed of scenarios at the time of signing, newer treatment options that have emerged since
the signing of the document, or questions regarding the competency of the patient at the time, further
complicate the situation. However, none of these issues are reasons to object to the use of the living will
in its entirety, but provides grounds to not respect the living will as the final answer in treatment.
Application
When a legal living will is presented, the physician must strictly adhere to the patient's wishes,
even if circumstances have changed following the writing of the living will. Ultimately it is the
responsibility of the patient to ensure their advanced directive is updated and is as comprehensive as
possible, but even when a living will has not been updated in some time or is not comprehensive, it must
be obeyed. In the case of Mr. Carrera, a living will has been provided that suggests that in the event of a
heart attack, the patient is to be revived with CPR. It does not appear to provide any other information
that would be deemed useful to this situation.
Objection
In the case of Mr. Carrera, the living will provided by the daughter lacks both the patient's
signature and a witness to the signing, and only has her signature. The document is from Mr. Carrera's
nursing home, which has been his residence for the last three years. However, without the proper
signatures, the document is considered invalid.
Decision
The living will must be ignored, as it is not considered a legal living will as a result of the missing
signatures.



Issue 3 - The Competence of Next-of-Kin
Material
In a situation where a patient is both incompetent to direct their medical treatments and no living
will is available, the next-of-kin is granted the right to direct the patient's treatment. Generally this
decision-maker is either the legal spouse of the patient or an immediate family member, should either
exist. The reason for this is that these individuals know the patient better than the physician or any
attending staff, and would be able to make decisions on behalf of the patient that would be in-line with
their values and wishes. This individual (or group of individuals, in some states) would then use the
substituted judgment principle; basically, what the patient would have wanted based on personal
information, including the patient's values and implied wishes. It is required that treating medical
professionals adhere to these wishes and values, and follow the treatment decisions made by the family.
However, this substituted judgment principle hinges on whether the surrogate decision-maker(s) is/are
competent enough to make the decisions in the first place. Should the surrogate decision-maker be unfit
to act in this capacity, and no other family member is present, a court-appointed third party medical proxy
must be used.
Application
As Mr. Carrera has a living daughter and no other family members, she would be appointed the
surrogate decision-maker. She states that her father would have wanted anything and everything done to
keep him alive. This would include anything from simple procedures to radical treatments, all of which
must be explained to the daughter prior to deciding which, if any, are in the best interest of her father.
Objection
It is suggested that the daughter may not be competent to serve as the surrogate decision-maker.
Since Ms. Carrera lacks reading and writing skills beyond a third-grade level, her competence is dubious
at best. While this in and of itself is not grounds to dismiss her from acting as a surrogate decision-
maker, the fact that she is mildly mentally retarded leaves some grounds to dismiss her in this capacity.
However, there is no information provided that she is incompetent and therefore legally incapable of
making decisions.
Decision
As no information is provided to deem Ms. Carrera mentally incapable of making these decisions,
and because she is 36 years old and therefore not a minor, we are to assume that she is in fact competent
enough to act as a surrogate decision-maker, and all avenues of treatment must be explored and
appropriate measures must be used. However, obtaining a court-appointed medical proxy to assist in
making these decisions, but not to make them in place of the daughter, should be used. Also, a
professional that is both familiar with mentally-disabled individuals and comfortable in discussing the
case with Ms. Carrera should be obtained prior to treatment. It is also advised that Ms. Carrera be
interviewed so as to determine her mental capacity. Should she be deemed incapable, the court-appointed
medical proxy would be available to direct treatment in her place.
Issue 4 - Futility and The Distribution of Rare Resources
Material
An important factor in deciding the allocation of resources is how well those resources are used.
If a resource is rare, the use of that resource should be tightly regulated. Bedside rationing, the
withholding of medical resources in a patient's treatment when the resource is rare or when it could be
better spent on another patient, is a common practice in healthcare. While this may seem unethical and
contrary to the nature of medicine, the use of bedside rationing is inevitable and unavoidable. In many
situations, patients may gain some benefit from the use of a resource, but the benefit is outweighed by the
cost of using the resource, whether due to monetary cost or the potential damage to other patients a lack
of the resource could produce. Examples of this practice range from withholding antibiotics when they
would provide little or no benefit to the patient, to the use of antivenin when a patient is likely to recover
without serious injury. Ultimately, bedside rationing is used when medical treatment would be futile.
Two types of futility exist - where a patient expects an effect the physician knows is nearly
impossible, such as the use of antibiotics to cure a viral infection, or where a patient or surrogate values
an effect the physician considers non-beneficial, such as life support for patients in a permanent
vegetative state. A treatment is deemed futile when either the effect hasn't occurred in the last 100 trials
of use, the patient lacks the capacity to appreciate the benefit from treatment, or the treatment fails to
significantly improve the patient's situation.
