What is the nature of the world around you

PHI-413V Lecture 5

Intervention and Ethical Decision Making

The application of bioethical principles in the context of different worldviews and religions will be the goal of this topic. Different models of ethical decision making suggest different steps and priorities, but the important thing to note is that all models are attempting to organize all of the relevant information in a case so that nothing is left out of consideration. Still, the way in which all of the relevant details in a case are considered will always take place within the context of a worldview. As such, the most important determinant of a bioethical decision is not a methodology but the worldview context in which the the methodology is functioning. Consider then how the Christian biblical narrative determines the values that are deemed relevant or important in a case and how different worldviews would impact the decision making in different cases.

Consider the following analysis from a Christian perspecive of the case study “End of Life and Sanctity of Life” in the American Medical Associations Journal of Ethics (Available in Loud Cloud readings). That case is analyzed from a Jewish and Buddhist perspective by different commentators. This case will be analyzed by addressing the four principles in the principalist approach, and then consider that data in light of the Christian worldview in order to recommend a course of action in accordance to Christian values and biblical principles.

Recall that the four principles of principalism include (1) autonomy, (2) beneficence, (3) nonmaleficence, and (4) justice. Depending on the case, different principles will come to have greater prominence in deciding an ethical course of action. At times there may be conflicts among the principles themselves, in which it will have to be determined which principle will have the greater priority. For example, a common conflict is that between a patients autonomy and what a physician considers to be beneficent, or in the best interests of the patient. A physician might see that a particular course of treatment will be beneficial for a patient (beneficence), and yet the patient refuses the treatment (autonomy). Should the physician simpy allow the patient to choose for themselves a course of action that will knowingly bring them harm? Is it right for the physician to coerce or force a patient to undergo a treatment against his or her will, and violate their autonomy, even if it will bring about some medical benefit?

How do the four principles apply to the case of 82 year old Mrs. Jones?

Autonomy: In this case, Mrs. Jones is incapacitated; she has been unconscious for two days and has no ability to communicate her desires for or against treatment. This is further complicated by the fact that she left no advance directive (a legal document that details her wishes for or against certain kinds of medical treatment should she ever become incapacitated such as a living will or a healthcare power of attorney). While Mrs. Jones’ family and the physian disagree about the appropriate treatment for her, it seems that determining what Mrs. Jones would have wanted is not possible. Thus, while her autonomy is certainly to be respected, in this case it is not something that is able to be obtained, given her condition (she would technically be considered incompetent and unable to exercise autonomy in her current condition).

Beneficence: Dr. Rosenberg believes that it will be in Mrs. Jones best interest medically to be put on temporary dialysis. He believes it to be the beneficent course of action; that which will bring about her good. Mrs. Jones’ family believes that dialysis will be a cause of undue suffering for her, and thus do not consider it to be the beneficent course of action. The fundamental disagreement lies here. Two parties, who are not Mrs. Jones’ herself, and who presumably do not have information about how she would have decided for herself, disagree about whether or not an action is truly beneficent for her. The principle of non-maleficence is closely related.

Nonmaleficence: Not only does Dr. Rosenberg have a moral duty to promote Mrs. Jones’ good, but he has a corresponding negative duty to not inflict evil or harm upon her. Mrs. Jones’ family believes that to place her on dialysis would inflict harm and suffering on her. Dr. Rosenberg believes it to be his duty to place her on dialysis, and that to not do so would be harmful to her. Dr. Rosenberg’s dilemma involves the belief that withholding treatment that has a good chance of restoring Mrs. Jones back to health with little risk is immoral.

Justice: Questions of justice usually come to the forefront in terms of the equal and fair distribution/allocation of medical goods and services (i.e., organ donation, health insurance, etc). In this case this principles does not play a major role. It might be said that it is unjust or unfair for Mrs. Jones to not decide for herself. But in the terms of this class, that concern would more appropriately be a question of autonomy, beneficence and nonmaleficence.

The above discussion sketches out how each principle would be relevant to or apply to Mrs. Jones’ case. But notice that you do not automatically have an answer to this dilemma. What should be done ethically? To answer this question, it is necessary to consider the four principles in light of an overarching worldview. Thus, how ought a Christian think about this dilemma?

To begin with, it is important to note that the Bible holds that all life is sacred (Gen. 2:7, Ps. 139:13-16, Exod. 20:13). Thus, whether a life is at its begging or end, it is valuable and sacred.

The dilemma in Mrs. Jones’ case is directly related to her perceived quality of life. Her family (presumably if they are being honest) does not desire that she remain alive and suffer. They perceive it better for her to stop living, than for her to continue living in a poor quality of life in which she would suffer. Dr. Rosenberg believes that her life is sacred, and that her quality of life is not so bad as to warrant ending her life early, if it can be saved with reasonable effort and low risk. For the Christian, while quality of life certainly matters, it does not determine the value of a life, or the worthiness of living for a person.

You might ask why exactly Mrs. Jones’ family is so ready to give up on a treatment modality (temporary dialysis) that will likely succeed? Meilander notes the importance of taking care of those in need and accepting their dependence upon those who love them and vice versa, accepting your own dependence when you are incapacitated, upon those who love you (2013, pp. 85-88). The reticence on the part of Mrs. Jones’ family seems to communicate a lack of willingness to deal with her care. It seems as if they want it to be over with, instead of fulfilling their duty to care for her and be active partners with Dr. Rosenberg in decididng what is in her best interest.

From the Christian perspective, it would be true that if Mrs. Jones had a personal relationship with Christ, her quality of life or existence would be improved dramatically were she to enter into God’s presence directly by way of her earthly passing. However, it would be radically mistaken to believe that it is up to some one other than God when that time would be. Does a refusal of dialysis constitute a reasonable decision? Or does it constitute a decision that functionally denies the opportunity for healing and thus denies God’s prerogative? It seems more likely that it is the latter.

In brief, it seems that Dr. Rosenberg is justified in his refusal to refuse reasonable and low risk treatment for Mrs. Jones. Ultimately, it seems that Mrs. Jones’ family does not want to take responsibility for her care, and is instead opting to determine her worth or value based upon a perceived quality of life.

In your own case study, consider how each of the four principles apply, and analyze those facts in terms of a wider worldview or religion. All ethical decision making takes palced within a worldview. The content of a worldview will determine what is valuable and what is not, as well as how a person would engage in decision making given those values.

Reference

Meilaender, G. (2013). Bioethics: A primer for Christians. (3^rd ed.). Grand Rapids, MI: Wm. B. Eerdmans Publishing Company.