J. S. is a sixty-five-year-old man who was treated at another
hospital with arthroscopic d衲idement of an infection at the site
of a right total knee replacement and was placed on long-term intravenous
antibiotics. He signed out of that hospital against medical advice.
One month later, he presented at our hospital with recurrent sepsis
of his knee.
Knee aspiration yielded frank pus with a white blood-cell count
of 80,000 cells per cubic millimeter. Gram-staining demonstrated
gram-positive cocci. The patient was placed on intravenous antibiotics.
The patient appeared cachectic, reporting a sixty-pound (27.2-kilogram)
weight loss over the past year. A metastatic workup, including a chest
radiograph, an abdominal sonogram, prostate-specific antigen, a
complete blood-cell count, erythrocyte sedimentation rate, and a
purified-protein-derivative skin test, was negative; however, an
occult neoplasm could not be excluded.
The patient displayed episodes of confusion, disorientation,
and argumentative behavior. Medical and psychiatric consults did
not determine whether this behavior was due to previous substance
abuse or a primary psychiatric disorder. Nevertheless, psychiatrists
at our institution determined that the patient lacked decisional
capacity.
Attempts were made to salvage the knee replacement, and the patient
underwent an extensive surgical d衲idement of the knee with insertion
of drains. He was placed on intravenous antibiotics. The plan was
for the patient to be managed with long-term oral suppressive antibiotics.
After treatment, the patient was transferred to a skilled-nursing
facility. Psychiatrists at the nursing facility deemed the patient
to have decisional capacity, and the patient was permitted to leave
the facility. He was discharged without antibiotics. Several weeks
later, he presented at our hospital with a grossly purulent knee.
The orthopaedic options were reviewed with the patient and his
brother. Removal of the components was recommended. The patient
did not want to "lose" his knee replacement, and he refused surgical
intervention. We did not believe that the infection could be either
controlled or eradicated with the components in place.
This case involves a host of ethical issues, including a patient's
right to refuse treatment, surrogate decision-making, resource allocation, professional
peer relations, competency, and consent to treatment. The central
issue, however, involves paternalism - that is, a
physician's decision to act for a patient's good without regard
for the patient's conception of what would be good in the given
situation. Why is paternalistic intervention usually unacceptable?
And when is it justified?
We can begin to appreciate the problem in this case by recalling
what all physicians know best: that we are committed to beneficence -
that is, acting for our patients' good. The orthopaedic
surgeons involved in this case clearly saw this as their duty and,
at the time of the second admission, recommended complete removal
of the knee components. According to a simple view of beneficence,
the doctors should do what they judge to be best.
Beneficence, however, can be rather complex. When a patient and
his or her doctor share a view of what is best, they proceed with
that course of action. When their views differ, it is not always
obvious whose perspective should rule. In this case, the patient's
view of what is best is different from that of his doctors. In fact, what
appears best to his doctors may be the worst alternative in his
eyes. Since the patient is the one who will have to live with the
outcome and since interference with his body is at issue, we have
good reason to give preference to his view. These are the reasons
why paternalism is usually unacceptable and why we usually allow patients
to make the final decision about whether or not to accept recommended
treatment.
Additionally, respect for a patient's autonomy, a basic premise
of medical decision-making, requires us to allow others to make
choices according to their own values and to live by their own lights.
An important issue to consider in this case is whether the patient
is in fact autonomous. Can he make choices in light of his values?
Can he provide reasons for his choices that reflect his values?
If he is not capable of giving such reasons, then respect for his
autonomy is not an issue. When a patient lacks autonomy, doctors
should override the patient's stated preference and act to restore
or create autonomy. When future autonomy is not possible, doctors should
act to achieve what a reasonable person would see as best.
In this case, where one set of psychiatrists found the patient
to lack decisional capacity and another group found that he had
the ability to make decisions about treatment for himself, the most we
can say is that J. S.'s capacity for making an autonomous decision
is not a clear call. His decisional capacity is somewhat diminished,
but he may still be able to make a decision that reflects his values.
The degree of mental incapacity, the degree of invasiveness,
and the impact on his future all have been taken into account. If
having knee function is very important to J. S. and if treating his
knee properly would not extend his life by much because of other
disease, then invading his body with anesthesia and surgically removing his
appliance would not be justified. On the other hand, if J. S. could
not understand that he was likely to die from the infection or to
lose his leg entirely and if the other disease was not life-threatening,
paternalistic intervention despite his expressed refusal could be
morally justified.
In sum, paternalism can be justified when the benefit would be
significant to any reasonable person and when the patient in question
lacks the capacity to make the decision. The more long-lasting the
invasion, the more significant the benefit and the more dramatic
the lack of capacity will have to be in order to justify paternalistic
interference.
James D. Capozzi, M.D.
Department of Orthopaedics
Mount Sinai Medical Center
1065 Park Avenue
New York, N.Y. 10128
Rosamond Rhodes, Ph.D.
Director of Bioethics Education
Mount Sinai Medical Center
One Gustave Levy Place
New York, N.Y. 10029
Further Reading
Buchanan, A. E., and Brock, D. W.:Deciding
for Others: The Ethics for Surrogate Decision Making. Studies in
Philosophy and Health Policy Series. New York, Cambridge University
Press, 1989.
Dworkin, G.: Paternalism. In Paternalism, pp.
19-34. Edited by R. Sartorius. Minneapolis, University of Minnesota
Press, 1983.