Case 4: Therapy for a 48 year old alcoholic patient and Commentaries

- Masashi Shirahama, M.D.
Director, Mituse National Health Insurance Clinic
Lecturer, Department of General Medicine,
Saga Medical School, 2615 Mitsuse, Mituse-mura, Kanzaki-gun, Saga-ken, 842-0301 Japan

Eubios Journal of Asian and International Bioethics 8 (1998), 105-111.

The patient was a 48 year old craftsman. He likes alcohol and drinks much every day. When he drinks he becomes short-tempered. He seems to be alcoholic. He has two daughters aged 4 and 6, and a wife. They asked him to stop drinking and asked him to go to the hospital for alcohol dependence but he became angry and he didn't go to the hospital.

One day he came to the emergency room of a big private hospital because he became unconscious. The blood test result was: GOT 300, GPT 250, NH3 was 300mg/dl. It showed he was suffering from alcoholic liver injury and alcoholic encephalopathy. During the first 3 hours glucose, vitamins and lactulose were given to attempt to recover he consciousness but his condition did not get better, so emergency dialysis was started to absorb alcohol and he became conscious and finally he could go back to his home after 1 month's stay in the hospital. When he came out of the hospital the doctor in charge told him that he needs to come for regular medical checks twice a month and he should not drink again and he agreed to do so. But he didn't come to the hospital for the regular medical check.

And he came to the emergency room again with the same problem after two months. The second time the doctor did the same therapy and he could recover in one month. But the cost of the dialysis for this kind of alcoholic poisoning turned out not to be covered by the public health insurance for multiple times. The patient was discharged from his company and now he is on welfare.

The private hospital manager told the doctor in charge "The hospital will not pay for this patient's dialysis again. If he returns to the hospital for the same reason, please do the usual therapy such as glucose, vitamins and lactulose except hemodialysis."

What should this doctor in charge do for this patient?

Commentaries on Case 4

1. Commentary by Atsushi Asai & Takuro Shimbo
Department of General Medicine and Clinical Epidemiology
Kyoto University School of Medicine, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-01 Japan
Tel/fax: 81-75-751-4246

This case described here includes various medical and ethical problems. To make our discussion clear, we would like to first discuss the medical situations on which ethical consideration is based. There are at least two medical problems to be clarified. The first question is whether hemodialysis (HD) is medically indicated for treatment of alcoholic encephalopathy. Is HD really effective to improve the patient's encephalopathy? It is doubtful that HD is recommended as a standard therapy for this kind of medical condition. Although use of HD for alcoholic encephalopathy could be logically understandable, no evidence has proved it is effective and beneficial for a patient in alcoholic encephalopathy. It's use should not be considered as a treatment if it is not physiologically effective. On the contrary, from the standpoint of clinical medicine, we have to use it to save the life of the critically ill comatose patient if it is effective regardless of its cost and coverage by national health insurance. At this moment, we are afraid, that we are unsure about it.

The second medical question is whether or not the patient is suffering from a mental disorder. We will discuss it in relation to competency. In this case, psychiatric evaluation is by far the most urgent task for all parties involved. Does alcoholism itself constitute a mental disorder and therefore make the patient incompetent automatically? If it is the case, what to do is a psychiatric consultation. The physician in charge should discuss this issue with the patient's family and, jointly with them, try to persuade him to see a psychiatrist. Our primary duty would be to protect a mentally handicapped person who lacks capacity to make beneficial decisions in the best interest of himself. If he could be judged competent while he is sober despite his illness, we have to discuss medical plan with him when not drunk. Mental illness may not always mean impaired competence. Hence, he can be supposed to keep ability of self-determination for himself and his life when he is sober. If he was never sober, he would not be able to be competent. Some would also declare that alcoholism is not illness and such persons intentionally choose to be drunk based on their desires. In that case, they would be treated as completely competent persons who make adverse decisions for themselves for some reason. Outcomes of irrational decisions made by such competent adults may not deserve unconditional protection provided by medical staff and our society.

