Interesting ethics scenario

[onaliseth]

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Paul Cook, age 12, advanced bone cancer. The tumor above his knee has already spead to his leg and doctors are worried it may spread to his lungs soon, at which point the cancer will inevitably cause death within 1 year. The medical team suggest amputation of the leg as soon as possible to prevent the cancer from spreading further. The estimated success rate of immediate amputation combined with chemotherapy is 65%.

Paul's parents do not want the amputation. They are Christian fundamentalists who seriously doubt in conventional medicine and want to send Paul to a private alternative medicine clinic in Costa Rica which apparently does cancer treatment in the form of specialized diet, herbs, and shark cartilage. These treatments are obviously evaluated as useless by the medical team and will most certainly cause Paul to die at the clinic. Paul shares his parent's view and does not want to lose his leg. He's a remarkably intelligent and well-spoken young boy who fully understands his own predicament. No one questions his parents' unconditional love for him and the fact that they sincerely think they are trying to save their son's life in the name of their faith.

Social services demands Paul be taken out of his parent's custody and that he goes through with the amputation and chemo.

Who should decide on Paul's well being - the State or himself and his family? Do the doctors have a responsibility to intervene against the family's wishes if it means saving his life, or respect the family's wishes and fundamental values?

 

[da8s0859q]

Paul Cook, age 12, advanced bone cancer. The tumor above his knee has already spead to his leg and doctors are worried it may spread to his lungs soon, at which point the cancer will inevitably cause death within 1 year. The medical team suggest amputation of the leg as soon as possible to prevent the cancer from spreading further. The estimated success rate of immediate amputation combined with chemotherapy is 65%.

Paul's parents do not want the amputation. They are Christian fundamentalists who seriously doubt in conventional medicine and want to send Paul to a private alternative medicine clinic in Costa Rica which apparently does cancer treatment in the form of specialized diet, herbs, and shark cartilage. These treatments are obviously evaluated as useless by the medical team and will most certainly cause Paul to die at the clinic. Paul shares his parent's view and does not want to lose his leg. He's a remarkably intelligent and well-spoken young boy who fully understands his own predicament. No one questions his parents' unconditional love for him and the fact that they sincerely think they are trying to save their son's life in the name of their faith.

Social services demands Paul be taken out of his parent's custody and that he goes through with the amputation and chemo.

Who should decide on Paul's well being - the State or himself and his family? Do the doctors have a responsibility to intervene against the family's wishes if it means saving his life, or respect the family's wishes and fundamental values?

Former Justice Holmes comes to mind; "The right to swing my fist ends where the other man's nose begins."

Paul & Co. are signing a death warrant, but that's also what they want to do, having presumably had everything laid out for them.

Similarly, I accept the fact that I may be killing myself when I jump out of planes. A different story, but a similar ideal.

The fact that the alternative treatments has a ~0% chance of seeing the kid through any great length of life is immaterial compared to the fact that I do not think it's the State's position to force medical treatment onto someone - a minor, no less - when he as well as the parents are dead-set against it.

Docs have a responsibility to see people to good health, but I do think they're crossing a line when they start forcing the issue. It's like sticking a life-saving tube into some Jehovah's Witness to pump some blood into the guy to replace the 50% or so blood volume he's lost between a traumatic accident and bleeding in the ED; might save the guy's life, but... still.

 

[lord_jeebus]

If the kid was 1 year old, I'd say amputation and chemo.

If the kid was 18, he can do whatever he wants.

So I think it's a question of whether or not he is capable of making his own adult-level health care decisions. If he is indeed "remarkably intelligent," and able to explain in his own words (with his parents out of the room) why he thinks herbs are best for him, I think that his wishes should be respected.

What if instead of wanting alternative medicine, he and his parents just said that they wanted to put him in hospice and let him travel the world before he dies, instead of going through painful surgery and chemo. The question of who makes the decision should have the same answer, but it may be easier to sympathize.

 

[Tired]

Minors do not have the right to make medical decisions except in very limited realms that are clearly spelled out by the law. Parents do not have the right to refuse lifesaving treatment for their children, regardless of the reason behind it. This isn't really a dilemma at all, as the only reasonable (and legal) course of action is for the state to intervene.

