Introduction to Ethics: Application and Logic

Lindsey Rasmussen

LP4 Case Study

Summary of Case Study: A Family Donor

A woman has a serious kidney disease and has been undergoing dialysis, but the treatments are no longer as effective as they used to be. Testing indicates the woman’s brother is an eligible kidney donor, but after weighing the alternatives because of the risks involved and his belief that he and his sister are not close enough to take that kind of risk for each other, he decides not to donate a kidney to his sister. The doctor is faced with an ethical dilemma, what should he tell his patient?

Facts and Evidence

The woman being treated for kidney disease is 19 years old. She is on a dialysis machine, but the efficacy of her treatments is declining. The attending physician suggests members of the woman’s family undergo testing to determine how compatible their tissue is for kidney donation, before the woman’s condition deteriorates any further. It is determined that the woman’s brother is the only family member whose tissue is compatible enough for him to be considered a potential donor. The doctor meets with the brother to discuss risks and benefits of the procedure. Although he had undergone testing to determine if he is a potential donor, the brother decides not to donate a kidney to his sister. The physician reiterates the risks involved and suggests the brother rethink his decision given the seriousness of his sister’s condition and what little time they have. Again, the brother refuses. What should the physician tell his patient?

Assumptions

I have made the following assumptions about this case study: (1) the woman will die if she doesn’t receive a kidney transplant in the near future; (2) her brother thought it was very unlikely he would be compatible enough to be considered a potential donor, which is why he underwent initial testing; (3) he was also pressured into being tested by his parents and other family members; (4) the woman is significantly younger than her brother which is why he doesn’t consider them “close enough to take that kind of risk for one another”; (5) the brother is single and doesn’t have a partner or a family of his own yet; (6) the brother is selfish and has only considered how he will be affected by donating a kidney; (7) the brother must not care much about his sister or what may happen to her; and (8) the brother made his decision too quickly.

As I continued to analyze this case study I also came to realization that I have made further assumptions about the physician, which include the following: (1) the attending physician is a man; (2) the physician is an ethical practitioner and takes his oath to do no harm, very seriously; (3) the physician abides by all applicable laws, rules, guidelines, principles, responsibilities, obligations, etc. of his profession to the greatest extent possible; and (4) not only is the physician an ethical practitioner, but he strives to be as ethical and moral as possible in his day-to-day life because he believes it is the right thing to do.

Social Influence

Socialization is the sum of experiences that make us we are; it teaches us our language, cultural norms, values and beliefs, an understanding of others, as well as whom we are as social creatures. In short, socialization is a lifelong process of learning how to interact with people and become a member of society, making us all products of our social experiences (“Socialization”, 2010, slides 2-3).

This being said, it becomes evident that my assumptions about this case result from my own socialization. For example, let’s consider for a moment the last assumption I made regarding the brother: he made his decision too quickly. From the facts of the case, it seems as though the brother learned of his potential to donate, met with the attending physician, and made his decision not to donate a kidney to his sister, all on the same day or at the very least, within a short period of time. I believe he should have taken more time to make such a significant decision. I believe this because my family experienced something similar this past year.

My father was diagnosed as having atrial fibrillation (the most common form of cardiac arrhythmia) 6 or 7 years ago. For most part, his condition was able to be adequately regulated with medication. However, this past year he began cycling in and out of A-fib rapidly, without warning, and despite the medication he was on. Various adjustments to his meds and a number of cardioversions proved unsuccessful at maintaining a normal heart rhythm for any significant period of time. As a result, his cardiologist suggested he undergo a catheter ablation – essentially burning away the malfunctioning heart tissue – a procedure that may take place if medication does not work.