So far, we have two brief conclusions. First, if HD had proved physiologically and epidemiologically ineffective for alcoholic encephalopathy, it should not be done. Second, the patient's family and physicians have to jointly make decisions about what to do on behalf of this patient if the patient was judged incompetent. In the following, we would like to discuss ethical problems, supposing that HD is effective and the patient is competent. Ethical inquiries to resolve dilemmas that the physician has confronted would require us to scrutinize a role of each individual involved in this difficult, but not uncommon case. What is a right of the patient for medical care? We believe that he has a right to have sufficient medical care for his liver disease regardless of his personal and social characteristics. The bottom line is that medical professions, medical institutions, and society as a whole cannot discriminate the patient based on the fact that he has been alcoholic and unemployed. He is eligible to undergo medically indicated treatment, especially in an emergent and life-threatening situation. Can we legitimately maintain that expensive HD for the patient is futile because he drinks again anyway and injures his liver again in the long run? If we set the goal of HD as to alleviate his liver injury so that he can live longer in good quality, the goal is never accomplished as long as the patient continues to drink. Even if we can save his life this time, he will eventually die of his alcoholic liver damage. However, judging futility based on prediction of future failure, not on the fact, is unacceptable and dangerous. Such judgment may affect medical decisions in chronic basis, but it should never be applied in the emergent case discussed here, or based on unilateral decisions. In addition, no one would disagree that to save life in an emergent setting is one of the most important goal of medicine and no one would properly argue that saving life is futile because of future death.

Second, what is responsibility of the physician? His medical decision regarding indication of treatment should not be influenced by opinions of any non-medical staff. Opinions of the medical manager seems legitimate because his hospital has no duty to pay for HD for this patient. It would not mean, however, that the physician has a duty to follow the manager's comments, especially based on financial consideration. The physician has a responsibility to save the patient's life and promote his health. He has to educate the patient and make him understand what is going on his liver and what will happen without medical interventions. He has a duty to save the life of a critically ill patient by using expensive intervention uncovered by national health insurance as far as it is medically effective in an emergent basis. What should the physician do for this patient? Firstly, the physician has to evaluate patient's ability to understand and appreciate his current situation and likely future. When the patient is considered incapable to grasp the reality, then, he should be referred to a psychiatric consultant.

Discontinuation of alcohol intake is mandatory in this case. Psychiatric inpatient care should also be considered and discussed with the patient's family. Secondly, if the patient is competent, the physician is obliged to explain all relevant facts and the risk of relapse of alcoholic encephalopathy. Explanation should include that medical indication of HD for his condition may be effective, but not unequivocally accepted as a standard medical care, that the hospital paid the cost for him in the past two occasions but it would never happen again, and he and his family will have to pay the cost if he have such an intervention. The physician must also inform that he cannot guarantee the patient's health and well being unless the patient sincerely follows ordinary and standard care. The same discourse should be simultaneously given to the family. If the patient declared that he would continue to drink regardless of medical advise and does not really care about premature death while he is sober, then, HD should not be used. It is informed refusal of a competent patient.

Documentation of the content of the discussion in medical chart is essential. What if the patient is brought in coma to the hospital again before the discussion is made or before agreement is reached? In that case, the physician will have to provide the best medical care for him. HD can be used if the physician surely judge that it is medically indicated. The cost in this case should be paid, however, by the patient and his family.

Finally, we would like to discuss a controversial issue about responsibilities of the patient in medical care. Is it fair for us to say that patient's right to medical care is followed by his responsibility to seriously consider medical advice provided through his physician? In this case, is it justifiable to say that the patient was responsible for regular visits and usual and standard treatment for his liver and alcoholism? Undoubtedly, he would be medically and socially better off if he followed medical treatment. Medically speaking, his failure of having ordinary care results in his life-threatening situation, at least the second one. Does he have an unconditional right to undergo scarce and expensive treatment not covered by Japanese national health insurance, while ignoring basic medical advice or refusing ordinary care that is inexpensive and proved effective? Does our society and any medical institution is responsible for paying a lot of money for such patients? We are not sure about this matter.

HD is one of the most expensive medical therapy consuming the scarce resources. Is it unethical for us to feel that the patient's right to undergoing HD can be compromised by his failure to adhere to inexpensive and ordinary care?

2. Commentary by Kaori Sasaki

Dept. Sociology, Lancaster University, UK

I feel something woe when I read the result of the alcoholic patient because all the situation shows the nature of human-beings including our follies, our dilemma, our goodness etc. Especially it touches me so much that: a) what the patient himself said to the doctor that: let him alone; b) and that what the wife of the patient said to the doctor that: do not apply dialysis treatment to him when he falls into deep coma due to his over drinking.

She continued that she was so scared of his violence that she could not do anything while he seemed to lose his confidence, his mettle as a man. He seemed not to find the way to deal with and overcome his irritation and fear except drinking. This condition indicates real lively human life. I wonder if there are any good answers for this case.

----What is ethics and what is so-called autonomous decision for our human dignity?-----

Today, I want to say something different from other comments. I am going to pay attention not to the patient himself but to the others especially the doctor who gave treatment to him and the wife of the patient.

