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Running Head: CASE ANALYSIS
Case Analysis
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Case Analysis
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Reason for the Case
The primary reason for this case revolves around the decision to decide whether it is
ethical to deem the patient refusal of any treatment that artificially prolong her life and prevent
pain as being incapacitated to make decisions and therefore follow the normal treatment of a
metastatic liver cancer.
Summary of the Case
The summary of a sixty-eight (68) year-old woman suffering from metastatic liver cancer
that has spread to her lungs and pancreas is hereby addressed using the Jensen, Winslade, and
Siegler model of four quadrants together with a synopsis of the engagements of interested parties
with the patient;
Medical indications
Joyce is suffering from metastatic liver cancer. She has been in and out of the hospital for
several years and a few days ago moved back to California from Oregon. Her illness case is
critical as it comes with severe pain and cancer has spread to her lungs and pancreas.
The goals of treatment basically are the cancer diagnosis through palliative care. The
probabilities of success are constrained by the fact that Joyce clings on some beliefs about her
pain that make her refuse pain medication. She has a POLST form from Oregon that indicates
she does not want cardiopulmonary resuscitation and other treatments that will artificially
prolong her life whose date concede with a cancer diagnosis.
The plan is to classify her wishes as being grounded on an incapacitation to make
decision as found by a psychological evaluation which says that she is clinically stressed. In sum,
for her to benefit from the medical and nursing care, the decision need to be made on what harm
to avoid, to avoid the harm of preventing her conform to her wish or to prevent harm to other
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interested parties such as her daughter and the patients in the unit and have the cancer diagnosis
and palliative care.
Preferences
The patient is not mentally capable of making decisions regarding her health. The
evidence of this claim is constituted in the psychological evaluation which says that she is
clinically stressed. This, therefore, places the ground on whether to disregard her preference of
treatment that prevent any cardiopulmonary resuscitation-related treatment or pain medication.
As per the case, despite the patient clinging to her preferred treatment, she is yet to
receive any documented counseling regarding the benefits and damages of going her way. Since
she is deemed incapacitated, the surrogate here is Nurse Green who is the nurse manager in
consultation with Joyce daughter who are in a position to make a sound decision that will be of
more good than harm.
Joyce’s actual advance directive is archived in her former place of residence, a long-term
care facility, in Oregon and it has been difficult acquiring it while she has also given her
daughter a ‘Do Not Resuscitate” order. At the moment, she is unwilling to cooperate with
medical treatment since the previous attempt to explain her cause, she states that “God is
punishing me for my wrong-doings and abusing my body. I deserve it” and “Pain for purification
and penance.”
At the current state, Joyce right to choose may not be respected despite being supported
by various ethical theories and principles. Not able to access her advance directive, being
incapacitated to make a decision, and having her actions affecting other people such as the
daughter and other members of the unit will be used as the ground to denounce her preference of
treatment.
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Quality of life
There is no prospect of a return to normal life unless with a cardiopulmonary
resuscitation that will prolong her life as she has reached state’s statutory requirement of a
Physician-Assisted Suicide. If the treatment takes cause, there will be more mental and social
deficit on the patient as she has been living in agony and alcoholism in the last 25 years due to
unknown guilt.
Her present condition of guilt and alcoholism represent are the only factors that can make
her continued life undesirable. Plans to conduct a Physician-Assisted Suicide or giver her
comfort by palliative care will be determined by the ethical decisions done by the Nurse Green
who is the nurse manager.
Contextual features
The fairness issues expected to influence the decision are the fact that Joyce moaning is
disturbing other members of the unit and the confusion of Joyce daughter on why her mother is
taking such decisions. The nursing issue that should sway the decision is the psychology
evaluation that shows clinical stress. Limits of confidentiality are from the fact that the medical
team cannot be able to access Joyce’s actual advance directive and there is “Do Not Resuscitate”
order given to the daughter.