 

[Droopy Snoopy]

If it were up to me I'd saw the kid's leg off, put him in one-legged foster care, and sell his parents on the black market for scrap organs to pay the chemo bills. He'll thank me one day F it man, medicine has enough to do without hounding these brainwashed idiots to get care they don't want, won't pay for, and won't appreciate.

 

[Quix]

I want to say that parens patriae justifies removing the kid from the parents' care, but I would have to look more into it - it's been a few years since I did anything concerning ethics and minors.

 

[NCF145]

Shark cartilage. 60% of the time it works every time.

 

[34140]

You also have to think about quality of life if amputating his leg will save his life. He can never be a 'normal boy'.

i'd let them go and do their costa rica thing`

 

[lumbering]

My judgement would probably depend on the details of the situation, but my general view is to allow the child/parents to make the decision, even if I view it as egregious.

My reasoning is as follows:

1) The purpose of life is entirely subjective. The premise of modern medicine is often that extension of life trumps all other factors, but some may prefer to risk death to avoid painful/disabling interventions. Some view life missing a limb is meaningless. Some view chemotherapy as crude degrading torture. To me, this is a defensible position.

2) Belief in Christianity completely warrants refusal of medical treatment. If a sentient, omniscient, omnipotent, omnibenevolent supreme being exists, it becomes unclear that conservative therapy is less effective. Such a being could intervene at any time to alter the course of the disease...even if the statistical prognosis is poor. Many people believe that God created certain plants in part for our exploitation for medical purposes. If this is true, it is reasonable to believe that diet, herbs, and shark cartilage could have unexplainable potent healing powers. Furthermore, if there is an afterlife, there is little point in artificially extending life on Earth. By doing so, we may be causing unnecessary suffering and preventing this child from entering an eternal bliss.

3) This is, in effect, a classic clash between beneficence and autonomy-the desire to do good for our patients while allowing them the freedom to make their own decisions and guide their own care. Autonomy is more important, and when both child and parents agree, the most appropriate action is to fully inform them, to try to convince them, but not to force treatment of any kind. When the child is one year old, the autonomy of the child is held entirely by the parents, and so long as they are fully competent and acting in what they believe is in the best interest of the child, beneficence must be put aside. In the case described by onaliseth, the parents are competent because even though they believe something which may be false, this belief is consistent with their overall longstanding worldview. That is, they are not delusional. I would...with much melancholy and some anger...allow this hypothetical helpless child to die. Perhaps I am a coward.

 

[Slide]

I would let the kid and his parents do whatever he wants. My reasoning is:

Out of the four major principles of medical ethics, patient autonomy is the most important one in this case, clashing with beneficence. (the others being justice and nonmaleficence ). The current attitude in the US medical system is that patient autonomy overrides the state's decisions if 1) if the individual has the capacity to make an informed decision, 2) the patient or his surrogate decision makers express willing intent for his decision, and 3) after hearing both sides, the decision-maker is fully aware of his choices and still wishes to continue with his choice.

I may disagree with the patient making a decision that pretty much seals his death, but I am pretty sure that if this were to come up in a legal case, the judge would rule in favor of patient autonomy (unless GW and friends got involved).

 

[PeepshowJohnny]

This is basically the same situation as when kids of Jehovah Witness refuse blood transfusion, the hospital ends up giving it anyway. The logic is that as the kid has not reached the age of majority, he has not be been able to make an uncoerced choice as to if he will follow that religion and its tenants. Similar situation here, the 12 year old isn't competent to decide wether he'd want treatment or follow his parent's religious beliefs. The state steps in and forces the amputation.

 

[DoctaJay]

If it was something as simple as a blood transfusion to save the boy's life I might push the issue a little more. But cancer changes people's normal decision making process. For alot of people, going through horrors of chemo itself is worse than dying from the cancer. Others have seen countless family members go the traditional route and still die. Other's have see the traditional route work and then the cancer come back with full vengence. Often times the non-traditional doesn't work. Sometimes the parents can view it as a catch 22. Personally I'm not in favor of forcing the parents to make the decision, even though it may be better to amputate the leg, but unfortunately (in some cases) the parents are in charge and its their decision to choose teh best route for their child.

