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Conflict and Controversy in Medicine: Exploring Medical Ethics

October 24, 2012| Alpha Epsilon Delta

+Why Worry About Ethics? Patients and their families are at the core of medicine,

and every person has a different set of core values that need to be respected

New technologies, therapies and practices can sometimes encroach on the core values of patients

As future physicians, it is crucial for us to understand the nature of conflicts and controversies that can arise during our career

It takes practice to know how to think “ethically” : the earlier you start, the more effective your decision-making can be

+Ethical Responsibilities of Physicians Beneficence: physicians should take the course of

action that will be in the best interest of the patient Non-maleficence: physicians should refrain from

knowingly harming their patient or taking a course of action that will not benefit the patient

Striking a balance: only in very ideal situations can a physician meet all “requirements” of beneficence and non-maleficence. Therefore, the physician must use his/her best judgment to maximize benefit and minimize harm

+Ethical Rights of the Patient

Autonomy: the patient has the right to make decisions for him or herself, and the right to refuse treatment they do not feel comfortable with If the patient is unable to make decisions for him or herself safely

or effectively, the physician has the responsibility to take the course of action that is as beneficent as possible.

Knowledge: patients have the right to know (as much as possible) what will happen to them during the course of treatment

Dignity: the patient has the right to be treated in a dignified manner and be subject to courses of treatment that still preserve his or her human dignity, as best as possible.

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Autonomy Gone Wrong? Body Integrity

Identity Disorder

+What is BIID? Characterized by a strong desire to amputate one’s limb(s) Usually a strong, persistent feeling throughout life, rather

than a temporary compulsion Patients feel as though the affected limb should not be

there, and is not a “part” of their body The presence of the limb causes patients to feel extreme

depression, isolation, and anxiety over the affected limb. Such feelings can interfere with daily functioning

Some patients will (and have) gone as far as to amputate the affected limb themselves

Patients who have had the affected limb amputated report positive improvements in their life following the removal

+What is BIID?

Believed to be a “mismatch” between a person’s actual body and a person’s perception of their body

Recent neurological findings have shown that in patients with BIID, the brain literally does not recognize the limb being part of the body. However, the limb is still able to function normally

There is debate in the scientific community as to whether or not BIID is a “delusion” that can possibly be cured, or a true instance of poor “wiring” in the brain

+Dave Oppenshaw’s Storyhttp://youtu.be/WNps5_ndHzY

+Inciting Incident

In 2000, Robert C. Smith was heavily criticized for amputating the healthy legs and/or feet of two patients. Dr. Smith argued that he was following the Hippocratic Oath

by preventing the patients from taking more drastic measures to remove their legs

Most of the medical community did not agree since the legs did not “need” to be amputated, and because they believed other alternatives might be available

Dr. Smith’s patients reported a heightened sense of satisfaction in their life, and a significant alleviation in feelings of depression and anxiety.

+Initial Ethical Arguments Voluntary amputation of healthy limbs is directly

committing harms to the patient. Amputation is reserved for limbs that can, for whatever reason, no longer function.

Amputation is (for the most part) irreversible. If there is a potential for alleviating the distress caused by BIID, it would be a less harmful response

Amputation of a healthy limb is, in effect, “surrendering” to the mental imbalances present in patients with BIID

The ability for patients with BIID to actually make autonomous, informed decisions is in question. In many instances, BIID has manifested itself as delusional behavior

+Arguments for Amputation Allowing for surgical amputation may be minimizing

harms that patients could commit themselves. A study done by Robert First of Columbia University showed

that patients had done everything from use a wood chipper, shotgun or chainsaw to amputate a limb, to paying as much as $10,000 for black-market amputations

Patients, even those with BIID, must still be treated with respect and afforded the right of autonomous decision-making. We allow patients to refuse life-saving treatment due to

religious reasons; this situation is not nearly as endangering.

This operation has shown itself to be therapeutic. Patients report a better quality of life after the surgery. In addition, there is not yet any successful non-surgical treatment for BIID.

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Questions to Consider

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By performing a voluntary amputation, are surgeons “harming” their patients?

Follow-up: we allow for some fairly extreme alterations via cosmetic

surgery and hormone therapy. Could that also be considered “maiming” based on a delusional vision of the

human body?

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Should patients who present with BIID be considered

mentally stable enough to be their own autonomous agent?

Why or why not?

+Other actions inflicted upon the

body (ex: cutting, self-burning,etc) are considered

signs of mental illness and are discouraged. What separates

voluntary amputation (which is arguably more “intense”) from

self-harm? Or are they that different?

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If a child presents with BIID and wishes to have his/her limb

removed, how much autonomy would the child have in making this

decision? What role would the parents play?

Follow-up: if surgery has shown itself to be therapeutic, why could/ should such

a surgery be denied to a child?

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In denying a patient voluntary amputation, are we denying

them access to a dignified and satisfied life?