Saving Life or Trumping Autonomy? A Question for Health Care Providers

With technological advancement, health care is becoming complex for the individuals and meeting individual expectations have become a great challenge for Health Care Providers (HCP). Health care providers face ethical dilemma in everyday situation for taking decision for patient’ better health outcomes. The aim of this paper is to highlight the controversy between giving patients’ autonomy in taking independent decisions and health care professionals’ expertise to breach patient autonomy in order to save a patient’s life and to provide maximum benefits to the patient. Moreover, this paper also highlights the significance of culturally sensitive care in health care setting. Research shows that in most of the situations, HCPs take decision in view of their expertise in the medical field. However, on many occasions, both HCP and patients are not satisfied with the decisions that are taken in the best interest of the patient.


Case Scenario
A 37-year-old female at twenty weeks of gestation of her first gravida was presented in a semi-conscious state in the emergency room of one of the tertiary care hospitals in Karachi. On examination, it was revealed that she had developed hepatitis E (HEV) infection.
After discussion with the team on board, doctor on duty advised her to terminate the pregnancy (TOP). To carry out the procedure, a written consent was required from patient and her husband. Upon asking for written consent, patient expressed her inability to take independent decision for herself, as she was dependent on her husband for all kinds of decisions. This patient was accompanied by her brother-in-law as in the particular tribe she belonged to it was considered a culturally inappropriate to be accompanied by one's husband while seeking gynecological treatment. The medical team consulted her husband through phone call and asked for his consent. The husband refused to allow the termination of pregnancy and stated that, "I am a Muslim by religion and abortion is considered a sin in Islam and I do not permit it; even if my wife life is at risk". After 24 hours, the patient's condition deteriorated and she lost her consciousness. The case was discussed with the senior doctors on board. The decision to terminate the pregnancy was taken by the medical team for TOP after taking consent from her brother-in-law and the procedure was done successfully. After TOP, the patient's condition improved and she was discharged from hospital. However, the patient and her husband were not satisfied with the medical team's decision for TOP as they were totally against the termination of pregnancy. Patient and her family belonged to a very remote and underprivileged area, they were not aware about the right to take legal action against the hospital.

Assumptions
In the above scenario, the patient and her husband were incompetent and incapable of taking the right decision by the HCPs. Hence, taking a paternalistic approach they took it upon themselves to decide what was in the best interest of the patient's health and safety.

Underlying Ethical Concepts/Principles
According to Beauchamp and Childress [1], autonomy is a norm of respecting the decision-making capacities of an autonomous person, and beneficence means providing benefits and balancing benefits against risks and cost. In the current scenario, there is a conflict between the medical team's decision for beneficence of patient's life and respect for husband's autonomy regarding his decision about not opting for TOP. On one hand, patient family's autonomy should be respected as to what they want for themselves, but on the other hand, being a health care providers on duty board to protect patient harm and make every effort for the beneficence of the patient and their family. Hence, the two ethical principles conflicting here are "autonomy" and "beneficence". So the burning question is whether a health care provider should respect a patient's/family's autonomy or let the patient die?

Rationale for Ethical Dilemma
This could be considered as an ethical dilemma for a health care provider because there are two ethical principles in conflict here and in the end, there are similar outcomes of each principle. Because if a health care provider observes one principle on the one hand then the other would be violated.

