Medical Paternalism Cases

Medical Paternalism Cases

Case 1 (from the 2005 National Ethics Bowl)

Dr. Thomas Daley was happy to see Kelly Patterson. He had been following her budding acting career through the local community newspaper. A 17-year-old high school senior, she would be graduating in a few months and heading off to the state university to major in theatre. He recalls the shy, reclusive girl she was before her rhinoplasty some years ago. Although Kelly’s mother was initially leery of a nose job for her then 11-year-old daughter, she and Kelly were desperate to put an end to the merciless teasing by other children about her nose. According to Mrs. Patterson, plastic surgery on Kelly’s nose dramatically improved her self-confidence. “She just became a different person, so much more outgoing,” her mother said, “it made such a big difference in her social life.”

Kelly and her mother entered Dr. Daley’s office and made small talk for a minute or so. Dr. Daley then asked Kelly about her reason for the appointment. Kelly looked at her mother and then said that she had been doing research on the internet about breast augmentation surgery and would like to undergo the procedure. Dr. Daley first assured Kelly that she was perfect the way she was. He then expressed some reservations about performing the procedure and sent the Pattersons away with some informational booklets that detail risks and side-effects of breast augmentation surgery.

Later that month, Dr. Daley found himself at the conference on plastic surgery, talking informally to another plastic surgeon, Dr. Sarah Carlson. He recounted to Dr. Carlson his discussion with Kelly and Mrs. Patterson, and then added that, although he does not doubt that she is sharp enough to understand the factual complexities about the breast augmentation procedure, he still, nonetheless, felt morally uncomfortable with Kelly’s request. Dr. Carlson confessed that in southern California, where she practiced, it was not uncommon for girls Kelly’s age to undergo breast augmentation surgery. “Besides Tom,” she said, “if you’re ethically uncomfortable with performing the surgery, you can just tell her that you won’t do it, that she’ll have to find someone else.” Dr. Patterson nodded and pointed out that where he practices, most plastics surgeons refuse to do breast augmentations on adolescents.

A few weeks later, Dr. Daley met with Kelly and her mom. They discussed the procedure in detail. Kelly’s remarks and questions reflected a thorough understanding of the risks and side-effects of the procedure.

Case 2 (from the 2001 National Ethics Bowl)

Kevin Wright came to Dr. Robert Smith, a general surgeon at Falkirk and District Infirmary in Scotland, with an unusual request. He wanted one of his legs to be amputated below the knee. Dr. Smith referred Mr. Wright, a teaching assistant from Essex, to the senior psychiatrist at Falkirk and District Royal Infirmary, Dr. George Dodds, for a psychiatric consultation. After meeting with Mr. Wright, Dr. Dodds said that he could not support the surgery and so advised Dr. Smith, the surgeon.

Despite Dr. Dodd's negative recommendation, and without further consultation, Dr. Smith amputated Mr. Wright's leg below the knee, as requested. Earlier in the year, Dr. Smith had carried out an amputation on a German citizen, Hans Schaub. In both cases there was no medical reason for amputating the limbs. The limbs were physically healthy and not diseased or deformed in any way. According to a report by Dr. Smith, Mr. Wright subsequently e-mailed him and said that he was very happy after having been in misery for thirty years. Dr. Smith admits that he does not understand the motivation of these patients: "It is a concept I still have difficulty in understanding," he said.

Both patients were diagnosed as suffering from Body Dysmorphic Disorder, a condition in which people feel that some part of their body is defective. This disorder is not listed in the Diagnostic and Statistical Manual (DSM-IV), the standard manual of psychological disorders used in the United States. Those experiencing this disorder experience intense dissatisfaction with the presence of one or more limbs themselves, and in some cases will even attempt to amputate the limb themselves, often with undesired results. Apparently psychological and psychiatric therapy does little to assuage their desire to have a limb removed.

Although the operations were performed in National Health Service hospitals, the patients were private patients who paid the cost of the operation personally. Dr. Smith received no fee for the surgery.

When Dr. Smith revealed that he intended to perform a third amputation, this time on an American psychoanalyst (Greg Furth, a Jungian analyst in New York) who also wanted a healthy limb removed, the hospital board learned of his plans and refused him permission to perform the operation. At a news conference, Ian Mullen, a spokesperson for the hospital board said: "I don't believe it's appropriate for this type of operation to go ahead without consideration being given to the potential implications for the local reputation of the hospital and the concerns that might arise among the local population.

Case 3 (from the 2006 National Ethics Bowl)

In April of 2004 Julie Lacey of Fort Worth, Texas was told by a pharmacist at her CVS local drugstore: "I personally don't believe in birth control, so I'm not going to fill your prescription. Outraged, Ms Lacey, who had come to the drugstore at night for a last-minute refill of her prescription for the Pill, immediately protested to the assistant store manager. This did not result in her getting the prescription filled, so the next day she lodged a complaint with the CVS district manager. After doing so she received a call from the pharmacy supervisor, apologizing, and assuring her he would have her prescription filled and sent to her that day.

Situations similar to the one encountered by Ms Lacey have become an increasing matter of concern to groups concerned with reproductive rights. "Refusing woman the Pill is a very disturbing trend, " said Gloria Feldt, President of Planned Parenthood Federation of America. On the other side of the issue, members of Pharmacists for Life International, an anti-abortion group, contend that they have the right to refuse to fill prescriptions for the Pill. According to the organization's President, Karen Brauer, R.Ph., "our job is to enhance life. We should not have to dispense a medication that we think takes lives."

In regard to the claim that the Pill "takes lives," many anti-abortion pharmacists (and anti-abortion physicians also) accept the idea of a "post-fertilization effect" associated with use of the Pill. This idea is developed (as well as elsewhere) in an article authored by Dr. Joseph B. Stanford, Assistant Professor of Family and Preventive Medicine at the University of Utah (Archives of Family Medicine, Feb., 2000), cited widely by anti-Pill groups. In Dr. Stanford's opinion, the Pill fails to prevent ovulation and fertilization of eggs with much greater frequency than most experts maintain. Furthermore, according to Dr. Stanford, such fertilized eggs (which anti-abortionists consider to qualify as human beings) cannot attach to the uterine wall because, he believes, the wall becomes hormonally altered when a woman uses the Pill.

The claim that the Pill hinders implantation, however, has never been confirmed scientifically, according to Dr. David Grimes, a clinical professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine, and a leading authority on contraception. Even the American Association of Pro-Life Obstetricians and Gynecologists concedes that it is only speculation, says Dr. Grimes. Furthermore, reproductive rights groups point out that in addition to preventing unwanted pregnancies, oral contraceptives may be used for other important purposes. For example, they note, the Pill may reduce the risk of cervical cancer. "There are easily more than twenty non-contraceptive uses for the Pill", according to Dr. Giovanna Anthony, an attending physician in obstetrics and gynecology at Beth Israel Hospital in New York City.

At this time three states, Arkansas, Mississippi, and South Dakota, have enacted "conscience clauses" that provide legal protection specifically to pharmacists who refuse services on moral, ethical, or legal grounds. Similar legislation has been introduced recently in eleven more states. The laws of most states, however, allow drugstores to require pharmacists in their employ to sign agreements that they will dispense all lawfully prescribed medications. Recently a pharmacist in Wisconsin (allegedly) refused to fill a women's prescription for the Pill, and the State department of regulation and licensing filed a complaint against the pharmacist.