Выбор
Мое финальное эссе по "Моральным Дилеммам в Медицинской Практике"
Main moral dilemma at stake
The main characters in this dilemma include Adam Henry; his parents - namely, his father, who seems to be more engaged in the case in court than the mother; Fiona - the narrator of the story, who is a judge; various advisors, who are giving their perspective on the case and analyzing the moral dilemma from different standpoints.
Adam has a life-threatening disease - leukemia. He is in need of urgent leukemia treatment, and blood transfusions alongside with the treatment. He is still a minor - he will enter the legal age of 18 in three months. Mr. Henry’s parents, as his legal guardians, who identify themselves with the Jehova’s witnesses system of beliefs, deny blood transfusions for their son. Asking Adam to give his opinion on the matter resulted in the same answer - he does not want blood transfusions due to his religious beliefs.
Adam’s health is deteriorating in an almost exponential manner, which implies that in case he does not receive blood transfusions urgently, he might die very soon - it will also be a very painful and agonizing death, as was described by one of the healthcare experts.
The difficulty of this case lies partly in the fact that Adam, in a legal sense, is still a minor, which implies he has no legal right to make decisions about the course of his treatment. The court, therefore, is faced with a question, whether or not to pursue enforcing treatment upon Adam against the wishes of his parents and Adam himself, who seems to be supporting his parents’ decision.
Upon hearing out the opinions of various parties, Fiona makes a decision to speak to Adam herself, in order to make a final decision regarding the matter.
Analysis of the case
At first sight, it might seem as though this case is rather simple. I would interpret such an impression as an illusion, made possible due to the clarity of narration and detailed case explanation. The “black and white” categorizing of Adam and his father that we can notice throughout the whole story greatly contributes to the aforementioned characteristic.
However, this case is not simple at all. Those dozens of probabilities of inner motivation that diverge from the voiced argumentation, possibly concealed by Adam and/or his parents might exist behind the curtains of this case. It is not the goal of this analysis to calculate those probabilities - the goal is, however, to get as close to taking into account and weighing as many of the influencing factors as possible.
I have chosen, therefore, to analyze this case from two different perspectives, as it seems as a necessary step, the one not to be abolished or refuted. A multiple standpoint analysis would allow us to carefully measure our way out of this dilemma, laying the path to a thought-through decision.
Two approaches have been chosen - Tronto’s interpretation of care ethics based approach, and principle ethics based approach.
Principle ethics based approach
The case of Adam can be easily broken down based on principle ethics. Firstly, the patient’s autonomy - Adam’s choice to vocally support his parents’ decision clearly seems to be an intentional one. However, other aspects of autonomy seem shadier in this case. For instance, one might question whether Adam does understand the consequences of his decision to a full extent. Adam knows he could die if he denies blood transfusions. However, “could die” and “will die” are two very differing expressions. If Adam believes he “could die”, which means there is a chance of him dying, but there is also a chance of him surviving - his decision is not autonomous. With a health status such as Adam’s - he will die even with treatment, if no blood transfusions are made. It is clear from the text that he is not aware of the certainty of his death.
Moreover, as described by one of the health advisors, the process of his death will be terrifyingly painful and horrible. Adam is not aware of that either. Therefore, based on the aforementioned factors, I will allow myself to conclude that the understanding aspect of autonomy is greatly violated in this case.
The last aspect of autonomy to look at would be freedom. It seems as though the court is going further with the case partly because it is suspicious of the absence of controlling influences on Adam. For instance, his father, who appears as a “black and white” religious thinker, might be able to control not only his son’s decisions, which is concern that lies on the surface, but also his course of thought - influencing a young child can sometimes be easy for a grown-up, no matter how mature or intelligent that child seems to be. Furthermore, Adam was born into the Jehova’s witnesses system, raised by it, and fed life values by it. As mentioned in the text, some of the members of his family’s community have visited him in the hospital, possibly trying to convince him to stand by his and his parents’ decision, which I see as a controlling influence. Moreover, it is known that in case Adam accepts the blood transfusions, he will be exiled from his religious community - not knowing precisely how strict and controlled it is (respect, money, living facilities, social hierarchy etc.), there exists a probability that Adam’s choice of acceptance would result in his family experiencing deficits, possible moral neglect from the members of their community - maybe as a punishment for not keeping their son from making a right (according to the community) choice, or maybe as a way of expressing social enmity - the range of possibilities is very broad in this case. I conclude, therefore, that freedom is violated as well. Besides, two of the three aspects of autonomy are not present, which motivates me to decide that the patient’s autonomy as a whole is not present in this case.
