Ethics

Elizabeths tests and biopsies were positive for the malignancy of colon. Elizabeths physician and the surgeon, engaged in the case, agreed on the fact that Elizabeths generally good health and conditions give possibility to make surgery and radiation and chemotherapy procedures, if needed.

However, while Elizabeths relatives, namely daughter agreed on the surgical involvement, they radically protest against telling real diagnosis to Elizabeth, taken into consideration her husbands recent death from colon cancer, his physical and familys moral and psychological sufferings. Weighted against these conditions, there exist the following basic alternatives for the surgeon that should be assessed in this decision-making model.

The first alternative is telling Elizabeth the information and diagnosis, the surgeon knows from her tests and biopsies, that is colon cancer. If such alternative is followed, the surgeon should provide Elizabeth with all necessary information, including possible implications of surgical involvement, the perspectives of chemotherapy of radiation use, the scope of tumor expansion in the organism, possibilities of recovery, legal formalities (including given written consent for operation etc.). The use of such alternative presupposes that surgeon tells all the truth in a straight way without concealing any bit of information from Elizabeth. Moral and psychological implications for Elizabeth and her family in this alternative are put aside the main objective of the surgeon is providing clear information, prospects, challenges and patients future. It should be noted that the provision of full information is among basic ethical principles in medicine.

The second alternative follows the same approach as the first, however, with certain corrections and reflection into Elizabeth and her family situation. The medical truth in this alternative is understood as a minimal scope of information a surgeon should provide for patient to secure hisher conscious consent on surgery. The surgeon is not required to tell all information from tests and biopsies, if a patient does not explicitly asks himher to do so. In this alternative a surgeon may diplomatically and rationally try not to tell information that may negatively affect psychological and moral conditions of his patient.

For instance, the surgeon may tell Elizabeth that tests showed colon cancer at the early stage of development and that due to her good conditions and health the surgical involvement would not be dangerous. However, it should be taken into consideration that taking this alternative the surgeon finds himself on the thin ice between truth and lie. The lie may be particularly detrimental if the colon cancer has already resulted in metastases.
   
3. The third alternative is engaging in close interaction with patient, based on trust, understanding and psychological help. In this alternative a surgeon should take all responsibility for telling the true diagnosis for Elizabeth. However, the surgeon should understand that such action should be accompanied by further close engagement with patients psychological stability, life, interests and support.

Finally, the fourth alternative possible in this situation, is that proposed by Elizabeths daughter. As the case suggests, she asked the surgeon to tell Elizabeth that she has problems with colon malfunction, which may be fixed through surgical involvement. This alternative suggests not telling the truth about colon cancer to Elizabeth.

In the following step we are to analyze Elizabeths capacity status and biomedical ethical dimensions of each alternative, based on Ideal Relationship to Patient and Central Practice Values.

Second Stage of Decision-Making Model
In considering whether Elizabeth is capable, partially capable or incapable we should focus on the case analysis.

The general information provided in the case suggests that Elizabeth is intelligent and independent 74 old widow. However general judgment, Elizabeth intelligence and good psychological conditions are explicitly showed in the case. When her husband suffered from terminal cancer she was the first to morally strengthen him.

She never cried near her husband and made all possible to reassure him, engage in warm conversations. Such behavior vividly demonstrates that Elizabeth is psychologically strong woman however, nobody knows how much effort it cost for her to keep all her grief inside.

Her relatives said that after the death of her husband she was in grief for about 2 months, however, managed to recover and devote all her efforts to her grandchildren and volunteering in church.
Moreover, in conversation with Elizabeths daughter the surgeon points to the fact that Elizabeth may be competent in medical issues and aware of possible implications of surgical involvement and cancer in general.

Such observation does not imply that Elizabeth got medical education, but more likely certifies to the fact that she has a good level of consciousness and awareness, notwithstanding her old age (Epstein, 2009). In counterbalance to these observations Elizabeths relatives tell the surgeon that Elizabeths will would be broken, if she knows about her cancer. Such claim is supported by Elizabeths conversation with her granddaughter, in which she said her husband would not suffer 6 months, if the surgeons not made a surgery to relieve metastases.

In our view, the last fact is not enough to qualify Elizabeth as partly capable, because such judgments are evidently caused by grief from the loss of close relative and they are quite normal for any person in such situation. All mentioned facts put together certify to the fact that Elizabeth may be described as capable patient.

The Assessment of Alternatives Based on Ideal Relationship between Professional and Patient.
The first alternative represents the approach, in which a professional treats hisher patient as the subject of autonomous decision-making, quite competent to decide on hisher medical treatment. This alternative presupposes telling Elizabeth detailed account of her tests and biopsies in the view of giving her all information for taking conscious decision on surgical involvement.

