The Right to Die Cruzan by Cruzan

Nursing and Ethical Choices

What are the utilitarian and Kantian justifications for Advance Directives?

The health care proxy and the living will are two ways in which a patient can express advance directives relating to health care and/or end of life treatment should that person become incapacitated. The utilitarian justification for advance directives is that the end justifies the means, or in other words the greatest good for the greatest number of people. If an advanced directive is given, it covers all the people involved and lets the patient's wishes be known ahead of time in case there comes a moment when the patient can speak for him or herself. The doctors and care givers will be obliged to accept this as the greatest good, because it relieves them of any duty to give care (if the directive has in place that it should be refused) and vice-versa. The Kantian justification for advanced directives is that it respects the autonomous position, that is, the individual right to refuse treatment (should that be the case). The individual makes it known ahead of time in the living will, for example, and this is respected as Kantian philosophy upholds autonomy as a basic right.

2. Why do clinicians still struggle to practice full disclosure of medical error? Explain briefly the key elements of disclosure.

Disclosure involves stating everything that went wrong with a medical error to the patient, even if the patient does not understand. Indeed, this can often be problematic because it can be simpler just to correct the error and lie to the patient without the patient becoming any the wiser. From a utilitarian perspective this behavior would be justified, but not from a Kantian perspective. For the sake of integrity and ethical treatment, it is in the interest of the doctor to disclose fully any medical error, even if it is easily remedied, no harm will result and it requires length explanation to the patient. This will help avoid future litigation which can be much more costly in terms of time and moneyu (Gallagher, n.d.)

Thus, as Philipsen and Soeken (2011) note, it is the clincian's duty and ethical responsibility to inform the patient of any medical error in treatment, even if the error is "insignificant." The patient still has a right to know, as do all individuals who are impacted by the error (staff as well). This allows the medical community to remain transparent, which is a foundation of trust in the staff-patient relationship. Thus, the ethical implications of disclosure and non-disclosure are clear: to not disclose a medical error is to act unethically and without the transparency and loyalty that is owed the patient as well as the members of the staff. The legal implications of disclosure vs. non-disclosure are also clear. The severity of the error is what is most likely to affect the outcome if the error becomes known and there was no disclosure made initially. However, it is also the case that legal action is less likely to be pursued if disclosure is immediate and the severity of the error is not significant (Edwin, 2010; Tabler, 2006).

3. The parents of Nancy Cruzan decided to terminate the artificial nutrition and hydration procedures that kept her alive. This decision required court's approval. Three courts heard their petition.

4. Why did the Missouri State Trial Court grant the parents' request to terminate the artificial nutrition and hydration even if Nancy Cruzan did not have advance directives?

The Missouri State Trial Court granted the parents' request to terminate the artificial nutrition and hydration of Nancy Cruzan because it assumed that they had the right to make that decision based on the idea of autonomy, assuming also that it was Nancy's wish that she not live in a vegetative state. However, as the appeal showed, there had not be convincing evidence put forward to indicate that this would have actually been Nancy's will, so the ruling was reversed. Essentially, as there was no advanced directive on the matter, there was no way for the court to decide that this was Nancy's will and the first court decision was made on the assumption that it was even though there had been no explicit or clear evidence to indicate as much.

5. Why did the Supreme Court of Missouri demand for "clear and convincing evidence" that Nancy would not wish to continue her lifesaving treatment?