A second aspect - non-maleficence comes into play as well. “Do no harm” - such a simply put expression bearing so much sense and moral obligation. Will the doctors do harm if they let Adam die? Will they do harm if they enforce blood transfusions on him, increasing his chance to live? All other aspects put aside, these could be interpreted as the core questions in this dilemma case. If Adam dies, there will possibly be family suffering (“possibly” - since we do not know, for instance, whether his father is lacking psychopathic traits; we are not sure if his motivations are purely religious as he keeps on insisting). If Adam dies, he will never have the chance to further develop his personality, poetry, career etc.
If Adam is enforced to take blood transfusions, and in case he lives, he might be grateful for that later in his life. He might as well, however, decide not to continue his life having forcefully violated his religious beliefs and being exiled from his community. There might be future suicide, but there might as well be a future happy life - the chances at this point of time seem to be distributed equally.
The third aspect - beneficence - could be interpreted the similar way as non-maleficence. It is rather hard to decide what would benefit Adam most in this complex situation, based on non-maleficence and beneficence. This leads me to give these two aspects taken together a smaller weight than that of autonomy. I am confident I have done reasonably so, since calculating (and speculating about) the chances of a certain life outcome as opposed to assessing the facts at our display hardly resembles a sufficient substantiation of the big decision we are faced with.
The fourth aspect - justice - is not very relevant in this case, since financial matters and health facilities distribution are not an issue in this case. However, the equality of distribution implies fairness - does having certain religious beliefs, which do not go in accord with more widely spread religious systems, subject the believer to be judged stricter and more radically by those with a different religion? One could argue many things as a response to this question - this would, however, make a separate infinitely long essay. I will just say - yes, in this specific case, fairness in distribution is present from a facilities perspective. However, it may be questioned, whether it is present from a human attitude perspective on the case, which was the reason of this case being brought up in court. According to Spencer H., justice extends not only to fair distribution but overlaps with freedom. “Each shall receive the benefits and evils of his own nature and consequent conduct” - many conclusions may be inferred from this statement, but I believe that we should not (yet) label the choice of the parents as a “benefit” or an “evil”.
Care ethics perspective
A care ethics perspective can broaden our insights into this case, and help us answer some of the remaining questions. We should, however, keep in mind the controversies surrounding care ethics as a moral theory - many argue care is not a sufficient foundation for an ethical theory, which is supposed to deal with complex moral questions, the analyses of which reach beyond solely care (Halwani R., 2003). Indeed, care ethics does not take into account many of the important factors - however, I have still decided to use parts of this method, focusing on assessing care precisely with this method, but giving more weight to the principle-based evaluation of the case.
As we can see from the text, it was acknowledged that care is necessary in Adam’s case. Bringing the case to the court implies high level of responsibility to respond to the necessity of caring about Adam. The care-giving aspect in this case could be interpreted in different ways - I will, however, stick to one interpretation, which is that the healthcare professionals are trying to find the most sensible way of meeting the needs for care by trying to assess as many factors in Adam’s case as possible in order to then be able to physically give that care. Care-receiving could raise certain issues - for instance, enforcing care on Adam by blood transfusions will make him respond to care physically. Morally, however, the answer at this point is unknown, as was elaborated in the section on non-maleficence.
Concluding remarks
I would propose one single solution, which is mostly based on the performed analysis of this moral dilemma - and partly based on the benefit of having an insight into a young mind, who was under parental influence at the age of 18, as many of us were.
My conclusion of this case would be to enforce blood transfusions on Adam. The argument of violated autonomy weighs the most in this deliberation, since, as discussed previously, two of its aspects that I consider most important are not existent. It seems to me that forcefully providing Adam the chance to live could benefit him in many ways. There will remain a chance of him being unhappy with this enforced decision - he will, however, survive. And Adam will have an opportunity to think and even possibly re-evaluate his values and beliefs. This is not an ultimate goal of this decision - but it seems as a very beneficial one if you look at it from a broad perspective. Adam may live his life and learn to make decisions whilst being free from controlled influence.
Furthermore, it is very tempting to avoid elaborating on the unsaid categorization of Jehova’s witnesses as a cult. In my opinion, in this specific case, the blind parental adherence to the biblical statements is about to cause Adam to die. As mentioned in the text, some of the Jehova’s witnesses do permit blood transfusions, because they are more flexible in interpreting the biblical statements, more critical in looking into the primary source of those statements.
Furthermore, Adam did not have the opportunity to choose his beliefs - he was raised as a Jehova’s witness starting from birth. This could partly shape his personality - however, there could be other aspects in him, which were not offered an opportunity to grow and develop.
In conclusion, by making this decision we have to accept the future risks it drags along with it. But we also need to be aware that Adam’s decision to support the wish of his parents was not an autonomous one.
Are we ourselves then violating Adam’s autonomy by enforcing the blood trsnfusion on him? The answer will be “yes”, in case the far future eventually reveals that Adam is deeply unhappy because of this decision. The answer could also be “no”, if Adam gets to live happily and rethinks his own decision, coming to the conclusion he was under controlled influence, which has affected his voiced choice.
