Medical Ethics Terrance Ackerman, in His Article

Medical Ethics

Terrance Ackerman, in his article Why Doctors Should Intervene, presents some of the complicated affective influences that enter into the doctor -- patient relationship when a patient is facing a life threatening situation. Patient autonomy has been the watchword of the medical community. Serving as the Magna Charta by which doctors have operated in their associations with terminal patients, honoring patient autonomy has been the guidelines by which doctors set limits on their involvement in patients lives. However, Ackerman makes a significant argument regarding conditions under which patient autonomy and a policy of non-interference are not sufficiently broad enough to address the real needs of the patient. The effects of the illness, he says, can create distortions in the patient's ability to make autonomous decisions. In this case, according to Ackerman, the doctor should position himself to actively engage the patient, and influence a different course of action than what the patient requests.

Ackerman defines patient autonomy as a policy which has helped formulate a number of patient rights. The right to refuse treatment is one of the key choices which should lie in the patient's control. Patient autonomy has given rise to the right to give informed consent to the doctor / medical staff prior to receiving treatment, and the right to receive competition medical care. These rights have been used to form a larger understanding of the policy of non-interference by the doctor and staff once a patient has made his or her decision. Once a patient has expressed his or her desires, the medical staff, in order to honor the patient's autonomy, is required to take a step back, and allow the patient to have control over their own lives.

This dynamic and often ethically challenging situation can place the medical staff in a position in which they must relinquish their own control over a situation, even if they believe they can better the life, or the quality of life of the patient. Just as one of the most serious and destructive issues of a serious medical condition is for the patient's loss of control over their own life, so is the doctors forced loss of control over his patient.

There is an assumed contract between the patient and doctor when the patient comes to the medical practitioner. That contract, in essence, says "I am a sick person, and you are a trained medical professional. Because you have the services I need, I am coming to you to allow you to perform your profession, which I expect will make me well." When a doctor first enters a patient's room, whether it is to conduct an annual physical exam, sew up a minor cut, or consult on the advancing stages of cancer, this assumed emotional and psychological contract guides and directs the doctors and patients choices and activities. However, when the patient's medical condition becomes life threatening, and the patient is faces with the prospect of long or painful treatment that does not have the guaranteed outcome of returning health, this contract no longer is in force. As a result both the practitioner and the patient are left in the awkward position of having to forge a new contract while at the same time wrestling with the questions of life altering treatment options.

Ackerman identifies a handful of issues which can obstruct the patient's ability to make objective decisions. For each of the situations, he cites painful examples of how these conditions have entered into his medical practice, and hindered his ability to proceed with treatment. Ackerman identifies that depression, denial, guilt, fear, or other social pressures can affect the patient's judgment, and impair his or her ability to make an informed decision.

Denial of the severity of a condition can affect the patient, and influence him or her to forestall treatment. When the condition is severe, or the treatment has no guarantee of success, as is often the case with chemotherapy of cancer, the patient's refusal to accept his or her limited options can affect his or her decision making ability. While the treatment options are clear for the doctor, the inability of the patient to accept the options can create treatments delays which only complicate a rapidly advancing disease. In the same way, depression can alter a person's rational abilities to make informed decisions. A depressed patient of Dr. Ackerman's refused to consent to treatment which would have positively affected her well-being. As a result, complications set in, and after consenting to the treatment after the passage of time, the resulting complications, due to the delay, cost the woman her life.

Possibly the most difficult obstacle for the doctor to address are social influences, which the patient or their family hold. In a minority of cased, the family may hold deep belief in supernatural intervention. When the family or patient refuse treatment because they believe in forces outside the ability of the medical staff to bring healing, and then the patient' condition worsens, or in the worst case scenario, the patient dies, who is the arbiter that decided that the doctrine of non-interference was the best course of action for the patient?

The core of the question reaches back to the issue of control, both for the doctor and the patient. When the patient's mental abilities are affected by either their disease, or the impending severity of treatment, Dr. Ackerman's position is that the patient is no longer able to 'give informed consent' and thereby the patient is no longer able to exert practical 'patient autonomy' over their treatment options. The patient's illness affects their perception of reality, and therefore they are no longer making informed decisions. In response, Dr. Ackerman's position is that the medical practitioner should then "actively seek to neutralize impediments that might interfere with the patient's choices." (Ackerman, p. 83)

Dr. Ackerman uses as his justification for continued action a desire to return the control over their condition to the patient. When the patient's perspective has been clouded by the difficult and often equally undesirable options of treatment over their advancing condition, the doctor should have the responsibility to continue to press for the most positive course of treatment if the patient is no longer able to discern between his or her options. As a result of this quandary, Ackerman insists that a change is needed in the understanding of the patient -- doctor relationship, and the assumed contract of submission to the doctor's ability to perform treatment when the patient's rational decision making process is hindered by the effects of their condition.