- Email: [email protected]
My turn and my right
Correspondence
when appropriate, treatment to allow a peaceful, dignified death. The bioethical issue here is a dearth of accessible appropriate health care rather than a surfeit of patient autonomy. I played a part in the development of General Comment 14 of the International Covenant on Economic, Social and Cultural Rights.
Peter Hall [email protected] Doctors for Human Rights, Abbots Langley WD5 0BE, UK 1 2 3
For JLAPUP see http://www. jlapressureulcerpartnership. co.uk/
1992
Caplan AL. Not my turn. Lancet 2012; 380: 968–69. Sokol DK. Is bioethics a bully? BMJ 2012; 345: e5802. United Nations. General comment no. 14. New York: UN, 2000. http://www.unhchr.ch/ tbs/doc.nsf/(symbol)/E.C.12.2000.4.En (accessed Sept 16, 2012).
Although a patient’s right to autonomy might be justifiably limited in rare circumstances, Arthur Caplan’s case fails to support this claim.1 First, forcing Mr Brennan to accept turning violates more than his autonomy: it also violates the principle of nonmaleficence by inducing pain.2 Although autonomy rights might be reasonably limited when a patient’s demands would harm other patients (eg, in matters of public health), we are given no information to suggest that this was the concern here. Autonomy might also be reasonably limited to avoid harm to professional integrity,3 but I am not persuaded that Mr Brennan’s physicians and nurses were worried about this. Neither discomfort with a patient’s choice nor fear of regulatory oversight justifies over-riding a patient’s wishes. A more ethical stance would have been to provide maximum support (emotional and otherwise) to the clinicians challenged with caring for this patient whose needs were extreme. We should avoid viewing cases like Mr Brennan’s as a dispute demanding winners and losers: mediation and clinical creativity might have uncovered an approach acceptable to all involved. For example, why couldn’t Mr Brennan’s pain be better managed
by giving extra doses of narcotics before turning? Considering alternative options might have identified a treatment plan that would have supported his autonomy while comforting both him and the caregivers responsible for his wellbeing. I declare that I have no conflicts of interest.
Mark D Siegel [email protected] Department of Internal Medicine, Pulmonary and Critical Care Section, Yale University School of Medicine, P O Box 208057, New Haven, CT 06520, USA 1 2
3
Caplan AL. Not my turn. Lancet 2012; 380: 968–69. Beauchamp TL, Childress JF. Principles of biomedical ethics, 6th edn. New York: Oxford University Press, 2009. Lantos J, Matlock AM, Wendler D. Clinician integrity and limits to patient autonomy. JAMA 2011; 305: 495–99.
Arthur Caplan1 is obviously correct that the value of autonomy has its limits and, more specifically, that if “a patient who refuses to be turned [thereby] imperils the safety or wellbeing of other patients then his autonomy ought to be limited accordingly”. However, Prof Caplan does not make a convincing case that the particular patient he describes should have been turned or that he should have been discharged as a result of his refusal. This patient was isolated to spare other patients the stench of his rotting flesh. His not being turned did not endanger others. The nursing staff felt frustrated in not being able to provide basic care, but this does not constitute good grounds for over-riding a patient’s autonomous decision to refuse life-extending basic care that, in his competent judgment, is not in his interests. A turn is a good one if it advances the patient’s interests, not if it makes nurses feel better. We are told that the patient refused to be turned because the turning was too painful and because he “intensely disliked being so dependent”. If the patient’s aim was to hasten his death while minimising his suffering and dependency, then he could have refused hydration and requested
sedation (with or without turning). He would then have died much more quickly and less grotesquely. His wishes would have been respected at less cost to him and to his medical carers. I declare that I have no conflicts of interest.
David Benatar [email protected] Philosophy Department and Bioethics Centre, University of Cape Town, 7700 Cape Town, South Africa 1
Caplan AL. Not my turn. Lancet 2012; 380: 968–69.
Arthur Caplan1 raises the ethical dilemma of a bed-bound patient with pressure ulcers who requests that no one turn him over in his hospital bed. As the findings of the UK James Lind Alliance Pressure Ulcer Priority Setting Partnership (JLAPUP) confirm, the opening premise that this “simplest, mundane case” is in contrast to “complicated medical decisions that are riddled with doubt and uncertainty” is false. Pressure-ulcer prevention and treatment are areas of profound doubt and uncertainty. Pressure-relieving mattresses and wound dressings are classified as devices rather than medicinal products. The European regulatory focus is on safety assessment, viability, and competitiveness of devices rather than population effectiveness. This leaves clinical uncertainty about outcomes in clinical practice.2 Wound care remains something of an evidence wilderness, with systematic reviews of evidence revealing a predominance of small, underpowered, and methodologically flawed trials.3,4 It is a sector in which practice is reliant on custom, opinion, and marketing, and where systematic reviews are being portrayed as a means of rationing access and reducing choice.5 The ethics of patients’ involvement in treatment decisions includes involving patients in discussions of treatment uncertainty. Between January and May, 2012, JLAPUP asked patients, carers, and clinicians on what they would like to see further research or where www.thelancet.com Vol 380 December 8, 2012
when appropriate, treatment to allow a peaceful, dignified death. The bioethical issue here is a dearth of accessible appropriate health care rather than a surfeit of patient autonomy. I played a part in the development of General Comment 14 of the International Covenant on Economic, Social and Cultural Rights.
