Physician Calls concerning DNR Orders

A community physician on staff at Alpha Hospital calls the emergency department there and informs the physician on duty that a patient of his, a 43-year-old woman, is going to arrive in extremis from "terminal" breast carcinoma. He says that she may be in cardiac arrest when she arrives or, if not, may be close to it and that he does not want anyone to try to resuscitate her. He says that he has been taking care of her for the past year and has all of her records.

She has never been to Alpha Hospital before. Her husband and son will probably be coming in with her on the ambulance. Should the emergency physician ask her colleague if he had discussed his decision with the patient, her family, or both? Should she disregard his request, since there is nothing in writing? How does she even know that it is really the patient's physician rather than an expectant heir on the phone? On the other hand, should she really prolong the woman's suffering if this is the end of a long, painful disease?


Commentary

Let us consider first the most general moral principles relevant to cases like this as well as what is involved in living up to one's responsibilities as a moral decision maker in cases of uncertainty about morally relevant facts. Then let's consider how a responsible decision maker ought to deal with this particular case, with its peculiar features and uncertainties.

MORAL OBLIGATIONS


It is an unfortunate but inescapable fact that moral obligations sometimes make incompatible demands on us. When this happens and we are uncertain how to resolve the conflict, we are faced with a moral dilemma.

Perhaps the most serious moral dilemma that a physician can face arises when the special moral obligation that defines the role of a physician — to do everything in one's power to preserve the life and health of one's patient — comes into conflict with the more general moral obligations to prevent needless suffering and to respect the autonomy of other human beings.


It is the sacred trust of the physician to preserve life and health. One who has been entrusted with this task is morally obligated to do everything in one's power to carry it out. For a physician to fail to do what is necessary in order to heal or prevent death, when this could have been accomplished had one exerted a reasonable degree of effort or known what one should have known, is a breach of both professional and moral duty.

Yet this does not mean that life must be preserved at all costs and no matter what the circumstances. When life can be preserved only temporarily and only at the cost of considerable suffering for the person whose life is to be preserved, the obligation to preserve life comes into conflict with the obligation to prevent needless suffering.

When undergoing a certain amount of suffering is necessary in order to prevent a life's being cut short by disease (as when surgery and its accompanying discomforts are necessary to correct a life-threatening condition), suffering serves a purpose. In such cases, the evil of the suffering is outweighed by the good of the life to be preserved, and hence the obligation to preserve life obviously overrides the obligation to avoid suffering.


But when preserving a life entails considerable suffering and when the life can be further sustained for only a short period of time, it is questionable whether the value of the added days or weeks (or perhaps even months) of life outweighs the cost in terms of suffering, especially if the benefits associated with such a life are rather minimal (because of increasing physical and cognitive deterioration). In such circumstances it becomes doubtful whether the obligation to preserve life overrides the obligation to prevent suffering.

Of course, it may not be easy to determine at just what point the positive benefits of preserving life no longer justify the cost in terms of suffering. But that determination, it seems, should be left up to the patient.

Here a third basic moral obligation on the part of the physician enters the picture: the obligation to respect the autonomy of another human being, even when that human being happens to be one's patient. There are difficult questions here about when, if ever, the physician's obligation to do whatever is medically best (so far as preserving the life and health of the patient is concerned) can override the patient's wish not to have a certain mode of treatment initiated or continued.


One need not view the patient's right to refuse treatment as an absolute. However, when initiating or continuing medical treatment has minimal benefits, so far as preserving health and life is concerned, and when these minimal benefits can be obtained only at the cost of much suffering, there does not seem to be much of a warrant for overriding the wishes of the patient. Of course, it is another matter if the patient insists on continuing medical treatment even after the physician has decided that it will only prolong needless suffering. Here all will agree, I trust, that the physician is obligated to respect the patient's wishes.

MORAL DILEMMAS


When the physician's moral obligation to preserve the life of a patient comes into conflict with the obligations to prevent needless suffering and to respect the patient's autonomy, and when the physician is uncertain how to resolve the conflict, the physician is faced with a moral dilemma. This uncertainty may derive from two different sources. The physician may be perplexed about how to answer certain hypothetical moral ques­tions.