Over the next few weeks, my parents talked to a number of cardiologists, nurse practitioners, and other specialists about the risks and benefits of a catheter ablation; they did their own research on the procedure, talked about what to do between them and, before making a final decision, they discussed things with me and my siblings. The decision was not an easy one, one taken lightly, or one chosen without serious consideration of the potential risks and benefits involved. My father, with the support of our family, reassurance from medical professionals, and knowing that research supports its effectiveness, he proceeded with the catheter ablation about two months ago. Now my father has a normal heart rhythm, without medication, something many of us take for granted.

I tell this story to demonstrate why I think the brother in the case study made his decision too quickly. We are told he was only informed twice of the potential risks and benefits associated with kidney donation, but never hear of any serious contemplation on his behalf, research he conducts on his own, or discussions he has within his family or with his sister. It seems as though he had his mind made up before even hearing what the physician had to say (which leads to my second and third assumptions – the brother didn’t think he’d be compatible and/or had been pressured into getting tested by the family). And even after being asked to reconsider, it seems like he immediately responds with “no”.

After what my own family has dealt with it only seems natural that the brother take more time to seriously think about his decision and talk about it with professionals, his sister, and other members of the family. The brother faces a very difficult choice and could benefit from consulting with his family and just taking more time in general, to think about what the right decision is.

Ambiguous Language

We often assume that everyone defines words the same way or understands certain vocabulary, statements, or phrases like we do. However, this is not always true and in this particular case there are a number of words, statements, and/or phrases that need clarification so that everyone who reads them has a similar understanding of the scenario.

Our case study opens with the description of a woman with a “serious kidney disease” and ends with a statement about the “serious nature” of her illness”, but we are never told what her disease or illness is, so to objectively gauge its seriousness becomes difficult. What does “serious kidney disease” or “serious nature” of an illness specifically mean? What does it mean to you? Chances are, your definition of “serious” is not exactly the same as mine, which influences the way we evaluate the woman’s condition, her brother’s decision, and the potential courses of action the physician should take.

Secondly, after the issue of tissue compatibility is discussed, we are told the woman’s brother is the only member of the family who “shows a degree of compatibility high enough to be considered a candidate”. I am not a doctor, so my own research into the subject reveals the donor and recipient must match in three distinct and important areas: blood type, tissue type, and cross- matching (Friedman & Peters, 2006). But in this particular case study, we don’t know if any tests other than tissue compatibility have been conducted; therefore, what does the brother’s “high degree of compatibility” really mean? More information is needed to make this determination.

Interpretation of two additional phrases also influences our perception of this scenario. We are told that the brother decides not to donate his sister a kidney after “weighing the various alternatives because of the risks” and he doesn’t “feel he and his sister have ever been close enough that they would ever take that kind of risk for each other”. Regarding the “various alternatives” statement, there are a number of elements that must be explained, like, for example, what does “weighing various alternatives” really mean in terms of behavior? Has he considered one alternative or many? Alternatives which are possible or far-fetched? How has he “weighed” them? And what about the risks mentioned? Risks for the brother or sister, risks that are likely or not? What are the actual risks associated with the “various alternatives”? The phrase which follows and addresses the brother’s feelings (or lack thereof) that “he and his sister have never been close enough that they would ever take that kind of risk for each other” also needs clarification. What does “never been close enough” mean in real-life terms? What is their relationship really like? Do they even have one? Does this matter? And additionally, what is the brother referring to when he says, “…that kind of risk”? Does his sister feel the same way? Again, does it matter? Overall, the point is that we don’t know, and therefore it is difficult to effectively and accurately assess the situation, the brother’s behavior, and ultimately what the physician’s course of action should be.

Lastly, the phrase “increasingly little time to spare” must be clarified to understand this case study as clearly as possible. Does it mean the brother has very little time to make a decision or change his mind? Or on the other hand, does it refer to the amount of time the sister has to live? Is it years, months, days...? Again, defining this phrase and answering the questions that follow, allows us to more accurately evaluate the sister’s condition, the brother’s decision, and the physician’s course of action, more accurately.

