2972NRS - Health Law and Ethics Case Study Assignment Solution

Legal Issues Identify and discuss the legal issues raised by the facts in the case study. This requires you to:

1. Consider the facts and identify the legal issues in relation to consent.
2. If Adam and Lilith wish to sue Dr Abel what type of action would that be?
3. Identify the elements that they need to be prove for the action to be successful?
4. Describes the standard of proof that would be required for the action to be successful, and who bears the burden of proof?
5. Describe the defence that Dr Abel could raise. This includes describing the elements of a valid consent (with supporting case law and legislation) and the process for obtaining consent in those circumstances when an adult cannot provide it themselves.
6. If Adam and Lilith are successful what outcome could they expect?

Ethical Issues

Referring to the Universal Declaration on Bioethics and Human Rights:

• Identify three principles that are relevant in this scenario
• Describe how the principles apply to the facts in the scenario
• Describe where a conflict between these principles may arise by considering the different values of each of the people in the scenario
• Describe a process to address this conflict.

CASE STUDY SCENARIO

Adam and Eve have been happily married for more than 50 years and have one adult daughter, Lilith. Before they retired Adam worked as an accountant, and Eve was a cosmetics consultant. Although Adam is relatively well for his age he has very poor eye sight. Eve suffers with chronic gastro-oesophageal reflux, recurrent urinary tract infections and diabetes. To help manage her unstable diabetes, Eve is visited three times each week by the community nurse, RN Mary.

Eve has always been quite particular about her looks; over the past few years has undertaken several cosmetic surgical procedures, including liposuction a facelift and rhinoplasty. Eve has always had the same surgeon, Dr Abel, perform these procedures and has been very happy with the result on each occasion.

During her routine visit, RN Mary notices that Eve appears pale, lethargic and slightly confused. Eve cannot recall Mary’s name or the reason for her visit. RN Mary observes Eve test her blood sugar levels and notes that the reading is normal. She then records Eve’s vital signs, noting a slightly elevated temperature, before assisting Eve to administer her regular dose of insulin. Concerned that Eve may be developing another urinary tract infection, RN Mary suggests that Eve may need to see her usual GP. Before leaving for the day, RN Mary discusses her concerns with Adam who says that he has also noticed that Eve has recently become quite forgetful. Recalling that Eve had a doctor’s appointment scheduled the next day, Adam assures RN Mary that he will mention these symptoms to the doctor during the consultation.

Dr Abel. Eve was keen to have some further cosmetic surgery and had booked an appointment to discuss the possibility of an abdominoplasty. Adam and Eve both attend the consultation with Dr Abel. While Eve is very keen to proceed with the surgery, Adam is a little hesitant. He raises his concerns regarding Eve’s forgetfulness, and her elevated temperature with Dr Abel. Having known Eve for several years, Dr Abel assures Adam that Eve’s current symptoms are probably due another urinary tract infection and prescribes her a course of antibiotics. Dr Abel then proceeds to arrange Eve’s admission to hospital for the abdominoplasty.

On the morning of her planned admission, Eve is taken to the hospital by Adam, and their daughter Lilith. By this time her temperature had resolved, but she was still a little confused. Both Adam and Lilith commented to Dr Abel that Eve didn’t really seem to be herself. Dr Abel assesses Eve, and asks her whether she still wants the surgery. Eve indicates that she is still keen to proceed. Just as Dr Abel is about to leave the room, Eve asks Lilith and Adam why she is in hospital. Lilith reminds Eve that she is having surgery to ‘fix her tummy’, to which Eve responds, ‘oh that’s good’. Adam looks at Dr Abel, and asks whether it would be best to postpone Eve’s surgery until she is less confused. Dr Abel reassures Adam that everything will be okay, and as Eve has indicated that she is keen to proceed, the operation should go ahead. Adam looks at Dr Abel and nods his head.

Shortly after, Eve is administered a pre-operative medication and drifts off to sleep. As the ward RN begins to work through the pre-operative paperwork, she sees that the consent form in the medical record has not been signed. Observing that Eve is sleeping, she asks Adam if he would sign the consent form that Dr Abel had filled in. Adam signs the form.