Such alternative bears on substantial features of agent approach, described by Ozar and Sokol in their analysis of patient-professional relationships. As Ozar and Sokol suggest, Here, the  professional  simply  puts  his  or  her  expertise at the service of  the patients aims and values. The dentists  task is only to give effect to  the patients choices,  responding as efficiently as possible  to fulfill  the patients  choices regarding his or her needs or desires (Ozar and Sokol, 48).

In this alternative, a surgeon functions as an agent of a patient, providing him with objective and empirical facts tests and biopsies, diagnosis, devoid of any moral and ethical dimension. The relationship between patient and professional in these conditions is functional and lacking interactivity.
The second alternative may be characterized as a mild version of guild approach however, it is characterized by using half truths and euphemisms to prevent the patient from knowing the true diagnosis and surgery perspectives. It is based on the assumption that a patient not competent in medical treatment, would not notice professionals lies, which are allegedly designed for patients benefit.
The third alternative reflects what Ozar and Sokol designate as interactive model, which synthesizes patients autonomy with physicians professionalism to create partnership, trust and understanding. As Ozar and Sokol suggest, In the  interactive model,  both parties
have  unique  and  irreplaceable  contributions  to. make  in  their  judgments and choices
together,  and both the patients  and  the  dentists values  serve as  determinants  of what
they do  together (Ozar and Sokol, 52).

Following this alternative requires the surgeon to be engaged in close communication with patient to understand her interests, fears, anxieties and needs (Veatch, 34). The surgeon should not just provide patient with objective and neutral facts, derived from tests and biopsies and leave the final decision to the patient, but instead provide her with tangible interpretation, psychological support and help. Interactive model, which fits the third alternative the best, is based on effective combination of autonomy and paternalism to find the most viable decision in a given situation.

The fourth alternative (not telling truth to the patient) presents the mixture of guild approach to patient-professional relationship and general moral dimension of surgeons profession.

According to Ozar and Sokol, treating patients as incompetent subjects, lacking autonomy in taking decisions in medical sphere, are major characteristics of guild approach to patient-professional relationship.

It is based on the assumption that patients lack sufficient professional knowledge and expertise in what relates to their medical treatment and, hence, every decision on medical treatment and information, provided to patients is up to physician (Ozar and Sokol, 45).
It is evident that such an approach should not be considered as an ideal pattern of patient-professional relationship, particularly in Elizabeths case, when she may be easily qualified as capable and competent.

However, it should be noted, that the fourth alternative does not present direct reflection of guild approach, because surgeon possible alternative is informed by Elizabeths relatives request. But, formally speaking, using such alternative would inevitably bear on all basic features of guild approach.

Overview of Patient-Professional Relationship Models
The analysis of alternatives in terms of ideal relationship between patient and professional was based on several models of Patient-Professional Relationship, discussed in medicine ethics literature. Let us briefly outline four of them guild model, agent model, commercial model and interactive model, and how they relate to the described alternatives.

Guild model presupposes strict distinction between professionals knowledge and expertise and patient. Patient is characterized as the subject lacking autonomy in medical decision-making process. Professional is considered to be the final instance of decision-making. Moreover, a patient in this model does not have to know about professional expertise diagnosis, tests etc., but only follows direct instructions of professional. As Ozar and Sokol rightly suggest, such model fails to perceive of medical treatment as value-based process The reason is  that therapeutic alternatives  are never value-neutral. All  therapeutic choices  involve selecting one set of  life  experiences  for  the  patient  over  another set,  and  the  knowledge  and  skills  that  the  dentist brings to  the situation are not adequate  tools  for comparing the value of  these possible experiences  within  the  patients  life (p. 47).

The outlined approach, as it was noted above, is best suited for understanding the fourth alternative. In this alternative the surgeon treats patient as a passive subject of surgical involvement, who is not eligible and qualified to know true diagnosis and other professional details.

The second model, discussed by Ozar and Sokol (2002) is agent model. In agent model in a reverse manner, a professional serves patients decisions it is up to patient to decide on the type of medical treatment etc. In hisher turn, a professional does not intervene into the sphere of patients personal experience, fears, anxieties etc. As Ozar and Sokol suggest, Here, the professional  simply  puts  his  or  her  expertise at the service of  the patients aims and values (p. 48). The main failure of this model lies in its inability to create trust and cooperation between professional and patient. The value of autonomy that this model allegedly promotes is, however, false. The outlined model best characterizes the first alternative of the surgeon, where he tells to whole story about Elizabeths decease and leaves the final decision to her without involving in partnership.