Compatible and Conflicting Ethical Values

The physician in this case study much chose a side – does he tell the woman what he knows about her brother (he’s a candidate for donation but has chosen not to give a kidney to his sister) or does he not tell her what he knows, thus protecting the confidentiality of the potential donor, who just happens to be the recipient’s brother? These two options are each supported by certain ethical values, some which both sides share (compatible values) and some that they don’t agree on (conflicting values).

In this particular situation, compatible ethical values include the following:

Autonomy: each individual has the ability to make their own decisions

Benevolence: the physician wants to do good for others

Freedom: the brother has the freedom to choose whether to donate a kidney or not

Obligation for the well-being of others: the physician has the duty to provide appropriate care to others

Non-maleficence: the physician is bound by the principle “above all, do no harm”

On the other hand, there are also conflicting ethical values – those that are not agreed upon:

Confidentiality: the physician has the duty to maintain confidentiality of his patient, the potential organ recipient, and the brother, the potential donor. Those who believe the doctor should tell the woman about her brother could think doctor-patient confidentiality only extends to the physician’s actual patient, the woman. Duty: the physician has an obligation to do no harm, by not telling the woman what he knows, he is causing her harm. Those on the other side of the issue could think telling the woman is only going to cause her unnecessary emotional harm.

Honesty: to be honest means to be truthful and straightforward. The physician should tell the woman about her brother because it’s the honest truth. On the other hand, those on the other side may think that honesty only pertains to information not obtained under privileged communication.

Responsibility: they physician is accountable for the woman’s life, by not telling her about her brother, he is not being responsible. On the other hand, those on the other side believe the doctor has a responsibility to uphold all applicable laws, rules, principles, and guidelines of his profession, one of which is to maintain the privacy and confidentiality of the potential donor.

Additional Questions

I posed quite a few questions during my discussion of ambiguous language; however, I have more questions. What follows is a list of questions I have, whose answers will help me choose the most appropriate course of action in this difficult situation:

What kidney disease is the 19-year-old woman being treated for? When was she diagnosed?

How long has she been on dialysis? What other treatments have been utilized or proposed?

How effective has dialysis been? How much has its efficacy decreased?

How many family members have undergone testing to determine tissue compatibility?

Are there any other family members or friends willing to undergo testing?

What exactly is the brother’s degree of compatibility? What is the highest rate possible?

Should a different physician have talked to the brother about donation, to avoid the potential conflict of interests?

How or why did the woman’s physician know about the brother’s compatibility?

Why did the brother agree to be tested in the first place? Did he have any intention of donating?

How did the brother ultimately come to the decision he did? What alternatives and risks did he consider when deciding what to do?

How old is the brother? Why aren’t he and his sister close?

What are the likely risks the brother faces if he chooses to donate a kidney to his sister?

What are the chances the sister’s body will accept the new kidney? What are the chances she will live if she doesn’t receive a kidney transplant? Is she on a donation list?

What does “increasingly little time to spare” mean?

What If Questions

I also have other, more general questions about organ donation and potential ethical implications, questions that push me think beyond just this one situation. They are as follows:

Should potential donors and recipients have separate physicians/treatment teams to begin with? Why or why not?

Should it matter if the potential donor is emotionally close to the recipient? What difference does this make? Should it? Why or why not?

Does a family member have an ethical or moral obligation to put themselves at risk to help another member of the family? Why or why not?

Is it ethical for a physician to urge a potential donor to donate or not to donate? Why or why not?

Is it ethical or moral for a physician to urge someone to take a particular course of action that harms him/her, but helps another? Why or why not?

How do the principles a physician is bound by support or contradict organ donation? Do these same principles relate to all aspects of the physician’s life or just in a medical environment?

A Similar Case

Doesn’t an attorney struggle with a similar dilemma every time s/he knows one of their clients has committed a crime, for example? It would be very easy for the attorney to go to the police or even the victim(s) and tell them what s/he knows about the crime and who has committed it. It seems like a very simple way of solving crimes, however, the attorney would be violating one of the oldest and most basic principles of their profession. The attorney has a duty to maintain their client’s confidentiality. This is referred to as attorney-client privilege and it’s important because it encourages the client to make a full disclosure to their attorney, so the attorney can represent the client as effectively as possible.