As John Donne (who is an English poet and vicar as far as remember) write and which was cited by Hemingway in his work For whom the bell tolls (1941); "we may well consider our tie with the others especially when we encounter dying and death: No man is an Island, intire of itself; every man is a peace of the Continent, a part of the main; if a Cold bee washed away by the Sea, Europe is the lesse, as well as if a Promontorie were, as well as if a Mannor if thy friends or of thine owne were; any man's death distinguishes me, because I am involved in Mankinde; And therefore never send to know for whom the bell tolls; It tolls for thee".

Death and dying is not only his but also ours; which triggered our much attention to, I presumed. In this situation, the treatment and dying process of the patient not only were affected by but also affected himself, the doctor, his wife and political-economy (such as social welfare and an administrative district). In other words, his death is a piece of our society (c.f. Continent). Many of participants, in the e-mail discussion, argue from the following point of vies:

a) social system for insurance and hospital management;

b) ethical or religious duty to the patient;

c) autonomous decision making, (c.f. or i.e. bioethics)(e.g. educated (enlighten) to be the autonomous, persuaded him to accept <i.e. so-called informed consent>).

However, from the above viewpoint to death like John Donne, in this occasion, I find difficulty to discuss this issue from the former three types of standpoints or so-called bioethics perspective which may direct you to think about inside its theoretical or ethical framework. So my point may be a bit outsider.

Let me give you one simulation of this case in terms of influence from the death upon the others especially his peerless persons. The doctor mentioned that his wife had looked relieved ---when he had bodily died ---- from the worry-some life which had been cased by the patient whose drunk habit had brought about his violence to his wife and his illness (hepatitis & deep coma). However, she may suffer now from feeling guilty for her judgment for his treatment since her decision indirectly resulted in his death. Her feeling at that time when she made up her mind -while she would like to be release from intolerable situation-may different from now the time when she may recognize that he has really passed away in her everyday life. She may miss him and may consider her determination as a sinful. A death is some how recognized step by step through a trivial round of everyday life after a bodily death. One does not accept a death fully when s/he encounter his/her bodily death but s/he shall be understood it gradually. So, death in our social life has been somewhat passing away from his/her society rather than a certain point when s/he is judged as such.

In spite of all, the wife and the doctor should face to an autonomous decision. On the one side, she had to explain her will for his treatment under that circumstance and on the other side, he ought to establish a certain judgment to a treatment for the patient with taking his and his peerless person (i.e. wife) wish into consideration. Whilst both of them might try to do their best for their decision for the remedy for the patient, both of them miss to think about his dying process bodily and socially, namely, after the point of death in the hospital at that time. It may cause them another woe from his death.

Just the above side cannot be solved no matter how earnestly and ethically the doctor works for the patient with his family (e.g. wife), I think. From my view, as one discussant mentioned, the doctor could say to the insurance authority that his illness was hepatitis C or other similar illness to his owns which could be applicable for social insurance. Then, this money problem may be solved. As another claimed, if a social worker might check his health and habit regularly, he might quite his habit. Then, his illness and problem may be resolved. The other also stated that if the doctor persuaded him --if necessary, with counseling or some assists--- to come to the hospital to take a treatment in order to be healthy; this problem could voluntary vanish. However, the issue as I stated can not disappear.

---Do you remember the doctor's own comment after all?--:

My decision was acceptable and ethical? Can I take an alternative way to a doctor? I still remain something regretful feeling for this issue. I hope that from here, we may discuss if the way in which we treat certain topics as issues is ethical or problematic. Many of what we call problems have been argued and comprehended within its theoretical framework and not beyond break through it. Finally, it just leads to a cliche for solving a problem which may cause self-satisfaction rather than helping day to day life of common people's who encounter illness and death. Because the head of our session, Dr. Macer, wants to provide a counter theme to American bioethics, we might well suspect the dogma of bioethics such as informed consent, autonomous decision making. The doctor's comment, I believe, is worth while consider and is good case in point because however he can be good enough a doctor from contemporary ethical and medical perspectives, this kind of question can come to his mind as far as he is a man who "is not an island".

3. Commentary by Stuart Sprague, Ph.D.

Medical University of South Carolina
Anderson Family Practice Center, Anderson, SC USA

I checked with a physician colleague who specializes in treatment of addiction and alcohol abuse. He said that he might not have used dialysis to treat the patient. Using the drugs and allowing the patient more time may have allowed the alcohol to be metabolized without dialysis. One key issue in the case is whether dialysis is necessary to keep the patient alive and prevent major damage to the brain and other organs. It seemed that the hospital manager was willing to pay for the drugs and his stay in the hospital, but not the dialysis. If the dialysis is necessary and it will not be paid for, the doctor is in a difficult position of being an advocate for the patient but lacking the resources to treat him appropriately. If dialysis is not necessary, the doctor should continue to warn the patient, but he could treat him as often as the therapy would work.

