A Patient's Ethical Dilemmas

The key ethical issue is that the patient has capacity to make a decision regarding surgery, and her autonomy should be respected, however the medical team is receiving conflicting information from the patient’s family about what the patient’s wishes are. Initially the patient was unable to communicate with the medical team due to a language barrier, and the patient’s husband insisted she wanted to proceed with surgery. Her children later state she told them she does not want to undergo surgery. The medical team cannot be sure what the patient’s wishes are. The physician then makes a suitable decision to involve an interpreter to communicate directly with the patient. After discussion with the patient, it is still unclear if the patient

is expressing her own wishes, or trying to uphold the wishes of her husband. The patient states she wants surgery, but her children insist she is only agreeing to surgery to appease her husband. There appear to be factors that could be interfering with her autonomy, such as anxiety and/or guilt and her responsibilities to her family.
Another key aspect of this ethical issue is obtaining informed consent. In order to give informed consent, the patient must be given adequate information about her diagnosis, prognosis and treatment options, and information must not be withheld. It must also be confirmed that the patient understands this information and the patient must not be coerced. It would appear that the patient understands the surgical option and that a cure is unlikely, however it is important that potential benefits and risks of surgery as well as any other appropriate treatment options are explained to the patient, and it is unclear if this has occurred.
Stakeholders
The stakeholders are the physician Dr. Martinez, the patient Mrs. Odundo, her husband Mr. Odundo, and their children.
Facts
Medical Indications
The patient’s medical problem is an onset of dysphagia that started a few weeks ago and has progressively worsened. She is then diagnosed with esophageal cancer that is unlikely to be cured with surgery. The problem is acute, critical and likely not reversible. While not exclusively stated, it seems that the goals of care the medical team would favour is palliation, as the probability of providing a cure with surgery is unlikely. However, it appears that goals of care still need to be established with the patient and family. While we know that the probability of providing a cure with surgery is low, we do not know what the chances of success are for symptom relief and improving the quality of the patient’s life after surgery. Whether or not the principle of beneficence would be upheld by providing or not providing surgery depends on what outcomes can reasonably be expected. Perhaps surgery would relieve her symptoms, allowing her to eat and drink and improve her quality of life in her remaining months. If the surgery is able to offer benefits that the patient feels outweigh the potential burdens, then beneficence would be upheld. The principal of non-maleficence would be upheld providing the surgery does not inflict unnecessary pain and suffering, and other treatment options that may provide benefit are also offered.
Patient Preferences
The patient is mentally capable and legally competent; based on the information provided there is no evidence of incapacity. The patient has stated that she wishes to proceed with surgery, but her children insist that this is not what she truly wants, and claim that she expressed this when her husband was not present. Although not explained in detail, it would appear that after discussion with the doctor the patient does understand her condition and prognosis, and has given verbal consent. However, it does not appear that the patient has been informed of all the benefits and risks of surgery or any other treatment options.
Quality of Life
The chances of the patient returning to a normal life after treatment are low. However, an important consideration which was not explained is whether or not surgery would provide symptom relief and improve her quality of life in her remaining months. Without treatment, her dysphagia will not improve and a decision will need to be made about whether to provide nutrition therapy to maintain her nutrition and hydration. If the treatment did successfully cure her cancer, I suspect she would not experience any lasting physical or social deficits, though she could certainly have some emotional and mental health impacts that last a lifetime, and there may be a chance of the cancer returning.
In circumstances when a physician is making an assessment about a patient’s expected quality of life after treatment, there are biases present that stem from their own personal values.