Synopsis of engagements
Joyce has several discussions with two of them involving nurses who asked why she
ought not to either take a Physician-Assisted Suicide or pain medication. The other one involve
discussions with her daughter who don’t understand and is confused despite accepting the “Do
Not Resuscitate” order.
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Relevant Ethical Principles and Theories, Laws, and Policies
Ethical principles
Autonomy
One person, as precisely a human person, does not have authority and should not have
power over another human person
Beneficence
Beneficence is an action that is done for the benefit of others. Beneficent actions can be
taken to help prevent or remove harms or to simply improve the situation of others. Physicians
are expected to refrain from causing harm, but they also have an obligation to help their patients
(Kockler, 2007).
Non-maleficence
Non-maleficence means to “do no harm.” Physicians must refrain from providing
ineffective treatments or acting with malice toward patients. This principle, however, offers little
useful guidance to physicians since many beneficial therapies also have serious risks.
Advance health care directive
An advance health care directive, also known as living will, personal directive, advance
directive, or advance decision, is a legal document in which a person specifies what actions
should be taken for their health if they are no longer able to make decisions for themselves
because of illness or incapacity.
Double Effect
The principle says that sometimes it is permissible to cause a harm as a side effect (or
“double effect”) of bringing about a good result even though it would not be permissible to cause
such a harm as a means to bringing about the same good end.
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Proportionality
It is a moral principle that one may employ to determine objectively and concretely the
rightness or wrongness of actions
Theories
Ethical Relativism
Ethical relativism is the theory that holds that morality is relative to the norms of one's
culture. That is, whether an action is right or wrong depends on the moral norms of the society in
which it is practiced.
Egoism
Egoism is the theory that one’s self is, or should be, the motivation and the goal of one’s
own action. Ethical egoism holds that actions whose consequences will benefit the doer can be
considered ethical (IEP, 2014).
Utilitarianism
Utilitarianism, at its most basic, states that something is moral, or good when it produces
the greatest amount of good for the greatest number of people, that is, greatest happiness
principle. In utilitarianism, good is defined as the existence of pleasure and the absence of pain
or utility (Britannica, 2002).
Kant’s Moral Theory
Kant's theory is an example of a deontological moral theory–according to these theories,
the rightness or wrongness of actions does not depend on their consequences but on whether they
fulfill our duty (CSUS, n.d.).
Natural Law Theory
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Natural law theorists believe that human laws are defined by morality, and not by an
authority figure, like a king or a government. Therefore, we humans are guided by our human
nature to figure out what the laws are, and to act in conformity with those laws (McKenna,
2013).
Case Analysis
To make the evident ethical decisions, in this case, there is a need to agree on some basic
principles and standpoints on what actually represent the moral conduct. The major ethical
issues revolving around the case of Joyce treatment include; the intention of doing no harm, the
desire to do good while being just, fair and sensitive to individual freedom.
Nurse Green can easily make a decision basing on the basic aspects of utilitarianism. To
discover what she ought to do in this case, she needs to first point out the various courses of
action that are at hand and feasible. Secondly, she will classify all of the likely goods and harms
that will result from each feasible course of action to all the involved and affected by such action.
Thirdly, she needs to select the course of action that offers the greatest happiness, benefit, and
less harm, after all has been taken into consideration.
According to the principle of double effect such situation like this, whatever action with
both good and bad effects is permissible when there is "proportionate reason" to tolerate the evil
outcome. The case of Joyce present just that, the action of proceeding with her diagnosis is both
beneficial as it makes others around her happy while allowing the hospital to do what it ought to
do, however, it comes with the bad consequence of not honoring Joyce individual freedom to
choose her cause. Similarly, the principle of totality justified attacks is referenced as the case of
Joyce the whole body will not benefit if she is allowed to moan in agony. She will die finally
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going contrary to this principle which says that if a suffering has a "proportionate reason" to
benefit the whole body in the long run, then there is need to tolerate the suffering.
