- Masashi Shirahama M.D.
Mitsuse Health Insurance Clinic, 2615 Mitsuse,
Mitsuse Mura, Kanzaki Gun, Saga Ken, 842-03 Japan
- Atsushi Asai, MD
Department of General Medicine and Clinical
Epidemiology Kyoto University School of Medicine, Kyoto University
Hospital, Sakyo-ku, Kyoto, 606-01 Japan
Email: email@example.com Eubios Journal of Asian and International Bioethics 7 (1997), 135-137.
The patient was 78 years old female. She has lived in the small mountain village and has been treated for hypertension and hypercholesterolemia for several years in the local clinic where she lives.
She lost her husband owing to cerebral hemorrhage one year ago and she was suffering from heart attack 3 months after her husband's death. She was referred to the big hospital in the city for further treatment. Her diagnosis was myocardial infarction.
The cardiac catheter showed occlusion of 3 vessels. The first PTCA succeeded in re-canalizing the left main artery. But it was re-occluded in one month. The second PTCA was tried, but it was failed owing to an anomaly of the artery. After that she was treated by drugs, but it caused liver damage, so she could take only some drugs which gave no side effect to her. A C bypass operation was also planned and she stored up her blood for the surgery, but it was stopped finally because of the risk of liver damage.
She had no symptoms to walk to the toilet, but when she washed her clothes she felt chest pain. The physician in charge thought she may return home if she wanted to and if she doesn't do much work. The oldest son in the city claimed that the patient may not go back to her house in the village. Because there is only one clinic and one doctor in that village and she cannot receive good emergency care if she suffers from a new heart attack in that village. But the oldest son cannot live with her because he lives in a small apartment house in the city.
The youngest son who lived with the patient for more than 3 years in the village wants her to go back to the home in the village, because she can live a good life with her 2 granddaughters. The patient perhaps wants to live again in the mountain village where she has lived more than 20 years and has a good natural environment. But she doesn't say clearly about that because it may hurt the oldest son. She said to the doctor "I don't fear the death because I could endure the hardest day of World War. I have nothing to look back with regret because I could take care of my husband. After he was discharged from the hospital in his first stroke, he could not speak well but lived happy days with his friends playing "Go". He died in the second attack after 3 months stay in his home."
The family members especially the oldest son and the youngest son cannot agree on the way how to treat their mother. What should the doctors do in such cases? Perhaps in Western countries the patient autonomy is the most important thing. But in Japan, especially older people don't say their opinion clearly.
This is a case based on my experience in my rural mountain clinic as a primary care physician. I think my comments are based on this career. I usually use the 4-box theory by AR Jonsen et al. in the book "Clinical Ethics" to analyze the case.
What are the ethical problems in this case?
The medical goal of this patient is not cure but to control the heart attack. She is old and she will do only her home work depending on her condition, so if she goes back to her home in the village, it will not further deteriorate her condition. The prognosis for this patient will not change if she will stay more in the hospital. So the medical recommendation is try to return her home and if she feels good she may live in the village. If her condition becomes worse in her home, she may go back to the hospital.
She wants to go back home, but she doesn't express her wishes clearly. In Japan, old people don't say his or her wishes clearly because they are afraid that it may break the harmony of the family members. Perhaps in Japan, 20-30 years ago, the oldest son was the almighty of the family and his opinion is the final decision, but now the power of each son and daughter are similar and they sometimes face disagreement of their wish to treat their old parents.
I think the QOL of the patient in her home is better than that in the hospital. She wants to live with her grand-daughters. She can also enjoy and grow beautiful flowers around her home. The weather of the mountain village is cooler than that of the city, so control of the temperature is needed for the patient especially in winter.
The family members' disagreement for the treatment is the problem. The oldest son wants the patient to live as long as possible, and the younger son wants her to live the life which she wants. I want to ask the oldest son the reason why he insists that the patient should stay in the city hospital. I think there are three reasons for him to insist the patient should stay in the city hospital. First, he thought of the death of his father, the patient's husband. He died with a second stroke after 3 months stay in the village home. The weather of the village is cooler than that of the city. Second, he also wants to care for the patient in his home as the eldest son, but in town it is expensive to live in the big house, so there is no room for the patient to stay there. But if she continues to stay in the city hospital he can take care of her constantly. Third, he thinks the quality of the care by the village clinic doctor is not so good as the care by the specialist in the city hospital.
What I did as a primary care physician in this patient's home. I called the doctor in charge of this patient in the city hospital. I don't know him directly, but the specialist said he also thought it would be good for her to go back her home even if it would shorten her life. He said "I don't know about her way of life in her home as you do." But the family member's opinions are not decided. I would like to talk with the family about the best future treatment for her.
