The Medical College - Page 31
himself. The courts have generally held that
constitu-
tional rights permit an individual to determine
what
happens to himself and his property; many of
these
rights have been codified in what has been
called a
"Patient's Bill of Rights."
Rousseau pointed out that a social contract was
neces-
sary because of the inherent inequality among
human
beings. Some are wise, whereas others are dull,
some are
strong, whereas others are weak. This inequality
is par-
ticularly striking in the patient-physician
relationship.
Physicians have wide knowledge and
experience,
whereas the patient may understand his own needs
and
value but has little information about his
clinical state.
Only detailed conversations with patients and
their fami-
lies can narrow this gap in such a way that
people can
make truly autonomous judgments about their own
care.
Physicians frequently appear to ignore the
required
balance between the principles of beneficence
and
autonomy. A physician recommends radical
mastec-
tomy for breast cancer. No options are provided
because
the physician believes he knows best. The
patient asks
for a second opinion and the physician refuses,
saying,
"I cannot take care of you unless I can make
all impor-
tant decisions." Here is presumed beneficence
gone
amok. A moment later the patient refuses all
surgery
and the physician says kindly, "It's your life
and you are
free to do anything you like." Here the
physician is
ignoring the obvious worried statement of the
patient
and threatening abandonment if the patient does
not
obey.
Aside from the physician's obvious arrogance
and
insensitivity, the key question must be: Is the
patient
completely autonomous when she refuses all
treatment
and walks out of the doctor's office? She has
been told
that she has cancer and must have what she
believes to
be a destructive surgical procedure. Fear of
disfigure-
ment and death have produced uncontrollable
anxiety
that causes her to attempt escape from the
situation.
True beneficence in this situation demands that
the
physician seek out the patient, and her family,
and
make certain that repeated efforts are made to
present
the true gravity of the situation. Beneficence
does not
mean the quick delivery of a series of
commands, but
implies shared responsibility, patient
education, and
understanding, and gentle persuasion where
necessary.
Indeed, correctly interpreting the proper
balance
between these two moral principles in any given
situa-
tion could be considered one of the key
responsibilities
of the practice of medicine.
The beneficence/autonomy concept must be
related
to the burden/benefit relationship of any
proposed
action. The balance between the risks or burden
of con-
tinued treatment relative to any anticipated
benefits
must be carefully considered. Sometimes life
itself, or
the treatment proposed to sustain life, is so
burdensome
that the patient claims the right to allow the
dying
process to proceed. Granting seriously ill
patients, or
their families, the right to refuse
life-lengthening treat-
ment is an important human issue that is
central to pro-
fessional practice. In many respects, the
judicial system
is ahead of most physicians in understanding
the issues
under discussion. Artificial feeding, for
example, a
technique that many would consider to be part
of the
basic humane care required for all patients may
also
become burdensome in certain situations where
any
benefits from such intervention is
minimal.
Obviously, the accuracy of a group of
physicians to
predict that meaningful life is no longer
possible for
the individual is central to any such decision.
Such a
need raises the issue of who can determine what
is
"meaningful life" and how can physicians best
learn
how to decide when the burden outweighs the
benefit
of any course of action.
38.
Which of the following statement(s) is/are
sup-
ported by the passage?
A.
The Golden Rule is not a sufficient
ethical
statement.
B.
Most physicians emphasize curing
illness
and preventing death.
C.
The Golden Rule views the physician
as
knowing what is best for the
patient.
D.
All of the above.
39.
Which of the following would probably
have
been chosen by the author as a title for this
pas-
sage?
A.
The Development of the Medical
Decision
Making Process
B.
Physician Reasoning and Autonomy
C.
The Practice of the Golden Rule
D.
Moral Reasoning and Medical
Decision
Making
40.
Regarding human rights, which
statement(s)
is/are NOT supported by the
passage?
A.
Hippocrates lived before that principle
was
established.
B.
Physicians must attempt to defeat the
dis-
ease first and then explain their
protocol.
C.
The courts generally have backed
the
physician as to knowing what is best
for
the patient.
D.
All of the above.
Adapted from Dr. Stephen M. Ayres, "Moral
Reasoning and
Medical Decision Making," MCV/VCU,
1990.
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