While the provider explains that the chance of a cure is low, he does not offer information about what quality of life can be expected both with and without surgery, which is crucial information for the patient to make an informed decision. Perhaps the physician believes the quality of life will be poor which is why he is only mentioning that the chance of cure is low. While the patient is voicing that she wants to proceed with surgery, all other appropriate options should also be explained such as comfort care and palliation. Perhaps chemotherapy or radiation therapy may be options to provide symptom relief, but inevitably would have negative side effects that need to be explained. All suitable options must be explained in order for the patient to make an informed decision regarding her course of

treatment.
Contextual Features
Family dynamics are certainly at play in this case. The patient’s husband clearly wants her to undergo surgery. Her children insist that she does not want to and is only agreeing to surgery to appease her husband. When the physician arranges for an interpreter assist so he can hear directly from the patient, she states she wants surgery, but because of her children’s objections, it is unclear if this is what she truly wants. We do not know if the children are being honest and the patient is being pressured by her husband, or if the children are providing inaccurate information about their mother’s wishes for some unknown reason or motive.
If the physician does not take the patient’s decision as expressed through the interpreter at “face value”, then it is also possible that the physician is allowing his own personal values to influence the care provided, by becoming involved and further exploring the potential family dynamics contributing to the patient’s clearly stated decision.

There does not appear to be financial or economic factors, however the children may have a financial motive to impede the surgery from occurring. It is also possible that religion and culture are playing a role; if it is true that the patient is putting her husband’s wishes above her own, this could be impacted by cultural values. Allocation of resources could be considered an issue as well, since her prognosis is poor, one may argue that these scarce resources would be better utilized for a patient with a better

prognosis.

Analysis
Respect for the patient’s autonomy is the main bioethical principle to consider in this case. Because the patient has capacity, ultimately her decision to pursue or not pursue surgery must be respected. Beneficence and non-maleficence must also be taken into account. It is unclear based on the information provided if providing surgery would uphold these bioethical principles. In order to make this determination, we must know what the expected outcomes of surgery are. As previously mentioned, perhaps the surgery would provide relief of symptoms to improve her quality of life in her final months. Non-maleficence would be upheld if the surgery does not inflict unnecessary pain and suffering and all appropriate treatment options with a potential benefit are offered to the patient. Another ethical consideration is the moral distress this could be causing for the physician. This scenario may cause moral distress for the physician if the physician feels he is being forced to act in a way that is not in the best interest of the patient.
Recommendations
The physician should consult the ethics committee and social worker and arrange a family meeting. In this meeting, all treatment options, prognosis, predicted outcomes, risks and benefits should be explained and goals of care should be discussed and established. It must also be confirmed that the patient understands all of this information. If the patient agrees to have a conversation with the health care team and an interpreter in private this may be helpful, although it seems that she wants her family present for these conversations and this must be respected. It may help to encourage the patient and family to discuss their personal values and goals. Encouraging and facilitating a discussion between the patient and her family about their goals and values may help them reach a common ground, or at least help them to better understand each other’s perspectives (Sedig, 2016).
The patient should be given adequate time to think about all of this information and then make her final decision. If she continues to pursue surgery, whether or not she truly wants surgery or is choosing to put her husband’s wishes above her own may never be determined with certainty. If she is choosing surgery based on her husband’s wishes, ultimately it is her choice to honor her husband’s wishes and proceed with surgery, and this decision must be respected. This view is supported in a commentary by Sedig (2016), who states that “respecting patient autonomy… includes respecting both how patients wish to make a decision and the decision made, even if the decision is to allow their family’s desires to supersede their own” (Sedig, 2016, p. 13). Sedig (2016) also acknowledges that it is not unusual for patients to consult with family members to help them make decisions and it is important to understand this to have a full understanding of decision making and informed consent.
If the patient did not have capacity, then the recommended course of action would be different as a substitute decision maker (SDM) would need to be determined. It would be important to ensure that the SDM is acting in the best interest of the patient and advanced directives should be considered if available. Other information that would change the recommendations in this case include information about surgery or other treatment options not being appropriate due to causing unnecessary harm and providing no benefit. If this were the case, then ideally the treating physician would not offer treatment, if it is not medically indicated. Lastly, if it was determined that the any of her family members were being excessively coercive, such as threatening to withdraw financial support or any other form of support, the team would need to intervene further (Sedig, 2016).