Amaro, Alejandra Amolenda, Patricia Anacta, Klarizza Andal, Charlotte Ann Antonio, Abigaille Ann Arcilla, Juan Martin MEDICAL ETHICS III: CASE 2

Case 2 E.P., a nurse in the intensive care unit takes care of Lola, a 70 y.o. with terminal colon cancer, who is suffering from pain which has been increasingly difficult to control. The attending physician ordered moderate doses of morphine. The family was told that at these doses, it may depress respiration and therefore may possible hasten death. Lola and her family have accepted her condition. All the members of the team, except E.P., see no problem in giving her an increasing dose of morphine.

Case 2 E.P believes that the morphine may hasten Lola’s death thus she cannot in good conscience, give the injection. The attending physician regards her refusal as a serious form of disobedience. One night, Lola became very restless and unable to sleep and was on severe discomfort and was asking for the injection. E.P. refused even with the pleading of Lola’s daughter.

Do nurses have the right to refuse medical orders? AMARO, A.

Do nurses have the right to ignore the wishes of the patient and the family on grounds of conscience? ANACTA, K.

Right to ignore orders? Right to ignore patient’s wishes? NO! Nurse could question the prescription ordered Nurse must attend to patient’s wishes but if it would cause harm to the patient, the nurse must address appropriately the wishes to the attending physician and address rightful orders for the patient NO!

Discuss the ethical issues involved in this case. AMOLENDA, P. ANDAL, C. ANTONIO, A. ARCILLA, J.

Pain and Dying  Pain is not an absolute human evil  Great good can come out of suffering when this is joined to the suffering of Jesus  Alleviating pain by medicine or surgery is not euthanasia even if patient’s life may be shortened by it.

Pain and Dying The opportunity to use suffering as a means of spiritual growth is not destroyed if painkilling drugs are used

Principle of Double Effect The act itself must be morally good or at least indifferent. The intentions of the agent must be to achieve the good effect and to avoid the harmful effects in so far as possible. The evil effect is only indirectly intended. The benefits of the action must be equal or greater than the foreseen harmful effects The good effect must directly come from the act itself and not from the bad effect.

Principle of Double Effect First, the treatment in this case, a high dose of morphine—is the only means to meet the end desired, which is the cessation of intractable pain. Second, the direct object of the act is to relieve pain. The hastening of death is just an accidental, even though foreseen result.

Principle of Double Effect Third, the good effect must, in our moral analysis, outweigh any unintended bad effect. Finally, the bad effect (possible earlier death) should not be the means to the good effect (pain relief). Very high doses of opioids are frequently used without patients dying shortly after administration of the drug.

Nurses’ Role in End-of-Life Issues With regard to end-of-life care, the Nurses’ Code of Ethics reiterates the obligation to respect all persons and their autonomy. Nurses are "leaders and vigilant advocates for the delivery of dignified and humane care." (Code of Ethics, p. 9). Nurses are required to alleviate suffering and provide comprehensive supportive care to those who are dying, even though, they know that some palliative care may hasten death.

Nurses’ Role in End-of-Life Issues However, nurses may not act with the sole intent of ending a patient’s life even though such action may be motivated by compassion, respect for patient autonomy and quality of life considerations. Because of the moral distress this kind of nursing care can provoke, nurses are encouraged to learn more about end-of-life care and contribute to the expansion of end- of-life care practices through research, education, practice, and policy development

Autonomy The principle of autonomy acknowledges patients' personal liberty, and their right to decide their own course and follow through a plan that they freely agree on. (Edge et. al., 1995) It is from this principle that rules about informed consent are derived. To decide freely requires that an individual has adequate information to comprehend the available options.

Autonomy Justice Cardozo wrote in 1914, "Every human being of adult years and sound mind has a right to determine what shall be done with his own body." Conflict with Paternalism Tendency among healthcare professionals to assume that they know what is best for the patient

Respect for Autonomy To respect an autonomous agent is to acknowledge that person’s right to make choices and take action based on that person’s own values and belief system Refraining from interfering with others’ choices Providing them with the necessary conditions and opportunities for exercising autonomy

Beneficence - “do good and avoid evil” - What counts as benefit and what counts as harm? Norms that arise from the Principle of Beneficence: Never deliberately kill innocent human life Seek the patient’s good Do not treat others paternalistically, instead, help them pursue their goals use wisdom and prudence in all things, that is, appreciate the complexity of life and make sound judgments for the good of oneself, others, and the common good

Beneficence If nurse E.P. administers the morphine, is it considered euthanasia? No, pain relief treatment given with a primary intention to relieve pain and reasonably necessary to achieve that outcome is not euthanasia, even if it does shorten the patient’s life.

Non-maleficence E.P.believes that the morphine may hasten Lola’s death thus she cannot in good conscience, give the injection…Lola became very restless and unable to sleep and was on severe discomfort and was asking for the injection. E.P. refused even with the pleading of Lola’s daughter. Conflict between patient’s autonomy and non- maleficence First do no harm Some argue that opioids themselves are harmful; however, serious harm is rare if the drugs are used properly, particularly in the setting of life-limiting illness.

Non-maleficence Pain is harmful emotionally, socially, spiritually, and even physiologically Pain relief treatment given with a primary intention to relieve pain and reasonably necessary to achieve that outcome is not euthanasia, even if it does shorten the patient’s life. Any intervention, including the use of pain relief drugs, carried out with a primary intention of causing the patient’s death and resulting in that outcome, is euthanasia.