Applying Law And Ethics In Practice
Often, healthcare personnel are faced with difficult decisions while in their line of duty. For instance a patient is brought in the ER and his condition evaluated. It is reported that the individual’s condition requires urgent medical attention. This individual does not have a penny to his name and is unable to pay for the medical attention that he is in dire need of. He is not covered by the medical insurance scheme that can offset the medical bill. As a medical practitioner, what action does one take. The medical practitioner has to ensure that the actions that he takes abide by the law of the land, that they are ethically sound and justifiable and also do not violate the hospital policy. In many healthcare institutions there are limited funds and making a decision to treat a patient free of charge would likely get a practitioner in trouble with the hospitals administration. There are legal issues tied to this scenario. For instance the EMTALA Act of 1968 requires that a patient be treated even in absence of funds to pay for the medical bill especially if the initial examination reveals need for urgent treatment (Buchbinder, &Shanks, 2007). Ethical considerations like the principle of beneficence that requires a medical practitioner to do his best to offer the best care possible to a patient come into play and it is imperative that the medical practitioner considers all the legal and ethical issues surrounding the case before making decisions. This is just an example of the challenges that medical practitioners come across in their line of duty and in which it is necessary to consider both ethical and legal issues while making decisions.This paper is going to focus on an ethical dilemma involving a geriatric with regard to treatment versus non treatment.
A 67 year old with chronic renal failure, hypertension and type 2 diabetes was initially admitted to hospital following a dense CVA which left him with aphasia and unilateral weakness. The patient develops a non functioning kidney and would need dialysis three times per week in order to survive. Family members are divided on whether to the patient should undergo treatment or not. This is a typical case in which the care giver faces a challenge on what action to take. The care giver in making a decision should consider the wishes of the family members (which is already divided), the patient’s ability to make decisions for himself, the ability to pay for the treatment options available, the legal requirements and the hospital policy especially with regards to ability to pay for the available treatment options. In making the decision, the care giver has to rely on the legal provisions and ethical principles that guide current medical practice and provide the fundamental framework for decision making and sustaining a healthy doctor patient relationship (Wacker, 2009). In making these decisions the doctor has to be careful to act within the provisions of the law. Actions that are taken in contravention to any of the legal provisions often lead to legal battles that often result in the litigant being paid large sums of money in compensation. On the other hand, the doctor has an obligation to abide by the ethical principles that reflect the values of the community with regard to value of human life and other critical aspects of medical treatment (Burkhardt and Alvita, 2007).
One of the common ethical principles is the principle of beneficence and non-maleficence. These are the core principles of medical practice. The principle of beneficence holds that a care giver/doctor/physician has to take actions that benefit the patient and are good in their nature. Non-maleficence holds that a physician/doctor/ caregiver does no harm to the patient while in the process of delivering care (Pozger, 2009). These ethical principles reflect upon medicine’s chief goal which is to return the sick to normal state of health (disease free) and essentially minimize the suffering closely associated with the disease conditions they are suffering from (Smith, 2012). The patient’s evaluation reveals that he has a non functioning kidney and that he would require haemodialysis, he has chronic renal failure, hypertension, type 2 diabetes and aphasia. A critical factor to be considered at this point is to evaluate the benefits such as improved quality of life that come with the life sustaining actions taken versus the costs such as the financial ability of the family to foot the bill that the interventions would take. Deciding to treat the patient in an effort to do good and minimize harm in accordance with the ethical principle of beneficence and non-maleficence, means that the patient would have to undergo dialysis for the rest of his life three times a week. The patient is also subject to other forms of treatment/ interventions that are designed to eliminate or reduce the other medical conditions that he is suffering from should the doctor choose to treat him. On the other hand choosing not to treat because perhaps the benefits may as well not outweigh the costs, the physician/ doctor/ care giver will be acting in contravention of the ethical principles that guide medical practice. It is possible that undergoing dialysis three times a week for the rest of his life may prove to be a huge financial burden for the family bearing in mind that there are other medical interventions required for the other conditions that he is suffering from. It is vital that the family shows willingness to foot the medical costs that would come with the treatment of the patient.
The ethical principle of beneficence and non-maleficence requires that the care giver does his or her best to ensure that the patient’s health is restored while at the same time avoiding harming the patient. In this case, medical interventions include offering treatment solutions for the aphasia, type 2 diabetes, hypertension and chronic renal failure. Haemodialysis is one of the interventions proposed for the non functional kidney and renal failure. But, a fundamental question has to be asked, what would be the impact of such interventions to the quality of life of the patient bearing in mind his age and other health considerations that are closely associated with the elderly. According to the Wiiliams and Stanton (2009), the elderly US population has a remaining life expectancy of 10.4 years and for the patient with End Stage Kidney Disease (EKSD) it is 2.6 years. William and Stanton (2009), further note that ESKD geriatric patients stand a higher risk of suffering from hypoglycemia and are less likely to gain or benefit from long term glycemic control. They note that the ESKD mortality risk among the geriatric is nearly 50% and that treatment of ESKD is 15-30% higher in diabetic patients than the non-diabetic patients.
