Packiaraj Asirvatham MA Bangladesh Journal of Bioethics 2012; 3(2):27-30 27 YOUR CONSENT AND MY DECISION – A CASE STUDY Packiaraj Asirvatham An independent researcher India. Email: Packiaraj.a@gmail.com CASE: Raju was a 30 year old male from Tirunelveli, India. He was running a small business enterprise in his town. He married Latha in May 1990. They lead a happy and peaceful life. In December 1990 he had a mild stroke. Immediately he was taken to the hospital and his family doctor suggested further investigation. So Raju underwent a scan and the primary result was not good. He was diagnosed with a tumour in his brain. A grade 2 Glioma developed in his brain and started to spread. After CT scan, he was asked to go for an MRI scan to exactly locate the tumour and its spread and the doctor found out that the tumour has spread a bit to the nearby part, that is, cerebrum to cerebellum. Since it is type two tumour he decided to remove the tumour by surgery. However, its not going to be easy. The Doctor invited the siblings and parents of Raju to decide on the treatment. He presented the treatment options to the family members. First option is to remove the tumour completely but the possibility of brain damage during surgery is 90% which may lead him to coma/paralysis/handicap. The second option is to remove 90% of the tumour and proceed with radiation therapy. In this way though he is not going to remove 100% of the tumour he will have a safer surgery and after the surgery a normal life span of 10 more years without any problems at least. In this context, the doctor asked the parents about their opinion and they opted for the second option of partial cure and safer surgery. After hearing their opinion the doctor proceeded with first option. Personally he took this case as a challenge and performed the surgery. The result was surprisingly positive, Raju was cured completely. with the successful outcome, the doctor proclaimed himself as a “miracle surgeon” and the family too are happy. CASE ANALYSIS Problem: I have analysed this case by using the Nijmegen method of case deliberation systematically. As a starting point, the moral problem can be stated by the following question. Is the act of doctor ethically justifiable in pursuing his own line of option in curing the patient? Facts: Raju is diagnosed with cancer, a life threatening disease. Though the diagnosis came as a shocking news for Raju and his family, they are optimistic in saving Raju's life since it’s an early stage of cancer. After regular scan the tumour is located and the surgeon observed and decided about the possibility of the treatment. There are two possible ways of treatments: first is to remove mailto:Packiaraj.a@gmail.com Bangladesh Journal of Bioethics 2012; 3(2):27-30 28 the tumour completely with the possibility of brain damage during surgery being 90% and this may lead to coma/paralysis/handicap. Second option is removing 90% of the tumour and proceeding with radiation. In this way though the surgeon is not going to remove 100% of the tumour Raju will have a safer surgery and after the surgery a normal life span of 10 more years without any problems at least. So the first option has 90% risk and 10% complete cure whereas the second option has less risk as well as moderate cure which will give at least 10 more years of life span to Raju. So it is very important to decide whether the doctor and the patient are going to take risk or play safe. Raju and his family members are so concerned about the welfare of Raju where doctor is so concerned about his duty of curing Raju to a maximum. However, since Raju is relatively young, recently married and the breadwinner of his family the whole issue of his surgery has multiple consequences. So Raju's came back with the first option where there is less risk as well as less harm to during surgery. The doctor is an experienced surgeon; he knows the social background of Raju and his family as well as the condition of Raju's disease. However, he goes with the second option where the risk is more as well as the cure is more. In the Indian context, paternalistic approach of doctor is inevitable. Basically doctors discuss with the family and the patients, however, predominantly they decide. In this case, though Raju and his family opted for the safer option the doctor went on with second option which is completely against the wish of the patient. The whole medical system is led by doctors where his healthcare team members and nurses have no say. The Doctor clearly understands the case of Raju and realises the needs of family but he took a calculated risk to save Raju’s life, but at what cost? ASSESSMENT: Raju is a young person and recently married who is at the peak of his life but cancer shatters the hope of Raju. Here, the doctor is the great hope of Raju and his expertise is remarkable. The complicated location of the tumour places a vital role and it increases the risk of surgery. If Raju develops any handicap/coma because of surgery then that is an ultimate loss to his family as well as for him. In the meantime, the doctor approaches the case in a more optimistic manner and he realised the risks as well. In this context, who decides what is good and what is not good for patient? The doctor or the family (Raju)? The Doctor knows the condition of the patient and the informed choices to his family however; he takes his own decision to save Raju's life. He is an expert in surgery however the perception of Raju's family and the