The Principle Of Not Choosing An Irreversible Path When Faced With Uncertainty

Upon swearing the Hippocratic Oath, graduating medical students bind themselves to an ethical code that ensures the overall progress and welfare of their patients. The American Medical Association’s Code of Medical Ethics (1996 edition), “has remained in Western civilization as an expression of ideal conduct for the physician.” (Lawson, 2010.) Today, most graduating medical school students swear to some form of the oath, usually a modernized version. (  However, medical ethic is still an important and touchy matter in the health field. Medical ethics is derived from Ethics; a moral philosophy that came about with the Sophists of Greece. Even as physicians have long since held themselves to a moral code, there have been rogue physicians who have subjected individuals to unethical experimentation and research. In Medical Apartheid, Harriet Washington details the systemic and medical abuse, discrimination meted out to African-Americans since colonial times. She details the appalling and unethical invasive experimentation and research practices performed throughout history to African-Americans. She opens her book by talking about James Marion Sims, a 19th-century surgeon who is venerated as a selfless benefactor of women for devising ways to repair severe vaginal injuries occurring during child birth. She talks about how he is celebrated despite the fact he honed his skills by performing scores of painful operations on the genitals of black slaves without amnesia. He refused to give them ether even when it was available but gave them to white women. A physician who “cut his way to the top”. His African-American human subjects were mere guinea fowls in his ploy for recognisance in his field. In a twisted Rob-Peter-To-Pay-Paul  manner, he violated every ethical code possible. In this case, Martin Luther King’s quote “The arc of the moral universe is long, but it bends toward justice” does not hold water. These women never had justice. 

Medical Ethics is the study and critical analysis of the ethical rules that arise in the interrelationships between law, medicine, life sciences, theology and biotechnology. (Lawson, 2010.) According to the American Medical Association, the Principles of Medical Ethics and the Opinions of the AMA’s Council on Ethical and Judicial Affairs that make up the Code offer guidance to help physicians meet the ethical challenges of medical practice.  Medical ethics is heavily stressed today even as the uncovering of past unethical procedures have prompted medical professionals to abide strictly by ethical codes. The medical ethics code is based on the principle of respect of autonomy; principle of nonmaleficience, principle of beneficience and principle of justice. (Beauchamp and Childress (2008.) The principle of respect of autonomy emphasises consent and the need to honor individuals’ decisions on matters concerning their health. The principle of nonmaleficience emphasises the old adage “do no harm and do more good” while the principle of beneficience is based on the need for physicians to provide healthcare in a humanitarian manner and demands that health care providers develop and maintain skills and knowledge, continually update training, consider individual circumstances of all patients, and strive for net benefit. () The principle of justice requires that procedures and medical experiments be fair and performed without prejudice.  The main point is can morality really be subjective? In different parts of the world what is considered wrong might considered right with the exceptions of murder, incest. Reproductive specialists who perform legal abortions with patients’ informed consent are indirectly doing harm to developing fetuses considered to be human. In this case; the question of morality is called into question. How about assisted suicide? A doctor is indirectly doing harm by killing off a human being at their request. A common thread that runs through these dilemmas is consent. The explicit, informed and voluntary agreement given by individuals to a request or procedure.  Hence, the advent of DNRs; a type of advanced medical directive.

DNR means “Do Not Resuscitate.” DNR orders are written instructions from a physician telling health care providers not to perform Cardiopulmonary Resuscitation (CPR). CPR uses mouth-to-mouth or machine breathing and chest compressions to restore the work of the heart and lungs when someone’s heart or breathing has stopped. It is an emergency rescue technique that was developed to save the life of people who are generally in good health. () Patients sign these medical directives after they are informed about the emergency and invasive procedures available to them in a fatal situation. These patients are explicitly saying that they do not wish to be revived or have extraordinary procedures done on them to save their lives. A article from the New England Journal of Medicine recounts a peculiar case of a man who tattooed his medical directive on his chest. Here is an excerpt “Paramedics brought an unconscious 70-year-old man with a history of chronic obstructive pulmonary disease, diabetes mellitus, and atrial fibrillation to the emergency department, where he was found to have an elevated blood alcohol level. The staff of the medical intensive care unit evaluated him several hours later when hypotension and an anion-gap metabolic acidosis with a pH of 6.81 developed. His anterior chest had a tattoo that read “Do Not Resuscitate,” accompanied by his presumed signature. Because he presented without identification or family, the social work department was called to assist in contacting next of kin. All efforts at treating reversible causes of his decreased level of consciousness failed to produce a mental status adequate for discussing goals of care” ( N Engl J Med , 2017.) In this case; there was a medical dilemma of withholding or withdrawing treatment at the expense of saving a life or adhering to a dying man’s engraved wish. There was no official medical directive and the doctor’s could not tell if the tattoo was a drunken mistake or if his wishes might have changed since he had the tattoo. The doctors initially decided not to honor the tattoo, invoking the principle of not choosing an irreversible path when faced with uncertainty. In this case, if indeed, the patient wanted to be resuscitated and they withheld treatment the patient would die and this could never be reversed. However, after a medical ethics consultation; the patient was not resuscitated and a legal DNR was made. The extraordinary measure the patient he took in the form of a tattoo counted as his consent to not be resuscitated in a life-threatening situation.

In the aforementioned situation, the principle of “Do no harm” directly clashes with the principle of respect of autonomy. Can a doctor let a person die on the basis of uncertainty? If there are no DNRs in a patient’s file then docrors are obliged to revive a patient but in this case there was only a tattoo. Respect the wishes of a man who might have tattooed himself on a drunken whim?  Morality can be subjective. There is no wrong or right answer in cases like this because at the end of the day; consent is principal. Do unto others what they would have done to themselves.


Here is the link to the mentioned article published in the New England Journal of Medicine


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