Academic journal article Issues in Law & Medicine

Getting Down to Cases

Academic journal article Issues in Law & Medicine

Getting Down to Cases

Article excerpt

Moral reasoning in clinical decisionmaking does not consist of drawing formal deductions from invariable abstract principles. It requires discerning judgment that weighs the uncertainties, complexities, and probabilities that the facts of a case present and determines how what is known about the case defines the principled basis for resolving whatever questions arise. (1) Reasoning must take account of reality.

No set of rules or unified theory can satisfy the demands presented by the facts of a given case, and the unreflecting invocation of a particular principle or a preordained solution can only deadlock any progress in moral theory and real life. Given our constitutional commitment to protect life and liberty, reconciling those values to the realities and uncertainties of human existence is the only way to sustain our way of life (2) and to avoid the tyranny of principles that can make life not worth living.

This case demonstrates the inadequcy of reasoning from the theoretical language of rights without strict regard for the facts of the case. It attempts to pit the "right to life" against the "right to liberty" (some would say the "right to die") in the belief that these are irreconcilable, in a situation that may not even warrant the assumption that a genuine controversy exists. It is only when we determine that the facts preclude a choice that upholds both of these rights that we must delve further into the case to determine which facts provide a principled basis for resolving this conflict in a way that gives due respect to each.

Based on my review of the facts, my primary conclusion is that the cause presents no real conflict and, accordingly, no justiciable controversy. If additional information establishes that there is a genuine dilemma concerning the consequences of withdrawing Mr. Stevens's feeding tube, I address the factors that need to be considered in order to reach a decision on that question.

The Case

Mr. Stevens is the victim of an accident that has severely and irreparably injured him. We do not know any details regarding the actual trauma he suffered or whether, and if so what, heroic measures were administered at the accident scene in order to save his life. These facts, as well as a more complete, detailed medical history, would help us place his current situation in a broader context. We would want to know where Mr. Stevens was treated prior to his discharge, e.g., in a head trauma or rehabilitation center, his course of treatment, and the reasons for his discharge. Based on what is presented, I assume that his current condition results from the irreversible effects of anoxia at the time of the accident. Despite the best efforts to restore Mr. Stevens's lost cognitive functioning, it is undisputed that his condition will never improve. He is totally disabled and is permanently dependent on the staff for all of his maintenance.

Absent medical opinion to the contrary, there is no reason to doubt the diagnosis or prognosis rendered by the physicians, although the court should inquire into the thoroughness and accuracy of the tests employed by the doctors in reaching their conclusion and examine the medical record to evaluate how his current condition compares with his course of stay. The court should seek further information about the nurses' belief that Mr. Stevens appears to act responsively and volitionally, visiting the patient to observe the behavior that the nurses and Mr. Stevens's eldest daughter attribute to some form of interaction. (3) It is not uncommon to mistake reflexive for volitional action, and we must avoid seeing what is not really there. We would need to know whether such behavior actually occurs and relate what they observe to his condition. Board certified neurologists experienced in the diagnosis and treatment of permanently unconscious patients are best equipped to explain the significance of the patient's movements. …

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