Right to Life

One of the rights mentioned in the Declaration of Independence is the right to life.

Since the 1970s the term “right to life” has come to be associated with the movement against abortion. But in a broader context, it reflects the belief that human beings may not kill others. The belief in the right to life is found in all major religions and traditions.

The right to life has many implications for medicine. Historically, physicians and other health care workers may not harm patients because this may threaten their lives. They may not assist with suicide; this is expressly stated in the Hippocratic Oath. In the United States today, however, many individuals want some control over death, including the choice of suicide assisted by their physician.

Two important areas of conflict appeared in the middle of the twentieth century. First, advances in medical care made it possible to keep people alive who could not recover their health. Sometimes this sustaining of life came at the cost of prolonged suffering.

Second, the absolute right to life of an unborn fetus conflicts with the right of a woman to control her own reproductive capacity. Birth-control methods, artificial conception methods, and abortion, if necessary, are measures to control the size of a woman’s family. Many women and their physicians have come to believe they have a right to make decisions related to reproduction, including using available technology, as they see fit.

Right to Privacy

The Supreme Court has ruled that there is an implicit right to privacy in the Bill of Rights, specifically in the Fourth Amendment. A series of court decisions affirming a woman’s right to use mechanical birth control and to have an abortion hinged on justices’ perceiving this right to privacy.

Patient confidentiality, which has been upheld by courts, is another manifestation of the right to privacy. Patient confidentiality is discussed in detail later in this chapter.

Right to Autonomy

Currently, medical ethics takes the position that an individual has the right to autonomy, which means the right to make independent decisions about his or her health care according to individual values and concerns, without constraint or coercion by others. This right is preserved even when the individual’s decisions do not match the values of the medical community or the individual physician. The right of autonomy is the basis for informed consent. Informed consent is consent based on understanding of a medical procedure and its possible outcomes. Health care professionals must provide complete information in order for patients to make informed decisions. The patient must have the mental capacity to reason and consider alternatives. Because of this, the law limits the autonomy of children or individuals with decreased mental capacity such as the mentally retarded or individuals whose mental capacity has been impaired by illness, those acting under the influence of drugs or alcohol, and those experiencing mental illness.

Respect for autonomy does not derive from the Hippocratic Oath. Rather, it comes from the thinking of European philosophers such as Immanuel Kant and John Locke.

Right to the Means to Sustain Life

Every society must grapple with the problem of equitable distribution of goods and services to its citizens and how to regulate that distribution over time.

This is not a problem when the supply is adequate, or when supply is greater than demand. For instance, in ordinary circumstances the supply of oxygen is more than adequate to meet the needs of the entire population.

It is when the amount of a particular resource is less than the desire for that resource that problems develop. In this case, resources are said to be scarce, and the society’s government must determine who will have access to the scarce resources.

At a minimum, every individual should have access to what is necessary to sustain life and preserve human dignity. Consideration of justice in distribution and access is especially important in social and political movements. Any society must find ways to respond to need while also rewarding contribution and providing for stability within the social system.

Do No Harm

The concept of nonmalfeasance means, first of all, doing no harm in any treatment given. This duty is found in the Hippocratic Oath. It is not taken in a literal sense because many treatments can have adverse effects. Rather, it is taken to mean that medical benefits should outweigh adverse effects.

This concept applies especially to scientific research. Guidelines for ethical research not only require informed consent but also restrict research with possible harmful effects to those patients whose conditions are so serious that doing nothing is likely to be as dangerous as the treatment or procedure being studied.

Do the Best Possible

The concept of beneficence, doing the best possible, is seen in some systems of ethics as a separate duty, whereas in others it is considered an extension of doing no harm. It is often difficult to pinpoint exactly what harm and good are; they may vary with a particular individual’s viewpoint.

