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[C60:1] An adult parent and their 13-year-old child are presented to the emergency department (ED) unconscious and in critical condition. Death is imminent unless they both get blood, but there is time to get a surrogate consent who is present. There is no living will or durable power of attorney on record. The patient’s spouse, who is also the other biological parent of the child, informs the ED practitioner that both of the patients are Jehovah’s Witnesses and that it is against their religion to receive any blood and therefore requests that no blood be given to both the spouse and child. The spouse also said they had numerous discussions about such a situation occurring, and not getting blood was what they wanted. Both patients are also wearing No Blood medical alert wristbands. What should the practitioner do?
[C60:3] What decisional limits does a surrogate have when making decisions that go against common medical practice and results in dire consequences?
[C60:4] All competent adults with decisional capacity have the right to autonomously refuse treatment even if it is life-saving. When a patient lacks decisional capacity without any record of oral or written consent, then the next level of authority is a living will, which does not exist. After the living will, the next level of authority is a durable power of attorney, which establishes the patient’s chosen surrogate or proxy decision-maker, which also does not exist. The next level of authority is the next of kin which in this case is the husband. With slight variations from state to state, the order of authority for proxy or surrogate is: 1) guardian, 2) spouse, 3) adult offspring, 4) either parent, 5) adult sibling, 6) adult grandchild, 7) adult friend, 8) guardian of the estate, 9) temporary custodian. As the surrogate decision maker, the spouse is to make decisions using substituted judgment. The surrogate decision maker is obligated to make medical decisions using the patient’s reasonable goals, values, and priorities, not the surrogate’s own goals, values, and priorities. This appears to be the case with the spouse, as evidenced with the Jehovah’s Witness (JW) wristband and with the surrogate’s justification of having numerous family conversations about such an event. The legal surrogate, using surrogate decision-making, is authorized to refuse life-sustaining treatment for the spouse, which in this case is the refusal to accept blood. Therefore, the practitioner is obligated not to give blood to the surrogate’s spouse.
[C60:5] On the other hand, when the patient is a minor, the surrogate does not have the legal or moral authority to withhold or withdraw life-sustaining treatment that is considered a medical standard of care. When going against medical standards of care for a minor, the state has the higher authority for the protection and well-being of its vulnerable citizens. Since the child is a minor and the life-sustaining procedure is a medical standard of care, the surrogate does not have the authority to refuse life-sustaining treatment for the child. Therefore, by protective state law, the practitioner is obligated to give blood to the surrogate’s child even if it is against the surrogate’s wishes.
[C60:6] Using substituted judgment, the surrogate decision maker decides to refuse life-sustaining procedures to maximize the spouse’s best interests based on the spouse’s goals, values, and priorities. Since the spouse is the legal surrogate and is basing the decision using appropriate surrogate decision-making, the practitioner has the professional obligation of beneficence (do good) and nonmaleficence (do no harm) to not give blood to the surrogate’s spouse. From the spouse’s perspective, giving blood to the surrogate’s spouse would not be considered a “good” and would be considered a “harm.”
[C60:7] On the other hand, because the child is a minor, the child has never been autonomous, which logically means that it is impossible to exercise substituted judgment as there are no competent and autonomous goals, values, and priorities to make a substituted judgment decision. As a result, decision-making for minors cannot be based on a minor’s autonomy; instead, it must be based on what would maximize the minor’s best interests. Since refusing life-sustaining treatment would go against the professional best practice or medical standards of care and would also go against the state’s interest of protecting the well-being of its vulnerable citizens, it follows that legally, professionally, and morally the practitioner ought to provide the life-sustaining treatment of blood.
[C60:8] The state has a moral obligation to legislate for the protection and well-being of its vulnerable populations. Adults are allowed to individually determine what well-being is within the constraints of not violating the rights and liberties of others in society. A civil right is a social or public policy concept. Whenever someone has a civil right, that means that others have an obligation of some sort. There are two types of rights; positive rights and negative rights. A positive right is when others have an obligation to provide something. A negative right is when others have an obligation to not interfere.
[C60:10] There is near-universal agreement on most negative rights, which is the obligation of others to not interfere, but there is more disagreement on positive rights, which is the obligation of others to provide something. However, some universal positive rights for children are the obligation of others, to provide appropriate food, clothing, shelter, education, and medical care.
[C60:11] For the surrogate’s spouse, the spouse has the negative civil right to refuse life-sustaining treatment, meaning that others have a social obligation to not interfere in that decision even if they disagree with it.
[C60:12] For the surrogate’s child, as a vulnerable minor, the child has a positive civil right to receive life-sustaining treatment that is in line with medical standards of care.
[C60:13] Where disagreement could arise is whether or not the child has a positive right to have both parents, meaning that both parents would be obligated to get blood if they needed it regardless of their wishes. However, generally the focus will always be on areas of agreement, not on disagreement, meaning that the in this case the practitioner ought not to provide blood to the surrogate’s spouse but provide blood to the child.
[C60:15] The recommendation is for the practitioner not to provide blood to the surrogate’s spouse but provide blood to the child.
[C60:16] Not providing blood to the adult is in line with autonomy (informed consent), beneficence (do good), nonmaleficence (do no harm), and justice (be fair). Providing blood to the minor is appropriate based on beneficence (do good), nonmaleficence (do no harm), and justice (be fair).
(Choice A) Do as the surrogate dictates and do not give blood to either patient.
A is wrong because it fails to consider what is in the best interests of the minor. In emergencies, practitioners are morally and legally obligated to provide potentially life-saving therapy that meets the medically medical standards of care for minors.
(Choice B) Override the surrogate and give blood to both patients.
(Choice D) Get a court order to give blood to both patients.
(Choice E) Give blood to the daughter but not to the parent.
An adult patient with schizophrenia is evaluated in the emergency department for acute rectal bleeding. A colonoscopy is recommended to diagnose and treat the hemorrhage. The patient refuses because they think that the procedure will give them HIV. What should be done?
[D60:3] In an emergency, what obligations does the practitioner have?
[D60:4] By definition, a medical emergency is when someone’s life or health is at risk, and there is no time to get informed consent. This case meets the medical emergency criteria. Therefore, whether or not the patient has decisional capacity is not even an issue, rather it is a distractor.
[D60:5] Because this is a medical emergency, the practitioner has the professional obligation of beneficence (do good) to provide what is considered to be medical standards of care to the patient. Failure to provide the medical standards of care would violate the professional obligation of nonmaleficence.
[D60:6] All patients admitted into the emergency department have the social or civil right to be treated and stabilized. In 1986, Congress passed the Emergency Medical Treatment and Labor Act (EMTALA) that prohibits “patient dumping” or the releasing of the patient without providing care. EMTALA gives individuals the right to emergency care regardless of their ability to pay. In this case, the state has an interest in making sure that all patients receive emergency medical treatment before being released or discharged.
[D60:8] Provide emergency treatment.
(Choice A) Do not provide treatment until the patient understands that treatment will not result in HIV.
(Choice B) Immediately call for a psychological evaluation to override the patient’s false belief.
(Choice C) Call for an ethics consultation.
(Choice D) Provide an alternative treatment option, even if it is not the accepted standard treatment.
(Choice E) Discharge the patient.
(Choice F) Provide emergency treatment that meets the best practice standard.
Obligation of others to Not Interfere
Obligation of others to Provide something