In either case there are still moral problems. One is the status of the doctor-patient relationship when the patient refuses to follow the treatment prescribed. This problem is not limited to one country, but is a problem for all physicians.

Doctors should use all their persuasive powers and assurances that they will not abandon the patient to seek to change destructive habits. They should also refer the patient to others, such as counselors and treatment centers, who have skill and time to devote to the patient. In the end, however, the decision to follow the treatment recommendations is the patient's alone. If the patient refuses to cooperate in getting better, the doctor must decide whether to continue being the patient's physician or to find the patient another physician who is willing to take on the challenge. My physician colleague asked whether the patient's employer could not have tried to help rehabilitate him by making continued employment dependent on following a treatment plan? Would that have persuaded him to change?

One problem in medical education is that physicians in training may meet many patients similar to this one and develop either a cynical attitude or a feeling of moral superiority to their patients. They are then not able or willing to establish long term relationships which are necessary for overcoming problems like alcoholism. We who are medical educators must work to see that this does not happen.

Another problem is how money is allocated for health care. I do not know the system in Japan very well. This is a private hospital, but it receives money from a government health plan to pay for this patient's care. Are there limits placed on the hospital by the government for a particular patient, a particular diagnosis, or by an overall budget that is limited? Would the patient be allowed to die or suffer major damage to his organs for lack of treatment? Did he have additional insurance when he was employed?

The hospital at which I work is private and is the only one in our city. Each year more that $10 million of medical care is given for which no money is collected. The other patients end up subsidizing the care of those who do not or cannot pay. Our managers have said that no patient who is gravely ill will be turned away or be given substandard care. Will this always be true? Will they be willing to provide free care as less and less money is available to pay for all care. There are financial pressures from the insurance companies and other sources to pay only for the cost of caring for their patients. We have much work to do in reforming our system of delivering and paying for health care.

As to what the doctor should do, I believe that the doctor's strongest obligation is to the patient. The fact that this patient did not cooperate is no reason he should be abandoned. If that were the case, we would all be abandoned by our physicians at some point. There is some reason the patient is choosing to be self destructive, and the physician may be able to uncover that and assist in removing it. Some sort of behavior modification plan with the doctor, the family, the employer, and perhaps others working together should be attempted. This is the heart of family medicine.

4. Commentary by Philip Hebert, M.D.

Physician, Toronto University, Canada

Your new case is an issue of justice. Is it fair to deny a patient a needed medical service on account of, what seems to be, a self-induced illness? The answer to this question is no: medical care ought only to be not given if the patient competently declines it or it has been shown in well-designed clinical trials to be unhelpful. Helpful, but scarce, care may need to be rationed but it ought to follow fair rationing principles: go to those most in need, to those most likely to benefit, to those longest on the waiting list etc. You haven't told me whether the dialysis was scarce; I presume he was denied it because he was a relapsing alcoholic. But would we deny a person with relapsing cryptogenic cirrhosis the same care? Presumably not -- we discriminate against alcoholics because we don't see them as ill as we do other people (who are not responsible for their illness). This patient's physician ought to advocate as strenuously as possible that his patient get dialysis & get it paid for by the state.

5. Commentary by Yooseock Cheong, M.D.

Physician, Dankook University, Korea

I think this type of patient rarely escape his bad habit (alcoholism) by himself. Alcoholism is absolutely a psychiatric problem more than physical problem. This serious case must need the help of a specialist (psychiatrist). So the doctor in charge should persuade him (or his family) to be admitted to the psychiatric department. The patient's own decision is the most important as a view of autonomy in this situation, but if his decision is absolutely harmful, doctor can contact family members to force him for psychiatric admission. In Korea, many important decisions have been decided due to the family member's will. Family bonds are very strong in our society, and many important decisions can be made against patient's will in such a special case. If psychiatric admission is not available and this patient returns in same problem, the doctor in charge have to give hemodialysis again in Korea. If doctor (or hospital manager) refuses this urgent patient, it's illegal. But I think it's just law-based idea, not practical, because it's not certain who should pay for this hopeless patient. There is no reason the hospital manager or insurance company would not cover repetitive alcoholism treatment. If doctor follows insurance company's policy, and do not give hemodialysis again, doctor will be charged.

He (or she) has a duty to protect and advocate for the patient. The doctor who gives hemodialysis to the patient can be laid off by the hospital manager if he repeats such a practice. The point is that there is a discrepancy between proper medical treatment & insurance coverage. There is no way we can argue against public health insurance company's policy if they say " The fund is limited." So, the doctor can open this case for discussion to public, but it will take a long time to arouse the attention of the public. And the doctor, again, has to bear the risk (because public health insurance company & hospital manager do not want to open this case) But I know there are lots of hidden warm-minded resources in our society. It's an another solution I hope.