Autonomy is a relevant ethical principle in this case because Joyce preferred not to have
any pain medication nor cardiopulmonary resuscitation treatment done on her while the principle
say that no one should exercise authority over another. Beneficence is also evident as the case
present Nurse Greens, the nursing manager with the decision of preventing or removing harm
while also weighing and balancing the possible benefits of going against Joyce preferred
treatment.
The issue of Advance directive is evident in the case as we are told that actual advance
directive is archived in her former place of residence and she has also given her daughter a “Do
Not Resuscitate” order. The principle of double effect comes into this case since Nurse Green
has to rely on some specific guidelines to determine if it is morally permissible to go against
Joyce will in pursuit of a good end of prolonging her life and making other interested parties
happy while knowing its opposite of what she would wish. This involves the conducted
psychological evaluation to deem her incapacitated to make decisions. This will use the
proportionality principle to determine the rightness or wrongness of those actions.
The case will render favoring the critics of Ethical Relativism who says that ethics is an
inquiry into right and wrong through a critical examination of the reasons underlying practices
and beliefs and should, therefore, make it immoral if Nurse Green decides to disregard Joyce
culture and belief. Egoism theory will be employed in this case as its weak version says that
although it is always moral to promote one’s own good, it is not necessarily never moral to not.
This means that there are situations avoiding Joyce personal interest may be a moral action.
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According to utilitarianism, a moral action is one that increases the total utility and offers
the greatest happiness. Having Joyce to go through palliative care or cardiopulmonary
resuscitation treatment will bring peace and no disturbance in the unit while it will restore joy to
Joyce daughter. Her preferred treatment only benefits her alone.
Kant theory is important to this case as the philosopher was not concerned with
consequences because he believed that if two people, Joyce and Nurse Green, propose different
action for the right reasons, then both are morally worthy, even if the actions may lead to bad
consequences. This, therefore, is the point of contention and the reason why Nurse Green need to
make a decision.
According to the Natural law theory, solving ethical dilemmas such as the case of Joyce
treatment should be based on the basic belief that everyone has the right to live their life. This
can be used by the nursing manager to project Joyce from herself and let her live by prolonging
her life and averting her pains.
Recommendations
From the case study of Joyce treatment dilemma, an ethical decision should take center
stage. The decision needs to be done based on the greatest happiness coverage as it involves
different interested and affected parties other than Joyce. Also, in efforts to respect Joyce
preferred treatment, the issue should be driven outside the clinical setting to offer her counseling
to help her make sound decisions. This will also help her recover from the clinical stress and be
in a capacity to make other decisions.
Impacts of old-fashioned cultural belief inclinations should be instilled in her to ensure
she does not allow her obligation to such beliefs take her life while there was another perception
of life. If a decision is made to proceed with palliative care or cardiopulmonary resuscitation
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treatment, then care should shift from managing the effecting of going against her wish and
facilitate her continued life.
To sum up, the case of Joyce treatment should have the pertinent ethical issue as whether
the benefits outweigh the burdens such as pain and abandonment of the daughter. At the end,
Joyce must be compelled or made to see the potential benefits of a medical and nursing care
outweigh her preferred treatment due to the potential harms.
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Case Analysis
References
Britannica. (2002). Utilitarianism. Retrieved from
http://www.utilitarianism.com/utilitarianism.html
CSUS. (n.d.). Kantian Ethics. Retrieved from
http://www.csus.edu/indiv/g/gaskilld/ethics/Kantian%20Ethics.htm
IEP. (2014). Egoism. Retrieved from IEP: http://www.iep.utm.edu/egoism/
Kockler, N. J. (2007). The Principle of Double Effect and Proportionate Reason. Retrieved from
AMA Journal of Ethics: http://journalofethics.ama-assn.org/2007/05/pfor2-0705.html
McKenna, B. (2013). Natural Law Theory. Retrieved from Study:
http://study.com/academy/lesson/natural-law-theory-definition-ethics-examples.html