This case is similar to the family donor case in that the physician has the duty to maintain confidentiality of the potential donor (doctor-patient confidentiality), just as the attorney has the duty to maintain client confidentiality (attorney-client privilege).

It may seem like an easy fix for the physician to tell the woman her brother is a potential donor but he refuses to do so, so that she and the rest of the family can pressure the brother to “do the right thing” and donate a kidney to save his sister’s life. But this is not ethical and perhaps even illegal, because the potential donor is entitled to confidentiality and privacy regardless of his relationship to the recipient.

Likewise, the attorney could easily help solve a crime by telling the authorities what his client has disclosed to him, but again this is not ethical nor it is legal. The client’s communication with his attorney is protected by attorney-client privilege. In other words, the attorney must maintain the client’s confidentiality regardless of the crime that has been committed.

Potential Solutions and Consequences

A physician is ethically responsible for promoting the best interests of the patients in their immediate care and advocating for the health of society at large, which includes all potential patients. This is also known as beneficence, one of four professional principles a physician is bound by. The other three principles binding a physician include the following: non-maleficence (not harming patients), respect for autonomy (promoting patient self-determination) and justice (promoting equal distribution of life-enhancing treatments) (Ladin & Hanto, 2012).

Organ transplantation from living donors seems to violate one of these principles – do no harm – because it involves taking a healthy organ from one person and placing it into another. In other words, one person is deliberately made a patient to benefit another person who is already a patient. In addition to this inherent dilemma, organ donation by living donors, especially those related to the recipient raises a number of ethical questions that haven’t been completely answered yet. Furthermore, there exists major ethical concerns involving living related donors, which focus on the possibility of undue influence, emotional pressure, and coercion (Committee on Increasing Rates of Organ Donation, 2006 p.263, 267). Thus, all things considered, the physician is truly between a rock and a hard place…what should he tell his patient?

One potential course of action for the physician is to abide by all applicable laws of confidentiality and privacy and not share any information pertaining to the potential living donor, with the recipient. In other words, the physician would tell the woman, his patient, nothing of his knowledge of or conversation with, her brother, the potential donor. This is typical protocol when it comes to organ donation, and furthermore, the person evaluating the brother should have been a different medical profession altogether so there would not have been this conflict of interests in the first place.

This course of action is perhaps the most ethical solution to this very difficult situation. If the physician proceeds as if he knows nothing about his patient’s brother, the brother’s compatibility and subsequent decision, he can proceed as “normal” as possible with his patient. They can continue with dialysis and pursue other avenues of organ donation, such as placing her on the waiting list for a kidney and hope one comes along in time to save her – either from a different living donor or one that is deceased. The physician also avoids causing his patient undue duress or violating any ethical codes or medicinal principles. Another potential course of action is for the attending physician to tell his patient he knows her brother is compatible but her brother has refused to become a donor. The physician’s motivations for doing so may be well-intended, but would be in violation with laws and rules governing confidentiality and privacy. Furthermore, it may disqualify the brother as a donor altogether if is ascertained he has been unduly pressured or coerced – whether by the woman, their family, the doctor, etc. – and does not by his own free will wish to donate a kidney to his sister. The possible consequences from this course of action are not likely to benefit any of the people involved in this scenario and the physician may cause more harm than good, violating yet another principle he is bound by.

A third possible course of action is the physician alludes to his patient there is a member of her family who is compatible enough to be considered a candidate, but who has declined to do so. The physician doesn’t say who this person is and is careful of the pronouns he uses when referring to this person, but nonetheless encourages the woman to talk with each of her family members who underwent testing. Although this course of action could be effective in bringing the brother and sister closer together, it may not change his decision, or it may not be effective on any level. Consequences of this course of action are difficult to predict and the doctor is dangerously close to breaching patient/donor confidentiality and privacy. Perhaps the most likely consequence is that the woman experiences additional and unnecessary emotional pain.

