Wednesday, July 11, 2007

Hospital Ethics: Limited Resources

Here's an ethical dilemma presented to my CPE group:

Mrs. CZ is a 71 year old woman who has a recently diagnosed lung cancer for which she has refused surgery and radiation therapy. She developed pneumonia distal to the tumor and was admitted to the community hospital in her rural county. She has shown no signs of improvement for 7 days and has continued to refuse treatment for lung cancer. She is now comatose and requires mechanical ventilation. The victim of an automobile accident is brought to the hospital with a crushed chest, apparent pneumothorax, and broken bones in the extremities. The patient requires a respirator immediately. Of the six patients on the six respirators in the unit, Mrs. CZ has the poorest prognosis. She seems unable to be weaned and thus would probably die if ventilatory support were discontinued. Should she be removed in favor of the accident victim?

How would you answer?


Keith Taylor said...

Being an engineer, I know absolutely nothing about hospital stuff other than what I can infer from your paragraph.

But I do infer this. If a rural county hospital has six respirators, then they can't be all that hard to come by. They can get on the phone and go borrow one from a neighboring county. In the mean time, they may have to put an intern on an air bag to manually aspirate someone in the hospital til it gets there. They should probably bring it in an ambulance.

Never ask a turbine guy a spare parts question.

I know this isn't where you meant to go with this line of questioning, but that is where I ended up. Sorry.

the reverend mommy said...

I would ask first 1) Has she signed a DNR of any sort? What does her living will say? Who is the immediate family and what are they saying? What stage is the Lung cancer? Stage I? Stage IV? The hospital will have had discussion with the family/Mrs. CZ about these issues. Do NOT remove from life support is any person in the family is making noises about it -- litigation time.

It seems a false dilemma BUT I understand the thrust of the dilemma is set up for you to wrestle with utilitarian ethics vs. deontological types of ethics. Those who subscribe to utilitarian types of ethics vis a vis John S. Mills would begin to list values of each life along with probabilities and prognoses etc.

I take a more deontological approach -- I would claim the obverse of Occam's Razor. That is not the law of parsimony but the law of complexity -- every situation is much more complex than it ever seems. There is always another solution -- as the prevous commenter said.

These types of cases are always reductionist to the point of nominalism, yet are valuable to determine heuristic maxims that can help guide decisions.

John Meunier said...

Wow. I love this.

The first two commenters just demonstrated a major criticism of ethics based on hypothetical quandaries.

People tend to resist the factual straight-jacket the situation proposes and see the cases as artificial and contrived to drive specific kinds of conflicts - which they usually are.

For me, I'd question the premise that taking the old lady off the ventilator is the best choice among our six ventilated patients.

If forced into the sharp-edged little box of the quandary, I'd say the obligation is to continue the care for the person already getting positive care.

Dan Trabue said...

"I take a more deontological approach -- I would claim the obverse of Occam's Razor."

I understood only about half of this sentence, but it sure sounds purty!

Larry B said...

Hmm. Like Keith, I am an engineer. I have no formal training in ethics. So when I look at the medical facts presented in the case, it appears to me that both patients are equivalent in that both need a respirator to survive.

We also know nothing more about the other patient such as their age, their family, their history. So the question for me becomes can the worth of an individuals life be judged solely on their abillity to make a full recovery. And I would not agree that this is a valid premise from which to make a judgement. As such, then I would make the decision that, as a physician, it would be unethical for me to remove treatment from a patient that would diretly result in a patients death, and would not remove her from the ventilator.

Matt said...

I would say that I am not qualified as a doctor (to make a judgment about either of the patient's medical care needs), a lawyer/judge (to make a judgment about the legality/appropriateness of either action), or as a pastor (to make an advisement about the ethics / morality of either action).

chris said...

I would shut off all of the machines in the hospital, get some fake tears brewing, appear on FOX news at 9pm that night and complain how all those poor people died because we didnt have socialized medical care....

boy i would make a good liberal wouldnt i?

/sarcasm off...

seriously though, as a DR/leader in an emergency situation, sometimes you have to make decisions about who lives and who dies... its not pretty, but it happens... that being said, im pretty sure that ethical and legal reasons would prevent removing the terminal patient from life support... at that point you would just have to do everything else possible to save the 2nd patient... there are always other options as were mentioned above, and ive never been in a hospital that wasnt full of bored interns just itching to kiss a residents ass... so finding ones to manually ventilate wouldnt be too hard... once youve done that, its a simple matter to find another facility to take the patient to, or to complete any procedures necessary to restore his normal breathing...

Dan Trabue said...