Be Faithful to Reasonable Expectations

The concept of fidelity, being faithful, comes from the Latin term fides, which means faith. In the case of medical practice, fidelity is usually interpreted as meaning faithful to reasonable expectations. Although patient expectations vary, there is general agreement that a patient can reasonably expect to be treated with dignity, treated by individuals who honor their agreements, and treated by competent providers. Patients can also expect that they will be cared for by individuals who adhere to the ethical standards of their profession, to statutory law, and to accepted medical and scientific practice.

Be a Patient Advocate

The concept of fidelity includes the expectation that patient needs come first. An advocate is a person who intercedes on behalf of another person. A medical assistant functions as an advocate for patients by suggesting appropriate community referrals to the physician, by making sure that all insurance claims are complete, by following up to help patients receive insurance coverage if additional information will make that possible, and generally by working to protect patients’ rights (see Highlight on Patient’s Bill of Rights later in this chapter).

In order to protect patient safety, it may even be necessary for a medical assistant to report unsafe or illegal behavior to proper authorities. The first step is always to follow up within the organization by reporting to the supervisor any incident or situation that could cause potential harm. If no action is taken after a reasonable amount of time, the situation should be documented in writing (as a memory aid) and reported to the next person in the chain of command. If a medical assistant has followed up within the organization without resolution of an unsafe or illegal situation, he or she should report the incident to the appropriate government agency. For example, if unsafe or illegal behavior is being exhibited by a physician or nurse, the medical assistant should report the behavior to the state authority that licenses that individual. These agencies have different names in different states—for example, Board of Registration (Massachusetts), Board of Medical Practice (Minnesota, Delaware, and Vermont), or Board of Medical Examiners (Oregon, Louisiana, New Jersey, Nevada, and others). Any type of report must be based on firsthand evidence. In most states, reports can be made online, and these reports can usually be made anonymously. Information about professionals whose licenses have been revoked or suspended is also available online in many states.

Tell the Truth

The concept of veracity has increased in importance since the nineteenth century. Veracity is not found in the Hippocratic Oath. It has developed with the evolution of the scientific tradition. Today it is seen as a proactive duty—physicians and other health care professionals must provide truthful information without having to be asked. It is a tenet of modern science that scientific knowledge belongs to all. Results of experiments must be accurate and reviewed by other scientists to see if the results can be replicated, then published for the benefit of all.

Give Each Person a Fair Share

The concept of justice requires that each individual be given his or her due and implies that he or she deserves a fair share of resources. However, there is often an underlying belief that an individual must contribute or bear a portion of the burden before being allowed to get certain resources. Justice in the context of medical practice appears not only in terms of distribution of medical resources, but also in the belief in the right to compensation if a mistake is made.

Deciding what is “fair” is difficult because different situations may require different guidelines. In the United States, the tendency is to believe in “first come, first served.” But in an emergency department, serious conditions must take precedence.

Reproductive Issues

Conflict surrounds the issues of contraception, abortion, and other issues related to reproduction. With regard to pregnancy, some people feel that the duty to follow divine law or natural measures takes precedence over an individual’s right to autonomy. This results in differing beliefs about how appropriate it is to use contraception and artificial measures to become pregnant. There has been controversy about the “morning-after pill” (marketed under the name Plan B). Because it has been found to be relatively safe, it was approved as an over-the-counter medication for women older than age 18 by the Food and Drug Administration (FDA) in 2006.

Another controversial issue is abortion. Some argue that the fetus’s right to life outweighs the woman’s right to privacy in determining—with her physician—the proper course of her medical care. Since the original U.S. Supreme Court decision in 1973 upholding a woman’s right to obtain an abortion in any state (Roe v Wade), the Court has been called on to rule many times on various state laws that seek to limit this right. The Partial-Birth Abortion Ban Act of 2003, which prohibits a specific abortion procedure that can be done in the second trimester of pregnancy, is an example of a federal law that restricts a woman’s right to abortion in some cases. It was upheld in the Supreme Court case of Gonzales v Carhart in 2007.

Stem Cell Research

A promising area of research for medical treatment involves the use of embryonic stem cells. These cells, taken from fetal tissue, are able to mature into different types of tissue. Embryonic cells may be found to be able to reduce, or possibly even reverse, the symptoms of Parkinson disease and other diseases.

