in each case, answer the questions at the end
of the case and give researched references to support your assertions; also,
explain what would be the ethical course of action and the legal requirements
for action in the case.
Case One
Mrs. G. has an aneurysm in her brain that, if
untreated by surgery, will lead to blindness and probably death. The surgery
recommended leads to death in 75% of all cases. Of those who survive the
operation, nearly 75% are crippled. Mrs. G has three small children. Her
husband has a modest job, and his health insurance will cover the operation,
but not the expenses that will result if she is crippled.
When informed of this, Mrs. G. is in great
emotional turmoil for a week or so until she makes her decision. She refuses
treatment, because she does not like the odds. There was, after all, only a one
chance out of sixteen for a real recovery. In addition, she could not come to
grips with exposing her family to the risk of having a mother who would be a
burden and not a help.
Can a patient with serious obligations, such
as a family, refuse treatment? What odds of recovery would be good odds?
Case Two
Mrs. S., an 85-year-old housewife, becomes
aware of breathlessness and is easily fatigued. She is known to have had a
heart murmur for 2 years. She consents to come to a research hospital for
cardiac catheterization, which confirms the presence of severe, calcific aortic
stenosis with secondary congestive heart failure.
Because of the unfavorable prospect for
survival without surgical intervention, the recommendation at the combined
cardiac medical-surgical conference is for an operation. The physician explains
the situation to Mr. and Mrs. S. and recommends aortic valve replacement. It is
noted that the risk of surgery is not well known for Mrs. S,’s age group, and
that early mortality is usually around 10 percent, with 80 percent achieving
good functional results after 3 years. Her lack of an obvious disease makes her
a relatively good candidate for a successful surgical outcome, despite her age.
Mrs. S. appears to understand the discussion
and recommendation, but requests deferral of the decision and shows signs of
denial of the problem. She has no other medical problems, her husband is in
good health, and their marriage appears to be happy. They are financially
secure and enjoy a full set of social and recreational activities. She returns
on three subsequent occasions for simple, supportive attention. The physician
decides not to employ psychiatric assistance or other measures to reduce her
denial and begins to use conversation to reduce her anxiety associated with her
decision.
Does Mrs. S.’s apparent denial of her
condition make informed consent impossible? Is the physician ethical in
reducing her anxiety about her apparent refusal of treatment when the physician
believes treatment is medically indicated?