Arguments for the Decision taken by the Medical Team
Hippocratic Oath is an oath historically taken by physicians swearing to practice medicine honestly at the time of graduation and they are supposed to stick to the oath during their clinical practice.
Taking into consideration the Hippocratic Oath "….I will apply, for the benefit of the sick, all measures which are required…. ". In the current case, the health care professional's (HCP) decision for TOP was completely in favor of the patient and there was no other interest of the HCP except patient's beneficence.
Moreover, when this case was analyzed in the light of the teaching of Islam, there were different opinions given by different scholars; however, all sunni shiet scholars are of the opinion that a mother's life is more important than the fetus and hence, abortion is allowed in Islam in order to save mother's life.
On the issue of life of a woman, most of the Muslims think that a mother life takes precedence over the fetus life because mother's life is an actual source of life and a fetus life is potential to mother's life. Ayatollah Fazel-Lankarani [2] says, aborting a fetus is not allowed under any circumstances after the spirit has been breathed into the fetus, and before this time, it is not allowed unless the mother's life is in danger. According to Imam Khomeini [3], abortion for saving the life of the mother is allowed, whereas abortion is not allowed in the case of a mentally retarded mother if her life is not endangered.
In addition, the official judiciary notification bill was passed in 2004 to the national legal medicine organization which consists of 51 conditions for inducing abortion; among them, one condition was "the life of the mother was in danger" [4]. According to legal laws in Pakistan, abortion is considered illegal but there is one exception i.e., a mother's health is in danger then it could be allowed to save the mother's life. Patel [5] states that in Pakistan, till 1997 abortion was permitted to save the life of the mother but then the law was amended in the light of injunctions of the Quran and Sunnah. At that point also, abortion became legal in cases where it was necessary to provide treatment to the mother.

Counterarguments for the Decision taken by the Medical Team
In the above case scenario, patient was not fully conscious to give consent for TOP and her husband was also against the TOP. Health care team took the decision against the family's wish and went ahead with TOP. It is quite evident that the health care team violated the family's autonomy and used a paternalistic approach.
Autonomy is "self-rule, the ability to do as one wishes" [6]. Every person is independent and can make decision according to his/her wishes for medical treatment. Physicians and nurses should always think about the values and wishes of the patients regarding their treatment options [6]. Based on the liberalism theory, family should be allowed to take decision for themselves and they should always have the freedom to take decisions for themselves. In addition, as pointed out by Fried, Stein, O'Sullivan, Brock, and Novack, [7] physicians value the concept of patient or family's autonomy but always place it in the context of other ethical and legal concerns and do not always accept specific actions required for autonomy. Furthermore, Falkum and Forde [8] revealed that most of the physicians considered themselves experts in making decisions for patients and fifty percent of the physicians admitted that they give information to the patient in a way that patient have no choice but to agree with them.

Discussion
The intention was to save the mother's life because with severe Hepatitis E infection, a mother sustains the pregnancy to full term. Patra, Kumar, Trivedi, Puri, and Sarin [9] concluded that in pregnancy, viral hepatitis caused by HEV infection had a higher maternal mortality rate and worse obstetric and fetal outcomes than did pregnant women diagnosed by other types of hepatitis. According to Azmat, Bilgrami, Shaikh, Mustafa, and Hameed [10] states "Once the organs have formed, abortions are only allowed to save the mother's life". In addition, if we weigh beneficence and non-maleficence at one hand and on the other family's respect for autonomy on the other in this case medical manipulation resulted in great benefit for the patient's health and family in the end and leaving the patient just for the sake of respect for autonomy would have resulted in adverse outcomes. According to Mustafa [11], "it is also considered a great importance of societal benefit and public interest over the rights of an individual. This overriding consideration can be an example of autonomy contradicting beneficence.

Recommendations
Health care providers should educate the patient and their family about the importance of antenatal visits timely detection of any fetal abnormality.
Health care providers should counsel and facilitate patients and families for mutual decision making in health related issues.
Health care providers should be strongly encouraged to give culturally competent and safe care to the patients.

Conclusion
To conclude, confronting such ethical dilemma is a big challenge for the health care professionals to deal with particularly when a patient is in a critical situation and there is no room for waiting or delaying the decision. Being health care professionals it is our prime responsibility not to harm the patient and to provide maximum benefit to the patient. However, it is equally important to respect patients' preferences for care. What further complicates the matter that in this competitive era, culturally appropriate care is another big challenge for the HCP. Therefore, for a win situation, there should be mutual consensus between the patients and HCPs; therefore, it is essential to involve a patient in early decision making according to the weight of the benefits and risks for that patient. Patients and their families should be provided proper information and guidance to avoid conflict while making life-saving decisions.