Medical Ethics

Hi, Craven...

Interesting question. The answers were easy to come by for me.

#2 obviously was born in the wrong body, and if given the sex change operation he would most likely be much happier, wouldn't keep trying to take his own life, and would probably live to a ripe old age.

#3 has a lot to live for, and the operation's success rate is excellent.

#6 would be worth it to take the chance with the transplant operation to give this child a chance at living. It has its whole future ahead of it.


I feel sorry for the others, but even with the operations their expected outcomes are bleak, except for the 5 patients in #4. But, as horrible as their situation is, it is not life threatening, and the possibility of having cataract surgeries in the future is a real possibility.

OK - now there is an American state (sadly I don't remember which - could it be Vermont?) which has postulated likely number of years of good quality life resulting from expensive medical procedures as a way of making decisions in the face of scarce resourcing of tertiary health care.

I think this is a not unreasonable basis for ethical decision making - but I guess I would also be wanting to factor in possible benefits to others (as in ground-breaking surgeries that MIGHT lead to massive future benefits.)

Ok
in: cataract people
sex change man
sole provider man


Next, in my view, would be the overweight man with a five year useful transplant expectation and the baby - possibly with the baby first because of the research value of the procedure as well as the desire for a baby to have a chance at life.

The old lady and the smokers would be last to be considered - because of the very low chance of a quality outcome.

Clearly, the cases raise the opportunity for a decision based on some scale of "goodness" or deservingness - partly around age, partly around risky behaviour, partly around "main-streamness" - but, if one views risk behaviour/"naughty behaviour" as a determinant, one is then getting into a whole ethical dilemma which is likely to soon include genetics, judgement about normal behaviours like adolescent-risk-taking and suchlike - as well as a whole new Puritanism based around so-called scientific dogma about health (which changes constantly - I have often said that chocolate is the new adultery!)

I am tired and have likely babbled - but I hope I have been somewhat clear.

1) This man needs a heart transplant, he is very overweight. A heart transplant would give a further life expectancy of about five years. YES, because the survival time is better than that for the other ones I didn't choose (had a hard time deciding between this and #5) plus the chance of death without the procedure is very high.

2) This man needs a sex change. He has been waiting for five years for the operation and has attempted suicide on three occasions. Sex change operations are known to have an extremely high success rate, far higher than for any other surgical procedure. YES. This is a good candidate because the success rate is high and the outcome for not doing this is possible death.

3) This father is the sole income provider for a wife and five children. He needs a coronary bypass, which stands a 90% chance of being completely successful. YES but not based on his income needs. Hospitals are supposed to be need-blind. The decision was made solely on success rate, and the high potential for death without the procedure.

4) These 5 patients all need cataract operations. All have been waiting for over a year and all are unlikely to be able to do their current jobs if their eye problems are not resolved. Sorry, but no. Their job situation is immaterial. You have to triage.

5) These 2 60-cigarette-a-day smokers need operations to have malignant tumors removed. Their life expectancy is thought to be no more than 6 months. Sorry, but no. Not a high chance of survival there. You have to triage. It was a hard call, to decide between this one and #1.

6) This 2-month-old baby needs a heart and lung transplant. The surgery needed is so new that no-one knows the chances of the baby's survival. Sorry, but no. Not a high chance of survival there. You have to triage. Experimental surgery is all well and good (heck, it's necessary), but there's no time or resources for the luxury of experimentation.

7) This 80-year-old lady has just had a very serious car crash and is now in a coma in the emergency ward. Sorry, but no. Not a high chance of survival there. You have to triage.

Sex change: yes, his medical problem has arisen through no fault of his own and has a good chance of success

Coronary Bypass: yes, 90% success rate, his children deserve a healthy father

Baby: though the chances of success are unknown, one very imprtant vehicle of medical science progress is high-risk cutting edge surgery.

7) This 80-year-old lady.. She's still in the emergency ward? Seems a bit early to give up and push her off.

5) These 2 60-cigarette-a-day smokers.. Maybe I'm reading this wrong but if their life expectancy is 6 months that's a known. You didn't list how long the others have.

3) This father is the sole income provider.. I chose this just because it seems that coronary bypass is somthing that is always a rush thing. It doesn't seem to be something you can put off.

For me the most confusing thing here is the lack of info for HOW SOON things need to be done. With #1 - he needs a heart transplant. How long before his current heart gives out? Could be a day.. could be a decade.. It just seems like knowing that would be a critical factor in deciding priorities. Perhaps that was left undisclosed for a reason??