6. Commentary by Frank J. Leavitt, Ph.D.

Faculty of Health Sciences, ISRAEL

Thank you for giving me the opportunity to comment on this interesting case. I am a strong believer that medical treatment should be given with no regard whatsoever for whether or not the patient is to blame for the condition. Physicians should not sit in moral judgment on their patients and sitting in such judgment can lead to a slippery slope where homosexuals, drug addicts, etc. might be refused treatment.

Therefore in the specific case the patient should get the dialysis and the health service would be ethically wrong to refuse it. The physician in my opinion has an ethical obligation to think only of the health and life of his patient. He must do everything to help his patient get the dialysis, perhaps transferring him to another hospital if necessary.

7. Commentary by Kenzo Hamano, Ph.D.

Philosopher, Nagoya Institute of Technology, Japan

This case certainly shows the importance of the team approach in the complicated cases involving chronic conditions, which often contain psychological and social elements. What I mean by "team approach" includes not only doctors of various kinds but also social workers and various support groups. The case in question clearly shows that the doctor in charge is forced to face a problem beyond his or her power as a doctor. The patient should have been given psychiatric help and the social workers' office should have intervened to prevent further disaster. In the present condition, the problem which the doctor faces is a kind of perennial ethical question for which there is no easy answer. The doctor, whose primary obligation is to relieve a patient's suffering and cure disease, must not abandon the patient to his or her death for mere financial reasons. However, because the financial concerns cannot be ignored and, above all, for the sake of patient's and patient's family, the doctor must seek psychiatric intervention and a social worker's help. In real life there might be a limit to what the doctor and other people can do to solve problems. Still the doctor must do whatever he or she can do to prevent a real tragedy with the help of different kinds of professionals and patient support groups .

8. Commentary by Ole Doering

Institute of Asian Affairs, Hamburg, Germany

I appreciate your attempt to get into a concrete discussion, particularly because this is what we need in order to approach a common understanding of what medical (and of course bio-) ethics is about, and which are the specific patterns in terms of methodology and agenda.

Case 4 is both, interesting and significant, the latter in two ways: Firstly, it shows the importance of categorical discrimination, here between legal, moral and ethical dimensions of a problem. Secondly, it is an everyday case which shows that there can not always be clean and overall satisfying solutions provided by ethical deliberation, but there is normative orientation, at least more light on the structures of the respective problem.

The very tricky case of how to deal with the therapy-reluctant alcoholic patient can be the reference point for all sorts of arguments in medical ethics, ranging from social responsibility awareness over human dignity to the slippery slopes, and the tension between individualist and communitarian claims. I will focus on some aspects which seem crucial to me, and there will have to be a lot left unmentioned. Naturally there won't be discussion of the medical treatment here, because that would exceed my qualifications.

Although I am not familiar with Japanese health insurance laws, I gather that legally it is just to disapprove a reiterated expensive medical treatment at some time. But this is not the level of the ethical problem. As to achieve an ethical understanding of the case we need to know and deliberate much more about the basic human conditions involved, and to figure out their systematic configuration.

At first, we have to identify the people who are involved in this case. It would be rather superficial only to look at the patient (P), the doctor(s) (D), and the private hospital (H) (or the insurance behind it). The presumed fact that these parties in this case are the only "legal partners" might hint at another problem, which lies in the interpretation of laws only dealing with matters of a somehow "public sphere" or interest. Because this tends to marginalise or even to exclude the legal responsibilities among family members, who in fact do not have a legal representative such as the insurance as a legal person caring for the interests of all members, as soon as the father (in a paternalistic family) has turned to violate the family interests. Germany, for instance, has recently tried to fill parts of this legal gap by identifying and punishing intra-marriage rape as rape in any other social setting. Similarly, there could be discussion about strengthening the legal (or moral or social) status of legitimate family member's claims. Of course there are very serious objections against the meddling of legal structures into privacy, at least because it always may turn out to be some Trojan Horse for unethical interests. But, to go beyond pointing at this legal problem requires more sufficient discussion than I can offer in this short statement. However, ethical thinking, particularly in medical ethics, always ought to keep an eye on the legal sphere, because it needs the assistance of legal means to succeed in its aim to achieve something good for the people. But we should not mix together ethics and legal thinking.