Application
The use of this rare blood, especially in a terminal patient, is a textbook example of futility. Even
if the use of this rare blood could provide benefit, the fact remains that Mr. Carrera is terminally ill, and a
blood transfusion is unlikely to relieve the symptoms he is exhibiting. While his daughter is of the same
rare blood type, her blood is unavailable for due to reasons which will be discussed later.
Objection
Ms. Carrera has stated that her father's implied wish is that everything be done to save his life.
Since there is not enough evidence at this point to determine whether she is competent enough to serve as
the surrogate decision-maker in this situation, we would be required to perform a blood transfusion.
While recovery from Mr. Carrera's symptoms due to the transfusion is astronomically unlikely, we should
follow his daughter's instructions.
Decision
Ultimately, withholding the blood transfusion for potential benefit to future patients far outweighs
its use in a zero-sum situation such as this. We should not request the blood from the nearby bank.
Issue 5 - Non-Maleficence and the Concept of "Do No Harm"
Material
"As to diseases, make a habit of two things - to help, or at least to do no harm." This line, found
within Epidemics I of the Hippocratic Corpus, is the longest surviving and perhaps the principal code
within medical ethics. It instructs physicians to never harm a patient during treatment. Doing so was
catastrophic to one's medical career thousands of years ago, and through malpractice lawsuits and public
shaming the repercussions remain the same today. Everything in a patient's treatment should be done
with the underlying motive of making the patient well. This generally excuses physicians from negative
consequences stemming from a failed treatment when the motives are pure and good, but to actively
sabotage a patient's treatment or to provide treatment the physician knows is harmful is a grave
miscarriage of medical justice.
Application
In this situation, since the use of the rare blood obtained from the blood bank is futile, Ms.
Carrera could act as a donor for her father. However, as she is HIV-Positive, we would violate the most
fundamental code of medical ethics. Since CDC research has shown a 90% chance of HIV infection due
to blood transfusions, we would almost certainly be infecting Mr. Carrera with HIV in a futile attempt to
save his life.
Objection
Mr. Carrera is terminally ill, and it is unlikely that he would experience any symptoms of HIV
before his death from cancer. Consequently, we wouldn't necessarily be causing him harm by providing
knowingly-tainted blood when it is highly unlikely to make his situation any worse. While ethically
deplorable, using his daughter's blood, even if it is tainted with HIV, is not something to dismiss so
quickly from a purely medical view. Additionally, depending on Ms. Carrera's viral load, we could
theoretically use her blood and lower the risk of infection by giving her father (and Ms. Carrera,
theoretically) antiretroviral drugs.
Decision
At this point, since HIV is a relatively slow-progressing disease, the issue of giving Mr. Carrera
his daughter's blood is not quite black and white. However, the possibility of exacerbating the cancer
symptoms as a result of the HIV infection makes this a last resort.
Issue 6 - Confidentiality and Disclosure
Material
It is important to keep in mind that releasing someone's medical information, even to family
members and especially when the person in question is not a minor, is forbidden. This is such a sacred
belief that there are laws that prevent the disclosure of this information to other parties, in the form of
doctor-patient confidentiality. This is to espouse the idea that a patient can be completely honest and
open with a doctor without fear of this information being made available to third parties. This
confidentiality is so integral to modern medicine as to be nearly impossible to breach except in severe,
often legal-related, situations. It is simply one of the unbreachable aspects of the medical system.
Disclosure, or the lack thereof, is not quite so clear. Physicians may withhold information from
patients, especially when they believe the disclosure may actually cause harm to the patient; this is known
as therapeutic privilege. For years physicians have been aware of the placebo effect, as well as the benefit
a positive outlook can have on a patient's treatment. For instance, if a cancer patient is told they have a
few years to live, they may or may not live the estimated years simply due to how they respond. Patients
who take such information poorly are more likely to decline in health than those that develop a positive
outlook. Informing a cancer patient of metastasis, the spreading of cancer from one organ or system to
another, is often as detrimental to the patient and their treatment program as the cancer itself. As a result,
physicians may withhold this information from their patients in the best interest of their treatment, as well
as their quality of life for their last few years of life. While this is a legal gray area, and may lead to
allegations of malpractice, the burden of proof that such withholding of information is actually beneficial
so great as to greatly diminish its practice.
Application
As we cannot betray a patient's confidentiality, and the release of sensitive medical information is
a complicated procedure filled with myriad regulations and laws, we would not be allowed to disclose
Ms. Carrera's HIV status to her father under any circumstances, as she has indicated she does not want her
father to know. If we were to use her blood for a transfusion, we would not necessarily be required to
disclose the source of the blood to the father.