1) This man needs a heart transplant, he is very overweight. A heart transplant would give a further life expectancy of about five years.
TREAT

2) This man needs a sex change. He has been waiting for five years for the operation and has attempted suicide on three occasions. Sex change operations are known to have an extremely high success rate, far higher than for any other surgical procedure.
WAIT

3) This father is the sole income provider for a wife and five children. He needs a coronary bypass, which stands a 90% chance of being completely successful.
TREAT

4) These 5 patients all need cataract operations. All have been waiting for over a year and all are unlikely to be able to do their current jobs if their eye problems are not resolved.
WAIT

5) These 2 60-cigarette-a-day smokers need operations to have malignant tumors removed. Their life expectancy is thought to be no more than 6 months.
WAIT

6) This 2-month-old baby needs a heart and lung transplant. The surgery needed is so new that no-one knows the chances of the baby's survival.
TREAT

7) This 80-year-old lady has just had a very serious car crash and is now in a coma in the emergency ward.
TREAT

I picked four to treat because I couldn't pick less. Each of the four above, I assume, are in immediate life and death situations that cannot wait 24 hours. I am not concerned with the ages, backgrounds, genders or family connections of any of these people. I am not concerned with the reasons behind any of their illnesses although I am less likely to treat someone who needs a tumor removed and has six months to live than an 80 year old lady who is in immediate danger. Contrary to those views ahead of mine, I am not of the opinion that the sex change operation should be given priority ahead of any others that I consider 'more urgent'. I think that although the operation itself may be what the person is looking for that a more helpful treatment would be psychological help and therefore the immediate treatments must go to those who are physically more ill than he.

Of course a lot more info would change my mind on these.

I have no guarantee that the suicidal sex change would stop being suicidal after the operation-- maybe the suicidal thoughts stem from something beyond his desire for gender change. He has to wait in my triage.

The cataract operations are important, but not life-threatening. They can wait.

The smokers have six months, they can wait.

No data on whether #1, #3, #6, and #7 are going to die in the near term without help. My assumption is that if #3's chance of survival is excellent, he is probably in the best shape of the four.

I would treat them in the order of immediate threat-to-life, REGARDLESS of expectation of longevity or their contribution to society. Or the probability of operation success.

I would treat #7, #6 and #1, because they SEEM from the information given to be closest to death without help.

fishin'

The reason for little data on life expectancy is because that kind of data is usually guesswork.

Really? Don't doctors list how long a person is expected to live (roughly..) if they don't get a transplant when a person is put on the transplant lists? Wouldn't the progression rate of cataracts be something they could monitor and know that it took 2 years to progress to point X so it would take Y months more to get to point Z?

Or am I misunderstanding what you were saying?

Doctors give such timeframes but I always figured they wre not very accurate. Obviously a clear timeframe would make these decisions easy, if one patient is going to die tommorow but the other has 6 months by all means treat the fellow who's already saying his prayers.

But medicine isn't an exact science, the text was taken from a discussion book and I don't know enough about medicine to make the question medically sound, so I'm just looking to see what people's criteria are.

Am I right to assume yours is simply the urgency in relation to time/death?

I don't know that that would be the only factor but it would be a big one. The primary thrust of the question was "Who would you treat first?" so if I had the luxury of time I'd treat them all.

If I treat the guy that isn't going to be critical for 3 years and in the mean time the old lady dies I'd feel pretty badly. If I knew he had 3 years and she was going to go in 6 hours without surgery I'd expect to see him in surgery next week and I'd be scrubbing up to work on her.

So age and post-surgery quality of life are not high on your criteria?

What about numbers? There is a case with 5 patients but it isn't life threatening.

I'm with you on the time issues but remember you don't get to treat them all in the question. It's not an order but rather you treat some and the others will not be treated.

I'd not treat the baby for e.g. because the chances for survival are unknown, the procedure is untested and even if all goes well a heart and lung transplant at that age would mean a child who can't play sports and would not properly grow.

So if you did not have the chance to treat them all who would you choose? I know the data is limited but I reckon that absolute certainty in medicine isn't always available.

OK, in the original question it says "you can treat 3 but the rest will have to wait."

If you remove the option of me going back after waiting then things might change some and I'd look more at things like the quality of life afterwards.

With the original idea my thinking was that my 1st objective would be to keep them all alive. I could go back afterwards and do follow-up surgery to work on improving quality of life if needed. The numbers didn't mean much to me. I'm only one person so I'd only be able to operate on one of them at a time as it is.

If I'm not allowed to go back then I'd probably chose #2, 3 and 4. 3 and 4 have the least risk of dying (that I can control) and in the case of #2, the best known chance of long term survival.

I didn't remember that it said they have to wait. It would be a better text sans that bit.

Another moral dilemma issue, but I find these fascinating.
Another good one, Craven.
I would choose #1, #3 , and #7,
based on the information given.
#5 will die regardless of the surgery
#2 can still get psychiatric help or
hospitalization, if needed to avoid
suicide.
#4 without the cataract surgery,
they will be legally blind and
entitled to SS disability, so they
could wait
#6 the infant's chances of
survival are a complete unknown,
and the infant is not the financial
support for a family.