Monday, February 16, 2009

Think of a moral dilemma you might face at your place of employment. Choose one theory of action morality and use it to determine the morally correct

Think of a moral dilemma you might face at your place of employment. Choose one theory of action morality and use it to determine the morally correct course of action. Discuss the dilemma and the applicaiton of the moral theory.

journal question #1- medical ethics

I admit this question stymied me- I am not sure about what action morality is, honestly.  

I work in a place where there are a lot of decisions made for patients who cannot speak for themselves.  I would say that each shift I work, there is always some question that floats around the unit- "Are we doing the right thing for this patient?" I never hear "Are we doing the right thing for the hospital" or "the bottom line" but since I am in a caring situation, those things will not confront us when we are at work- our goal is to save the patient. At times, this is against all odds, and one does wonder, is it against what the patient herself would want?

Quick one sentence situations- A very intelligent MD, at the end of his life, wanting to prolong it even though this involved shocking him numerous times- his wish was to shock. A 96 yo woman who keeps saying "I want to go home" and her kids don't/won't listen.  A non-compliant patient, although one that was learning how to take care of himself, getting left off the txp list in what can only be described as a personality conflict.  A man who was not quite homeless, but had defiantly taken a turn towards that, who had no family, but health insurance being kept alive because no one had the legal right to say let him go. 

So, I will take the last situation. It's interesting, as this patient was thought to have no health care when he came in. He was driving with a friend, and was able to get to his destination, and when his friend got out of the car, he was found slumped over the steering wheel, unresponsive. It took a fair amount of time for the EMTs to get there, and when they did, he had no rhythm . He was shocked and brought back into a sinus rhythm.  Estimated time down was 10-20 min, but since there was not a good person reporting, it was hard to know. 

He was brought to the U, placed in intercool, a balloon pump, and a vent. He had a swan placed, a picc and an a-line, in addition to peripheral lines. Upon admission, he was missing toes, and his feet were in a horrid state- indicating that his diabetes was out of control. Indeed, his first BGL was almost 800. 

He had no next of kin, we could not find him in our system as having health care, and his friend reported that he had not seen a Dr. in over 40 years.  We eventually found out that he had already paid for his cremation,  and while not having an advanced direction, seemed to accept that when his time to go was time- well, it was time to go. It was also discovered that he had good medical insurance, through Ford. 

Since he had been with us, he had shown no signs of meaningful life. He was heavily sedated to be sure, but even when he was not, there may have been indication he was sensitive to changes in light, but his pupils were fixed and dilated. 

One of the RN's reported that his care was upwards of 150k a day for the first few days. With the vent, and the balloon pump and intercool, those machines in themselves run about 15-20k a day. He was on at least 10 different drugs and subjected to many tests each day, including lab tests every hour to manage the insulin levels. It was mandatory that we continue treatment. 

So, the question is this: This man did not have family, he did not have the wherewithal to take care of his own needs; He had one tooth, no dentures, and uncontrolled diabetes. Since he had health insurance and could afford care, he choose to not take care of himself. He must have been in a fair amount of pain given the state of his feet. 

So, given this silique, one would suppose that Kant would support the decision of the hospital. This is in direct opposition to utilitarianism-where the support of well-being and to alleviate suffering seems to be in diametric view to Kant and in this case, moving to palliative care would have been the correct thing to do.

  Where I get confused is the issue of happiness...or supporting autonomy. It seem that Kant also supports the dignity of the person. This seems to be clearer to me- the gentleman here did not seem to be the type of person that would support this continued support. But we have no way to know.  But if we were to assume, Kant would also support not continuing "extreme measures" in this case, and this man was unwilling to take even the smallest measures he controlled himself to ensure his health. 

We'll never know in this case- this gentleman suffered extensive system breakdown after 2 weeks on our unit. In the end, there was no saving him. We knew this from the moment we got him on the floor, but nothing could be done.  

In this case, using utilitarianism (Mill) and Kantism seem to lead to the same path. I guess that's what made it all the more frustrating for us as health care people.

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