Main moral dilemma at stake
The main characters in this dilemma include Adam Henry; his parents - namely, his father, who seems to be more engaged in the case in court than the mother; Fiona - the narrator of the story, who is a judge; various advisors, who are giving their perspective on the case and analyzing the moral dilemma from different standpoints.
Adam has a life-threatening disease - leukemia. He is in need of urgent leukemia treatment, and blood transfusions alongside with the treatment. He is still a minor - he will enter the legal age of 18 in three months. Mr. Henry’s parents, as his legal guardians, who identify themselves with the Jehova’s witnesses system of beliefs, deny blood transfusions for their son. Asking Adam to give his opinion on the matter resulted in the same answer - he does not want blood transfusions due to his religious beliefs.
Adam’s health is deteriorating in an almost exponential manner, which implies that in case he does not receive blood transfusions urgently, he might die very soon - it will also be a very painful and agonizing death, as was described by one of the healthcare experts.
The difficulty of this case lies partly in the fact that Adam, in a legal sense, is still a minor, which implies he has no legal right to make decisions about the course of his treatment. The court, therefore, is faced with a question, whether or not to pursue enforcing treatment upon Adam against the wishes of his parents and Adam himself, who seems to be supporting his parents’ decision.
Upon hearing out the opinions of various parties, Fiona makes a decision to speak to Adam herself, in order to make a final decision regarding the matter.
Analysis of the case
At first sight, it might seem as though this case is rather simple. I would interpret such an impression as an illusion, made possible due to the clarity of narration and detailed case explanation. The “black and white” categorizing of Adam and his father that we can notice throughout the whole story greatly contributes to the aforementioned characteristic.
However, this case is not simple at all. Those dozens of probabilities of inner motivation that diverge from the voiced argumentation, possibly concealed by Adam and/or his parents might exist behind the curtains of this case. It is not the goal of this analysis to calculate those probabilities - the goal is, however, to get as close to taking into account and weighing as many of the influencing factors as possible.
I have chosen, therefore, to analyze this case from two different perspectives, as it seems as a necessary step, the one not to be abolished or refuted. A multiple standpoint analysis would allow us to carefully measure our way out of this dilemma, laying the path to a thought-through decision.
Two approaches have been chosen - Tronto’s interpretation of care ethics based approach, and principle ethics based approach.
Principle ethics based approach
The case of Adam can be easily broken down based on principle ethics. Firstly, the patient’s autonomy - Adam’s choice to vocally support his parents’ decision clearly seems to be an intentional one. However, other aspects of autonomy seem shadier in this case. For instance, one might question whether Adam does understand the consequences of his decision to a full extent. Adam knows he could die if he denies blood transfusions. However, “could die” and “will die” are two very differing expressions. If Adam believes he “could die”, which means there is a chance of him dying, but there is also a chance of him surviving - his decision is not autonomous. With a health status such as Adam’s - he will die even with treatment, if no blood transfusions are made. It is clear from the text that he is not aware of the certainty of his death.
Moreover, as described by one of the health advisors, the process of his death will be terrifyingly painful and horrible. Adam is not aware of that either. Therefore, based on the aforementioned factors, I will allow myself to conclude that the understanding aspect of autonomy is greatly violated in this case.
The last aspect of autonomy to look at would be freedom. It seems as though the court is going further with the case partly because it is suspicious of the absence of controlling influences on Adam. For instance, his father, who appears as a “black and white” religious thinker, might be able to control not only his son’s decisions, which is concern that lies on the surface, but also his course of thought - influencing a young child can sometimes be easy for a grown-up, no matter how mature or intelligent that child seems to be. Furthermore, Adam was born into the Jehova’s witnesses system, raised by it, and fed life values by it. As mentioned in the text, some of the members of his family’s community have visited him in the hospital, possibly trying to convince him to stand by his and his parents’ decision, which I see as a controlling influence. Moreover, it is known that in case Adam accepts the blood transfusions, he will be exiled from his religious community - not knowing precisely how strict and controlled it is (respect, money, living facilities, social hierarchy etc.), there exists a probability that Adam’s choice of acceptance would result in his family experiencing deficits, possible moral neglect from the members of their community - maybe as a punishment for not keeping their son from making a right (according to the community) choice, or maybe as a way of expressing social enmity - the range of possibilities is very broad in this case. I conclude, therefore, that freedom is violated as well. Besides, two of the three aspects of autonomy are not present, which motivates me to decide that the patient’s autonomy as a whole is not present in this case.
A second aspect - non-maleficence comes into play as well. “Do no harm” - such a simply put expression bearing so much sense and moral obligation. Will the doctors do harm if they let Adam die? Will they do harm if they enforce blood transfusions on him, increasing his chance to live? All other aspects put aside, these could be interpreted as the core questions in this dilemma case. If Adam dies, there will possibly be family suffering (“possibly” - since we do not know, for instance, whether his father is lacking psychopathic traits; we are not sure if his motivations are purely religious as he keeps on insisting). If Adam dies, he will never have the chance to further develop his personality, poetry, career etc.