The ethical conflict arises because the cells of live human embryos may be killed during research activities. In addition, a possible source of embryonic cell tissue is from aborted fetuses or fertilized ova not used for in vitro fertilization. Researchers who use fetal tissue stress that they use only tissue from spontaneous abortions (miscarriages). Antiabortion advocates argue that if there is an increased need for fetal tissue, a time may come when women might be influenced in their decision whether or not to have an abortion if they could sell their fetus’s tissue for research and/or treatment. In 2001 the federal government introduced a policy that federal funding would be available only for research using the 64 then-existing stem cell lines. This policy was reversed in 2009, and federal funding is now available for additional stem cell lines.

Genetic Engineering and Cloning

A number of ethical issues surround the practices of genetic engineering (making, altering, or repairing genetic material) and cloning (reproducing genetically identical cells or individuals).

One is the issue of genetically engineered crops and other food products. This encompasses practices as diverse as injecting milk cows with growth hormones in order to get them to produce more milk to incorporating material from bacteria into plant seeds. Opponents argue that we cannot predict all of the possible effects of manipulating genetic material and are likely to see unexpected and unwanted consequences to ourselves or other species.

Gene therapy is a term used for experimental treatments that attempt to treat or cure disease by giving patients new genes or parts of genes that may have been synthesized in the laboratory, taken from human tissue, or engineered from genetic material of animals or other species. Research efforts are overseen by the Recombinant DNA Advisory Committee of the National Institutes of Health (NIH). A clinical study of a gene therapy treatment for arthritis was suspended in July 2007 after the death of a patient.

Human cloning is prohibited by several states, but efforts to pass legislation on the federal level have not succeeded to date. Experiments in animal cloning continue, although critics claim that it results in unhealthy animals and needless suffering. There are serious concerns about safety and health if cloned animals were introduced into the food supply chain.

Refusing or Withholding Treatment and Physician-Assisted Suicide

The right to refuse treatment is well established for adults. The 1990 Patient Self-Determination Act establishes the duty of hospitals, nursing homes, and health maintenance organizations (HMOs) to inform patients or new subscribers of their right to express their wishes related to health care and to refuse treatment. The act also establishes the right of an individual to prepare an advance directive that specifies what treatments he or she would like to receive, and what ones he or she would not wish to receive, if the individual were to become incapable of making those decisions at a later time. Courts have held an individual’s right to refuse treatment in such high regard that they have allowed mentally ill patients to refuse treatments for their mental illness.

When an individual requires resuscitation or life support to stay alive, there may come a point where it seems that the treatment is resulting in more suffering (harm) than benefit. This is especially true if it is unlikely that the person can recover his or her health or normal function. If there is a written document expressing the person’s wishes, life support may be removed or discontinued. In the absence of an advance directive, an individual’s family may bring to court a petition to remove life support. Such a petition must be supported by witnesses other than those who file the petition, stating that the incompetent individual expressed a desire to avoid being kept alive by artificial means. Life support has been interpreted to include ventilators, antibiotics, and even tube feedings.

Physician-assisted suicide and euthanasia (literally, “good death”), sometimes called mercy killing, evoke fears that the power to take life will be abused—that it will be used more for the convenience of others than for the well-being of those who are dying. Advocates for the disabled have argued that allowing physician-assisted suicide or euthanasia could be the first step in society’s determining that the severely disabled are too much of a financial and physical burden and having them euthanized.

Throughout the 1990s, an individual physician named Jack Kevorkian provided patients with degenerative, terminal illness a machine that provided an injection of lethal drugs. He was sentenced to 10 to 25 years in prison in 1999 and was released after 8 years in 2007 after he promised not to assist in any additional deaths.

In 1997, Oregon became the first state to legalize physician-assisted suicide, allowing physicians to write a prescription for a patient of a lethal dose of pain killer or other medication. The physician is not allowed to administer the medication. The U.S. Supreme Court upheld a challenge to the Oregon law in 2006. The discussion about physician-assisted suicide occurs in every state, but to date similar legislation has failed to pass in any other state.

