HPPA 514 Biomedical Ethics Ethical Argument: Autonomy v Nonmaleficence

Heba Fakir

6/24/22

I chose the journal article What Should Physicians and Chaplains Do When a Patient Believes God Wants Him to Suffer. The scenario presents a patient that requires surgery but refuses post-operative analgesics because “God wants me to be in pain.” The provider explains to the patient that being on analgesics will help him decrease his risk of getting post-operative pneumonia, as the post-operative pain can prevent patient from breathing properly from the pain. [1]

This is case of autonomy versus nonmaleficence principles. Autonomy is an ethical principle in medicine. It is based on the patient’s right to make their own choice in regards to their medical care; in autonomy the clinician advises the patient based on best practices and experience and the patient has the power of self-determination. The patient has the right to freely accept or reject the clinician’s recommendations. Patients have the ultimate responsibility in decision making, and clinicians would respect the patients preferences. Even so, it is important to note that in autonomy, clinicians are not required to adhere to inappropriate demands by the patient. Nonmaleficence is another ethical principle in medicine that refers to not harming patients. In medicine, this primarily means to prevent further injury or reduce risks of complications. [2]

In the scenario described, the patient choosing to forgo post-operative analgesics because of his religious beliefs is based on the ethical principle of autonomy. Whereas, the clinician’s concern on the risk of pneumonia if the patient refuses post-operative analgesics is based on the ethical principle of nonmaleficence. 

The purpose of medicine is to relieve suffering. However, we can still try to accommodate the patient’s beliefs and maintain the clinician’s professional boundaries. When deciding between 2 ethical principles, like autonomy v nonmaleficence, it is not necessary that 1 principle is prioritized in every situation. In this case, if withholding the analgesics decreases the success of the operation, undermines post-operative recovery, or endangers the patient’s health then I believe the physician should refuse the patient’s request. However, if withholding the analgesic does not upset the patient’s health then the physician should respect the patient’s autonomy even if they disagree with it. Also, if the provider’s main concern is post operative pneumonia then there are some actions that can be taken to prevent it like using prophylactic antibiotics or giving the pneumococcal vaccine prior to surgery. [3] [4]

There’s also the helpful role of the chaplain, that help in a situation like this. Chaplains are certified religious leaders that provide spiritual care in non-religious organizations like healthcare facilities, or, even in the military. Chaplains can understand and even open up the patient’s religious reasoning to different alternatives. They can discuss alternative understandings within the patient’s religious beliefs. Chaplains should not be inclined to the physician’s judgment, instead they should attend to the patient’s spiritual good. In addition, providers have another route which would be involving the patient’s family, friends, or community into the clinical discussion.

Overall, in ethical situations like this there is not one ethical principle that prevails over the other. The provider must be courteous and try to accommodate that patient’s choice to respect their autonomy. The provider must exhibit patience to understand and explore the patient’s reasoning regarding their refusal for treatment. At the same time, the provider cannot take on requests that contradicts the provider’s professionalism.

References:

[1] AMA Journal of Ethics, 2018. What Should Physicians and Chaplains Do When a Patient Believes God Wants Him to Suffer?. 20(7), pp.613-620.

[2] Jonsen, Winslade, W. J., & Siegler, M. (2015). Clinical ethics : a practical approach to ethical decisions in clinical medicine / Albert R. Jonsen, Mark Siegler, William J. Winslade. (8th ed.). McGraw Hill.

[3] Garly, M. L., Balé, C., Martins, C. L., Whittle, H. C., Nielsen, J., Lisse, I. M., & Aaby, P. (2006). Prophylactic antibiotics to prevent pneumonia and other complications after measles: community based randomised double blind placebo controlled trial in Guinea-Bissau. BMJ (Clinical research ed.), 333(7581), 1245. https://doi.org/10.1136/bmj.38989.684178.AE

[4] Uptodate.com. 2022. UpToDate. [online] Available at: <https://www.uptodate.com/contents/pneumococcal-vaccination-in-adults> [Accessed 19 June 2022].