Ethical Conundrum

Todd Fraser on 15-04-2012

A while ago I looked after a chap who had tried to kill himself by gassing himself in a car. It turns out he had metastatic bowel cancer - he knew he was dying and was scared of dying painfully, dignity destroyed, no longer in control. Not unreasonably, he was intubated and resuscitated and a bed in ICU was requested. His pupils were dilated and sluggish prior to intubation, and he was extending to painful stimulus. Though the signs are not good, senior colleagues believe it is possible he will recover. His family was contacted, and they were unaware the disease was now metastatic. However, they were concerned that he would not want to be resuscitated given the likelihood he will have a poor prognosis from his malignancy. I'm interested in the ethical issues of this case. Normally, if someone tries to commit suicide it is assumed they do not have the capacity to make decisions for themselves. But does that apply in this case? Do his family have the right to withdraw treatment?

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James O'Connor wrote 04-16-2012 05:53:13 pm
Interesting problem.

I guess you've got little choice but to continue his treatment until he can be formally worked up and evaluated. Its not clear from the story how advanced the malignancy is, and what his prognosis is. Its also possible he has depression related to this diagnosis, which may impair his ability to make decisions.

I'm not sure the views of the family are relevant unless they have enduring power of attorney.

Matthew Bailey wrote 04-16-2012 06:10:36 pm
Thanks for the post Todd, I'm going to apply the principle -"would I be happy to receive the treatment?". So, I would convince myself that the patient is actually correct that he has metastatic disease with poor prognosis, convince myself that the patient was (probably) not depressed or disorganised in thought immediately prior to this event. If I was convinced of both beyond reasonable doubt, then it is time to let the guy die. That's what I'd want for me.

Jo Butler wrote 04-16-2012 06:46:09 pm
The fundamental issue here has to be whether or not he has capacity. There is nothing to suggest that he doesn't, but we don't know that he does. Where does the obligation lie? I can't tell.

If that's the case, then if we make a decision based on "what would I want" then we are substituting our judgement for theirs. Is this reasonable? I'm not sure that it is.

sharyn milnes wrote 04-19-2012 10:08:29 pm
This man's capacity is not the issue here, he is incompetent anyway as he is unconscious. Decisions made for this man in this sense are made with a framework for any other unconscious patient in the ICU.
Advance Directives - decisions we know the patient has articulated at a time prior. This includes a MEPOA, Advance Care Plan or Advance Care Directive.
Substituted Judgement: a decision made with knowledge of the patients values and beliefs and is one we believe the patient themselves would make if they were able to do this.
Best Interest: this is a contentious one but in this sense is usually taken as 'medical' best interest so benefit vs burden of treatment. Of course most people would believe that their values and beliefs should inform what is in their best interest. It is important to recognise when you use the term 'best interest' it is often your own beliefs about benefit vs burden that informs the decision.

I would think this man has in a sense told us what he thinks about life with cancer and this can help us ascertain a substituted decision i.e. the decision he would make if he were able to make it. It is essential we continue to respect this man's autonomy to make his own choices but in doing so appreciate things that affect those decisions - relationships with family, faith, wishes for living a life free of pain, independence etc.

As a side note - people make decisions that appear irrational all the time but they are still competent. To be deemed competent (or

James O'Connor wrote 04-23-2012 08:08:32 pm
His competency IS an issue if you are using substituted judgement. You're assuming you know what he wants when capable of making decisions about his welfare. From what we know, this might not be true.

I think most people would assume that he would not want to live like this and the fact that he has attempted to kill himself is proof of that. But the problem is knowing where to draw the line. What if he is a T6 paraplegic who is depressed because his girlfriend left him, then tries to hang himself? Should we assume he "doesn't want to live this way?"