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11 The use of ethics consultation regarding consent and refusal
The Case
A 63-year-old female unconscious patient involved in an MVA was brought urgently to the O.R for repair of bilateral femur fractures. The anesthesiologist administered a general endotracheal anesthetic for a 6-hour operation during which the patient received six units of packed red cells and other blood products. She was transferred to the intensive care unit (ICU) still intubated and ventilated. The following day the anesthesiologist visited the patient, who was now awake but still dependent on mechanical ventilation. She signaled that she wanted to write something given a pad and pencil. She wrote, “I am Christian Scientist, I want to go home NOW.”
Mary Baker Eddy founded Christian Science in about 1866. Her textbook entitled Science and Health with Key to the Scriptures became the primary source for the Christian Science philosophy, which has unique beliefs concerning illness and healing. There are approximately 500 000 members of this group, found mostly in the US.
A foundational belief of the Christian Science church is that illness is an illusion and that an ill person can simply change their perception to alter or eliminate their illusory illness. All drugs, surgery, or other conventional medical treatments are unneeded and ultimately ineffective. Prayer is the only effective way to change the course of illness, by revealing the noncorporeal nature of all existence, including the nonphysical nature of the human body. A body that is spiritual is not in need of physical treatment.
Christian Science theology describes the corporeal world as a kind of shared illusion. In this sense, Christian Science bears a resemblance to the fundamental Buddhist idea that the world of the senses is illusory. Christian Scientists believe that immortality is actually and only achievable by the perfection of the spiritual mind. Disease is an imperfection of the spirit perceived as a physical problem.
Religious freedom and state interests
In the US there is a complex history of the relationship of the state to religious groups. Even though the framers of the Constitution were adamant that there should be a separation of church and state, such that the state could make no laws favoring any church, there have been times when religious groups were given special privileges or permission to indulge in what would otherwise be illegal conduct. Recently, religious groups and their followers are more commonly being held to the same standards as other members of society with their religious standing or preferences not allowed to excuse harmful conduct just because it conforms with religious preferences. For example, the tradition of churches providing “sanctuary” for people wanted by the civil authorities was abolished with the ecclesiastical courts in sixteenth-century England. But the idea that churches can still provide protection from civil prosecution for their own clergy and some church members lingers. Recent revelations that many Roman Catholic Churches in America and Europe failed to report the repeated criminal activities of its clergy are potent evidence that some churches still do not wholly submit to the authority of the state.
The Christian Scientist church and the state
Among the many aspects of her Christian Science philosophy, Mary Eddy was explicit in her direction that believers should be obedient to the authority of the law and of states, including state health laws. She was a progressive regarding the treatment of women and children, and was also a believer in civil liberties and individual freedom.
However, the American tradition of “freedom of religious belief” is not identical with a right to freely practice religious behavior that may be harmful to others or to society. At times, Christian Scientists have come to public attention because a member or members have denied standard healthcare for their children. Rejection of vaccination for Christian Scientist children may lead not only to the suffering and complications of common childhood diseases for the unvaccinated children, but may also lead to the propagation of diseases like measles within the whole population, thus harming others. The state, however, has an enduring interest in the health of its children and its general population.
The majority of the US still has specific legislation that protects parents from charges of child abuse or neglect when they deny their children certain resources, including some medical care, for religious reasons. The 1972 case Yoder v. Wisconsin allowed Amish to be exempt from the duty to educate or to send their children to school.1 The decision was justified on the basis that it was necessary for preservation of the Amish way of life. There are numerous examples of religion-based exceptions to public health requirements such as rules that children be vaccinated to attend public school.
However, there are no legislative protections for religious citizens accused of more serious crimes and felonious harms. In August, 1990 the New York Times reported on several cases of parents charged with felonies after deaths of their children occurred as a direct result of the parents’ failure to seek medical care for them.2 Although the majority of such cases resulted only in civil penalties such as fines or sentences requiring public service and promises to seek medical care for their remaining children, there are now some cases in which parents have been sentenced to prison time. A more recent example occurred in 2008 in Wisconsin wherein parents allowed their 11-year-old daughter to die of diabetes.3 The child deteriorated while her parents and other couples treated her only with prayer. The father and mother were accused of reckless homicide and were sentenced to some prison time every year for 6 years and probation for 10 years.
In our case, the patient is an adult who appears to be decisionally competent and the complexities of dealing with minor or incompetent patients are (fortunately) not involved.
Case discussion
How should the anesthesiologist respond to this patient?
After reassuring the patient, the anesthesiologist decided to consult with several colleagues and hospital officials, with the following results:
(1) The attending orthopedic surgeon was called and suggested that his patient be sedated indefinitely so that she does not harm herself or disturb the surgical repairs.
(2) The Chief of Staff (COS), who was also a surgeon, agreed with the attending surgeon.
(3) The hospital Chief Executive Officer (CEO) decided to call the hospital system lawyers.
(4) Anesthesiology colleagues at the state university suggested calling the chair of their hospital ethics committee, and provided a name and phone number.
(5) An attempt was made to contact local elders/readers from the Church of Christ, Scientist, but there was no phone registered to the local church.
Can the advice of the orthopedic surgeon or the COS be justified by reference to ethical principles or ethical reasoning? Neither the orthopedic surgeon nor the COS suggested that their advice to chemically restrain the patient could be justified on any but practical grounds. Federal laws regarding physical and chemical restraint now require that the use of any restraint must be re-evaluated frequently. The patient was cooperative, so chemical restraint beyond appropriate analgesia was not needed.
Related posts:
Informed consent and the pediatric patient
Communitarian values in medical decision-making: Native Americans
Ethical considerations in interventional pain management
Conflicts of interest in research funding
Physician conscientious objection in anesthesiology practice
Opioid therapy in addicted patients: background and perspective from the US
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