 

[Depakote]

I say let the kid go... his parents want it, he wants it.

It's cancer. He has a 2/3 shot at surviving the treatment and getting into remission. I'm assuming this does not include relapse and secondary malignancies. Cancer treatment itself is a *****, if he isn't jumping at the chance to have is leg removed and his actively dividing cells nuked to hell, I can understand his and his parent's hesitation, especially with that 1 in 3 chance that it will be all for nothing in the short-term, anyway.

State intervention would be medical paternalism going a bit too far.

 

[Gut Shot]

Who should decide on Paul's well being - the State or himself and his family?

This reminds me of the Starchild Abraham Cherrix case:

"...for all his apparent sophistication and thoughtfulness, is still a teenager living at home under the strong influence of his parents and their values. It is not clear that he will choose to pursue the lifestyle, philosophy or stance toward medicine that his parents exhibit when he reaches adulthood. As he broadens his experience of the world and attains greater independence he may or may not reject traditional medicine."

 

[PreMD86]

I don't really see the ethical dilemma? People are allowed to consume alcohol, cigarettes, and fast food to their clogged heart's desire. Do doctors force them to diet or quit drinking/smoking? Do parents ever lose their kids for condemning them to a life of obesity?
Doctors are supposed to serve as the interface between science and the general population, and to merely be health consultants to their patients. In no way should a doctor ever force a patient to consent to a procedure or prescription, no matter how beneficial it may be. Doing so simply compromises doctor-patient relationship to an extent that is inconceivable.

Bottom line: Its a free country- let the kid and his parents do whatever the heck they choose.

 

[Gut Shot]

In no way should a doctor ever force a patient to consent to a procedure or prescription, no matter how beneficial it may be.

If the patient in this dilemma were legally capable of making his own decisions, I would agree with you... but then it wouldn't be much of a dilemma. Doctors can and do force unconsented procedures onto minors or the incapacitated if it is deemed lifesaving. Sorry, but we sometimes have to act as a little more than a liason. Get used to it.

 

[MattD]

Minors do not have the right to make medical decisions except in very limited realms that are clearly spelled out by the law. Parents do not have the right to refuse lifesaving treatment for their children, regardless of the reason behind it. This isn't really a dilemma at all, as the only reasonable (and legal) course of action is for the state to intervene.

The question being posed is one of ethics, not law. I'm not saying I disagree with your ends, but law does not always equal ethics. They're worth discussing separately from one another.

 

[PreMD86]

If the patient in this dilemma were legally capable of making his own decisions, I would agree with you... but then it wouldn't be much of a dilemma. Doctors can and do force unconsented procedures onto minors or the incapacitated if it is deemed lifesaving. Sorry, but we sometimes have to act as a little more than a liason. Get used to it.

Please define lifesaving? The problem with calling a procedure with 65% success rate "life-saving" is the slippery slope it sets up for where to draw the line. Is 10% success rate still worth the loss of patient confidence? What about a procedure with 1% success rate compared to the herbal treatment at 0%?

Besides, from my understanding, when the patient is a minor or incapacitated, their health care proxy has full legal right to decision making.
If the proxy is not there and a decision has to be made immediately, I understand doctors making the decision most beneficial to their patient.

Also, I believe doctors have an obligation to make medical decisions that increase the quality of one's life, not the quantity. No doctor is qualified to conclude an amputation is preferable to death. I think it is, most sane individuals think it is as well, but it's a decision only the boy's parents can make for themselves.

 

[Bravofriendly]

Please define lifesaving? The problem with calling a procedure with 65% success rate "life-saving" is the slippery slope it sets up for where to draw the line. Is 10% success rate still worth the loss of patient confidence? What about a procedure with 1% success rate compared to the herbal treatment at 0%?

Besides, from my understanding, when the patient is a minor or incapacitated, their health care proxy has full legal right to decision making.
If the proxy is not there and a decision has to be made immediately, I understand doctors making the decision most beneficial to their patient.