Objection
In the interest of both full-disclosure and legal protection, we would be required to inform the
father of the HIV infection, provided he regains consciousness and is coherent enough to ask. Since the
next logical question would be how he was infected, we would have to inform him that the blood he was
given was tainted, and eventually where it came from. Since this would be a clear violation of law, we
therefore cannot even consider a blood transfusion without the daughter's consent to inform her father of
her HIV status.
Decision
Disclosure of his daughter's HIV status is inevitable if we proceed with a blood transfusion from
her. Without her consent, this precludes us from performing the blood transfusion at any point.


Issue 7 - The Cost of Care
Material
Ultimately, and rather unfortunately, the amount of care to give a patient rests in the financial
costs, and who must bear the burden. In the United States, government programs such as Medicaid and
Medicare, as well as state programs like Medi-Cal, are given to people 65 or older, poor, or both, to assist
in paying for medical expenses. All programs include stipulations for the disabled. The programs are
designed to assist people in paying for health care when they cannot receive it through other means like
employee benefits, or the financial burden is considered too great for the patient. These programs have
lists of treatments and procedures that are or are not covered, and few exceptions are made. Medicare and
Medicaid accounts for roughly 23% of US spending (in the 2011 budget), and that percentage is expected
to increase over the next decade as a large population enter retirement and Medicare eligibility. As a
result, tighter regulations and oversight will be required.
Application
Since Mr. Carrera is covered under Medicare, his expenses for this situation are covered. The
treating physicians should be able to perform any medical procedures necessary, provided they are
covered under Medicare.
Objection
The use of government-subsidized health care in the treatment of a terminally ill patient could be
considered excessive and futile. When the prospects of the patient are not expected to improve
dramatically as a result of expensive "heroic medicine," the value of sustained but ineffective care could
be construed as wasteful. The resources used, not limited to the financial pool available to Medicare
recipients, might be better spent on patients that have a higher chance of survival and recovery.

Decision
Treatment beyond what is covered by Medicare is ill-advised and ultimately futile. Anything
beyond palliative care is most likely pointless.
Issue 8 - Letting Go
Material
In some situations, it is in the patient's best interest to simply provide pain management and let a
disease or illness run its course. When the cost of medical care is simply too great, the amount of care is
beyond extraordinary and the prospects are grim, sometimes it is in a patient's best interest for doctors to
realize that nothing can be done. This can be a difficult situation, but ultimately we must realize that man
is mortal, and everyone must yield to the finality of death.
Supporters of the equivalence thesis, which states that killing and letting die are equally immoral,
would equate letting a patient die with actively killing them. However, according to James Rachels, this
fails to take into account the circumstances involved. For instance, according to the equivalence thesis,
allowing a patient to die instead of living in pain would be equal to a man murdering his wife out of
jealousy. Rachels, however, suggests that, in respect of a patient's autonomy and reduction of pain and
suffering, euthanasia is completely morally permissible. He further states that passive ("letting die") and
active ("killing") euthanasia are generally on par with each other, and in some situations active euthanasia
may be more morally permissible than passive euthanasia. It is important to note that active euthanasia
requires voluntary consent from the patient.
Application
In this case, Mr. Carrera's prospects are quite grim, and simply letting the disease progress is a
valid option. One could argue that active euthanasia at this point could actually be beneficial, but without
approval from Mr. Carrera or his daughter, the point is moot. Still, passive euthanasia remains a viable
option for this situation.
Objection
As stated earlier, the first law of practicing medicine is to do no harm. No harm could be greater
than killing a patient, or allowing a patient to die while one stands idle. Some may argue, usually from a
sanctity of life view, that you must do everything you can in order to prevent death. Thus, allowing Mr.
Carrera to die is tantamount to murder, and is a travesty.
Decision
While it may be difficult to convince Ms. Carrera of letting her father pass, it should be the
primary option presented, especially if all information is presented to her, specifically his low chance of
survival and futility of extreme medical intervention.
Recommendation
It is the opinion of this author that Mr. Carrera's treatment should be purely palliative at this
point. Mr. Carrera should be admitted to surgery to stop the blood loss due to his colon cancer, but
further treatment is futile. Ms. Carrera should be presented with all of the information regarding her
father's condition, and strongly urged to allow him to pass naturally. If she still refuses, further inquiry
into her competence could show that she is not capable of determining the treatment for her father, and
the information would be presented to a court-appointed medical proxy. Ultimately, little more should be
done for Mr. Carrera than to allow him to pass naturally and painlessly.