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Table of Contents

Think

Assess

 Patient: Autonomy

 Practitioner: Beneficence & Nonmaleficence

 Public Policy: Justice

Conclude

46c*. Self-Treatment & Family-Treatment


[C46:1] A seasoned faculty member at a well-respected medical school was speaking with a junior colleague. In this conversation, the young medical practitioner said they “won’t allow” their parents to be vaccinated because a well-known cardiologist said that there was an increased risk of myocarditis or pericarditis associated with being vaccinated. The young practitioner readily admitted that they and their three offsprings were fully vaccinated with all the “usual” vaccines.

[C46:2]

TAC: Think - Assess - Conclude

I. Think: What is the question?

Should practitioners be making medical decisions for family members?

[C46:3]

II. Assess: Specify & Balance the four principles of bioethics

Patient: 1) Autonomy - Informed Consent

[C46:4] Regardless of age, if the parents have decisional capacity then the parents should be the ones who should be making the medical decision as to whether or not to get vaccinated. The parent’s offspring statement that they “won’t allow” the parents who are in their 80’s to be vaccinated” is very troublesome and would be potentially unethical if the parents have decisional capacity and want to be vaccinated. However, perhaps the parents have deferred their medical decision-making offspring because they are a practitioner. That would certainly be within the parent’s legal rights to do so. But then the question is, why was the term “won’t allow” used? More discussion is necessary to determine just what the term “won’t allow” actually means.

[C46:5] If the parents do not have decisional capacity, then the next step would be to determine if the parents have a living will. If not a living will, then a durable power of attorney. If not a durable power of attorney, then there is the typical ordering of surrogate decision makers: 1) guardian, 2) spouse, 3) adult offspring, 4) either parent, 5) adult siblings, 6) adult grandchild, 7) adult friend, 8) guardian of the estate, 9) temporary custodian. This ranked list assumes that the closer the relationship is with the patient, the more likely they will share similar cultural worldviews and know the patient’s reasonable goals, values, and priorities for appropriate surrogate decision-making. However, if there is a conflict of interest, such as medical professionalism, then, it may be in the patient’s best interests to defer medical decision-making to a more neutral or less emotionally vested party. 

[C46:6] Supposing that the offspring is the appropriate surrogate, the surrogate’s role and responsibility would be to make medical decisions for the parents using substituted judgment. Substituted judgment does not mean substituting the parent’s goals, values, and priorities with their own, but rather the opposite. The surrogate’s role and responsibility are to use the parent’s goals, values, and priorities when making medical decisions. It is unclear from the information provided as to whether or not the offspring is using substituted judgment correctly or not. More discussion would be needed in order to make such a determination.

[C46:7] Although it is unclear from the information given whether or not the offspring is violating the principle of autonomy, it does seem that the perceived risk of harm from the inoculation is possibly being amplified by their protective emotions, making it more difficult for the offspring to evaluate whether or not to vaccinate themself and children.

Practitioner: 2) Beneficence & 3) Nonmaleficence

[C46:8] The medical community holds that practitioners have a professional obligation not to treat themselves or family members because it can compromise prognosis, treatment, and outcomes.

[C46:9] The American Medical Association (AMA) Code of Medical Ethics Opinion 1.2.1 states:

Treating oneself or a member of one’s own family poses several challenges for physicians [practitioners], including concerns about professional objectivity, patient autonomy, and informed consent.… When the patient is an immediate family member, the practitioner’s personal feelings may unduly influence [their] professional medical judgment. … They may also be inclined to treat problems that are beyond their expertise or training. … In general, physicians [practitioners] should not treat themselves or members of their own families.

[C46:10] This case seems to represent a situation in which the offspring’s personal feelings have amplified the minimal risk of harm of the COVID vaccine. Some people are indeed more risk aversive than others. However, if such risk aversive propensities are emotionally amplified, it increases the risk of harm to others because of not practicing the medical standards of care, then that practitioner can be held accountable. Additional reasons for why practitioners are not to treat family members are because the patient who is a family member or friend may not be willing to openly disclose relevant historical information that might be embarrassing, the uncomfortableness and avoidance of conducting an intimate physical examination, and the change of role responsibilities such as in the family structure. These are just a few consequential reasons why practicing medicine on a family member is against medical standards of care and unprofessional.

4. Public Policy: 4) Justice

[C46:11] Justice is the fair distribution of benefits and burdens throughout society. Society has successfully implemented the safe development, access, and administration of the SARS-CoV-2 vaccine for all citizens starting with the most vulnerable populations such as nursing homes and seniors. The parents, in this case, have a negative right, meaning that others in society have an obligation of not interfering with their choice to be vaccinated. This right seems to have been violated by the parents’ offspring by “not allowing” the parents to get vaccinated. The parents also have a positive right, meaning that others in society have an obligation to provide access to the vaccine to the parents. The parents’ offspring “not allowing” of the parents to get vaccinated and not providing the parents access to get vaccinated violates the parents’ negative and positive rights and is, therefore, a violation of justice, in addition to its being a violation of public safety for the good of society.

[C46:12]








[C46:13] Balancing is reordering the four principles of bioethics in hierarchical order as determined by the specific case. With the limited amount of information provided, and the need for further discussion, it appears that the hierarchical order of the principles would be:

1) Justice 2) Nonmaleficence, 3) Beneficence 4) Autonomy.










III. Conclude: Nationally or Professionally True Answer

[C46:14] This case exemplifies how making medical decisions for family members can be emotionally challenging and unduly influence professional medical judgment. As a result, it appears that the daughter did violate the parent’s civil rights, violated medical best practices by making medical decisions as a practitioner for family members, misinterpreted by emotionally amplifying the medical risk information, and may have obstructed the parent’s autonomous decision-making.

[C46:15] All of this could have been avoided by abiding by the medical standards of care that state: “practitioners should not treat themselves or members of their own families.” AMA Code of Medical Ethics Opinion 1.2.1


[C46:16] Question for the reader: 

Does the case analysis change if the parent’s offspring’s words “won’t allow” were replaced with “didn’t want”? Why or why not?

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Civil Rights

Obligation of others to Not Interfere

Negative Right

Obligation of others to Provide something

Positive Right

Practitioner

Principles

Unethical

More Discussion

Ethical

Autonomy

X


X


X

Beneficence

Nonmaleficence

Justice

X