Commentary on Case Studies: Case 1 (EJAIB 7:4)

- Dr Angeles Tan Alora, Director
SouthEast Asian Center for Bioethics
Rm.226 St. Martin de Porres Bldg., University of San Tomas
Espana, Manila, The Philippines

Eubios Journal of Asian and International Bioethics 7 (1997), 171.

From a purely scientific/physiologic view, hemodialysis will not make Mr. X well. At best it will temporarily relieve some of the ill effects of his chronic renal failure and prolong his life (or dying process?).

Hemodialysis for chronic renal failure is burdensome. Whether it is Mr. X, his family or professional healthcare givers that provide Mr. X's care it is physically, emotionally and psychologically taxing. In situations like the Philippines where funds and services are scarce hemodialysis is even more burdensome - to initiate it requires strong justification.

Weighing benefits versus burdens hemodialysis for Mr. X is an extraordinary measure - benefits are disproportionate to burdens and hemodialysis is an optional measure.

Without explicitly knowing Mr. X's wishes the same might be implied from Mr. X's precious statements and actions. Family members in the Philippines are closely knit. A brother who "has been taking care of him" for the last year would have had a lot of time to observe Mr. X and be able to deduce what he would have wanted. In out matriarchal society Mr. X's mother would have been more actively involved in sharing what she known of her son, his wishes and his values. Mr. X's implied wishes could then be followed.

At the same time, in the Philippine setting a family who has spent and cared for an irreversibly ill patient for one year, who has observed doctor's and other healthcare givers as "doing their best" would easily accept the recommendation not to dialyze. All they would need is the compassionate and clear explanation from the doctor that everything that should be done has been done, that no one has been lacking in care or concern and that his time has come.

Commentary on Case 2 (EJAIB 7:5)

The Case Presents many Problems in our Culture

1. Decisions for an elderly sick are made by her children for a variety of reasons. The children feel they know what is best for their mother, they do not want to burden her with the pressure of decision making, she herself hesitates or chooses to have them decide.

2. Children disagree in their choice. Each one feels he knows what is best for his mother.

In the Philippines it is usually the child providing the financial support of the parent who makes the decision. If no one does, then it is the child with the highest social standing and again if none, then it is the eldest child. Other children who are not as financially well off or socially of high standing are assigned to physically stay with the parent and care for her.

Modern technology that seems to offer the best treatment is always a temptation for those who are ill or are related to someone ill. No doubt the eldest son believes the city will provide his mother the best care.

The younger son however seems to view his mother's condition more holistically. In the village she will be in a familiar environment with people and surroundings she lives. No doubt too this son believes this is best for her health.

Our elderly prefer to live where they have lived all their lives. Many times to displace them in order to take advantage of better medicine is cruel - it is in the end not truly better medicine and they die sooner and unhappily. Our elderly do not worry much about dying but worry more about the loneliness that goes with being left alone.

Sons will have to talk to their mother regarding the benefits of each place and ask what she really wants - then they should follow her wishes. Whichever place she chooses to stay, the distant son should try to make frequent visits to see her. All she needs is a little concern and a little love and maybe a little medicine so as not to be too uncomfortable.

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