Introduction
This case study shows an example of a young woman, Janet, who survived an accident in which her husband died. Although Janet survived the accident, the doctor found that she had suffered a severe head injury, and the prognosis for the woman was poor. Moreover, the patient has been pregnant for about nine weeks. Before Janet dies, she writes advance directives to doctors and demands that they never try to take any medication to prolong her life when she is overwhelmed by her condition. She is later transferred to a hospice, receiving palliative care, with her other life support removed. Although doctors keep Janet alive due to her pregnancy, her parents refuse to comply, saying their daughter does not want a life extension.
Discussion
There are some ethical and legal dilemmas in this case. According to Park (2012), the first step in making decisions in difficult situations is identifying the moral issue. In Janet’s case, a decision must be made as soon as possible because, according to doctors’ forecasts, the woman’s condition will worsen, but the child will continue to develop. In this case, health workers’ main problem is deciding whose interests are more important in this situation – the mother or the fetus (Siwatch et al., 2020). On the one hand, in advance directives, Janet indicated that she did not want to be medically supported. However, on the other hand, these instructions were written before the patient knew of her pregnancy.
After identifying the problem, doctors need to collect all the necessary information to help make the right decision. This information includes but is not limited to, patient information and “family members as caregivers or surrogates” (Park, 2012, p. 151). Because Janet cannot make decisions in her condition, healthcare decisions are left to her agents. Her primary agent was her husband, who died in an accident. A woman’s parents are her secondary agents who must make decisions regarding the continuation of their daughter’s treatment.
Ethical considerations, in this case, are heightened due to the presence of legal issues. First, doctors told Janet’s parents that the prognosis for their daughter was not good a month after the accident. It means that, for a month in the hospital, doctors provided Janet with assistance, which she refused in advance directives. Second, physicians are required by law to maintain a woman’s condition until the child is born (Siwatch et al., 2020). However, the doctors did not initially carry out a complete diagnosis of the patient’s condition, and Janet’s pregnancy was revealed only a month after she was admitted to the hospital. That indicates violations of the standards of medical care by doctors.
Another problem is that in the event of the final death of the mother’s brain, negative consequences for the child are possible. Dodaro et al. (2021) note that most children during pregnancy in a vegetative state are born prematurely and have severe health problems. In such a case, violation of the patient’s advance directives and non-compliance with the treatment decisions of surrogates will not have sufficient grounds. Furthermore, the doctor, referring to the State of Kansas law, noted that decisions made by the patient before pregnancy have ‘no effect’ during pregnancy. Since the fetus cannot make decisions on its own, its interests must be above the interests of the mother.
In addition, transferring a patient to a hospice raises ethical questions. Hospices are not considered for life support but only for the provision of palliative care to people in critical conditions to improve their quality of life. However, in her instructions to doctors, Janet indicated that in the case of a persistent vegetative state with a poor prognosis, she did not want any medical assistance, including nutrition and hydration. Consequently, the transfer of a woman to a hospice violates her desires since this assistance will be provided until the moment of final brain death. However, this decision must be made by Janet’s parents as her surrogates.
After collecting all the information, it is necessary to consider all possible solutions that apply to a given situation. The answer to this situation requires the involvement of doctors, legal counsel, an ethical committee, and social workers (Siwatch et al., 2020). The first option is to follow Janet’s advance directives and take her off life support. The second alternative is to transfer the patient to a hospice under the decision of the patient’s parents, who are her agents. The third option puts the fetus’s interests above the mother’s interests, so the patient’s life must be supported until the child’s birth. Each of these alternatives has ethical and legal advantages. For example, option 1 is entirely in line with the patient’s wishes and has an ethical justification. The second alternative considers Janet’s parents’ treatment decision, who are her official representatives, and has a legal argument. The third option has ethical and legal justification but may harm the patient.
To select the optimal alternative, it is necessary to collect additional information. For example, it is required to assess how the hospital where Janet is currently located can support her life until the child’s birth. Therefore, “counseling must include some data on the prognosis if somatic support is considered as an option” (Dodaro et al., 2021, p.465). In addition, social workers must determine who will be chosen as the child’s guardian. Considering that Janet’s parents have made the decision not to continue their daughter’s treatment, there is a possibility that they will not want to take the child into their care.
In this case, compliance with the healthcare decision made by Janet’s parents is optimal. The rationale for this alternative is based on the fundamental ethical principles of healthcare (Park, 2012). First, healthcare professionals must respect patients’ values and decisions and follow advanced directives where available. Even though Janet refused any medical care, the hospice will provide decent living conditions for her. The ethical rationale for moving a patient to a hospice is that the role of healthcare providers is to benefit the patient. In addition, the patient’s parents, who are both healthcare professionals and understand the severity of their daughter’s condition, made this decision.
Moreover, healthcare providers must eliminate or reduce all patient harm; therefore, considering the risks for the fetus and mother is worth considering. There is a possibility of death for the child associated with the death of the mother’s brain (Dodaro et al., 2021). Using the mother as an incubator for the fetus has no ethical justification. Furthermore, there is no guarantee that Janet’s parents will want to become the child’s guardians, so the medical prolongation of the patient’s life until delivery also raises an ethical dilemma related to the social protection of the child.
Conclusion
Thus, in Janet’s case, transferring the patient to the hospice will be a compromise solution for all parties. In the advanced directives, the patient refused medical prolongation of life. Moreover, as her agents, the woman’s parents decided to transport their daughter to a hospice for palliative care. Moreover, from a legal point of view, serious violations were committed by doctors who could establish the patient’s condition and detect pregnancy a month after the accident. The case study does not indicate whether the clinic can support Janet’s vital functions necessary for the development of the fetus. In addition, social questions arise regarding the child’s fate due to the lack of official guardians.
References
Dodaro, M. G., Seidenari, A., Marino, I. R., Berghella, V., & Bellussi, F. (2021). Brain death in pregnancy: a systematic review focusing on perinatal outcomes. American Journal of Obstetrics and Gynecology, 224(5), 445-469. Web.
Park, E. J. (2012). An integrated ethical decision-making model for nurses. Nursing ethics, 19(1), 139-159. Web.
Siwatch, S., Rohilla, M., Singh, A., Ahuja, C., Jain, K., & Jain, V. (2020). Pregnancy in a Persistent Vegetative State: A Management Dilemma. Case Report, Literature Review and Ethical Concerns. The Journal of Obstetrics and Gynecology of India, 70(4), 310-313. Web.