I would shut off all of the machines in the hospital, get some fake tears brewing, appear on FOX news at 9pm that night and blame it on the gays.

Boy, I'd make a good conservative, wouldn't I?!

the reverend mommy said...

Ooops. That's what I get when I get tired. I sure slip into seminaryspeak real fast.

rocksalive777 said...

I just had flashbacks to my Intro Ethics course. *shudder*

I'm with Johnny Mill on this one. To disagree with Rev. Mom, Mill's teacher, Bentham, may have tried to measure each life, but I feel that Mill would have suggested the doctors go for the surest bet. If the accident victim has a higher chance of living, the resources should be spent on him. Mrs. CZ's refusal of treatment (seemingly) indicates that she had made peace with her fate. Unless, of course, the victim is a murderer and Mrs. CZ is a saint, but I prefer to avoid the random objections such as this.

Now you say she has the worst prognosis. So are there any less extreme circumstances, such as a patient on a respirator whose life does not depend on the machine? (Ok, so I don't know if they use respirators for prevention, but it's worth a shot).

Anonymous said...

Based on my experiences as a physician in both Nebraska - truly Gods Country, despite what Texans might tell you! :) - and Missouri, what would most likely to happen is that the patient from the automobile accident would not be presented to the community hospital if they would not be able to adequately take care of that patient. The patient would most likely be transported to another nearby hospital that could accept and manage a trauma patient in which your scenario describes. EMTs and other emergency services personnel radio ahead to alert hospitals about the patient and the hospitals capability to accept.
Treating your scenario as is, if confronted with limited resources and the trauma patient has a better chance for survival, I would advocate terminating Mrs. CZ's ventilator for the trauma patient. Easy to say and do? Of course not. Tough times requires tough decisions. With a scaricity of resources, you try to slavage those who can be salvaged...period.
Just my .02cents.


Anonymous said...

In the mean time, they may have to put an intern on an air bag to manually aspirate someone in the hospital til it gets there.

Hey Buddy, I'm sure you meant ventilate! Aspiration is not a good thing, and as an anesthesiologist I guard against. To aspirate means when food or liquid enter the airway and could be fatal. Thanks for the chuckle! BTW, if I were in your domain I would not know the difference between a thingamajig and a do-hickey!


Gord said...

If the patient has not signed a DNR and the family (who would likely be pushed into the role of alternate decision makers if that patients wishes are not clear and teh patient is incapable of makingg a choice) are not willing to sign off on discontinuing care is it really a legal or ethical possibility?

THat being said, I do think that the reality of our medical systems (in both Canada and the US) are that some triaging is necessary. BUt then again, if the accident patient is that gravely injured, what is the gaurantee that she/he is any more likely to survive?

Oh and in my context neither would be in the small hospital I visit at--we don't have the equipment or staff to provide that support. Which one is better able to survive transport to another facility?

the reverend mommy said...

Yes, I agree. Mills would have weighed each life individually; thus it becomes utilitarian ethics in a very linear fashion.

My point exactly is that this is a False dilemma because of my second point: reality is alway much more complicated than it appears, that is life follows a law of complexity.

There is no "easy solution" because in reality there are no "easy problems."

There is no "edge of chaos" that can be described nor can self-organized criticality be proposed as a general paradigm for complex adaptive systems. Hence, there is no solution. These questions are non-linear.

the reverend mommy said...

That is they are non-linear in that they are iteratively related.

John said...

I'd pull the plug on Mrs. CZ given the restrictions of the scenario. This is true "battlefield triage" as one of the chaplains here at the hospital put it.

Either way, lawyers could make a killing from this scenario.

the reverend mommy said...

This is the classic "lifeboat" scenario (sometimes called the balloon debate.) They probably are looking to see how you reason it out. I'd prepare something over the "violin player" scenario (about abortion), the "Sherriff and the Mob" (going against the will of the crowd), the "Nurse and the Will" (patient non compos mentis writes new will that only the nurse knows about), and so on.

There used to be a document floating around with all of them somewhere on the internet...

BTW, CPE may have you come to one conclusion, but your BOOM may want others -- for instance, I believe that utilitarian ethics are too secular because they do not leave any room for the Providence of God. Call me a screaming conservative (yeah, right) for that one, but it is what I strongly believe.

John said...

Probably. There's the ethics of a committee of ministers with plenty of time on their hands to ruminate, the ethics of the emergency room physician who has a horrific decision to make, and only a couple of minutes to make it.

This is not the sort of decision that as pastor I would ever have to make. But it is the sort of decision that doctors face.

DannyG said...

Time to whistle up a Med-Evac flight!