Compared with a principles-based approach, taking a care ethics approach to patients who believe they are a burden may be more effective for addressing moral dilemmas related to treatment, according to research published in Bioethics.

Two clinical ethicists from the department of medical humanities at VU University Medical Center in Amsterdam, The Netherlands, shared the case of Mrs K, a 66-year-old patient with leukemia, and examined the ways in which physicians can approach treating a patient who feels like a burden.

Mrs K recently received a bone marrow transplant, but because of rejection symptoms, is now taking an antirejection treatment. Although a cure is possible, the treatment is both taxing and extensive and presents a host of physical and mental challenges. Although Mrs K had previously focused on survival, her mindset has shifted: She says that she is burdening her husband and feels that he deserves better. Mrs K feels that life is no longer worth living and has considered stopping her antirejection treatment, which will result in her death.

Noticing that Mrs K’s mood has been poor over a long period of time, the treating physician suggests antidepressant therapy; they believe that by treating the patient’s depression, the patient will be more optimistic about continuing the antirejection therapy. Mrs K’s husband — also a physician — strongly disagrees with this course of treatment. Mrs K’s care team contacts the clinical ethicist to address this moral dilemma.

In addressing this ethical issue, the authors consider 2 different approaches: the principle-based approach and a care ethics approach. The principle-based approach to addressing ethical concerns prioritizes respect for autonomy over other concerns. Conversely, the care ethics approach focuses on “being attentive and responsive to the caring needs of those involved in the care process.”

That is, the moral dilemmas are evaluated in the context of the patient’s identity, biography, and relationship; autonomy is viewed as relational, not individual.

In the case of Mrs K, the care team’s initial concerns were with the patient’s autonomy in relation to informed consent and what would most benefit Mrs K, as well as the patient’s ability to make “well-informed, well-considered, and voluntary decisions.”

The authors noted that in cases where respect for autonomy trumps other obligations or principles, the principles-based approach is preferred; however, after applying the principle-based approach to Mrs K, the care team continued to feel uneasy, primarily because Mrs K’s main motive for discontinuing treatment was her belief that she was a burden.

As a whole, the team thought it could do more to provide for Mrs K. In cases like this one, a care ethics approach may be more effective in examining the questions presented by the patient. This alternative approach focuses on “being attentive and responsive to the needs for care of those involved in the care process,” which, the authors noted, can be much more specific than receiving — or not receiving — treatment.

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In describing the 4 pillars of a principles-based approach — respect for autonomy, beneficence, nonmaleficence, and justice — the authors concluded that this approach does not adequately address the major motive that is affecting Mrs K: her belief that she is a burden. Alternatively, the care ethics approach prioritizes a holistic approach to medical care; the 5 key elements are attentiveness, responsibility, competence, responsiveness, and cooperation.

“[I]n this approach, respecting autonomy is not so much about informed consent but about supporting the patient to deal with her present physical and mental condition and to repair and retrieve her life together with that of her partner,” the authors wrote.

The care ethics approach requires that physicians ask and answer the following question: What does the patient need in order to deal with the changes in her life, both in her own body and in the relationship with her partner?

“A care ethics perspective focuses on supporting the patient and those who are involved in care for the patient,” the authors concluded, “acknowledging the relational context of the patient’s life and experience.”

Reference

Metselaar S, Widdershoven G. Moral dilemmas in (not) treating patients who feel they are a burden [published online April 23, 2019]. Bioethics. 2019;33(4):431-438.

This article originally appeared on Medical Bag