Also, I believe doctors have an obligation to make medical decisions that increase the quality of one's life, not the quantity. No doctor is qualified to conclude an amputation is preferable to death. I think it is, most sane individuals think it is as well, but it's a decision only the boy's parents can make for themselves.

Nicely put. My thoughts exactly.

 

[Sartre79]

Kid is a minor, disease is not immediately reversible so Doc has to do what parents say.

 

[Gut Shot]

Please define lifesaving?

Although I didn't explicitly state it, I wasn't really referring to the specific quandry posed in this thread. The classic example of administering "lifesaving" therapy against parental wishes is, of course the Jehovah's Witness scenario (which does play out in real life, from time to time).

Besides, from my understanding, when the patient is a minor or incapacitated, their health care proxy has full legal right to decision making.

Some states are different than others, but in my home state there is a well established system for obtaining a court order to treat in emergent cases, even against parental wishes.

No doctor is qualified to conclude an amputation is preferable to death. I think it is, most sane individuals think it is as well, but it's a decision only the boy's parents can make for themselves.

I know what you're saying, but look at it like this: if you allow the boy and parents to head off to Costa Rica, pretty soon you have a dead boy. If the state intervenes and the treatment is performed, fifteen years down the road you may have an adult (we'll call him Hop-Along) who says "Gee, thanks, Doc, after I grew up I decided that my parents are both batsh*t crazy and I'm really glad you stepped in and saved my life, even though I didn't want you to at the time."

That, to me, is the crux of the decision to intervene. The parents are not acting in the best interests of their son, and the son isn't old enough to know what his best interests are. I'll take a 65% chance of having a one legged teenager who's pissed at me. It would be preferable to a lifetime of wondering what might have happened had the state intervened.

 

[PeepshowJohnny]

Kid is a minor, disease is not immediately reversible so Doc has to do what parents say.

No treatment is 100%. Look at ALL in kids. It's not immediately reversible, but the success rate they've gotten is so good now, that if you were a parent who's child was diagnosed with it and refused treatment, you'd be hard fought to win the right.

But aside from the law, I still think it's the morally correct thing to do to override the parents in this situation and get the kid the amputation. In all honesty, this kid (if he were to live his life out naturally, without having ever got cancer) would probably have grown up to share the same beliefs and idea as his parents. So, if it were PAUL'S child, he'd make the same situation. Outside of minor quibbles, people usually end up believing the same things as their parents more often than not.

However, there are always the kids who are totally different. You know, kids who were brought up in cults and grew up and ran away from it. The child who's parents are hardcore Christians and he's an atheist (or visa versa). Even though it's not the most common thing, there's a decent chance that if we took cancer out of the equation, Paul would grow up and be the kind of person who would disagree with his parents and wish for an amputation.

Letting the kid go without treatment guarantees his death and prevents him from ever reaching the age of majority and precludes the possibility that he would ever grow up to change his mind. That is morally unacceptable.


Or for thos who want the short form:
The ONLY ethical choice in this scenario is to preserve the child's autonomy. The only way to preserve the child's autonomy is to do everything within reason to allow him to reach the age of majority. Even if he reaches the age of majority and is pissed that he lost his leg (would have prefered to die) this was still the correct choice.

 

[PreMD86]

I know what you're saying, but look at it like this: if you allow the boy and parents to head off to Costa Rica, pretty soon you have a dead boy. If the state intervenes and the treatment is performed, fifteen years down the road you may have an adult (we'll call him Hop-Along) who says "Gee, thanks, Doc, after I grew up I decided that my parents are both batsh*t crazy and I'm really glad you stepped in and saved my life, even though I didn't want you to at the time."

That, to me, is the crux of the decision to intervene. The parents are not acting in the best interests of their son, and the son isn't old enough to know what his best interests are. I'll take a 65% chance of having a one legged teenager who's pissed at me. It would be preferable to a lifetime of wondering what might have happened had the state intervened.