In the commercial model the relations between professional and patient are formalized to meet the demands of market economy According  to  the  commercial model,  a member of a  profession  is  simply another  producer selling his or her wares  in  the marketplace (Ozar and Sokol, 48). However, both patient and professional abide to certain norms their cooperation and trust are paralyzed by competition, lack of moral responsibilities if they are not fixed by law etc (Walter and Eran, 2003).

Finally, the fourth model is interactive model, which is credited by Ozar and Sokol as the ideal relationship between professional and patient. Interactive model is based on cooperation between patient and professional, based on mutual understanding and synthesis between expertise and personal views of a patient. As Ozar and Sokol argue, In the  interactive model,  both parties have  unique  and  irreplaceable  contributions  to. make  in  their  judgments and choices together,  and both the patients  and  the  dentists values  serve as  determinants  of what  they do  together (p.52). It requires understanding, empathy, and coordination. The main advantage of this model is that, however final decision belongs to patient, a professional has an opportunity to influence it by his expertise and moral support.

Interactive model is the best suitable for understanding the third alternative of the surgeon. It is based on surgeon understanding of patients biography, her anxieties, fears and trying to influence patients final decision through knowledge and psychological support.
Central Practice Values in the Application to Decision-making Alternatives.

The main central practice values in American medicine are the following (taken from Ozar)

1. Extending Biological Life (by cure of a life-threatening condition or by life-extending therapy when treatment cannot end the life-threatening condition).

2.  Patient autonomy in health care decision-making.

3. Restoration of normal physiological functioning (as determined by statisticalbiochemical norms)

4. Preservationmaintenance of functions involved in Activities of Daily Living (ADLs ) -- and some special functions associated with typically chosen patterns of life.

5. Eliminationlimitation of pain (and other symptoms that interfere with functioning).

6. Prevention, i.e. of future life-threatening or function-limiting processes includes inoculations, etc., education for self-care, and medical and other regimens to limit the adverse impact of chronic incurable physiological conditions (e.g. diabetes, heart disease, etc.).

7. Preferred patterns of practice (i.e. practicing in ways that facilitate the individual practitioners most proficient habituated modes of relating, diagnosing, treating, etc. and the benefits to patients these make possible)

8. Information and understanding, i.e. of the processes and causes of illness, for the sake of self-knowledge and to facilitate a persons have a coherent story about self to tell to self andor others.

9. Efficiency in the use of resources.

It should be noted that alongside with these 9 basic values, we use the value that is according to Ozar is not included in the list of Central Practice Values Biographical Life, a sense of wholeness of the self, integrity, living a story that is coherent with who one is, because it is useful for understanding alternatives in this case-study.

Let us apply mentioned values and principles to the discussed alternatives.
The first alternative fully abides to several values, outlined above. First of all, it abides to the principle of full information. Indeed, in this alternative the surgeon provides Elizabeth with all knowledge of tests, biopsies and surgical involvement, which are necessary for her understanding of situation, self-knowledge etc. Moreover, this alternative meets the value of respecting patients autonomy, because the surgeon leaves final decision, concerning surgical intervention to the patient (Walter and Eran, 2003).
The second alternative does not fully meet the information value, because the surgeon conceals the full truth and provide the patient with partial information. This results in a deviation from the principle of autonomy, because the information, provided for the patient is not adequate for taking autonomous and conscious decision.

The third alternative meets the largest number of principles and values of medical practice. First of all, it is based on patients autonomy, because in any case Elizabeth is the last instance of decision-making in this situation due to her capability. Moreover, the third alternative provides the full scope of information on diagnosis and surgical intervention.  Moreover, it is based on the assumption that in the case of patients consent the main function of surgeon would be to prolong her life even in the case of metastases and other aggravations, caused by cancer.

Finally, the third alternative reflects additional value, used in this analysis, referring to Biographical Life, a sense of wholeness of the self, integrity, living a story that is coherent with who one is, because is implies the surgeons deep involvement in the family situation of his patient, her psychological conditions and trying to understand her experience.

As it was noted above, the fourth alternative is based on interaction approach, presupposing dialectical link between patient and hisher physician, including coordination, partnership, trust and mutual understanding.

Finally, the fourth alternative neglects patients autonomy, because the surgeon prefers not to tell his patient the truth about her diagnosis. Moreover, this alternative falsely interprets the additional value used in this analysis. The surgeon assumes that following relatives requests gives him the most sufficient knowledge of patients life, fears and anxieties. However, it is more likely that it reflects more of relatives anxieties, than that of the patient.