doctor is differed consequently the doctor decided against the interest of the patient; however he is with good motive. The autonomy of the patient is violated though he was informed about the various choices but his consent was not been executed. Another argument is that the instrumentalisation of the patient. Doctor would have liked to develop himself and his knowledge on surgery by doing more risky surgery where it is inevitable. Meantime, he could have thought of saving Raju's life perfectly since he is full of life. But the family of Raju is worrying much about the consequences. For them the Bangladesh Journal of Bioethics 2012; 3(2):27-30 29 safety of Raju is more important than cure whereas for doctor cure is more important with safety. On the other hand, if anything goes wrong with surgery the doctor is not going to be held responsible as well as he is not going to suffer like Raju and his family. Although, the whole issue is centred around Raju, however he does not have any authority over the doctor as well as his family. When a person is affected by a disease he automatically loses his social authority to his family members/caretakers consequently his autonomy is a threat. Though the autonomy of the person is more important it is hard to prove that a patient is really exercising his autonomy when he is making crucial decisions at the hospital context in India. In addition the patient - doctor relationship is very hierarchical in India where absolutely the doctor decides what he thinks is right for a patient along with patient and his family members some extent. This is because medical fraternity predominantly think that many of the lay people lack medical knowledge and on the other hand people also think that the doctor is more wise and knowledgeable so they can make better decision than patient. DECISION MAKING: This incident took place in 1990. The doctor treated Raju with his own decision and took a calculated risk and remarkably the surgery went well. Now Raju is surviving with two children and his wife without any problem. He is completely cured. His family has deep gratitude towards the doctor. In this context, can we justify the act of the doctor? At least he could have described his decision to the family of Raju and would have undertaken the surgery. The conflict of interest between patient and doctor is always at crossroads. There is no consensus all the time. However, people believe more in doctor’s decision than their own. They strongly believe that doctors decision would be alright in medical context and they strongly believe that no doctor will do harm to their patient. Obviously, the question of who decides is at stake? Is it the patient, the family of the patient or the doctor? Here it is the doctor who decides. The paternalistic approach of doctors is very much part of Indian health care system which often surpasses the autonomy of the patient. In the meantime with regard to beneficence and non-maleficence the doctor is abiding with ethical fibre. Because of the doctors treatment the patient is cured and the family also benefited by the service of the doctor and he did not harm the patient though he put the patient under risk. In addition, since it’s a private hospital he provided a maximum best service for what he is paid. On the whole he abode with the ethical practice on ground however, it is very hard to understand why he acted against the interest of the patient and his family? He could have understood that the family is very much worried about the possibility of bad consequences and analysed the possibility of complete cure and the maximum risk. Ultimately, the real wish of the patient is cure. To be more specific, with regard to the surgery the patient wished a safer surgery. It is a normal precautionary step . The doctor would have focused much about the ultimate wish of cure then subsidiary wish of safer surgery. Again the responsibility of the doctor always pushes him to proactively engage in medical practice. It is Bangladesh Journal of Bioethics 2012; 3(2):27-30 30 always very evident that many a times doctors proactively save life of a patient where the patient himself/herself has different opinion (For example a failed attempted suicide persons wish is to die but once he is taken to hospital and consequently his/her life is saved, which is completely against the interest of the patient.) To conclude, the doctor’s act of saving the Raju's life from cancer is respectable and also he followed the necessary procedures of informed consent however, he treated the patient in his own way and saved his life. Can autonomy be violated if it is beneficent to the patient? When we weigh the case in the light of all four parameters of autonomy, beneficence, non-maleficence and justice We can argued that the Doctor respected all other norms, however, he is proactively decided to take calculated risk which led to a complete cure. However since the patient is autonomous his consent matters a lot however his ultimate wish is cure. Since he is cured completely it can be ethically justifiable because the doctor followed another three important parameters of beneficence, non-maleficence and justice along with autonomy of the patient. The Doctor might have focused more on the real wish of the patient, that is, to be cured at any cost! So on the whole contexts and consequences ultimately decide than autonomy of a person or the authority of a doctor in Indian medical contexts though everything is interlinked!