Your shortcomings seem to be in your desire to step in and intervene regardless of the cost- That's good, it means you are compassionate about your patients and are likely a great doctor.
However, if you look at this objectively from an ethical persepctive, saving the boy is not worth the implications. If you intervene and make the choice for the parents, imagine how many parents of boys with similar diseases would be deterred from ever stepping foot in a hospital without ever having these life-saving options presented to them? How many boys would you save by reaffirming the patient-doctor trust that must underline every decision made? How many patients made sure to tattoo "DNR" on their chests after Terry Schiavo? The ends just simply do not justify the means.

Another hole in your arguement is your assumption that the boy would grow up to thank you for your actions. What if, theoretically, the boy grows up to be the next hitler- all thanks to your decision.
What it all seems to boil down to is your belief that life is always preferable to death. If it is for you, fantastic, chop off your kid's leg. But some people have different beliefs than yours or the states, and must be respected above all.

 

[PreMD86]

That, to me, is the crux of the decision to intervene. The parents are not acting in the best interests of their son, and the son isn't old enough to know what his best interests are. I'll take a 65% chance of having a one legged teenager who's pissed at me. It would be preferable to a lifetime of wondering what might have happened had the state intervened.

Another thing: To people who believe administering medicine condemns you to eternity in hell, refusing treatment IS their way of acting in the best interest of their son. Until you can prove them wrong, I think it is unethical to call them crazy and intervene.

 

[The Angriest Bird]

Losing one leg is a big deal. But just think about how many people who live happily with a missing leg, or even more than that. And who says they can't be highly achieved individuals? Whenever in doubt, look at Stephen Hawking and FDR.

 

[Gut Shot]

Another hole in your arguement is your assumption that the boy would grow up to thank you for your actions.

I actually don't assume this. I even say "may" and italicized it in my above post. Indeed, the 12 year old may grow up and resent being saved at the expense of his leg. That's a risk, but compared to the certitude of death it's one that I would take. If it were easy it wouldn't be a very good dilemma.

The construction of this ethical conundrum is quite clever in a few places. Notice how the therapy only offers a two thirds chance of success, and notice how the boy is described as being very intelligent. Red herrings, I say.

(One legged Paul Cook) x (0.65) x (Odds of later resentment) > Dead Paul Cook

If you want to see a real case of paternalistic medicine run amok, read up on the Donald "Dax" Cowart case.

 

[Gut Shot]

Another thing: To people who believe administering medicine condemns you to eternity in hell, refusing treatment IS their way of acting in the best interest of their son. Until you can prove them wrong, I think it is unethical to call them crazy and intervene.

I'm sorry, but as a pragmatist we simply have to draw the line somewhere. Religious beliefs, however sincere, do not confer immunity from our laws and societal standards. If a couple believed that sodomizing their children would save them from eternal Hell, would you stand back and let them have at it?

 

[Gut Shot]

P.S. For what it's worth, on a personal level I agree with you. Anyone who wants to send their kid to Costa Rica for herbal treatment of an osteosarc needs to have his/her toes yanked from the gene pool. Alas, my ideal of professional neutrality sometimes gets in the way.

 

[smq123]

Another thing: To people who believe administering medicine condemns you to eternity in hell, refusing treatment IS their way of acting in the best interest of their son. Until you can prove them wrong, I think it is unethical to call them crazy and intervene.

Not in a legal sense.

Jehovah's Witnesses do not believe in using donor blood products, so they will refuse to accept blood even in cases of trauma or surgery. And that's fine, as long as they are adults. The children of Jehovah's Witnesses, on the other hand - you can give them blood products, even if their parents scream and kick.

 

[Gut Shot]

The children of Jehovah's Witnesses, on the other hand - you can give them blood products, even if their parents scream and kick.

I don't know if you've encountered this personally, but the parents almost never scream and kick. One of the nuances of their belief system (which has evolved since this became an issue) is that the consent is really the kicker. Junior's soul will be spared as long as they don't consent to the treatment. When the decision is removed from the parents they're almost always quite relieved. Junior gets to live and everyone still has access to Heaven.

