|ETHICS IN MEDICINE University of Washington School of Medicine
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Sample Case AnalysisCase:
John, a 32 year-old lawyer, had worried for several years about developing Huntington's chorea, a neurological disorder that appears in a person's 30s or 40s, bringing rapid uncontrollable twitching and contractions and progressive, irreversible dementia. It leads to death in about 10 years.
John's mother died from this disease. Huntington's is autosomal dominant and afflicts 50% of an affected parent's offspring. John had indicated to many people that he would prefer to die rather than to live and die as his mother had. He was anxious, drank heavily, and had intermittent depression, for which he saw a psychiatrist. Nevertheless, he was a productive lawyer.
John first noticed facial twitching 3 months ago, and 2 neurologists independently confirmed a diagnosis of Huntington's. He explained his situation to his psychiatrist and requested help committing suicide. When the psychiatrist refused, John reassured him that he did not plan to attempt suicide any time soon. But when he went home, he ingested all his antidepressant medicine after pinning a note to his shirt to explain his actions and to refuse any medical assistance that might be offered. His wife, who did not yet know about his diagnosis, found him unconscious and rushed him to the emergency room without removing the note.
What should the care team at the emergency room do?
This is a case of treatment refusal of potentially life-sustaining treatment when the competency of the patient to decide is questionable. Also at issue is the distinction between the acute and chronic conditions of the patient.
The precedent for cases such as this one is fairly clear. When the patient's preferences are unclear, and the acute condition is easily treatable, and the harm of not treating is very great, medical teams can feel comfortable about providing the treatment for the immediate life-threatening condition, creating an opportunity to talk with the patient about his preferences regarding his chronic condition at a later time.
Notice that the facts of this particular case determine if the precedent case is applicable. If the medical team was very familiar with this patient's expressed preference to refuse any medical treatment or if the available treatment for the acute condition was considerably less certain to be effective, the case could be decided differently. The clinicians would look for a different precedent or consider whether it made a significant difference to be very clear about the patient's beliefs and certain about his competency to decide to refuse.
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