What Would I Do?

If I were the physician in this scenario, I know exactly what I would do…nothing. I would not tell my patient anything of what I know because in a “perfect” situation I wouldn’t know anything – I would not have been the medical professional to deal with a potential donor because of the inherent conflict of interests that this poses. In other words, the potential recipient of the organ transplant should have a completely different and separate medical team from the potential donor.

Although I cannot change this aspect, I would still proceed with the same course of action and act as though I knew nothing pertaining to the brother other than what is general knowledge. As a medical professional bound by specific principles, laws, rules, and guidelines, I have a number of duties and obligations. First and foremost, I must not do any harm – telling my patient what I know about her brother would most likely result in causing some sort of harm or unnecessary emotional pain to my patient. Secondly, I have the responsibility to keep information confidential and private. If I were to disclose that the brother is compatible enough to be considered a potential donor, but did not want to donate one of his kidneys to his sister, this would breach the confidentiality and privacy that a potential donor is entitled to, regardless of his/her relationship with the potential recipient. This is not a choice for me to make – if the brother tells his sister that should be his choice and his choice only. Overall, this scenario is very difficult and complex. It seems as though some aspects of the case have been mismanaged from the very beginning, thus creating more problems than perhaps are necessary. This being said, I believe my course of action (not telling the patient what I know, effectively maintaining confidentiality and privacy of the potential donor) is the “best” course of action. By “best”, I mean the solution that would be most consistent with applicable laws, rules, obligations, guidelines, and principles of the medical profession, cause as few problems as possible for all people involved, and is most aligned with my own sense of what is right, ethical, or moral.

After not telling the patient what I know, I would proceed with things as “usual”. We would likely continue the regimen of dialysis treatments and explore other possible alternatives. If this hadn’t been done already, I would place her name on the list of those awaiting a kidney donation and do anything and everything I am capable of, to help her live a fulfilling and comfortable life, given her illness and circumstances. I would make sure my actions were always consistent with her wishes and in her best interests, among other things already mentioned.

Application of an Ethical Theory

My course of action is to not tell the patient what I know about her brother (specifically that he is a potential donor, but is refusing to donate a kidney to her) I am maintaining the confidentiality and privacy of the potential donor, something he in entitled to regardless of his relationship to the recipient. This course of action is also consistent with applicable laws, obligations, and principles of the medical profession, as well as my own sense of what is right, ethical, and moral.

This being said, the theory that best fits the course of action I have chosen, is Rights Theory. In this theory, the rights set forth by society are upheld and given the highest priority (Rainbow, 2002). In other words, by maintaining the privacy and confidentiality of the potential donor I am upholding the rights of society and giving them the highest priority. References

Committee on Increasing Rates of Organ Donations (2006). Organ donations: Opportunities

for action. Retrieved from http://www.nap.edu/openbook.php?record_id=

11643&page=R1.

Friedman, A. & Peters, T. (2006). Make me a perfect match: Understanding transplant

compatibility. Retrieved from http://www.aakp.org/aakp-library/transplant-

compatibility/index.cfm.

Ladin, K. & Hanto, D. (2012). Family physicians role in discussing organ donation with patients

and the public. Retrieved from http://virtualmentor.ama-assn.org/2012/03/ecas3-

1203.html.

Paddock, C. (2010, January 27). Atrial fibrillation treated much more successfully with catheter

ablation than drugs. Retrieved from http://www.medicalnewstoday.com/articles.

Rainbow, C. (2002). Descriptions of ethical theories and principles. Retrieved from

http://www.bio.davidson.edu/people/kabernd/Indep/carainbow/Theories.htm.