Peter Hall [email protected] Doctors for Human Rights, Abbots Langley WD5 0BE, UK 1 2 3
For JLAPUP see http://www. jlapressureulcerpartnership. co.uk/
1992
Caplan AL. Not my turn. Lancet 2012; 380: 968–69. Sokol DK. Is bioethics a bully? BMJ 2012; 345: e5802. United Nations. General comment no. 14. New York: UN, 2000. http://www.unhchr.ch/ tbs/doc.nsf/(symbol)/E.C.12.2000.4.En (accessed Sept 16, 2012).
Although a patient’s right to autonomy might be justifiably limited in rare circumstances, Arthur Caplan’s case fails to support this claim.1 First, forcing Mr Brennan to accept turning violates more than his autonomy: it also violates the principle of nonmaleficence by inducing pain.2 Although autonomy rights might be reasonably limited when a patient’s demands would harm other patients (eg, in matters of public health), we are given no information to suggest that this was the concern here. Autonomy might also be reasonably limited to avoid harm to professional integrity,3 but I am not persuaded that Mr Brennan’s physicians and nurses were worried about this. Neither discomfort with a patient’s choice nor fear of regulatory oversight justifies over-riding a patient’s wishes. A more ethical stance would have been to provide maximum support (emotional and otherwise) to the clinicians challenged with caring for this patient whose needs were extreme. We should avoid viewing cases like Mr Brennan’s as a dispute demanding winners and losers: mediation and clinical creativity might have uncovered an approach acceptable to all involved. For example, why couldn’t Mr Brennan’s pain be better managed
by giving extra doses of narcotics before turning? Considering alternative options might have identified a treatment plan that would have supported his autonomy while comforting both him and the caregivers responsible for his wellbeing. I declare that I have no conflicts of interest.
Mark D Siegel [email protected] Department of Internal Medicine, Pulmonary and Critical Care Section, Yale University School of Medicine, P O Box 208057, New Haven, CT 06520, USA 1 2
3
Caplan AL. Not my turn. Lancet 2012; 380: 968–69. Beauchamp TL, Childress JF. Principles of biomedical ethics, 6th edn. New York: Oxford University Press, 2009. Lantos J, Matlock AM, Wendler D. Clinician integrity and limits to patient autonomy. JAMA 2011; 305: 495–99.
Arthur Caplan1 is obviously correct that the value of autonomy has its limits and, more specifically, that if “a patient who refuses to be turned [thereby] imperils the safety or wellbeing of other patients then his autonomy ought to be limited accordingly”. However, Prof Caplan does not make a convincing case that the particular patient he describes should have been turned or that he should have been discharged as a result of his refusal. This patient was isolated to spare other patients the stench of his rotting flesh. His not being turned did not endanger others. The nursing staff felt frustrated in not being able to provide basic care, but this does not constitute good grounds for over-riding a patient’s autonomous decision to refuse life-extending basic care that, in his competent judgment, is not in his interests. A turn is a good one if it advances the patient’s interests, not if it makes nurses feel better. We are told that the patient refused to be turned because the turning was too painful and because he “intensely disliked being so dependent”. If the patient’s aim was to hasten his death while minimising his suffering and dependency, then he could have refused hydration and requested
sedation (with or without turning). He would then have died much more quickly and less grotesquely. His wishes would have been respected at less cost to him and to his medical carers. I declare that I have no conflicts of interest.
David Benatar [email protected] Philosophy Department and Bioethics Centre, University of Cape Town, 7700 Cape Town, South Africa 1
Caplan AL. Not my turn. Lancet 2012; 380: 968–69.
Arthur Caplan1 raises the ethical dilemma of a bed-bound patient with pressure ulcers who requests that no one turn him over in his hospital bed. As the findings of the UK James Lind Alliance Pressure Ulcer Priority Setting Partnership (JLAPUP) confirm, the opening premise that this “simplest, mundane case” is in contrast to “complicated medical decisions that are riddled with doubt and uncertainty” is false. Pressure-ulcer prevention and treatment are areas of profound doubt and uncertainty. Pressure-relieving mattresses and wound dressings are classified as devices rather than medicinal products. The European regulatory focus is on safety assessment, viability, and competitiveness of devices rather than population effectiveness. This leaves clinical uncertainty about outcomes in clinical practice.2 Wound care remains something of an evidence wilderness, with systematic reviews of evidence revealing a predominance of small, underpowered, and methodologically flawed trials.3,4 It is a sector in which practice is reliant on custom, opinion, and marketing, and where systematic reviews are being portrayed as a means of rationing access and reducing choice.5 The ethics of patients’ involvement in treatment decisions includes involving patients in discussions of treatment uncertainty. Between January and May, 2012, JLAPUP asked patients, carers, and clinicians on what they would like to see further research or where www.thelancet.com Vol 380 December 8, 2012