Introduction
Dr. Newman certainly does have a difficult case filled with difficult decisions. There are ethical, legal, medical, and personal factors that weigh very heavily in any decision that is made about Gene King’s treatment. He has talked with an ethicist, a colleague, a lawyer, and a psychologist in order to help him sort out all of the thorny issues that have been raised by the reappearance of Gene King’s cancer.
Dr. Newman, of course, is aware of his responsibilities as a medical professional, and understands the ethics of treatment and how the scenario is to be played out, in ordinary times with ordinary cases, if any of them are. But this case is not ordinary, and he has some decisions to make that he knows will be in the best interests of his young patient. He has had a conference with Gene and his parents, and they have expressed a desire for an alternative treatment that Dr. Newman isn’t sure is medically sound, nor is he sure it will result in another remission of Gene’s cancer. Because they were all three fairly adamant against ordinary treatment, especially the chemotherapy that Gene underwent before, that made him very sick, Dr. Newman has determined that he can himself suggest alternative treatments that are medically indicated and are standard treatments, or those that are considered acceptable under the medical “standard of care,” (Clifton Larson Allen, 2011, from the American College of Physicians, 2014) to which all physicians subscribe.
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Dr. Newman is also aware that there indications and preferences at work that ultimately will guide any decision that is made. These indications and preferences fall under the headings of medical indications, patient preferences, quality of life, and contextual features (Jonson, Siegler, and Winslade, 2010). This paper will discuss these four indications and preferences, but the general theme of the paper is death and dying.
Medical Indications
Gene’s cancer has returned after months of remission in which there was no cancer present in his body. Medical indications referred to questions concerning beneficence and nonmaleficence. These questions have to do with successful treatment goals and selecting the appropriate treatment options for anyone under a physician’s care. While it is true that the cancer was in remission, it is not unusual for cancer to return to someone who is been in remission, so the cancer return was through no fault of Dr. Newman’s. The family has been apprised of the situation, and they are aware that there are treatment options available to them with standard medical care, although they are hesitant to subject Gene to any further treatments that are similar to the ones he had had in the past. But rather than continuing to treat Gene in the same way as before, Dr. Newman has decided to ask Gene and his parents if they would consider specialized cancer treatment at any of several cancer treatment centers, including St. Jude’s Children’s Research Hospital. That way, Dr. Newman can be certain that they are getting excellent care that complies with the ACPs Standard of Care,, and that option would eliminate the possibility that the family is not chasing the option they mentioned in Cuba, which has no evidence of researched efficacy. Dr. Newman, in this case, cannot be a party to or a part of that wish, although it is the parents’ right and the patient’s right to accept that treatment option for themselves.
Patient Preferences
Very clearly, and quite forcefully, Gene’s parents suggested that they were willing to accept the nonmedical treatment in Cuba in lieu of further standardize medical treatment in the United States. They have been informed of the risks of further treatment, and the fact that Gene may die even with appropriate medical treatment. But Dr. Newman believes that the parents are responding emotionally rather than mostly rationally, and he isn’t sure, that if they truly understood what they were thinking about getting themselves into, they would do it. But that is a judgment call that Dr. Newman has to make, based on their conversation, along with any follow-up conversations they may have..
Dr. Newman, of course, knows that the American Medical Association (2001) has enumerated a number of rights that patients have when they enter medical care in the United States, among those being the right to receive information which discusses the benefits, risks, and costs of appropriate treatment and/or treatment alternatives, up to and including the opinions of independent professionals apart from the patient/physician relationship. He also knows that the family, speaking for the patient, has the right to make decisions about all of the patient’s health care needs, and he knows that patients can accept recommended treatment or refuse recommended treatment. Dr. Newman knows that the patient and his family “has the right to courtesy, respect, dignity, responsiveness, and timely attention to his or her needs,” and that they also have the right confidentiality. As well, there is the right to continuity of care, meaning that the physician must cooperate in coordinating “medically indicated care” with other medical professionals who happen to be treating the patient as long as treatment is indicated, and that the physician cannot discontinue treatment unless alternative arrangements are made. Finally, Dr. Newman knows that the family is entitled to adequate healthcare, however it is available.
Quality of Life
The biggest issue in this case are issues of quality of life. Gene has stated that he had does not wish and will not comply with any treatment that involves chemotherapy, because that experience was intensely negative for him the last time he experienced it. In some ways, although chemotherapy is a part of standard care for cancer patients, it does limit a patient’s quality of life. A return to normal life is uncertain for Gene, although he reports that he feels just fine now. The Dr. Newman knows that, if the cancer progresses, Gene will not be feeling just fine, but instead will be experiencing some pretty severe pain if the cancer is not treated. Essentially, this is the dilemma the Dr. Newman faces. He knows that if they don’t get the appropriate treatment, Gene’s condition certainly will worsen, and if the patient and his family take too long to come back to standard medical care, it may be too late to save him. But it is also true that he may not be savable, anyway, regardless of whatever treatment protocol they choose to apply. But Dr. Newman feels ethically bound to initiate appropriate cancer treatment in a standard medical model.
Contextual Features
Contextual features refer to those things that have to do with issues of justice and fairness. In this case, there don’t appear to be any conflicts of interest. The treatment option mentioned by the parents in Cuba Dr. Newman doesn’t consider a professional medical option, so there is no conflict of interest between the two in his own mind. The clinical decision Dr. Newman is making is clearly and only in the patient’s best interest, not decided on because Dr. Newman just wants the extra patient. There are, however, some religious issues that have the potential to impact whatever decision is made in the case, although they do not impact Dr. Newman’s choice of clinical procedures. There are no other parties, that he knows of, who have an interest in whatever clinical decisions are made.
Conclusion
After Dr. Newman weighed all of the factors involved in the case, his ethical decision was to cooperate as fully as he could with the patient and his family, without being a party to or being a part of the decision to go to Cuba for shark fin treatment for Gene’s cancer. He has decided that standard medical treatment in a facility whose sole focus is the treatment of cancer in children is the most appropriate option, and one that he believes and hopes the family will agree with, given sufficient time to understand the reason for it. He feels most comfortable making that decision in light of the American College of Physicians’ Ethics Manual (Snyder, 2012) concerning unorthodox treatments. That ethics manual states that “The physician should discuss realistically and dispassionately with the patient what can be expected from different methods of care. The physician should not abandon the patient who elects to try an unorthodox treatment and should regard the patient’s decision with grace and compassion. In general, the physician should not participate in such treatment. When the treatment is clearly harmful to patients, the physician should seek the best means by which to protect the patient and, where possible, have the dangerous therapy challenged.” Given the feedback that he got from his colleague, a lawyer, a psychologist, and the ethicist, along with all he knows about medical treatment, his decision has been made.
- American Medical Association. (2001). American Medical Association code of ethics. Retrieved from http://www.acaai.org/
- Clifton Larson Allen. (2011). What does “standard of care” mean for physicians, nurses, and hospitals? Retrieved from http://www.larsonallen.com/
- Jonson, A. R., Siegler, M., and Winslade, W. J. (2010). Clinical ethics: A practical approach to ethical decisions in clinical medicine, 7th ed. New York: McGraw-Hill.
- Snyder, L. (2012). American College of Physicians ethics manual: Sixth Edition. Annals of Internal Medicine, 2012. Vol. 156, No. 1.
