PATIENT CHOICE & THE ETHICS OF HEALING

In this Sunday’s NY Times oncologist Mikkael A. Sekeres describes his dealings with a Jehovah’s Witness patient, dying from leukemia and with profound anemia, who refused blood transfusions. 

The article raised important moral/ethical/medical and spiritual issues.  What is the role of the physician/medical establishment in advising and administering treatments to someone who refuses them? It was clearly a difficult time for the medical and nursing staff who cared for the patient as well as for the patient and his family of devout believers.  Dr Sekeres respected his patient’s wishes, tried to work around his refusal to be transfused, and ultimately witnessed his death. Afterwards there were discussions regarding whether or not more could have been done to save him.  Sekeres ultimately concludes that “our responsibility must be to our patient’s goal more than to our own…”  I agree. 

The difficulty arising from these issues is that not all physicians and medical teams do agree with this assertion.  On a daily basis we see physicians and family members forcibly take charge of medical decision making despite the expressed wishes of patients.   We see living wills, advanced directives continuously being ignored.

All this is complicated by patients themselves in a clearly weakened mental and physical state,  who seem to “change their mind” when it appears that their lives are imminently threatened by disease and death. 

Many bioethical issues arise from these real life situations.  Why should patients be the ultimate arbiters of their own fate? What about withholding medical treatment of treatable disease states? What about euthanasia either passive or active? At what point do we accept a patient’s decisions? And when (if ever) is it OK to override them?  How do family emotions and disagreements play into last minute alterations in end of life planning? 

Would professional teams of medical staff/ ethicist / spiritual leaders etc offer a sounding board for such difficult times?  The impact of such personal decisions have profound economic implications for the totality of health care as well.  When nearly half of all ICU/CCU patients in any given hospital should probably not be there (according to independent physician/nursing assessments)  the financial burden of health care costs loom large.  As stated I applaud Dr. Sekeres approach and attitude in this patient’s case.  While we are trained to save lives at “all costs” it should remain in the hands of individuals how they live and ultimately how they die.

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