 

[smq123]

P.S. For what it's worth, on a personal level I agree with you. Anyone who wants to send their kid to Costa Rica for herbal treatment of an osteosarc needs to have his/her toes yanked from the gene pool. Alas, my ideal of professional neutrality sometimes gets in the way.

Heh.

 

[Gut Shot]

Losing one leg is a big deal.

Only if it's the third leg.

 

[Gut Shot]

If you intervene and make the choice for the parents, imagine how many parents of boys with similar diseases would be deterred from ever stepping foot in a hospital without ever having these life-saving options presented to them? How many boys would you save by reaffirming the patient-doctor trust that must underline every decision made?

Ummm, zero. How does zero sound? Look, however vivid these little scenarios are, they occur with rarity in real life. If I understand correctly, by your logic we're supposed to let Paul die so that other parents won't hesitate to bring their kids to us... so we can stand by and watch their kids die from otherwise curable diseases. Yeah, you need to chew on that one a bit longer.

How many patients made sure to tattoo "DNR" on their chests after Terry Schiavo?

Everyone who wanted to, I hope.

 

[cbass1350]

god the media would have a field day with this

 

[Sartre79]

No treatment is 100%. Look at ALL in kids. It's not immediately reversible, but the success rate they've gotten is so good now, that if you were a parent who's child was diagnosed with it and refused treatment, you'd be hard fought to win the right.

But aside from the law, I still think it's the morally correct thing to do to override the parents in this situation and get the kid the amputation. In all honesty, this kid (if he were to live his life out naturally, without having ever got cancer) would probably have grown up to share the same beliefs and idea as his parents. So, if it were PAUL'S child, he'd make the same situation. Outside of minor quibbles, people usually end up believing the same things as their parents more often than not.

However, there are always the kids who are totally different. You know, kids who were brought up in cults and grew up and ran away from it. The child who's parents are hardcore Christians and he's an atheist (or visa versa). Even though it's not the most common thing, there's a decent chance that if we took cancer out of the equation, Paul would grow up and be the kind of person who would disagree with his parents and wish for an amputation.

Letting the kid go without treatment guarantees his death and prevents him from ever reaching the age of majority and precludes the possibility that he would ever grow up to change his mind. That is morally unacceptable.


Or for thos who want the short form:
The ONLY ethical choice in this scenario is to preserve the child's autonomy. The only way to preserve the child's autonomy is to do everything within reason to allow him to reach the age of majority. Even if he reaches the age of majority and is pissed that he lost his leg (would have prefered to die) this was still the correct choice.

There is a distinct difference b/t Cancer and Say Critically high insulin levels, or some other disease that is non-emergent (from a relative standpoint). A physician would treat the high insulin levels and report the parent for abuse in the later, but the nature of the disease and the parental/child wishes overrule in the former situation (cancer). It is a hospital/clinic, not a prison. We just covered this in our ethics class.

 

[PeepshowJohnny]

There is a distinct difference b/t Cancer and Say Critically high insulin levels, or some other disease that is non-emergent (from a relative standpoint). A physician would treat the high insulin levels and report the parent for abuse in the later, but the nature of the disease and the parental/child wishes overrule in the former situation (cancer). It is a hospital/clinic, not a prison. We just covered this in our ethics class.

There is a distinction, but only in time. The principles are still the same: you have to ensure the kid gets adequate treatment for his disease.

Scenario A: Kid shows up with insulin overdose. Parents are screaming "Don't treat him, don't treat him!" In this situation, I'm bulldozing my way through the parents to get to the kid if I have to. There is no time to attempt to address the parents complains. Maybe they're crazy, maybe they're hysterical, maybe they're just stupid. The one hypothetical situation I can think of is if a kid shows up who's got a terminal condition and he's on comfort measures (but he should be in a hospice program amd not going to the hospital anyway). Regardless, all you can focus on is keeping the kid alive at this time because it's an emergency.

Scenario B: I diagnose kid with acute lymphoblastic leukemia in my office. Parents say they don't want chemo. Now, this kid neats treatment (and the parents don't have the right to refuse for the ethical reasons said many times before). However, this kid isn't emergently dieing. I've got some wiggle room. I can talk to the parents for hours to address their concerns. I can call a family conference. I can have a religious/ethics conference and bring in their religios representative, one from the hospital, an ethics board, etc. And if all my maneuvering fails, THEN I go the legal route and get the kid treatment.