Eve’s surgery proceeds as expected and after an overnight stay in hospital, she is discharged home. Several days later, during her regular visit, RN Mary notices that Eve has not recovered at all well from her surgery. She has an elevated temperature, is tachycardic and much more disorientated than she was before the surgery. RN Mary arranges for Eve to be transferred back to hospital. Unfortunately, Eve had developed a post- operative infection and sepsis. Despite optimum care, her condition rapidly deteriorated and Eve passed away. Adam and Lileth are devastated. They believe that, given Eve’s confusion and possible urinary tract infection Eve should not have been operated on and wish to sue Dr Abel.

Introduction

Due to rapid advancement in healthcare sector, several diagnostic and surgical procedures are available for the treatment of an advanced or chronically life threatening situation. People are keen to avail the advanced healthcare services as they are also aware of all these services. Surgical treatment has moved towards non-invasive therapy line which has successfully reduced the morbidity and mortality. Despite advancement, medical fraternity is facing huge challenge regarding legal and ethical issues as depicted in the given case study. Adam and Eve both are happy with their daughter, Lilith. Eve has worked as a cosmetic consultant and she is very particular for her looks. She is suffering from chronic gastro-oesophageal reflux, urinary tract infection and diabetes. Community registered nurse, Mary, visits her to help her for management and follow up three times per week. Eve has undergone various cosmetic surgical procedures in the past. During home visit, Mary noticed few symptoms and also discussed with her husband to visit general practitioner. Mary found out Eve is looking confused along with elevated body temperature though her sugar level was within the normal range. She expressed her concern for Eve that she might be having urinary tract infection. Adam also shared these symptoms with Mary that he has also observed the same vital signs. He assured Mary that he will discuss all the symptoms with the doctor during next visit. Eve scheduled her next visit with Dr. Abel who has conducted her cosmetics surgery. She was keen for her next surgery although that was not required at that moment. Dr. Abel gave an assurance to Adam that she will improve after the surgery which did not happen and her condition worsen. Lastly, she passed away leaving her husband and daughter alone. The given case study depicts several legal and ethical issues pertaining to healthcare treatment. This case is a perfect example of medical negligence where Dr. Abel took the final decision of surgery despite advising them to receive treatment for urinary infection (Sohn, 2012).

Legal Issues

Suffering due to medical negligence has become an important aspect of healthcare industry. A medical professional owes some responsibilities or duties to the patient once consulted for any illness. Doctors are trained to practice as per the legal laws to avoid any medical negligence (Rao, 2009). In the presented case study, Dr. Abel took Eve for the cosmetic surgery rather than discussing about her infections and other associated symptoms. He assured her family that her condition will stabilize after the cosmetic surgery. In general circumstances, surgery should not be conducted without stabilizing patient health condition. Patient, Eve was interested for the surgery as she was concerned for her looks. Here it was the responsibility of Dr. Abel to pursue her for the treatment of infection control rather than a cosmetic surgery. She was not recommended for any diagnostic test before commencing the surgery. Without knowing her actual condition surgery was performed resulting into death of the patient. Dr. Abel did not pay attention for her infection and performed the procedure for economic purpose. He did not think of the final outcome of the surgical procedure.

Deficiency of services denotes imperfection and inadequacy in quality of services provided by the medical doctor (Rao, 2009). Eve did not receive right treatment for infection control despite her husband expressed his concern. It was Dr. Abel’s responsibility to explain Eve’s condition before going for the procedure which did not happen. Doctor must informed the family about the treatment and its impact on health. The need of the hour was to treat infection first and then carry out the surgery if needed as it was the keen interest of Eve to look good. Dr. Abel must discussed negative outcomes of the surgery if infection not controlled properly. Inadequacy and deficiency of services both forms legal aspect for the case study. Eve’s family have right to complain against Dr. Abel.

Consent form must be obtained before performing any procedure. In this case, Dr. Abel himself filled up the form when Eve was sleeping and was asked her husband to sign it. A consent form highlights possible benefits and risks of the medical treatment. It also constitute a legal issue as risks associated with the surgery were not informed to the patient and her family. The need of conducting surgery was not told to Adam as he was worried for Eve. In situation when patient is not able to give his/her consent a family member must be explained about the whole procedure along with the outcomes (Anderson & Wearne, 2007).

