One of the ideas central to medical ethics is that of patient autonomy. The conflict though is always determining exactly how much autonomy the patient possesses. Is it morally permissible to allow a patient to have complete autonomy? Do patients lose rights when they go to a doctor? Should a doctor do what a patient wants or what is in the best interest of the patient? Adding to which is the question, if the doctor is to do what is in the best interest of the patient, should or should the doctor not also consider the ramifications of a medical decision on all those affected by the decision on the individual? Integral to all these ideas is the idea of informed and voluntary consent, in that when it comes to making a medical decision the patient should be informed and with that information voluntarily consent to it. An idea contrasting patient autonomy is paternalism, which is where the doctor would do what he or she thinks is in the best interest of the patient, disregarding the patient’s wants or desires. These are the particular ideas, among some others discussed later, that will be analyzed in context of the Cowart case.
Dax Cowart was a regular guy till a freak accident severely injured and handicapped him into the hospital. Several times on the way to the hospital, though, Cowart requested for others to participate in his death by either asking the Farmer who found him to give him a shotgun, or asking the ambulances to not take him to the hospital and instead let him die where he was. Even when Cowart reached the hospital, he asked a nurse to either give him medication that will kill him or to do something that will help him take his own life. Neither the doctors, nor his mother would listen to his pleas for death, and the doctors having had his mother sign a consent form for surgery went on to perform it on Dax (Munson 99). Dax continually through the rehabilitation process wished to die and continued to ask others to partake in his death. Later, he would go on to say that the reason he wished to die was because the pain throughout the whole process was unbearable, and even if he does enjoy his life now, he still believes that every person has the right as to what can or cannot be done to their body; patient autonomy isn’t something that can be compromised, and ultimately the decision always lies with the patient as to what should be done with their body in a hospital.
Looking at this case, if the doctors had given Cowart more pain medication, which was afterwards determined they could have, then it is quite possible that Cowart would not have had this intense desire to die. Also, he might not have had as strong of an opinion on patient autonomy and this evidenced in the fact that Cowart states if all the circumstances were the same now he would still want to die because he believes patient has right to what should be done with their body (Munson 101). This is considering if the circumstances would have been the same, but if more pain medication had been given to Cowart, it would not be the same experience or circumstances, and therefore his opinion afterwards might have been altogether different. Cowart strongly believes in patient autonomy, but another issue to look at here is that Cowart had been brought to the hospital through the ambulance. It was not the doctors’ choice to have Cowart in the hospital, and considering the extent of his injuries, the doctors simply proceeded to do what they had been trained to do in their profession. Of course, the obvious questions here are whether the doctors should always feel the need to save patients or whether it is right for the doctors to feel that? But, considering a doctor’s entire training is about how to save lives, the doctors’ cannot be blamed for doing what they had been trained to do, especially considering that they saw how many patients in his condition had continued to live happy lives, and so in their view they were doing the right thing.
In a patient and doctor relationship, the patient comes to the doctor and not vice-versa. The patient comes because the patient is seeking medical advice that he or she is does not have the knowledge or training of, and while doing so the patient is giving up a level of autonomy to the doctor automatically. The doctor’s job then, ethically speaking, would be to discuss with the patient what their options are, the implications of each, and what the doctor thinks is the best thing to do. Then the patient can either agree or disagree, and if the patient neglects a necessary treatment that is vital for them, then it is still required of the doctor to inquire why the patient thinks that way and argue with the patient about what should be done. Ultimately, if the patient still disagrees with the doctor on a necessary medical decision, then the doctor should tell the patient to sleep on it or think over it and then possibly the next day have another discussion, and from there decide what the proper course of action should be. This was never the case in Cowart’s situation, Cowart from the beginning had been asking to not be treated and allowed to die, and all his pleas were ignored with the idea that Cowart was simply speaking out of his temporarily painful condition (Munson 99). After the treatment, Cowart had still wished to die, and the doctors brought in a psychiatrist to check if he was sane, it was verified he is; still, the doctors simply ignored his wishes. This brings about some things to consider.
One consideration is that his mother and the doctors acted in a paternalistic manner, in ignoring his wishes and doing what they thought was in the best interest for him before the treatment, and even after the treatment when he was verified to be sane. This does not seem to be completely ethical, as it ignores a competent patient’s wishes for what should be done to him or her, rather the path the doctors should have taken, possibly after the treatment, was the aforementioned process of discussion. The doctor should have properly discussed with Dax what the possibilities are after rehabilitation and treatment and why he shouldn’t necessarily considering dying, instead of simply saying he shouldn’t want to die (Munson 99). Such a process might have given Dax a different perspective. If Dax still wanted to die though, I believe the doctor’s response to him was proper when he told him that once his fingers were operated on, Dax could get a gun and shoot himself, but needs to stop asking others to partake in his death. The doctors’ role in this entire process was simply to treat him, as they may have had legal restrictions on their ability to act on his wishes. Even if those legal restrictions did not exist it could still be morally proper for the doctors’ to deny Dax’s wishes, in light of the knowledge they had of the possibilities Dax could enjoy after treatment. However, if Dax’s condition had been much worse, such as terminal, the doctor’s act to ignore his wishes might not have been morally acceptable. Regardless, the doctors’ were not entirely correct in the procedure and should have had that discussion.