While the tactics are different, the principle remains the same; parents can't refuse reasonable medical treatment on their minor children's behalf.

---

On another note, for all the people willing to cut this kid completely loose, you still have other issues to address other than if you're going to lop this kid's leg off or not. This kids got an osteosarcoma. He's already probably in a great deal of pain, and it's just going to get worse. Also, you need to address this kid's mental health. If you let this kid loose to some sham psychic surgeon or herbalist, he's not only going to die (which may even happen if you amputate) but die a miserable death. These issues need addressed as well.

 

[PreMD86]

Say you force the kid to have treatment. Who should have to pay the bill?

Now that's an ethical dilemma. Well played, sir.

 

[Flaxmoore]

Say you force the kid to have treatment. Who should have to pay the bill?

The physician. The parents (and child, which in this case is significant) both declined the treatment. The doc's doing it so they can sleep at night, so the doc should pay.

 

[PreMD86]

The physician. The parents (and child, which in this case is significant) both declined the treatment. The doc's doing it so they can sleep at night, so the doc should pay.

So, the way to free health care for the 40+ million uninsured is to simply refuse treatment? Score, I'll make a mental note next time I go in for something really expensive.

 

[soonereng]

I liked the legal/ethical situation brought up on ER last week. A guy got shot in the back during a burglary and wanted to decline surgery to remove the bullet from his vertebral body becuase it could be matched to the gun of the clerk he held up. Said clerk, the only witness, was in a coma having been hit himself. A court forced him to have the surgery. If he would have left the bullet where it was, he might have become paralyzed. He was willing to take that risk to avoid prosecution. Thoughts?

Kind of similar to forcing people to give swabs for DNA samples. For me, this seems to be violating a person's fifth amendment rights.

nor shall be compelled in any criminal case to be a witness against himself

You are in essence being forced to be a witness against yourself.

The forefathers surely could not foresee this development, but it would be interesting to see what the language would read had they known, to see if they truly intended for people to be able to withold evidence in cases against them.

 

[PeepshowJohnny]

I
I liked the legal/ethical situation brought up on ER last week. A guy got shot in the back during a burglary and wanted to decline surgery to remove the bullet from his vertebral body becuase it could be matched to the gun of the clerk he held up. Said clerk, the only witness, was in a coma having been hit himself. A court forced him to have the surgery. If he would have left the bullet where it was, he might have become paralyzed. He was willing to take that risk to avoid prosecution. Thoughts?

I thought that episode was ridiculously stupid. The principle is good but the way the characters acted is unbelievable and they bungled it. You have this guy who LIES about why he has pain, when confronted that he has a wound on his back he LIES that he got it from work, when they confront him it's a bullet wound LIES about being a driveby victim, and then everyone suddenly decides to believe his preposterous story that he was hanging around at the store and got confused with one of hte robbers when he tried to stop them? For somebody who's been an ER for a decade now, Abby acted like a ******. Quality of the show is in the dumps.

 

[Flopotomist]

One of the other things to consider here - the parents who are adamently against medical intervention drove their kid to a physician at some point. Why?

I think one of the best ways to consider this philosophically is to use the Rawl's technique of "stepping behind the curtain."

To do this, the decision maker imagines that he will step behind a curtain, make a decision, and when he emerges from behind the curtain, he magically may end up being any of the individuals affected by the decision.

I certainly would opt for the hope of life in that case as opposed to certain death.

 

[Terpskins99]

Minors do not have the right to make medical decisions except in very limited realms that are clearly spelled out by the law. Parents do not have the right to refuse lifesaving treatment for their children, regardless of the reason behind it. This isn't really a dilemma at all, as the only reasonable (and legal) course of action is for the state to intervene.

Yop, thats the law. If parents are against lifesaving treatment, then the state is permitted to intervene with an underaged patient. The minor's wishes are irrelevant. This is a common question that pops up on boards.

