The Case Study of Katherine: Insight into Bioethics

Bioethics Case Study

Family Wishes and Harm to the Patient

Situational Awareness

We are aware of the following facts in Katherine's case:

1.Katherine is in a comatose state. After arresting several times, she remained comatose and presumably irreversibly unconscious. After other complications, her state progressed to slow multisystem failure. She was beyond the capability of experiencing the burden of pain by her vegetative state

Katherine had not made it clear by written directives nor communicated any specific instructions to her family (evident by the fact they are in disagreement) about withdrawing life-sustaining treatments if she ever became irreversibly unconscious and lost decision-making capacity.

The proxy, in this case the family, must rely on the reasonable treatment standard because Katherine's wishes were never clearly communicated. Following the third resuscitation and development of multisystem failure, the family disagreed on further treatment determinations. The consultation committee clarified options, but indecisiveness persisted. Agreement was eventually reached.

Proxy decisions regarding life-sustaining treatments were as follows:

After second resuscitation and comatose state: ventilation, tube-feed dependency, and long-term care facility for full treatment

Remained comatose and developed slow multisystem failure (slow dying process): cessation of invasive treatment but continued ventilation and feeding

Development of paralysis of the gut: continue feeding

The provider complied with the family's determinations.

Katherine died from feculent emesis and massive aspiration after only ventilation was exercised and all other treatment terminated.

We are also aware of the following good and bad features of the case:

1.Without the life sustaining treatment (i.e. ventilator, tube feeding) Katherine would die, and death is always bad. However, Katherine is comatose and the bad associated with death is reduced by the brain damage and not experienced in any way.

Life is good, yet not for Katherine because her multisystem failure and comatose state effectively prevent her from experiencing life and being aware of life.

The suffering of the family is bad and opposition to any of their decisions would add stress and contribute to their anguish.

Continuation of treatment despite multisystem failure is a considerable financial burden.

Prudential Reasoning

What is good in this situation and how can it be achieved?

Patient's Perspective Katherine was unable to function as a moral agent and she left no advance directives. She is incapable of experiencing any good or bad.

Provider's Perspective The decision to stop life support, resulting in death of the patient, is immoral unless there is an adequate reason to justify the bad outcome, death. First, the bad features we associate with death would not occur in Katherine's situation because much of her brain is already destroyed and people dying in a state of unconsciousness do not suffer. Death will not take much more from Katherine and if Katherine ever did regain consciousness, her body would cause her significant discomfort and pain because the multisystem failure is beyond repair. Second, Katherine's death would cause only minimal pain to her family because so much of her life has already been destroyed by her comatose state and system failure. Third, Katherine's death would cause no social harm. The doctor may also ask how much good the treatment is achieving. Katherine is beyond experiencing pain and the treatment does no good for her. From a reasonable perspective, the treatment is simply prolonging life to lifeless person.

Disagreement within the proxy is also significant. If members are in discrepancy than the final decision may be weak and unstable. This makes it easier for the doctor to question their decision and offer his counter. In fact, if the proxy is debating and uncertain the doctor should most definitely step in.

From the provider's perspective, Katherine's family really has no idea what her intentions are. She is slowly dying in an unconscious state and her family has refused invasive treatment for her systematic problems yet supports the sustainment of her life. If the provider chooses to comply thus far, which is disputable, he should step in at the point of paralysis of the gut. There is no reasonable justification to resume feeding and induce aspiration.

Proxies' Perspective It is reasonable for the family to employ treatment following Katherine's first recovery and relapse. The idea of Katherine's recovery and her benefiting from treatment was still plausible. However with comatose development and multisystem failure they must ask if providing such treatment will reasonably result in good. I The family did eventually choose to withhold invasive treatments which is reasonable considering Katherine's many problems and quality of life. Further invasive treatments would simply cause more harm than good. If they knew Katherine wanted life-sustaining treatment after this state, this is a reason in favor of the treatment. However, simply wanting it would not make it morally good either. The proxy must act on the basis of substituted judgment which will at least lead to a morally credible outcome. While the treatment seems to provide no benefit to patient, society, nor the family, some people do see the preservation of human beings as morally good. However no moral conviction (religious etc.) seems to justify their unreasonable decisions here. I see no plausible explanation as to the perspective the family held except quite simply, they didn't want to see her die and that is not suitable reason. This is the only reason why they choose to force food to a lifeless body that can't sustain the simple feeding process. The idea that they were in dispute shows they were uncertain with their reasoning as well.

Final Resolution

It is important to point out that the family is not making a choice between one ethical and one unethical option, rather two ethically reasonable options. If an older patient is comatose with multisystem failure and vegetative existence, it is difficult to see how moral reasons could justify prolonging her life. However, continuing such treatment is not immoral. From an ethical perspective, it may be argued that continuing with treatment causes no harm to her. However, she is experiencing no benefit from the treatment. The costs of providing treatment with no benefit to the patient is unreasonable. The ethics of right reason find nothing to justify the life-sustaining treatment. The case raises the question of the proxy's ability to insist on treatment considered medically inappropriate. In this case, the family isn't totally adamant on the continuation of the treatment. There is no sign that a suggestion or opposition by the doctor would cause extreme controversy. Perhaps reasonable members would be able to help the others see it this way. The doctor is obligated, especially following the decisions after paralysis, to offer the more reasonable ethical option.