Adrian Rutt, 541

CASE 4-2
As pertaining to case 4-2the case dealing with the benefits and harms of high-risk

chemotherapythe commentary offers a few options that both Dr. Eyberg and the patient Dr.

Cavanaugh can consider. One of the options is to give priority to the principle of

nonmaleficence: that is, when there are options of both high risk and low risk, the safer option

ought to be the one chosen even if the benefits are not comparable in magnitude to the benefits of

the high risk procedure. Another option suggested is that the patient treat both procedures as

morally and practically the same as the ratios of harm-benefit of each procedure are the same.

The third and final approach presented is the utilitarian approach: that the high-risk procedure

would produce the most net good, so the patient would be morally required to do it.

First, the physician should proceed by sitting down and having a conversation with the

patient, Dr. Cavanaugh. One should note that the three potential avenues are not by any means

obvious as to which one fits the situation best, and the best one can do is to discuss the matter

intensely and seriously with all the parties involved and affected. That said, Dr. Eyberg should

first lay out all three options making sure to note and emphasize the statistical risks of each

method. Though it is true that this preliminary step might not present Dr. Cavanaugh with any

clearer picture, it is necessary in order to understand so that when he does eventually go one

route, he knows all the harms and benefits associated with it.

It seems that in the particular case before us, the conservative route would be the best

option. With the low success rate of HSCT therapy, it would be better if Dr. Cavanaugh is

advised to go the route that guarantees more time with his wife and children than the one that

could instantly end his life. If Dr. Cavanaugh were younger - say, in his thirties or forties - it

might have been worthwhile to undergo the procedure. Dr. Eyberg should also take note of the

age/success rate of people who undergo HSCT therapy in order to nudge the patient in the right
Adrian Rutt, 541
2

direction. I can only imagine that the older one gets, the larger chance there is of infection and an

accompanying inability to fight it off. According to the commentary, this route would be more in

line with the second approach: seeing the options as about the same. This would allow outside

factors - i.e. family, friends, children - to come in and help Dr. Cavanaugh make a more well-

rounded decision. If it is true that the second option sees both procedures as about equal, then the

matter of taste in this case would no doubt be affected by other factors besides just the

treatment.

Thinking that Dr. Eyberg should nudge the patient in the conservative direction is by no

means a confident analysis: it could be true that Dr. Cavanaugh says hed rather have a better

quality of life during his remaining years than any at all. The patient could argue that hed rather

go the high-risk, high-reward route because the conservative wait-and-see route would

undoubtedly still entail grueling chemotherapy sessions and, at least for a time, a low quality of

life. One should not underestimate a patients resolve in this matter: if Dr. Cavanaugh is less

confident about the conservative route it might be better, after all, to go the high-risk route. This

is clearly a difficult case, but that is because the concepts of benefit and harm, themselves are

controversial (Veatch, et al, p. 72). If the patient and Dr. Eyberg continue to measure benefits

and harms differently, theres really no telling where or how this case could end up.

MRS. HEATH CASE

The point at which there is a clear sense that something is wrong or that something could

go wrong is when, upon being told that she would die without the surgery, Mrs. Heath scoffs at
Adrian Rutt, 541
3

the doctor and storms out of the room. However, this isnt unusual. People getting angry, upset,

or erratic upon being told life-altering or life-threatening news often act the way Mrs. Heath

acted in the doctors office. On first glance, then, this situation isnt wrong, but it has the

potential to turn into an ethically problematic case. As Veatch says, unlike physical signs and

symptoms there are no objective signs that one is involved in an ethical problem (Veatch, et

al, 25). Such is the case here. More specifically, if Mrs. Heaths denial and outrage continue -

that is, Mrs. Heath does not calm down and approach the situation rationally - this could present

problems for Dr. Carter and the hospital staff. If a patient is going to die without a particular

surgery, but the patient denies needing the surgery, what is there to do?

Before one admits to being in an ethical deadlock, other relevant facts and factors need to

be gathered and analyzed. One of which is Mrs. Heaths mental health history. Mr. Heath notes

that he remembers [Mrs. Heaths] doctors saying this might happen as she ages, but she appears

not to remember this, and seems unable or unwilling to accept that she needs surgery. In other

words, doctors and hospital staff should sit down with Mr. Heath and talk about the nature of

Mrs. Heaths mental health. Does she not remember things a lot? Does she get easily confused?