Who is involved from an ethical perspective? Next to H, D and P there are the family members of P, and there is society. If we put aside society and general claims to distribute and allocate medical devices for everyone justly, with the associated duty for everyone to take care for his or her own health, the most important parties involved in this case are the wife and the two children, briefly P's family (F). If we take a patriarchal family for granted here, we have to take into account a set of moral obligations of P to his family. No matter which moral rights and duties have actually been constituted within this context, there is a very clear ethical responsibility of P to provide F with all achievable means to make a good living beyond them. On the other hand, F has responsibility to enable P to fulfill this duty, as far as possible. As described in the case example, F seems to have fulfilled its part, though this might turn out to be a superficial assumption after a closer look.

Unfortunately, the description of the example leaves us wanting too many accurate details of the real case to qualify us for a comprehensive ethical decision. At first, it seems to suggest that the focus should be put on the relationship between doctor(s) (D) and hospital (H). Granted that it might be in the interest of those two parties to be very clear about the terms of their relationship, this very relationship is, by definition a legal one, because it is based on legal contracts. It does not seem to make too much sense to postulate a particular ethical impact of this dual relationship. Still it would be legitimate to discuss the ethical responsibility of D and H, for the other patients (and for the members of health insurance), in terms of a just distribution and accessibility of resources, and to enlarge this discussion to society as a whole. But this is not my point here.

It seems to be more significant to scrutinize the relationship between D and the patient (P). This might be the direction of the line of argument the authors of our case description had in mind. And indeed, in this constellation we encounter more than contractually. legally encoded rights and duties. Because evidently there always ought to be a human dimension at work between D and P, next to technical aspects of the medical job, labeled as the emotional, psychological and moral factors. While in the D-H perspective P becomes an object to be handled, somehow more (D) or less (H) favourably, the D-P perspective has to address P as a subject. In addition, I believe it is still common ground to say that also D is to be regarded as a person, though it is not desirable to have D as deeply subjectively involved as P because of his objectivating medical diagnostic and therapeutic tasks. So, to put it into rough terms, the patients part of the D-P relationship is heteronomically consisting of rational (strategies to gain health etc.) and irrational (fear, hope, beliefs etc.) aspects as well as the doctor's, but usually with a greater share of rationality with D. This is the reason for both, the humanness and the difficulty to handle medical ethics problems. In most cases there is a considerable vagueness and ambiguity within the descriptive individual and mutual interest-settings, interest calculations, mental capacities, expectations etc.. Though for the sake of ethics an accurate description should attempt to narrow down this vagueness as far as possible, it can not be a reasonable claim to get rid of it and to provide utmost transparency. That is the challenging situation we have to live with consciously.

What are the ethical issues of this case? This depends on our understanding of ethics. I submit that ethics is different from other ways to prescribe what we should and should not do. The first mode of prescription is the most natural and least rationalized (though not irrational) way of morals. Morals and morality consists of what people commonly regard as right and wrong and the principles they obey in acting. The second one is ethics. Technically, ethics as a scientific discipline attempts to rationalize moral arguments and to draw general as well as contextual (applied) conclusions from this procedure, it includes questions such as if and why ethically good willing and acting is possible at all. The special focus of ethics lies on the motives and reasons for our (good) actions. The third mode of prescription is the legal attempt to formulate a framework for our actions, in order to prevent people from doing things the state (sovereign) does not want them to do, and to encourage actions it welcomes, including the private sphere where legal institutes such as treaties and contracts are politically sanctioned. Ideally, legal norms are compatible with ethical norms and, if indicated, ethical arguments should guide legal reforms. Obviously, these three modes, as sketched here, are tightly interrelated in ethical practice. And each can refer to both of the others. This makes it imperative, especially for ethics as a scientific discipline, to identify the respective prescriptive mode we are using actually.

The first ethical issue mentioned in our example is clearly a case of irresponsibility against oneself and against other people seriously depending on one's due support. F had requested P reasonably to act according to his duties by explaining to him that he should look for help and see the hospital. P openly violated against this duty and did not care. He did not only dismiss his responsibility against his family, but also to his own health. So what? We do not know the motives and reasons of P. If we don't wish to curtly accuse P of being immoral, or refuse help because we deny legal justification of his claims, we have to look closer into his personal and family affairs. But without further information, we can not do this. To reach a conclusion here, it will be crucial to understand whether P's irresponsible actions are just as negligent as they seem, or if there are factors in his personal or family background discounting his responsibility. P might need help, not only physically against his alcoholism, but more likely some psychological or socio-psychological treatment. D could consider this and refer P accordingly.