For example, is the physician morally obligated to respect the wishes of the patient to forgo further treatment even if the patient has clearly undervalued the worth of the portion of life to be preserved? Uncertainty may also stem from doubts about certain morally relevant factual matters. For example, the physician may have doubts about the exact prognosis for this patient or about the voluntary character of the patient's choice to forgo further treatment.


In the face of these kinds of moral dilemmas, there is a strong temptation to deny their existence, for the recognition of such dilemmas imposes a heavy moral responsi­bility. One must make a choice, even when the facts are not completely clear and there are no clear moral guidelines. The desire to escape from the burden of having to make such hard choices often leads to the denial that one really does have a choice. This denial may take several forms.

One form of denial consists in the retreat to moral absolutism, the view that certain kinds of acts (such as killing, for example) are wrong under any circumstances and no matter what the consequences. Thus, the pacifist avoids having to decide when wars are morally justified by insisting that no wars are justified.

All killing is wrong, no matter what the circumstances — even the killing of a mad sniper who is shooting dozens of innocent passersby. Similarly, one might try to avoid making hard decisions about when preserving life is no longer morally obligatory by adopting an absolutist stance and holding that it is always morally obligatory.


Unfortunately, such absolutist stances are difficult to sustain when one reflects on their implications. One can maintain such a position only if one is able to stomach the consequences of such a position; and few are able to do so. Thus, a commitment to an absolute prohibition on killing commits us to standing by while the mad sniper shoots an innocent passerby. It also commits one to refusing to increase the morphine dosage for a dying patient whose last hours are filled with agony, on the ground that this might kill the patient.

Similarly, a commitment to an absolute requirement to preserve human life commits one to resuscitating a patient even when the only result will be to prolong the patient's agony for a few more days.

Another avenue of escape from moral responsibility consists in attempting to "pass the buck." The physician may take the position that it is her responsibility only to make decisions concerning what mode of medical treatment will be most effective with respect

Table. Common Methods of Escaping from Responsible Moral Decision Making.

1. Pretend that moral dilemma does not exist.

2. Deny that there is a choice.

3. Refuse to accept responsibility.

4. Use lack of certainty regarding circumstances and consequences as an excuse for not making a choice.

to preserving health and life and, possibly, to decide when further medical treatment becomes pointless. Moral decisions, it may be suggested, are not the responsibility of the physician. It is the responsibility of the patient's family — or, perhaps, of some board of moral experts — to make such decisions. The physician should respect the authority of others on these moral matters, and should simply carry out their directives by applying her medical expertise in accordance with those directives.


This comes dangerously close to the Adolf Eichmann mentality of obeying one's orders whatever they are. There are, of course, good moral reasons for consulting the patient's family (they are, after all, an interested and concerned party) and for consulting some board of impartial advisors who are experienced in dealing with other similar cases. It is not only legitimate but also obligatory for the physician to consult these other persons in making moral decisions.

It is, however, quite another thing to abrogate one's moral decision-making responsibility altogether and decide merely to follow the direc­tives of others. That kind of deference to the authority of others must be recognized for what it is: an evasion of moral responsibility. Apart from certain legal restrictions that may bind the physician to carrying out the wishes of the patient's family or the directives of some medical ethics board, whatever decision the physician makes — even if it be to follow the advice or orders of others — is a decision for which the physician himself is morally responsible.

One cannot escape moral responsibility by deciding to follow the directives of others, especially if in following these directives one acts in a way that is not in the best interest of the patient or acts in defiance of the patient's own wishes. This principle holds true whether one takes orders from the patient's family, or from a board of medical ethics, or even from the law (which may proscribe withholding medical treatment needed to preserve life, no matter what the circumstances).


We might be inclined to excuse the physician who obeys the law when it requires her to abide by the decisions of the patient's family or the directives of a medical ethics board, even when this goes against her own judgment of what is in the patient's best interests, because she fears legal punishment if she does not. But there is no excuse for the physician who simply refuses to make a judgment herself and blindly follows the directives of others, for that is an act of moral irresponsibility.