 

[Terpskins99]

The question being posed is one of ethics, not law. I'm not saying I disagree with your ends, but law does not always equal ethics. They're worth discussing separately from one another.

Who says the law is independent of ethics? Laws were written in order to enforce ethics.

Anyhow, I notice that some people are answering the question either based upon what they would prefer to do versus what they are required to do. I think both responses are important to discuss simultaneously.

 

[osli]

The law is pretty clear in this case, at least in the US.

Ethics is another story. Our law is based on our system of ethics, but it is not the only one, and even within our deontological medical system there are different views of what elements are most important. Anyone in this thread can answer the question with respect to his/her own ethics, or alternatively can answer the question with respect to the prevailing ethical model of the US medical system (mostly equivalent to the law), but no one can provide a definitive ethical response that is equally valid for all persons everywhere.

You can't simply state "the parents are not acting in the best interests of their son" and it be unequivocally true. "Best interest" is something that can only be defined within an ethical framework, and other persons may have a different framework than ourselves. And we can't declare theirs "invalid" simply because it is different.

I'm not saying that all ethical systems are equally valid, but there is certainly more than exactly one such valid system.

The "dilemma" is what it is precisely because there is no universal ethically correct answer.

 

[45408]

In no way should a doctor ever force a patient to consent to a procedure or prescription, no matter how beneficial it may be. Doing so simply compromises doctor-patient relationship to an extent that is inconceivable.

srsly? Suicidal patients are committed against their will. A delirious patient will get whatever treatment the team thinks is necessary.

 

[LJDHC05]

From what I remember, if the child and the parents are in agreement there is no basis for offering the minor autonomy because he essentially has it through his parents, under the assumption that he agrees with their views.

The parents are not denying the child due diligence in providing access to health care and therefore they are not technically neglecting him and the state's case for protective custody is more or less nullified.

Beyond that it's up to the parents to either grant an informed consent to accept the treatment offered by the physician, to seek alternative treatment with someone else or to withhold treatment completely.

That's the ethically based answer that will keep you from being sued and prevent the state from infringing on the patient's constitutional right to freedom of religion. In reality, it's a despicable case that will probably never come up in your pediatric oncology practice.

 

[Terpskins99]

From what I remember, if the child and the parents are in agreement there is no basis for offering the minor autonomy because he essentially has it through his parents, under the assumption that he agrees with their views.

The parents are not denying the child due diligence in providing access to health care and therefore they are not technically neglecting him and the state's case for protective custody is more or less nullified.

Beyond that it's up to the parents to either grant an informed consent to accept the treatment offered by the physician, to seek alternative treatment with someone else or to withhold treatment completely.

That's the ethically based answer that will keep you from being sued and prevent the state from infringing on the patient's constitutional right to freedom of religion. In reality, it's a despicable case that will probably never come up in your pediatric oncology practice.

As paraphrased from my source...

Parents cannot withhold life-or limb-saving treatment from their children.
The child cannot give permission. A child's refusal of treatment is irrelevant.

I believe this is an application of the Child Abuse Prevention and Treatment Act.

From the hospital's perspective, failing to provide life saving care to a minor would constitute medical negligence.

 

[LJDHC05]

As paraphrased from my source...

Parents cannot withhold life-or limb-saving treatment from their children.
The child cannot give permission. A child's refusal of treatment is irrelevant.

I believe this is an application of the Child Abuse Prevention and Treatment Act.

From the hospital's perspective, failing to provide life saving care to a minor would constitute medical negligence.

Thank god for ethics consults then...

 

[45408]

As paraphrased from my source...

Parents cannot withhold life-or limb-saving treatment from their children.
The child cannot give permission. A child's refusal of treatment is irrelevant.

I believe this is an application of the Child Abuse Prevention and Treatment Act.

From the hospital's perspective, failing to provide life saving care to a minor would constitute medical negligence.

There is then the question of whether or not it's "life or limb saving treatment," if the treatment may not produce the desired results. In this situation, it appears that the parents DO wish to seek out life-saving treatment - it's just that this treatment is not, shall we say, going to be in the category of evidence-based medicine.