The second ethical issue raised by our case is the unkept promise, a general ethical problem vividly debated in philosophy. P had declared that he agrees with the explained regular medical check and that he should not drink again. But he would not keep either of these promises. By this, he not only worsened his expectations for successful treatment, he also tainted the sense of trust which is constitutive for both, a family life and a promising D-P relationship. So what? Do we understand why P went on drinking, and why he did not go to hospital? Do we even know why he agreed, and what he took his agreement to be - was it an empty formality or a serious promise in the first place? We don't learn about this in the case description. But, as widespread experience with alcoholism suggests, there still are legions of possible scenarios, at least making relative the accountability of P. And each of them would bear quite a particular impact on the ethically right answer to the question what to do with P. Because there is a considerable probability in assuming that alcoholism is merely a function of underlying problems, it could turn out to be part of a mayor disease, requiring a different therapeutic approach after thorough scrutiny. Continuous indifference and self-neglect of the given kind would hint into this direction. In this sense, no private hospital or health insurance would be entitled to deny an even more expensive support. This might also indicate a liability of D for improper diagnosis. All of this, without adequate information, remains speculative, though it hopefully provides us with some ethical orientation for this case. The unkept promise as such is not an ethically telling matter of fact.

Thirdly, if we do read the case with no second thoughts about accountability and proper description, and if we consequently generalize the negligent character of the actions, it might indicate that P is also responsible for the effects of cases like his on the whole health insurance structure. As the private hospital can not survive without fulfilling the terms of the insurance it is in the best interest of all patients that no resources will be distributed unjustly. This is what H and D must, and P should care about. Provided (without sufficient evidence here) that P's actions and non- cooperations are plainly motivated by severe indifference, ignoring fine information and explanation of all relevant consequences, including due dismissal from the insurance: under these circumstances it could be ethically justified to discharge P from his company. The ethical impact of this measure can only be found out if we learn more about what it means that "he is now on welfare", regarding the specific context and the coverage for medical treatments (The German "welfare", or social security, system might differ significantly from the Japanese in this respect). Further, depending on the degree and content of the patient's ignorance, it could be ethically required to save F from the (potentially violent) influence of P. D could initiate procedures to protect F and to shelter P from self-destruction.

The fourth of the ethical issues prompted by our example is an objection of compassion against the generalizing approach. What is the merit of refusing haemodialysis with the consequences of suffering and probably the passing away of P, and what would be lost if H turned a blind eye on few poor fellows like him? Isn't it actually not an ethical but a material problem of sufficient access to every indicated medical support at any time? It certainly is a material problem, and this objection becomes even more relevant as soon as we leave the given contexts of our real societies. In an abstracly construed ideal medical system there trivially won't be constraints in supply and accessibility. But this might also bear some significant counter-aspects, especially if we consider the meaning of health-care under the emphasize of care. Wouldn't at least some people become more and more careless about their health, and wouldn't this result in a lot of avoidable suffering? I feel this is an ethical problem, and it might even give some credit to a paternalistic approach, at least if a couple of further preconditions were described in the case example accordingly. In this sense, a paternalistic answer might be the following: Even if P would be treated all the way again and again, this would neither seem likely to help him escape alcoholism, nor to make him work on the reasons and causes for his drinking, on the long run, nor would it help the wife or the two children. It merely could ease the mind of D for a while. In this light, the decision of H to refuse further treatment might appear as a catalyst or to enforce measures, and thereby to avoid letting P and his family drift into more and more catastrophic conditions, because this decisions breaks up the routine of more or less conveniently scratching the surface of the problems. Such a turn is not cynical only if it does not result in discharging P from the health care system but if it leads to transfer him from one too limited therapy or compartment into another one capable of providing more appropriate care.

Now, what should this doctor in charge do for this patient? D can not solve these problems, but he has to decide. The evident answer, as always, is to help the patient. But, to be pragmatic, we have to look for the means to help, and here means can only be understood as accessible means. They do obviously depend on the circumstances. If H legally refuses to pay for further haemodialysis, we can complain about hardship, but one has too look for other possible sources for payment. Generally, this could be some public foundation's or welfare's money, or some private source, be it a charity foundation, the help from friends or relatives, or from D's own pockets. In the given example the latter does not seem to be a promising option, although it should not be a taboo to ask D for support in a very limited few cases, and if no other means are in sight. Anyway, this is a very personal decision of D, and will be grounded on moral sense rather than on ethical prescription.

The doctor's decision should take into account the real facts of the case, as indicated above. And it should reflect D's professional and personal options. We are not sufficiently familiar with the given situation to give an answer as we might do in the legal or moral mode. Still we can point at the guiding questions. It might be prudent to reinvestigate the medical case, to check all diagnostic and therapeutic options once more, possibly D could refer P to psychological counseling. Furthermore, D ought to talk empathically with P to learn more about his personal structure and to search for further medical or socio-psychological indications. D should proceed accordingly with F, in trying to create a mutually open, trustful personal atmosphere of understanding among all people involved. This may help to make professional explanation more intelligible for P, and P's problems to act reasonable more understandable for D. Finally, tricky cases like this one should be discussed with third parties such as ethical supervisors or at a committee of qualified colleagues, with the aim of illuminating all relevant facts and to do everything possible to improve the situation for P and F. All of this ends up in the answer: take an ethical perspective and try it again! The one thing ethics can and shall not do is to provide prescriptions such as the Ten Commandments or a legal code. Ethics is prescriptive in a way that encourages and orientates people to find their own enlightened understanding and concrete answers.