Terminally ill patients and their families are often looking for a trusted advisor with whom they can discuss their fears and concerns. Even when a physician is not morally willing or legally able to provide a means for a patient to end his or her life, there is increasing recognition of the value of frank discussion and reassurance that patients will not be left to cope alone.

Advance Directives

On the basis of personal beliefs, patients can formalize their decisions about treatment in terminal or end-of-life situations in a number of ways. These include do-not-resuscitate (DNR) orders, living wills, health care proxies, and organ donor cards, all of which fall under the heading of “advance directives” (Box 3-1). An advance directive may specify care to be given or avoided and name a person to make medical decisions for the individual should he or she become incompetent. This is usually a spouse, child older than age 18, member of the clergy, or close friend. Medical advance directives should always name a single individual to make decisions, with an alternate if possible. This is often a difficult choice, especially for an elderly person with several children (Figure 3-1). In addition, the patient may want to provide for donation of any organs that are useful. Organ donation (or donation of one’s entire body) and procedures for determining who may give permission if the patient has not left a directive are outlined in the Uniform Anatomical Gift Act.

Signed originals rather than photocopies of the advance directives should be held by the named surrogate, and the patient should keep copies with his or her important papers. It should also be noted in the primary care physician’s records with a copy if possible so that the surrogate can be contacted if necessary.

DNR orders should be in the medical record, and the staff should be informed of the patient’s wishes. If the patient is at home, the family must have a copy of the DNR order to show emergency personnel, who otherwise will be legally obligated to resuscitate the patient.

Removal of life support means that no form of support, including mechanical breathing, feeding, or medications to prolong life, should be given. Pain medication and sedation are continued if necessary after removal of life support.

A living will is a document executed by an individual that gives medical professionals instructions about how that person wishes to be treated in the event he or she becomes incompetent. A living will may also give instructions regarding organ donation, autopsy, or donation of the remains to a medical school for anatomy dissection. Many states allow an individual’s wishes to donate organs to be noted on his or her driver’s license or on an organ donor card that can be carried in the wallet. In the event of a fatal auto accident, the police—who usually use the license or other documents to make identification—can notify ambulance personnel that the deceased is an organ donor.

A person usually names an agent to carry out his or her wishes if he or she is unable to do so. A health care proxy names the person who is charged with this responsibility and may also give specific instructions to the designated person concerning medical issues. Laws regulating living wills and health care proxies vary from state to state, and it is important for patients to use forms that will be valid where they live. This may require the assistance of an attorney.

Gathering Information

Information that needs to be gathered includes (1) background about the situation; (2) facts related to the specific problem; (3) information about the people involved, such as their knowledge of the situation or their mental capacity; and (4) the laws or institutional policies that relate to the situation.

Identifying Conflicting Values

A conflict does not always involve lofty values. It may be as simple as one person’s wish to not cause problems, to save time, or to avoid a hassle. However, this desire may conflict with professional duties or with another individual’s right.

If a medical assistant is working in a facility where individual staff members do not always follow established procedures (e.g., do not always run controls for laboratory tests), the desire to go along with co-workers and avoid conflict may be strong; however, the duty to act with fidelity is not being met. The medical assistant may be personally performing the needed controls, but the knowledge that others are not doing so creates a conflict between personal reluctance to violate the autonomy of a co-worker and the professional duty of fidelity to patients.

Determining Relative Importance of Conflicting Claims

To determine the relative importance of conflicting claims, an individual needs to clarify his or her goals and weigh the conflicting values. It is important to remember that when values conflict, an individual or group makes a decision about importance that is valid within its own context but may not conform to the values of other individuals or groups.

For example, in the case of abortion, some people believe that the right of a fetus to life outweighs all other rights. Others believe that a woman’s right to autonomy in medical decisions about her body, and the consequences to a child of being unwanted, diminish or outweigh the absolute right to life in the early stages of a pregnancy.