Currently, use of EBP (evidence Based Practice) in medical practice has been advocated for over experience, as use of experience often deters development within the medical practice. Therefore a more informed decision with regard to quality of life after interventions would be based on current available information on the effectiveness and significance of the interventions to be taken. Physicians/doctors are under no obligation to provide forms of interventions that are futile. The above mentioned statistics enable a physician to better judge the futility (conceptual futility) of the available treatment options. Having noted that mortality among the geriatric patients is nearly 50% and it’s even higher in geriatrics with co-morbid infections like diabetes and cardiovascular disease, it is critical that the decision be made in consultation with the patient. The patient has to be fully aware of the available options and all important information that pertains to the treatment options available to him.
In an ideal medical practice setting, the ethical decisions with regard to treatment are shared with the patient. It is the physicians/ doctors obligation to inform the patient on the established treatment interventions available to him and advice him on the best intervention or option that would serve his medical interest best. The patient may choose agree with the physician’s recommendation (thereby give his consent), or choose another of the options available or choose to forego all the interventions altogether. In advising the patient, the physician would have fulfilled his ethical obligations and would have in essence involved the patient in the decision making process. Incase the patient chooses another option the physician is free to attempt to convince the patient of the best option although he is not to coerce the patient into agreeing with him. The patient’s autonomy should prevail in such a case.
Another dimension of axiological importance to the decision making process is the legal considerations. There are certain forms of legal frameworks in place that overtly provide the necessary guidelines that guide the actions taken my medical practitioners while in their line of duty. One such legislation is the EMTALA Act of 1968. This Act contains provisions that require health care providing institutions to provide a mandatory screening test to an individual admitted to the ER (Emergency Room) and further provide stabilizing treatment or interventions for medical conditions that are deemed to be urgent irrespective of whether the individual is eligible for the medical benefits outlined in the chapter (AHIMA, 2012). The Act further directs that a hospital would be deemed to have met the requirements of this Act if they informed the patient or the individual acting on the patient’s behalf, of the any further examination needed and the risks and benefits that come with the treatment options available to the patient. If for example, the hospital decides to deny the patient hemodialysis, they would be acting in contravention to the EMTALA Act which expressly requires that patients with urgent medical needs be advised on the available treatment options and given the essential service in order to save their life. Unless the patient or his proxy chooses not to be treated, it is illegal for the hospital to deny the patient hemodialysis. The patient reserves the right to be treated (access hemodialysis). This on the other hand doesn’t mean that the hospital cannot bill the patient if it so wishes. The hospital reserves the right to bill the patient but has no right to deny service on the premise of inability to pay for service. This requirement in essence requires that a patient be actively involved in decision making process with regard to his treatment options. It is advisable that the family members are also involved in the process of making decisions especially when it has been determined that the patient lacks the ability to make decisions for himself.
In the State of New York, the patient reserves the right to be involved in the process of making decisions (US Dept. of Health, 2010). It is a legal requirement that a patient is given all the necessary information that he needs in order to give an informed consent with regard to a proposed treatment plan. Such information must include the risks and benefits that come with each treatment plan. It is then a legal requirement that the physician/ doctor discusses with the patient and family all the forms of interventions available together with the risks and benefits. The patient has a right to refuse any form of treatment and reserves the right to be informed of the impact of such a decision on his health. The doctor has to abide by this legal requirement. He has no control over whether he can treat or not treat the patient. The doctor can choose to treat but if the patient rejects the treatment then he has not choice but to accept the patient’s decision.
In conclusion, the decision on whether to treat the patient or not, is dependent upon certain ethical considerations, legal requirements, the family decisions and the patient’s rights. Best decisions are made in view of all the above issues and essentially endeavor to promote the quality of life of the patient without acting in contravention of any the legal frameworks and ethical principles.
AHIMA, 2012. Title 42- The public health and Welfare. [online] Available at: http://library.ahima.org/xpedio/groups/public/documents/government/bok1_036039.hcsp?dDocName=bok1_036039 [Accessed 14 May 2012] Buchbinder, S.B. and Shanks, N.H., 2012. Ethics and law. In: Gartside, M and Reilley, T. Introduction to healthcare management. Burlington. MA: Jones & Bartlett Pub. Ch.15.
Burkhardt, M. and Alvita, N., 2007. Ethics and issues in contemporary nursing. 3rd Ed. New York: Delmar and Cengage Learning.
Pozgar, D.G., 2009. Legal and ethical issues for health care professionals. 2nd Ed. Burlington: Jones & Bartlett Pub.
Smith, S., 2012. End of life decisions in medical care: Principles and policies for regulating the dying process (Cambridge bioethics and law). Cambridge: Cambridge University Press.
US Dept. of Health, 2010. Your rights as a hospital patient in New York State. [online] Available at: http://www.health.ny.gov/publications/1449/ [Accessed 14 May 2012] Wacker, G., 2009. Legal and ethical issues in nursing. 5th Ed. New Jersey: Prentice Hall Pub.
Williams, M. and Stanton, R., 2009. Chapter 8: Kidney disease in elderly diabetic patients. Geriatric nephrology curriculum. Massachusetts: Joslin Diabetes Center.
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