Though it is very important to help the doctor to develop a proper way of dealing with the problem the crucial task for ethics, as I submit it, would be to provide a comprehensive structure of all characteristics and claims involved, and to inform all agents, D, H, P and the relatives about their ethical options. To do this takes time, more time than usually calculated for dealing with patients. This can due to a painful process for everyone involved personally. Because ethics is not primarily about moral biases or legal calculations, but about understanding and doing the right accordingly.

9. Commentary by Masashi Shirahama, M.D.

As usual I would like to comment this case by using Jonsen's 4 box method. This time I discussed this case with my Japanese friends on bioethics discussion in Japanese. I quoted few comments from this discussion. But I thank their earnest participation.

<Medical Indications>

Some participant commented on the medical indications of hemodialysis for this kind of patient. I agree that alcohol intoxication is usually recovered by infusion. The diagnosis was difficult whether this patient's unconsciousness was owing to only alcoholic encephalopathy or hepatic encephalopathy. In any case, the famous medical textbook Washington Manual wrote "for life-threatening overdoses, hemodialysis may be useful" and it is hard to say hemodialysis is not indicated in this case. But the first thing to do for this patient is to change the bad habit of alcohol drinking and the hemodialysis is the last thing to do. From the point of Medical Efficacy and Risk, we must not forget that the emergent hemodialysis make some side effect such as hypotension or electrolyte imbalance.

<Patient preferences>

To evaluate the competence and capacity of this patient is an important problem. But in Japan, the patient's rejection to psychiatric consultation is strong and it is hard to persuade the patient or family to do so. I think the explanation of this kind of alcoholic disease is not appropriate, but the main problem is that the doctor could not make the good relationship with the patient and the family.

As Dr. Hirata, a general practitioner commented, this kind of alcoholic patient is difficult to treat and it is difficult to develop a good patient-doctor relationship. One of the causes of this difficulty is the doctor's feeling that this kind of noncompliant patient is hard to treat and time consuming. Pastor Hagiwara's commented that the doctor and medical staff need to treat the patient and the family with love. But it is a hard thing to do without God's help. I find one article "Doctors have feelings too" by Dr. William M Zinn, JAMA 1988;259:3296-3298, and I think this kind of emotional content is not avoidable and important part how to treat the so-called difficult patient.


The medical staff didn't know the thing the patient lives for. He seems happy when he go back to his home after the first admission to the hospital. But in the second admission he looks embarrassed in the second admission after he recovered from unconsciousness. He didn't want to speak with medical staff. And the medical staff didn't know and ask him what makes his QOL better.

<Contextual Features>

1.Family. The patient's wife and his 4 and 6 year old daughters are his only family to visit him. His wife said that she could not ask him to stop drinking because when she asked him he did violence to her. When the doctor in charge said to his wife "It is difficult to continue hemodialysis to him", she answered "I understand it. This is the consequences of his deeds." At last the patient died and his wife seemed safe. She might feel free from the hell on earth. But in this discussion, Dr. Fujibayasi (a psychiatrist in the community mental health center) commented on the influence of his disease on his little daughters. The diseases influence not only the patient but also the family members.

2. Cost is also the main problem in this case. As Dr. Matushima wrote, it is a technique to write the disease such as "acute renal failure" which the hemodialysis treatment is indicated to get money from public health insurance in Japan. But I think this kind of technique cannot solve the real problem. I now write the real disease when I asked the public health insurance to pay for the medical treatment. When some treatment or tests are rejected to be paid because of overdose or not indicated, I write an objection to the health insurance committee with some copies of articles or standard textbook book and ask the committee to answer why such kind of tests or treatments were rejected. I think doctors should pay more attention to the cost, but the doctors should do the expensive test or treatment if they are necessary and save further unneeded test or treatment.

3. The team approach with other staff such as psychiatrist, public health nurse, MSW was needed in this case. I learned from this discussion that if the patient cannot go to see the doctor, the family member or the doctor in charge can consult with the psychiatrist or public health nurse in the community mental health center. I think this kind of team approach could have changed the result of this patient. Alcohol dependence is one of the dark sides of medical field, but it is not a rare disease. As Dr. Fujibayashi said non-psychiatric doctors should learn the team approach with other staff for these kind of alcoholic problem.

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