Consider two cases where a patient ended up with an implanted device D that benefits the patient by ameliorating an otherwise fatal medical condition.
Alice got in a fight with Carl the hospital janitor. The janitor grabbed the first weapon at hand—an injector for device D—and stabbed Alice with it, thereby ensuring that Alice now has D implanted in her.
Alice’s twin sister Brenda got D duly implanted by Carl’s sister Dr. Diana, a physician at the hospital.
Now suppose that Alice and Brenda both demand a physician to remove D.
It seems that Alice’s demand is completely on par with the demand to remove a bullet or a kidney stone. But normally a physician needs to make a judgment that a procedure requested by a patient is likely to on-balance benefit the patient, and ought to refuse otherwise. If a physician is asked to remove a bullet or a kidney stone, but professionally judges that the patient will die without the bullet or kidney stone, they must refuse the request. It thus appears that the physician ought to refuse to remove D from Alice, unless there are significant burdens from D to Alice (maybe D is not a burden at all, but Alice just wants to die).
But in the case of Brenda, removing D is not just “a procedure”, but it constitutes the withdrawing of a medical treatment. On a standard view, just as one must withhold a medical treatment when a patient competently demands withholding it, even if the treatment would save the patient’s life, a demand for withdrawing is exactly on par, and hence must be honored, even if D does not impose any significant burden on Brenda.
Suppose the standard view is right. Then the above shows you can have two patients who are in exactly the same physical state, and are making exactly the same demand, but the demands are treated differently by standard medical ethics. The reason they are being treated differently is that in Alice’s case, D’s presence does not constitute a medical treatment because D was injected by the janitor in the course of a fight, while in Brenda’s case, D;’s presence does constitute a medical treatment because D was duly injected by a physician.
I find this troubling. It seems to be taking medicine as something magical, as if the status of D inside Alice’s and Bob’s became different when D came to be present “medically”.
Maybe one way to avoid the “magical” thinking is to think that consensual medical implantations come with an explicit or implicit agreement between the patient and the provider (the medical professional or maybe the medical institution) to withdraw the item should one so demand it? Then the magic is not due to medicine but due to promising. (I don’t think this completely resolves the questions, because not all promises need to be kept.)
4 comments:
There is an entire literature on this issue, much of it driven by orthopedic implant related concerns (as you mention in your following blog entry). Notably, the fact that it takes a surgical procedure to cease a treatment influences the ethics. Quoting from one such article:
“From the viewpoint of patient autonomy, a patient with decisional capacity should be able to decline or discontinue a treatment. If only this principle is taken into consideration, then it can be argued that a patient always has the right to have an implant removed, whatever the consequences. However, according to the principle of non-maleficence, physicians should not perform harmful interventions on patients. If a patient asks for a medically harmful explantation, then the two principles will clash. The conflict is exacerbated by the fact that the explantation of an implant is both an intervention (as is all surgery) and the discontinuation of an intervention. Qua intervention it is disallowed since it harms the patient, but qua discontinuation it is required since the patient has a right to end her treatment. “
Hannsson So, “The ethics of explantation.” BMC Med Ethics. 2021 Sep 8;22:121. doi: 10.1186/s12910-021-00690-8
Great to know!
Notice that in my example the surgery could be pretty minor--the injection of epoxy into the artificial joint. One could probably imagine a setup (perhaps with a poorly made joint) where the doctor could make the artificial joint seize up permanently by applying external pressure, or by twisting the limb in a certain way, etc. But I suppose it's still an intervention on the patient, even if very minor. We can also have science fictional cases where you can just beam the epoxy in. Or perhaps the artificial joint is not completely internal to the patient--there is an outside portion, and you could drill through the outside portion, insert a needle, and inject epoxy, all without making any contact with the patient.
I also worry that the distinction between cases where an "intervention" is needed to disable a device and cases where no "intervention" is needed can be too minor to be morally relevant. Consider two cases where a patient has an implanted device. In one case, you shut it down by entering a code in a wireless remote control. In the other case, the device is just under the skin and has pressure sensors, and you gently tap the patient's skin in a specific sequence to turn off the device. In the first case, you aren't affecting the body except by shutting down the device. In the second case, you are affecting the body by gently compressing the patient's skin. I don't want to say that there is NO moral difference between the two cases, but it feels like it's very little difference.
Those procedures requiring written informed consent (like surgically cutting through skin, or high side effect chemotherapy) are generally considered more significant interventions than those that do not. If neither the remote use nor the tapping require written informed consent (another question in itself) they might be pretty equivalent.
I am not a lawyer of course, but I thought that deliberately touching a fellow human being against their will is a kind of assault, with exceptions for emergencies, etc.
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