A decision by a physician about any medical treatment of a patient should be based on a risk vs benefit assessment. The possible risks and chance of risk may be fully or just partially known. The benefit can be a known patho-physiologic benefit (directly affecting the underlying disease) or it may include a quality of life or life goals or values consideration that is usually poorly known by the physician but best determined by the patient. When the patient is unconscious and/or does not have the mental capacity to inform or decide, then the physician will look to a surrogate. But the physician must make some degree of assessment before the medical treatment is offered or carried out.
How does one look at a clinical scenario where there is no direct benefit of treatment to the patient? And what if, in addition, there are physical or emotional risks? Why would a patient be treated without benefit? Well, one answer would be that the treatment of the patient was primarily to benefit others. One example in which the act doesn’t involve a drug or medical procedure would be the isolation of a communicable disease patient so that others would not be exposed to the disease. Another might be the current consideration regarding isolation of known pedophiles beyond the period of punishment again for safety concern for others.
Beyond these custodial treatments, there are medical pharmacologic or medical procedural treatments which occur which again do not medically benefit the patient but primarily benefits others. Treating those who have committed sexual crimes by castration or hormone injections in an attempt to protect others might be an example. Another which has been carried out in the past was the castration or tubal ligation of a mentally defective female to prevent her from becoming pregnant. Some of the sedation or tranquilization of Alzheimer’s patients might be prescribed by physician primarily to try to make the patient easier to manage by the caregiver and perhaps ease the emotional burden suffered by the caregiver. In this example one might argue that this patient therapy may be beneficial to the patient by hoping to prevent injury but also it might not.
A good example of the kind of treatment which occurs in medical practice which one can wonder about the ethics and the medical propriety is that of administering increasing doses of a narcotic such as IV morphine to a patient who is nearing the end of life from a serious illness such as strokes or cancer and who is already unconscious and clinically not in pain or in discomfort in order to satisfy the concerns of the bedside family. In terminally ill patients, occasional respiratory or muscular behavior can occur which will frighten the observing family members but clinically does not represent a comfort issue for the unconscious patient. If further morphine is administered, for example, the respiratory rate may be slowed to the point where respiration stops and the patient will die as a consequence of the administration. If the patient had been conscious or stuperous and was in frank discomfort, then the benefit of treating such a terminal patient with morphine would be medically and ethically appropriate despite the risk of death from the drug. Ethical support for this conclusion would come on the basis of the “double effect” principle.
The principle balances the good effect of the act (benefit) against the bad effect (risk). For an act to be ethical it must meet all 5 parts of the principle: 1) The act must be good or morally neutral, 2) Only the good effect is intended, 3) The good effect is not achieved through the bad effect, 4) There is no alternative way to achieve the good effect and 5) There is a proportionally good reason for running the risk. The question becomes is it ethical for an unconscious patient who clinically appears comfortable and in no distress be treated with a narcotic to further depress the patient’s nervous system to try to prevent a behavior which is unsettling only for the unsophisticated family watching and to provide them comfort while at the same time possibly risking and causing the premature death of the patient? More on this issue in a later posting. ..Maurice.
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