Socialization (2010, January 7) [PowerPoint slides]. Retrieved from

http://www.abac.edu/jrivers/PowerPoint/Socialization.pdf. LP 4 Ethics Case Study Analysis Scoring Guide

Rating Scale:

10 points – Excellent. Flawless or nearly flawless work. 9 points – Good. Minor errors, flaws, or omissions. 8 points – Acceptable. Work is adequate to meet criteria at a passing level. 7 points – Minimally acceptable. 4 points – Needs improvement. 0 points - Criterion is not addressed.

Click on “Choose a rating” for a drop down menu.

Scoring Guide Criteria Ratings You state the title of the ethics case and summarize an ethical dilemma 10 Excellent using a neutral tone. (NOTE: The summary should state the problem presented in the case in no more than three sentences). You identify facts and evidence relevant to an ethical dilemma. 10 Excellent

You identify assumptions you have about the case and the people involved 10 Excellent in the dilemma/case. You explain how your socialization influences your thinking about the 10 Excellent dilemma/case. You define unclear, ambiguous, or contested terms used in the 10 Excellent dilemma/case. You explain ethical values relevant to the dilemma/case. 10 Excellent

You identify unanswered questions that are relevant to an ethical dilemma. 10 Excellent

You list "what if" questions you have about an ethical dilemma. 10 Excellent

You make comparisons to cases that are relevant and true or to an ethical 10 Excellent dilemma. You explain three possible courses of action to take for an ethical 10 Excellent dilemma, and potential consequences of each course of action. You select a position/course of action you would take, explaining reasons 10 Excellent for your selection. You apply an ethical theory to your position on an ethical dilemma. 10 Excellent

CORE ABILITIES - COMMUNICATE CLEARLY 10 Excellent ☐ Demonstrate mastery of grammar, spelling, punctuation, capitalization, word usage and sentence structure. ☐ Writing is organized (paragraphs, headings and subheadings, or other organizational devices). ☐ Writing is clear (it's easy to read and understand). ☐ Writing is concise (you use action verbs; you do not ramble or include irrelevant information). ☐ Writing is cohesive (words and ideas flow logically from one idea, sentence and/or paragraph to another). ☐ Use first person pronouns (I, me, my, our, we, etc.) when applying ideas to self; third person pronouns (he, she, they, etc.) when applying ideas to society or others; you avoid using second person pronouns (you, your, etc.) unless you are speaking about the audience's experience or actions. CORE ABILITIES - THINK CRITICALLY AND CREATIVELY 10 Excellent ☐ Provide sufficient, specific, valid, relevant support (i.e., facts. reasons, examples, details, statistics, anecdotes and quotes) to aid in understanding your ideas and information, and to support your conclusions and/or opinions. ☐ Avoid using absolutes (all, always, everyone, no one, totally, all of the time, etc.) and loaded language. ☐ You use neutral, descriptive language, avoiding "loaded language" in your deliberation about ethical dilemmas. ☐ Your work exemplifies critical thinking standards: clarity, accuracy, precision, relevance, depth, logic, significance, and validity. CORE ABILITIES: ACT RESPONSIBLY 10 Excellent ☐ Select valid, reliable, and objective sources of information. ☐ Document sources by providing APA formatted in-text citations. ☐ Provide APA formatted references for sources of information. ☐ Use quotation marks to indicate information that you have taken word- for-word from a source. CORE ABILITIES: FOLLOW DIRECTIONS 10 Excellent ☐ Format the work per the assessment task directions. ☐ Include your name on your assignment. ☐ Save your assignment per assessment task directions (last name LP number Name of assignment) ☐ Self-assess your work using the scoring guide ☐ Copy and paste the scoring guide at the end of the assignment (if assignment is a Word product) Total Points Possible 160 Total Points Earned 160 Percent grade = Total Points Earned divided by Total Points Possible 100 You meet deadlines. (Points subtracted from Points Earned score) - 5 percentage points if submitted after the due date Final Grade/Percent A/100