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resuscitate orders and living wills (also known as "advance directives"). Specifically, it will discuss the ethics of these orders, and how they relate to medical law and professional ethics. Living wills and do not resuscitate orders (DNR) are common methods for patients and their families to indicate their wishes during times of hospitalization and treatment. However, there are so many exceptional cases and circumstances surrounding these issues that they are continually controversial, and test the bioethical standards of the medical and legal communities. Where do patient rights and medical ethics blend, and where do they diverge? These are not simple questions to answer, as the research shows.
Living wills and do not resuscitate orders are usually created by patients and their families as a means to ensure their lives are not prolonged if they are suffering a debilitating or terminal illness, and they need life support or resuscitation. They are simple, legal documents that loved ones can write and create in a matter of minutes. In fact, many online locations offer generic and state specific forms, and there is also a national "living wills registry" online, where living wills can be posted, giving health care professionals access to personal wishes online. In addition, living wills and other forms of advance directives are becoming increasingly popular. A Washington D.C. reporter notes, "the American Medical Association estimates that 15% of the population has filled out some type of advance directive specifying what medical treatment they should be given if they are unable to offer guidance, or who will decide for them" (Moran 10). The process sounds simple and painless, but in reality, there are still many questions surrounding living wills and advance directives, and it is the healthcare professional who usually has to make quick judgment calls, or call in legal advice when living wills get complicated.
To a family member or patient, the idea of a living will or do not resuscitate order many seem binding and unquestionable. However, many circumstances challenge these orders, and the ethics of carrying them out are sometimes convoluted and questionable. For example, one cited case involved a 21-year-old pregnant female diagnosed with "PCP (pneumocystis carinii pneumonia), right parietal infarct (a blood clot in her brain) with left hemiplegia, and CMV (cytomegalovirus, an infection similar to mononucleosis)" (Kuczewski and Pinkus 73). It was discovered the woman was also HIV-positive, and there was a great possibility her unborn child was also HIV-positive.
The woman, also the mother of a 4-year-old, was placed on a ventilator, but no improvement was seen. After three weeks, her husband issued a palliative care sheet asking that the medical care team not perform CPR, and additionally, if the child delivered, that it not be resuscitated. Normally, these orders would have been carried out, but some members of the team felt that since the directive involved a pregnant woman and the unborn child, that there were other ethical issues at play. The hospital attorney agreed. He felt if the woman's child was allowed to die, the hospital and medical staff could face serious reprisals. The woman's social worker and primary care nurse did not agree. They felt the additional child would be a burden on the grieving husband, and could be a major economic hurdle for the family. In addition, the fetus was not yet able to survive on its own, and the mother would need to be sustained for four to five weeks for viability to occur.
Ultimately, the woman's condition deteriorated, and she died within 24 hours of the first legal and medical meeting regarding her case. However, the problem brings up many ethical questions. Who is ultimately responsible for advance directive orders? In this case, the woman could not speak for herself, and the closest relative was her husband, who made his wishes clearly known. However, the rights of the fetus also had to be considered. The authors of the case study note, "However, the rights of the unborn are still widely debated, and it is far less obvious that they can outweigh the well-established right of competent adults to be free of unwanted and burdensome medical treatment" (Kuczewski and Pinkus 77). This ethical question is difficult to decide, and even more difficult to implement. In this case, the doctor felt giving CPR to the woman would only prolong her life for perhaps minutes or hours, and would do nothing to greatly prolong her life and the life of her unborn child. If the age of the fetus had been different, this case probably would have ended in the courts. As it is, it is only one issue of many ethical issues that face medical professionals every day. Clearly, today a medical professional must not only consider the health implications of treatments, they must also consider the ethical implications of treatments in many difficult and demanding situations.
Often medical professionals are also confronted with the differing demands of a patient's family. For example, one ethics expert discusses the case he witnessed involving an eighty-year-old woman who suffered a paralyzing stroke. According to the expert, she was unable to communicate or to eat or drink or breathe on her own. She was kept alive by the machinery. For one of her children, this merely 'prolonged the inevitable.' For another, the 'vital signs,' no matter how dependent on technology, meant that her mother was still alive and that 'while there's life, there's hope.' For the physician the case was hopeless. Eventually, a court had to decide the issue and allow the woman to die (Radest 88).
Clearly, the doctor was caught in the middle of a difficult situation, and could not make a decision to allow the woman to die on his own. An ethics committee had to be involved, and finally the case went to court. The ethics involved here are clear. The doctor only had the right to maintain the woman's life, according to his own education and oath to maintain health, even in the face of ultimate death. The doctor does not have the ethical right to end life except when the family and/or patent have made their wishes known, and it is clear even then, there are many situations that try the ethical balance between wishes and law.
Clearly, ethics is an integral part of medicine today, and experts expect it to expand in the future. Today, the family, clergy, and even the insurance company must be consulted or at least thought about in ethical medical decisions. Tomorrow, these could increase to include managed-care providers, hospital ethics committees, and much more. One doctor notes, "The real ethical problems these days aren't about individual cases so much as about what's happening to hospitals and medical practices, and about what's happening to access for people who can't get medical insurance'" (Radest 91). Clearly, doctors must consider more than treatment and cure when they deal with patients today. They must also consider the ethics of every situation to keep their medical facility from facing legal woes and even fiscal disaster. Disgruntled families can sue, and this can lead to disastrous results for the medical community at large.
While every state now recognizes advance directives and DNRs, they can be interpreted differently in each state due to laws and legislation. Many physicians, fearful of legal reprisals, judge each advance directive on a case-by-case basis, and are reluctant to abide by the directives if the case is even the slightest bit unusual or questionable. Even if the patient and family have distinctly made their DNR wishes known, their wishes may not ultimately be adhered to because of legal worries and ramifications. Often, many experts contend, the medical and legal communities do not govern the advanced directives, the state legislatures govern them, and they have little understanding of the real issues and…[continue]
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