Has something like this ever happened before? It seems likely that Mrs. Heath has a history of

deteriorating mental health, and that this might be the cause of her reaction to the situation.

Similarly, any medication that Mrs. Heath is taking should be made known in this case,

as well as previous, non-mental health related medical history. As per the topic above, it might

also be useful to know (via Mr. Heath) Mrs. Heaths past attitudes and behavior when dealing

with medical professionals since it seems like theyve been in similar situations before.

Communication issues might also be playing a role here. Mrs. Heath may not fully

understand everything Dr. Carter is presenting on the PowerPoint, especially if he ends by saying
Adrian Rutt, 541
4

that without the surgery Mrs. Heath will most likely die. Mrs. Heath may be reacting poorly

(though understandably) to the fear of impending death. It stands to be questioned whether or not

Dr. Carter is communicating the issues of the situation in the most effective manner. It might be

useful to consider bringing in a social worker or someone who specializes in communication to

try to relate to Mrs. Heath and present the situation in a different light.

Lastly, it is important to know what precisely are the chances that Mrs. Heath will die

during the surgery. The case merely states that Dr. Carter explains to Mrs. Heath the data on

chances of death during surgery, but it seems to me that the exact numbers are not only

incredibly relevant but important for all the parties to know explicitly.

The primary ethical problem, then, is that Mrs. Heath is in denial about her health

situation, and because she is in denial about it, she is refusing the only treatment that will

prolong her life. In other words, Mrs. Heath is going to die unless she comes to terms with the

reality of the situation. Mr. Heath, Dr. Carter, and hospital staff are caught between wanting Mrs.

Heath to live and respecting her autonomy to make medical decisions for herself. The problem

isnt that Mrs. Heath is aware of the consequences of not doing the surgery and wishes to die; its

that she doesnt even acknowledge that something is wrong with her. If Mrs. Heath simply

wished to let nature take its course, saying death will come when it comes, there would be little

to no ethical problem in this case. Its precisely because shes in denial that the case raises ethical

difficulties. What makes the case even more problematic is the fact that Dr. Carter explains to

Mrs. Heath that she has a 60% chance at recovery and also explains that theres a chance (again,

not explicitly stated) that she might die during the surgery. All of these things make the ethical

dilemma more difficult, but are secondary to getting Mrs. Heath out of denial.
Adrian Rutt, 541
5

It seems that to continue down the same path of trying to get Mrs. Heath in the hospital

so Dr. Carter can try once more to explain the situation is not going to work, especially if time is

becoming a factor. Although it is unclear what steps Mr. Heath has taken in between their visits

to the hospital, it seems that there has been little to no success at convincing Mrs. Heath of

anything.

I think Dr. should consult other hospital staff first a foremost. This includes getting Mrs.

Heath a psychiatric evaluation and possibly allowing a social worker to attempt to communicate

the situation to Mrs. Heath. Another option might be to coach Mr. Heath on some things that

he and his wife can talk about it the more relaxed atmosphere of their home. It is unclear that Mr.

Heath has tried to convince his wife, so if this option is still available it would be wise for Dr.

Carter to suggest it. These options assume an underlying respect for Mrs. Heaths autonomy, but

also work off the assumption that to continue down the same path will not result in anything

good and might actually harm the patient. These routes, that is, are the least invasive and rely on

persuasiveness. As Veatch notes, though, respect for autonomy doesnt rule out reasonable

attempts to persuade a patient to follow a course that the doctor believes to be best (Veatch, et

al, 30).

It is clear that if it is decided that Mrs. Heath is competent - which doesnt seem likely -

there is very little room to work in this case. If, however, on the off-chance that Mrs. Heath is

deemed not competent enough to make such a decision, I assume the powers turn over to her

husband, Mr. Heath. In this case, both Dr. Carter and Mr. Heath would go through with the

surgery based on principles of beneficence (she will live longer) and nonmaleficence (she would

die without the surgery), though autonomy wouldnt entirely be in tact.

Adrian Rutt, 541
6