Academic journal article The Hastings Center Report

Respectful Service and Reverent Obedience: A Jewish View on Making Decisions for Incompetent Patients

Academic journal article The Hastings Center Report

Respectful Service and Reverent Obedience: A Jewish View on Making Decisions for Incompetent Patients

Article excerpt

Conflicts between staff and family regarding the care of elderly and incompetent patients have dominated my own involvement in clinical ethics consultations, and that of many of my colleagues. These conflicts are framed in categories that have become canonical in bioethics: the best interests of the patient, advance directives and substituted judgment, death with dignity, and the family's right to privacy, among many others. There are of course a range of issues--about tube-feeding, or resuscitation, or pain control, or restraints--and a range of conditions causing incompetence--dementia, stroke, psychosis, acute metabolic instability. Yet the major themes underlying the diversity of appearance are conflicts: over the goals of treatment, over the aggressiveness with which these should be pursued, and over who should decide.

I had been involved in these discussions--often long, sometimes heated--many times before realizing that I had been failing to identify what the underlying issue is, from the family's point of view. The failure was not mine alone. It was shared by nursing and medical colleagues. In retrospect, I believe the problem to have been one of perception, a substitution of ground for figure, as the Gestalt psychologists would put it. And bringing bioethical categories to bear was obscuring the family's point of view, rather than clarifying it.

The family members with whom I dealt were most commonly the patient's adult children rather than the patient's spouse, who was deceased, or incompetent, or overwhelmed. The children dreaded, rather than welcomed, their involvement in this task; there was, in their assumption of this role, no prideful claiming of a right. And while they might, in the course of discussion, claim superior knowledge of the patient's wishes and values and judgment of his or her best interests, these claims too did not exhaust the reasons why they demanded decisionmaking authority.

At its heart, the claim of these adult children was simple: for them, the duty of rendering medical decisions was continuous with, or an extension of, a general duty upon the family to care for its members who cannot care for themselves. As an ethicist and as a Jew, that claim should have been clear to me. Reaching sound decisions about medical care was, for these children, the last chance they would have to fulfill the Fifth Commandment: to honor their fathers and mothers.

In what follows, I want to explore the dimensions of this filial obligation, and how it may apply within typical clinical settings. The sources that I will bring to bear come from my own tradition, but I think they are (to coin a phrase) "small-j Jewish." Unlike many realms of Jewish reflection, the law and norms of the duty of children to their parents is not dominated by ritual or parochial concerns. The issues raised, and the ways they may be resolved, may be shared by persons of whatever background, as in this case.

Ethics Consultation: Mother, Daughter, Home Care Services. A ninety-two-year-old woman had been cared for at home by her daughter for the past eight years; the daughter is said to have made a deathbed promise to her father to tend the woman. The patient was admitted with an infection (probably pneumonia), which has now been cleared. She is ready for discharge, scheduled for tomorrow. However, she is not mobile and discharge evaluation has confirmed she is not "rehabilitable." In all respects, however, she has regained the same level of ability she had prior to admission.

Her daughter was described to me as "pathologically devoted." She has been by the mother's bedside day and night throughout this hospitalization, leaving only to nap for a few hours while someone else stays with her. This daughter refuses to sign high-care, long-term care nursing home papers for her mother, she wants to bring her back home. The physician agrees that with maximal community and home care support this could be attempted safely. …

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