A more subtle, but also more common, form of escape from hard choices consists in feigning ignorance or professing skepticism about the circumstances and conse­quences of the case one is considering. Unlike the moral absolutist, one does not deny the possibility of there being exceptional circumstances for the relevant moral principles; one simply denies that one can ever know that such exceptional circumstances actually obtain.

How can one know that the patient's condition is hopeless? Perhaps the diagnosis or prognosis is mistaken. Perhaps a new miracle cure will be discovered tomorrow. How can one ever be sure that the patient's consent is truly voluntary? Perhaps the patient's mind has been affected by the medication being administered. Perhaps the patient has been pressured by other family members eager to be relieved of emotional and financial burdens.


Asking such questions is, of course, quite legitimate. Indeed, the failure to eliminate any reasonable doubts that one might have about the circumstances of the case, before acting, would be a case of gross moral negligence. To be morally responsible, one must, as far as is feasible, make the inquiries necessary to resolve such doubts. If one simply uses these doubts as an excuse for not making any moral judgment, on the ground that one lacks sufficient information (but without trying to gain that informa­tion), one is shirking one's duty.

Moreover, when, after fully canvasing all the facts, one can find no good reason to think that a mistake in diagnosis or prognosis has been made (one has consulted with several other experts, for example) or that a miracle cure may be forthcoming, further doubts about these matters are unreasonable. If one has no concrete evidence to support the suspicion that the patient's decision to terminate further treatment is not fully voluntary, the appeal to the bare possibility that it is not is merely a rationalization for evading one's moral responsibilities.

IMPLICATIONS FOR THIS CASE


Now let us see what facing up to one's moral responsibilities means in this case. Many questions arise here. Some of these are purely moral questions; others are doubts about relevant factual matters. The moral questions are these: Should one really prolong this woman's suffering if this is the end of a long, painful disease? To what extent are the patient's own wishes, if known, decisive with regard to determining what one ought to do?

The answers to these purely moral questions may be fairly clear. One may think that if resuscitation efforts really will only prolong needless suffering, and if the patient herself wishes all such efforts to be discontinued, the physician's moral obligations to prevent pointless suffering and to respect the autonomy of others take precedence over the obligation to preserve life. And one may think that if, on the other hand, the patient wishes life-preserving efforts to be continued no matter what the cost in terms of suffering to herself, one must respect the patient's wishes and carry out one's duties as a physician.


It is difficult to dispute these answers to the purely moral questions. Unless one is an absolutist with regard to the obligation to preserve human life, one must allow that this obligation can sometimes be overriden by other moral obligations, such as the obligations to prevent needless suffering and to respect the autonomy of another.

It is difficult to understand why anyone would want to maintain that one should make use of medical technology in order to preserve a human life even when (a) this will do nothing more than prolong the patient's suffering and (b) it is contrary to the wishes of the patient. If these conditions obtain, then, since one is morally obligated to avoid pointless suffering and to respect the patient's autonomy, the morally indicated course of action is, it seems, to refrain from resuscitation efforts.

Unfortunately, settling the purely moral questions does not completely solve our problem about what to do in this particular case, since the moral questions posed were hypothetical in form: if resuscitation will merely prolong pointless suffering and if the patient wishes further such efforts to cease. But one may have doubts about whether these conditions actually obtain.


Is the patient really in an extreme, terminal state of breast cancer? How does one know this? Is nonresuscitation really in accordance with the patient's wishes? How can one be sure? It may be easy to say what decision one should make if one is certain about these matters. But what decision should one make if one is uncertain about these relevant factual matters?

The most important consideration, as we noted above, is not to use these doubts as a cop-out for avoiding moral responsibility. Many of our professed doubts are not real doubts but are only doubts raised to avoid decision making. One suspects that some of the doubts raised in connection with the present case are doubts of the latter sort: "How does she even know that it is really the patient's physician rather than an expectant heir on the phone?"