As per the laws, Adam and Lilith can expect that experts cancel out Dr. Abel’s registration for not practice in future. Another possibility could be that he can be sent to jail along with some amount paid to Adam in response to death of Eve (Thomas, 2009). Dr. Abel can also raise issues in his defense for example, Eve wanted to opt for cosmetic surgery without knowing its impact so he did the surgery. Feelings of Eve have received respect by the doctor as looks were important for her.

Ethical Issues

Three principles are important in this scenario-

• Principle of ignorance of medical needs
• Principle of causing financial burden
• Principle of giving patient centered care

Ignored medical needs is considered as an important ethical issue. A doctor must initiate the treatment which is more important for the patient welfare rather than putting him/her into unnecessary surgical procedure (Rao, 2009). Dr. Abel completely ignored the patient’s safety and conducted the surgery. An urgent need was to treat Eve’s urinary infection that has also been suggested by the nurse but not paid attention by the doctor. Measures must be taken by the doctor in an order to save life of the patient which was completely ignored by Dr. Abel. Eve was suffering from serious urine infection when visited Dr. Abel for the treatment and her condition aggravated more after the surgery. The allegation against the doctor is that he conducted the surgery without explaining its impact on patient health. Surgery has increased the health complications with serious side effects. Life is more important than a cosmetic surgery (Rothstein, 2010).

Unnecessary medical cost is another ethical issue for the current case study. Conducting a cosmetic surgery is a costly affair and puts burden on family unnecessarily (Thomas, 2009). This money could has been used for other treatment and medicines. The doctor conveyed a message to Adam that surgery would definitely help her to overcome the situation. Adam trusted the doctor and signed the consent form. Eve approached the doctor first instead of visiting a GP (general practitioner) for infection management. The patient completely relied on doctor’s advice which was against her health condition. Now the doctor must be penalized who is responsible for the death of the patient.

Patient centered care is important to protect their rights. It is not a new concept for healthcare but it has gained popularity these days as it helps to improve the healthcare outcomes in a better way. Healthcare professionals have been trained for quality healthcare services. It is also known as ‘patient or family oriented care’ as interaction happens between staff, patient and family members. Patient and family both plays an important role in service delivery and are the important components of the system. Another important point to be noted here is that the decision making process which is worked out by taking individual views of patients, families and health staff as well. It also improves relationship of patients and healthcare providers. In healthcare setting, decision pertaining to patient treatment is very important to understand. Negative outcomes have been observed if decisions are based upon the experience and opinion of health staff. The above stated issue can be mitigated by following patient or client centered approach in medical practice. This approach put the patient at the center of decision making process. Patient receives power to decide about his health. It does not mean that they got freedom for anything rather allows people to play a role of an expert hence resulting into better healthcare results (McCance, McCormack, Dewing, 2011). Client centered care seeks people’s desires, opinion to find out better solution. It is important to pay attention and respect to patient’s thoughts. Health of the people can be managed effectively through sharing of decisions.

In this case study, doctor did not sought any views from Adam and immediately performed the surgery. The life of Eve could be saved if the exact situation would have been discussed with Adam.

Conflict can arise as most of the treatment are expensive these days so this particular did not create any pressure on patient’s pocket. Another conflict could be that a doctor knows better about patient’s health so patient centered approach might not work in each scenario. Hence these conflicts cab be overcome by relating importance of positive outcomes associated with these approaches.

Conclusion

The doctor cannot be negligent while treating the patient. Wrong medical practices have resulted into death of Eve. Dr. Abel holds the full responsibility of the health of the patient. He must be punished for his error of judgement. A doctor must bring a reasonable degree of knowledge for right treatment and must exercise his/her skills for faster recovery of ill health. It is the duty of experts to judge reasonable and unreasonable degree of care. The medical law requires the medical practitioner to follow a reasonable degree of patient care. Two types of medical negligence have been described by laws- simple and gross. A doctor has to be penalized for simple negligence while he/she can be sent to jail for gross negligence. Dr. Abel has done gross negligence hence requires to send him to jail as per laws. The medical professionals must practice for patient centered care which involves role of patient for his own health related decisions. Medical error which comes out in the form of patient death must be dealt with medical laws in court so that such cases do not happen in future.