This is a rare case where a specialist respects the rural primary care physician's opinion in Japan. The specialist sometimes looks down the rural doctors. I think the education of qualified primary care physician in Japan is needed. But the specialist said "I can't persuade the oldest son to give up his opinion, the patient must stay in the hospital. It is the problem of the patient's family." I agree with his opinion. We doctors are not the main person to decide the patient's treatment. Doctors must wait for the family member who could lead their decision. In this case, the youngest son finally persuaded the oldest son with patience.
She returned home to the village 2 weeks ago. She could not stay in the bed. She felt chest pain when weeding the garden. But after she took the nitroglycerin the pain disappeared. She said it was hard to return from the life in bed to the life in her house. But she said it was good for her to return to live with family members. I think this case is a good case for those who have some children who want to care for them. But I also experienced many cases where the children don't want to care for the parents. The older peoples don't go away from the village where they live to the city where their children live.
The presentation of the case clearly shows that the medical situation of the patient does not require further inpatient care. Nothing more could be done for her. It is also apparent that her functional status would allow her to lead a social life with her family outside the hospital. Medically speaking, the opinion of the elder son seems pointless.
What are the ethical problems at stake in this case? First, there is disagreement between the two sons of the patient about whether she should stay in the hospital or not . The elder one thinks that his mother should be in the hospital so that emergent interventions are accessible to prevent her sudden death without delay. The younger one think that she should leave the hospital so that she can enjoy social life, for example, play with her granddaughters. This disagreement stems from conflicting ethical norms. One argues that her life should be protected at any cost, sacrificing possible good life with high quality in society. Sanctity of life should be prioritized. The other argues that one can take a risk to enjoy life. Quality of life should be prioritized.
It seems that both arguments are legitimate and ethically right. This kind of disagreement would be often resolved not by argument about which choice is ethically more right than the other, or which choice would give high benefit/risk ratio, but by argument about whose choice should be prioritized. Who should make the final decision when, like in this case, a patient is competent and well informed? Whose preferences should be followed when the patient wishes to come back home? She seems to recognize her condition and probable outlook and implicitly expresses her wishes that are consistent with her goal. There seems no problem to conclude that the physician in charge should discharge the patient and provide her with sufficient home care in cooperation with a physician in her village regardless of others' arguments. No difficulties would happen because the son who supports her wishes lives with her.
However, the second ethical question prevents us from simply suggesting that she be discharged. It rises from the fact that the patient has two wishes and they are in conflict inside her. As a matter of fact, we have to take care of four wishes held by the persons involved. They include wishes of the elder son, those of the younger son, and the patient's wishes for herself, and her wishes for her elder son. On the one hand, she wishes to leave the hospital and enjoy social life as her husband had. On the other hand, she seems to want to continue inpatient care because of her elder son. She wishes to avoid annoying him with a possibility of her heart attack in the situation where emergent interventions are unavailable. She may prioritize her wishes for the son at the sacrifice of her wishes to lead her life outside hospital. The very ethical question raised here is whose wishes we should respect. In Japan where interdependence and reciprocity are as prominent as, or more prominent, than individualism, we need to judge the appropriateness of decisions, taking the patient's desire, the family's desire, and the patient's wishes in the context of patient-family relationship. Needless to say, it does not hold true when a patient considers the wishes of his or her family are unacceptable and finds it contradicting to her benefits. In this case, however, the elder son's comfort may be as important as her wishes for the patient. Thus, the decision that the physicians in charge make will depend on which wishes we should take into consideration.
What sorts of practical procedures would follow? First, the physicians in charge should make the elder son understand that there is no point to continue inpatient care. If he expects that something more can be done, such an unrealistic idea has to be turned down. They should also address that continuation of inpatient care means nothing but endless confinement of his mother. We should ask him what he would want to do if he were his mother now. If he wished to leave hospital when he is in the same situation as his mother experiences, such a double standard in should be discussed. The double standard in decisions should be abandoned even if it purely comes from good intention. If he wishes to stay the hospital, then, we should recommend him not to impose his value judgment on another. Although her wishes may not be strong enough to exclude others' wishes, still, she wants to stay out of the hospital. When he agreed with ambulatory care of his mother, contradictions in four wishes would disappear.
The physician in charge should discuss with her in regard to her wishes in order to clarify what she really would. What would she want to do when her wishes on behalf of her son was taken into consideration? She may prefer to staying in the hospital because of the son's benefit. Whatever she choose and, as far as she is convinced and satisfied with her own decision, that is her autonomous decision and should be respected.
This case made us aware that we need to develop decision-making procedures to resolve ethical disagreement encountered in our culture. Unlike in North America (at least of textbooks), we have to understand human relationship in clinical settings as a trilateral one rather than bilateral physician-patient relationship. Bioethical thinking based on physician-patient relationship may not succeed to deal with dilemma involving a competent patient, his or her family, and a physician. It is a urgent problem to develop a method to solve disagreement presented above in consistent and universal manner.