Another issue to consider about the treatment of Cowart is that while in many cases of treating patients a discussion before treatment is usually possible, it might not have been the case in Cowart’s situation. Cowart was in an extremely horrible condition when he got to the hospital, and so the doctors had to act as quickly as possible. In their hurried actions, they advised Dax’s mother on what to do and got her to sign consent forms (Munson 99). It is possible that their action to treat Cowart, considering the immediate situation, was permissible. They possibly did not really have time to discuss with Cowart about going through treatment, as Cowart is not the only patient they probably had, and considering his immensely horrible condition they just needed to get the consent forms signed in order to the job they are trained to do in saving people’s lives. While, it may be acceptable that the doctors did not take an informed and voluntary consent from Dax, considering his situation, it is still another issue as to exactly what kind of advice they gave to Dax’s mother and if what information they had given her was sufficient for her to be informed and voluntarily sign the consent form. We do not know what exactly occurred there, and that is an issue of importance in the Cowart case in considering patient autonomy.
Some other interesting perspectives to also consider in the Cowart case are Utilitarian and Kantian. Cowart seems to continually argue a Kantian view that it is not okay what the doctor’s did because their actions suggest the view that the ends justify the means, which he believes violates the basic rights of a human being to have complete autonomy over his body (Munson 137). It seems that he believes that he should have been treated as end in himself, and not as a means for a doctor to save a life. He also suggests the Utilitarian perspective of John Stuart Mill when he speaks of considering acts of self-determination that are self-regarding and others-regarding; in the case of self-regarding acts the person should be left to their choice (Munson 137). He believed the doctors did not get his informed and voluntary consent on his treatment when he was in the hospital. This has already been discussed above, but I will mention just a few things in a little more detail. It might not have been entirely necessary of the doctors to receive his informed and voluntary consent, but the process of discussion with him might have been possible. Still, what must be considered in aspects to if what the doctors did is right in acting paternalistically is the number of hours and stress the doctors go through in treating one patient after another. It can become second nature to a doctor to know exactly what the possibilities of a patient is in their situation, and so in acting efficiently to save lives in the realm of the hospital, a doctor might treat the patient in a paternalistic manner; in the view of the doctors’ job in the hospital, this sort of action might be acceptable.
Some of the questions in the beginning of this paper were if the doctor should act in the best interest of the patient or what the patient wants or if the doctor should consider the impacts on everyone that is affected by the treatment of the patient? A Utilitarian perspective says it should be the latter of the three, but in the case of Cowart, there was really no one else outside of him and his mother. His mother was not dependent on him either. So in that view, it might have been important to consider the patient’s perspective more so than even his mother’s. But, this is where I believe, even though every patient has the right to reject treatment, there are some possible limits to patient autonomy in considering should the doctor do what the patient wants or what is in the best interest of the patient. As has been mentioned many times above, it is not the case with Cowart that he was bound to die, in fact for the doctors there was immense evidence that those who have been treated in situations like his continue to live great lives. Cowart even admits later that he was wrong, he enjoys his life now, and that the main reason for all his beliefs was the immense pain he went through (Munson 137). So, for Cowart to say what the doctor’s did in treating him is wrong, is in itself wrong because the doctors performed what their job was to do. Cowart was not going to die, and had immense possibilities of a happy life. The doctors’ knew all of this and that is why for them to hear a patient repeatedly saying they want to die, the decision borders on the ridiculous. The patient does not have the knowledge that doctors obtain through the intense training they go through. So, in the case of Cowart, it is almost the logical thing to do what the doctors did in treating Cowart. Yes, they acted in the best interest of Cowart and not according to what he wanted, but in comparison to what they knew and Cowart knew, what he wanted was not something logical and so the doctors did what they thought should be done for a person in so much pain. All sorts of things can be said about doctors acting paternalistically, but things have to be taken in perspective, with the fact that Cowart is possibly not their only patient, and they have to do things efficiently in the hospital.
Considering all of this, I believe one of the major issues is the perspective with which Death is viewed. Death is not always necessarily bad or good, it depends on the situation. In cases of neonates for example, it might not be a bad thing because there is not much a neonate that is suffering immensely would miss by dying. This, of course, changes though as age increases and there become a great many possibilities of things a person could achieve, experience, or in general live a pretty good rest of their life. The entire time, though, Cowart considers death to be something that is not bad, and is something possibly good because death would relieve him from his pain. While it is true that death would have relieved him from his immense pain, it is not the case he is terminally ill, and increased dosage of pain medication or better pain medication would have also relieved his pain. That is where the doctors’ fault lies. But I think the doctors’ are also right in treating him if death is viewed as something bad in the sense that it disallows possibilities of a pretty good life, which the doctors knew could very well exist for Cowart. If death is viewed in this scope, then what the doctors’ did in acting paternalistically was correct in the particular situation.
The implications of the doctors always acting paternalistically or the patient always having complete autonomy are dangerous as they allow for a lot mistakes and mistreatments to possibly occur. This is why it is important for there to be such things as informed and voluntary consent, and the need for discussion between a patient and doctor. The issue of patient autonomy is always going to be present, and I believe Cowart’s case gives us an opportunity to evaluate what should have been done right, what possibly was done right, and what the consequences of all these things are.
Munson, Ronald. “Confronting Death: Who chooses, who controls?” Intervention and reflection: Basic issues in medical ethics. Ed. Dax Cowart and Robert Burt. Thomson: Belmont, CA, 2008. 98-101, 134-137.