When doubts that are fairly easy to resolve (by asking the alleged physician for his license number or by calling the physician's office to request confir­mation) are raised and yet no attempt has been made to resolve them, one suspects that the doubts are less than genuine. How does the family physician know that the woman does not wish to be resuscitated? Of course, one should try to determine whether or not this is the case, and therefore, one should ask the other physician if he has discussed this matter with the patient or her family. If one does not attempt to answer such questions when the opportunity arises, one is failing to live up to one's responsibilities as a moral decision maker.


Thus, when one is faced with uncertainty about relevant factual matters, one's first moral obligation is to make every reasonable effort — with the information available and within the constraints of time — to resolve this uncertainty before deciding either to resuscitte or not to resuscitate. If time permits, one should attempt to confirm the authenticity of the telephone directive; one should call back the other physician and ask if he has consulted with the woman about resuscitation efforts; and one should consult with the woman's husband and son in order to gain further confirmation of the patient's condition and her wishes regarding further resuscitation efforts at this point.

To withhold resuscitation efforts without having made such inquiries would be to act in a morally irresponsible manner. But simply to go ahead and initiate resuscitation efforts because one has doubts about morally relevant facts, but without having made every reasonable effort to resolve such doubts, would be to act in an equally irresponsible manner.


As we noted earlier, there is often a strong temptation to try to escape taking moral responsibility for one's actions in such cases by claiming that one simply does not have enough relevant information (about the patient's condition and wishes) in order to decide what the morally indicated course of action is and thus that one must simply act in one's capacity as a physician by initiating the medically indicated course of action, that is, whatever medical procedure is called for by the immediate medical problem at hand (cardiac arrest, for example).

It is important to recognize, however, that if one has the opportunity to obtain this information and yet fails to do so, one does not thereby escape being morally responsible for initiating the "medically indicated" course of action. Such a course of action is not "morally safe"; it is "morally reckless."

ACTING UNDER UNCERTAINTY


Suppose, however, that one has made every reasonable effort to obtain relevant factual information but still lacks important relevant information. Suppose, for example, that inquiry reveals that neither the woman's physician nor the woman's family has discussed the matter of resuscitation efforts with her, so that one simply does not know what her wishes are.

Suppose the woman's husband and son profess ignorance regarding the terminal nature of the present stage of the woman's disease, and suppose that one is unable to find further confirmation of her own physician's prognosis either among hospital records or by asking other staff members who might know about her case (perhaps because there is no time for this), so that one has only the other physician's word on which to proceed. Thus, there may often be genuine doubts about relevant factual matters that cannot be resolved before acting, especially in cases of emergency medicine. What is one to do then?


If it is assumed that there is a lack of such important relevant information, a strong case can be made for choosing to err (should one's assumptions turn out to be mistaken) on the side of preserving human life. Death is, after all, irreversible. On the other hand, if one later determines that the woman did not wish to be resuscitated, and if the woman's condition really is extremely terminal, in all probability there soon will be another opportunity to comply with the patient's wishes by withholding further life-preserving efforts.

To adopt this "conservative" course of action under these circum­stances would not be morally irresponsible, since in this case one has fulfilled one's obligation to make every reasonable effort to discern the morally relevant facts and to act only in the light of such available information. Playing it safe under these circum­stances is not an act of moral recklessness.

CONCLUSIONS


What is most important, then, in cases of uncertainty, is that one face up to one's responsibilities as a moral agent. If one fails to do this, one will act wrongly whatever one decides to do. If one has failed to fulfill one's obligation to gain all relevant infor­mation, neither one's decision to initiate nor one's decision to withhold resuscitation efforts can be morally justified.


The same may be said about any decision made merely in order to comply with the directives of others. And, I am inclined to think, the same may be said about a decision in favor of resuscitation which is based on adopting an absolutist stance on the requirement to preserve life, without having considered the full implications of adopting such a position.

Of course, living up to one's responsibilities as a moral decision maker in cases of uncertainty will not, in itself, guarantee that one will make the right decision. One cannot be sure that one will always do the right thing. But one can be sure that one will always act wrongly (because irresponsibly) if one does not live up to one's respon­sibilities as a decision maker.

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