A woman enters the emergency room with stomach pain. She undergoes a CT scan and is diagnosed with an abdominal aortic aneurysm, a weakening in

Autonomy essentially means “self rule,” and it is a patient’s most basic right. As such, it is a health care worker’s responsibility to respect the autonomy of her patients. However, at times this can be difficult because it can conflict with the paternalistic attitude of many health care professionals. The following two cases address patient autonomy. The first involves the rights of an individual to decide her own fate, even against her physicians’ judgments. The second case involves the rights of a parent to care for her child in the manner that she sees fit.

Case 1:

A woman enters the emergency room with stomach pain. She undergoes a CT scan and is diagnosed with an abdominal aortic aneurysm, a weakening in the wall of the aorta which causes it to stretch and bulge (this is very similar to what led to John Ritter’s death). The physicians inform her that the only way to fix the problem is surgically, and that the chances of survival are about 50/50. They also inform her that time is of the essence, and that should the aneurysm burst, she would be dead in a few short minutes. The woman is an erotic dancer; she worries that the surgery will leave a scar that will negatively affect her work; therefore, she refuses any surgical treatment. Even after much pressuring from the physicians, she adamantly refuses surgery. Feeling that the woman is not in her correct state of mind and knowing that time is of the essence, the surgeons decide to perform the procedure without consent. They anesthetize her and surgically repair the aneurysm. She survives, and sues the hospital for millions of dollars.

Questions for Case 1:

• Do you believe that the physician’s actions can be justified in any way?
• Is there anything else that they could have done?
• Is it ever right to take away someone’s autonomy? (Would a court order make the physicians’ decisions ethical?)
• What would you do if you were one of the health care workers?

Case 2:

You are a general practitioner and a mother comes into your office with her child who is complaining of flu-like symptoms. Upon entering the room, you ask the boy to remove his shirt and you notice a pattern of very distinct bruises on the boy’s torso. You ask the mother where the bruises came from, and she tells you that they are from a procedure she performed on him known as “cao gio,” which is also known as “coining.” The procedure involves rubbing warm oils or gels on a person’s skin with a coin or other flat metal object. The mother explains that cao gio is used to raise out bad blood, and improve circulation and healing. When you touch the boy’s back with your stethoscope, he winces in pain from the bruises. You debate whether or not you should call Child Protective Services and report the mother.

Questions for Case 2:

• Should we completely discount this treatment as useless, or could there be something gained from it?
• When should a physician step in to stop a cultural practice? (If someone answers “when it harms the child” remind that person that there is some pain in many of our medical procedures, for example, having one’s tonsils removed)
• Should the physician be concerned about alienating the mother and other people of her ethnicity from modern medicine?
• Do you think that the physician should report the mother?

Autonomy Part 2

Maintenance of patient autonomy is one of the major ethical focuses of physicians. Therefore, a second discussion was also held that focused primarily on patient autonomy. This discussion also took a superficial look at euthanasia. For this discussion, a 58 minute video, Dax’s Case (produced by Unicorn Media, for Concern for Dying ; produced by Donald Pasquella, Keith Burton ; directed by Donald Pasquella New York : Filmakers Library, c1984) was used. The video tells the story of Dax Cowart, a man who was severely burned by an accidental propane explosion. The burns disabled Dax, and the physicians forced treatment on him. Though he survived the treatment, he still argues that he should have been allowed to refuse it so that he could die. The video is very useful; however, the videos of Dax’s burn treatments are very graphic and the video should be reviewed before it is shown to a group of students.

Questions:

• In the video, one of the physicians says that burn patients are incompetent to make decisions when they first enter the hospital because they are in such a great deal of pain. However, patients such as Dax can be in a great deal of pain for a very long time. In such cases, what should be done to determine competence, and when should this be done?
• Do you think the fact that Dax could not see a future for himself should have been taken into account when determining his competency? Could this have clouded his judgment? (He thought that he would end up on the street corner selling pencils)
• Do you think that the fact that Dax was going to recover, and had the possibility of living a happy life, made not treating Dax like suicide… or murder? What if he did not have this possibility?
• After his recovery, Dax attempted suicide. Should the physicians have let him die? Is it ever correct for a doctor to allow a patient to kill himself?
• Do you ever think that it is correct for a physician to break a competent patient’s autonomy? If so, is this one of those cases?
• Do you think that in this case, that the ends justified the means?