January 10th, 2018
Medical Ethics: Evaluating the Decision to make a “Do Not Resuscitate” order
‘Do Not Resuscitate’ (DNR) orders present a core ethical dilemma for medical practitioners. Sally’s case highlights various competing aspects that complicate ethical decision-making process in DNR orders. Although Sally is terminally ill, and the doctors have expressed no hope of her recovering from a metastatic cancer, she insists on enjoying life to the fullest and demands that the doctors conduct resuscitation in case she suffers cardiac arrest. Such an ethical decision comes to the fore when Sally is to attend a repeat thoracentesis under ultrasound guidance in the radiology suite, a procedure that is likely to result into a cardiac arrest. This paper argues out that the attending physician should not issue a DNR order, even though the resident at the inpatient service suggests that he writes such an order before sally proceeds to get the procedure.
One of the reasons that inform my argument is the ethical principle of autonomy, which argues that care professionals ought to respect the choices and decisions of others. It is clear that Sally has made her decision, that she would like a CPR in case she arrests. Although, her husband informs that he would like Sally to be comfortable, the physician and the resident have not discussed with him the DNR order specifically. Writing a DNR order would thus not only be going against Sally’s choice, but it would also be an indication of the failure to communicate with her family.
Another aspect in the decision derives from a rights-based perspective. Here, two competing rights apply – the right to life and the right to not be given degrading treatment. In this respect, Sally does not consider CPR a degrading treatment, and has explicitly stated her desire for physicians to conduct such a procedure in case of arrest. Accordingly, in this instance, the right to life, as judged by the recipient, Sally, should prevail even though professional argument is that CPR is likely not to result into any benefit in cases of metastatic cancer.
Another principle worth of note is the principle of nonmaleficence, which posits that the medical professionals ought to do no harm. In this respect, harm must be perceived in consideration of Sally’s wishes. Since Sally perceives that not performing CPR would do her harm, the physicians should not give a DNR order without first having to discuss it with her. Giving such an order without Sally’s consent would be placing the physician’s values above Sally’s values, which in essence would be doing harm. Such a consideration should also be made with respect to the principle of beneficence, which contends that the actions of the health professional should have a net benefit over harm. Although an argument would be that the DNR would achieve an overall net benefit by allowing Sally to pass on in comfort, this would be ignoring the harm resulting from failing to respect her wishes.
Giving a DNR order in Sally’s case would also be in contravention of the principle of justice. In this respect, justice should not be perceived in respect to the fact that Sally has had an equal access to care she has received so far. Rather, it should be perceived as to whether it is just to issue a DNR without the knowledge of a recipient who has the mental capacity to make decisions. Further, giving a DNR would mean that Sally has no equal access to CPR services.
A deontological perspective could argue for the physician to issue a DNR order in the view that the intent of such order was morally sound. In this respect, the intent would be based on professional guidelines that posit that DNR need to be considered where CPR is deemed to be of no benefit, as is the case in Sally’s condition. Presenting such a justification would however fail to recognize the second criteria for deciding on DNR orders: getting the consent of the client (if s/he has the capacity to make the decision) or from an appropriate individual designated to make the decision for the client. In this respect, Sally has the capacity to make the decision, and even where the professionals deem her to be unwilling to accept her prognosis, they have not discussed the DNR with her husband. As such, proceeding to issue the DNR would be unethical even considering the deontological perspective.
Finally, a DNR order in Sally’s case could be argued to be ethical if a utilitarianism perspective was considered. In this respect, it would be argued that the DNR would provide overall good to all stakeholders involved. Thus, one would have to consider benefits to such stakeholders as her husband (e.g. her wish for her to be comfortable), and benefits to the medical fraternity (e.g. saving the effort and cost for those who the CPR is shown to have benefits). However, such an action would mean violating other ethical guidelines such as respect to autonomy, non-maleficence, beneficence and justice. More so, making the decision without consulting Sally would be giving precedence to the physician’s values over Sally’s values. Accordingly, the physician should not issue the DNR. He should evaluate other approaches such reviewing details of what CPR entails, Sally’s prognosis, and the intensive care experience, not in a way to make Sally accept the physician’s decision, but in a way that allows her to make an informed decision concerning receiving CPR on getting a cardiac arrest.