To sum it up, four proposed alternative have their specific relation to the values of information and autonomy, as well as the additional value of biographical life, proposed in this study.
Third Step Additional Considerations.

It should be noted that the discussed case provides the surgeon with a lot of moral dilemmas and problems, difficult to resolve. The main contradiction, arising in this case, is between patients benefits and autonomy. The surgeons alternatives should be based on effective correlation between beneficence and autonomy principles that is, however, difficult to find. The most effective resolution of the case in terms of moral values may be at the same time detrimental to her health and life. These contradictions result in that final decision of the surgeon should combine his knowledge with intuitive understanding of this situation.

Step 4. Finding viable alternative
Proceeding from the value-based analysis of alternatives, let us discuss which of them is the most viable decision for the surgeon in this case.

The first alternative, presented, is solid in terms of directly following the value of patients autonomy and full information on hisher diagnosis, life prospects and aggravation. However, being right from the formal point of view, it does not take into account the complexity of Elizabeths case.

To tell Elizabeth full information on her diagnosis, illness, surgery to provide her with condition to take the autonomous decision, is the easiest and the safest way for the surgeon. Indeed, by following such alternative he refuses from responsibility, connected with the understanding of patients biographical problems, psychological conditions, family relations. Such approach may be described as commercial, because it does not consider a patient to be a person with feelings, fears, anxieties, but just the object of medical treatment.

The second alternative tries to avoid the deficiencies of the first by partial realization relatives request not to tell Elizabeth the whole story.

It aims at preserving balance between autonomy and truth, however, in the result it may confuse both the patient and the surgeon and aggravate Elizabeths psychological stability. It may happen, because if told a partial truth, she may suppose that the surgeon lies to her  this would break trust and mutual understanding.

The fourth alternative, described in this analysis, is based on the neglect of patients personal autonomy. The surgeon lies to the patient concerning her diagnosis and leaves her unaware of real facts and prospects. It should be noted that such alternative should be regarded as running contrary to the established medical practice values. This alternative is based on guild approach, which is characterized by paternalistic relationship to patient only a physician knows best what is good for a patient, while the latter is treated like a child having no sufficient knowledge and expertise. Patients problems, fears and anxieties are not taken into consideration at all. Patient has to patiently wait for final decision of the surgeon in the corridor and then, without any explanations or with false explanations (like all will be OK) follow his instructions (Veatch, 1988). Correspondingly, surgeons behavior in this alternative only aggravates patients psychological instability.

Finally, the third alternative, based on interactive approach, is the most difficult path, chosen by the surgeon, but it reflects the ideal relationship between patient and professional.

It is based on trust, partnership and understanding between surgeon and patient, and, hence, presupposes full engagement of the surgeon in the patients biography, living experience, fears, anxieties and psychological conditions.

First of all, following this alternative means that the surgeon has to tell the whole story to the patient, however, unlike the first alternative, after that he has to stay in close contact with the patient.

This includes attempting to persuade her in the positive outcome of the surgery, communicating with her relatives, trying to understand her character etc.

Hence, interaction between the patient and the surgeon should be described as ideal relationship, because it tries to overcome the limitations of autonomy and paternalism in distinctly ethical and human way. Another question, however, is the effectiveness of such an approach. For instance, one may argue that the fourth alternative provides the surgeon with possibility to treat patient without her consent and hence, prolong her life and restore health.

Such an approach, however, deeply contradicts the value of freedom and autonomy, protected by medical ethics.

Notwithstanding this, it may prove to be effective in resolving the situation. This paradox reflects the well-entrenched dilemma between autonomy and paternalism. However, as far as an ideal situation is concerned, the surgeon in our view should use the third alternative, which is the most theoretically grounded and ethically plausible.

Conclusion
To sum it up, four basic alternatives for surgeon behavior were analyzed, focusing on their accordance with ideal relationship between the surgeon and the patient, central medical values and general ethical principles. Two of the discussed alternatives significantly contradict the established ethical principles of autonomy. The fourth alternative directly limits the right of patients autonomy. The second alternative seeks to find balance between paternalism and autonomy, however, such attempts in the close sight seems to be false and implausible, if the truth is not told in a comprehensive manner.

At the same time, the first alternative being transparent and ethically plausible is, however, one-sided in the context of comprehensive ethical framework. It fully abides only to the one principle of autonomy, while neglecting the principles of interaction, cooperation, trust, understanding etc.

From the theoretical standpoint the third alternative seems to be the most plausible in the resolution of the surgeons dilemma, because it is based on the assumption that medical treatment is a comprehensive process, presupposing partnership and cooperation between patient and surgeon, based on equal rights.