If Adam is enforced to take blood transfusions, and in case he lives, he might be grateful for that later in his life. He might as well, however, decide not to continue his life having forcefully violated his religious beliefs and being exiled from his community. There might be future suicide, but there might as well be a future happy life - the chances at this point of time seem to be distributed equally.
The third aspect - beneficence - could be interpreted the similar way as non-maleficence. It is rather hard to decide what would benefit Adam most in this complex situation, based on non-maleficence and beneficence. This leads me to give these two aspects taken together a smaller weight than that of autonomy. I am confident I have done reasonably so, since calculating (and speculating about) the chances of a certain life outcome as opposed to assessing the facts at our display hardly resembles a sufficient substantiation of the big decision we are faced with.
The fourth aspect - justice - is not very relevant in this case, since financial matters and health facilities distribution are not an issue in this case. However, the equality of distribution implies fairness - does having certain religious beliefs, which do not go in accord with more widely spread religious systems, subject the believer to be judged stricter and more radically by those with a different religion? One could argue many things as a response to this question - this would, however, make a separate infinitely long essay. I will just say - yes, in this specific case, fairness in distribution is present from a facilities perspective. However, it may be questioned, whether it is present from a human attitude perspective on the case, which was the reason of this case being brought up in court. According to Spencer H., justice extends not only to fair distribution but overlaps with freedom. “Each shall receive the benefits and evils of his own nature and consequent conduct” - many conclusions may be inferred from this statement, but I believe that we should not (yet) label the choice of the parents as a “benefit” or an “evil”.
Care ethics perspective
A care ethics perspective can broaden our insights into this case, and help us answer some of the remaining questions. We should, however, keep in mind the controversies surrounding care ethics as a moral theory - many argue care is not a sufficient foundation for an ethical theory, which is supposed to deal with complex moral questions, the analyses of which reach beyond solely care (Halwani R., 2003). Indeed, care ethics does not take into account many of the important factors - however, I have still decided to use parts of this method, focusing on assessing care precisely with this method, but giving more weight to the principle-based evaluation of the case.
As we can see from the text, it was acknowledged that care is necessary in Adam’s case. Bringing the case to the court implies high level of responsibility to respond to the necessity of caring about Adam. The care-giving aspect in this case could be interpreted in different ways - I will, however, stick to one interpretation, which is that the healthcare professionals are trying to find the most sensible way of meeting the needs for care by trying to assess as many factors in Adam’s case as possible in order to then be able to physically give that care. Care-receiving could raise certain issues - for instance, enforcing care on Adam by blood transfusions will make him respond to care physically. Morally, however, the answer at this point is unknown, as was elaborated in the section on non-maleficence.
Concluding remarks
I would propose one single solution, which is mostly based on the performed analysis of this moral dilemma - and partly based on the benefit of having an insight into a young mind, who was under parental influence at the age of 18, as many of us were.
My conclusion of this case would be to enforce blood transfusions on Adam. The argument of violated autonomy weighs the most in this deliberation, since, as discussed previously, two of its aspects that I consider most important are not existent. It seems to me that forcefully providing Adam the chance to live could benefit him in many ways. There will remain a chance of him being unhappy with this enforced decision - he will, however, survive. And Adam will have an opportunity to think and even possibly re-evaluate his values and beliefs. This is not an ultimate goal of this decision - but it seems as a very beneficial one if you look at it from a broad perspective. Adam may live his life and learn to make decisions whilst being free from controlled influence.
Furthermore, it is very tempting to avoid elaborating on the unsaid categorization of Jehova’s witnesses as a cult. In my opinion, in this specific case, the blind parental adherence to the biblical statements is about to cause Adam to die. As mentioned in the text, some of the Jehova’s witnesses do permit blood transfusions, because they are more flexible in interpreting the biblical statements, more critical in looking into the primary source of those statements.
Furthermore, Adam did not have the opportunity to choose his beliefs - he was raised as a Jehova’s witness starting from birth. This could partly shape his personality - however, there could be other aspects in him, which were not offered an opportunity to grow and develop.
In conclusion, by making this decision we have to accept the future risks it drags along with it. But we also need to be aware that Adam’s decision to support the wish of his parents was not an autonomous one.
Are we ourselves then violating Adam’s autonomy by enforcing the blood trsnfusion on him? The answer will be “yes”, in case the far future eventually reveals that Adam is deeply unhappy because of this decision. The answer could also be “no”, if Adam gets to live happily and rethinks his own decision, coming to the conclusion he was under controlled influence, which has affected his voiced choice.