The trials to see what can be most

The Case:

My name is Stevie and I am a nursing
student currently learning what being an advocate for my patients is, how to
care for them, and how to handle ethical dilemmas when they are presented to
me. In the case of my father, he has received news of having stage II
esophageal cancer and not wanting treatment, knowing it will cause a grave
burden on him. I am faced with the ethical dilemma of going against my father’s
morals and what he believes in by signing for him to receive treatment for his

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Steven is a 53 years old husband and
father – he is married to Paula (49) and has three children Ashlee (31) and Zakary
(29) and myself (22). My father has been married for 25 years to my mother, his
oldest children being from his first marriage. My father works as a postman for
USPS, outside of work he likes to be kept busy: he enjoys walking the dog with my
mother, doing yard work, crafting and fishing. My father is very independent,
wanting to do his own work and make his own decisions for himself.  But, recently my father has been having
complications with bronchitis and went for a checkup at the hospital, knowing
that bronchitis is a sign of esophageal cancer. Esophageal cancer is very
prominent in my father’s side of the family, three males on my father’s side
have died from esophageal cancer, bronchitis being the leading sign to
discovering the cancer. After running test, the doctors have discovered that my
father has developed stage II esophageal cancer. Stage II esophageal cancer has
multiple ways that it can be layered and spread within the esophageal lining
and has the high chance of spreading to the lymph nodes in this stage. The doctors say they can start with
clinical trials to see what can be most effective for my father in treating his
cancer, but they also don’t know the extent of the cancer and if it has spread
or not. The options would revolve around a chemotherapy and radiation treatment
or an extensive surgery. Its stated by the UNM Comprehensive Cancer Center that,
“Treatment of patients with radiation therapy,
chemotherapy or both therapies after surgery has not been shown to affect
survival of patients with stage II cancer of the esophagus.”
This means that there is a
chance treatment may change the survival rate or may not work as needed. If my father could have an easy
surgery or medical treatment that could guarantee to save him then he would
sign for that treatment or surgery, but not in the case of an intense treatment
like chemo therapy or radiation. My father has always told my mother and I that
if he is in a state of illness that is hard to recover, or the only option is
to have hard and extensive treatment, that he does not want the treatment. My
father has never feared death, he always knew that in the case of a fatal
illness or disease he would welcome it to avoid the burdens that could be caused.
My father does not want to lose the ability to work, continue his hobbies, or
do the regular walks he takes because the treatment would cause him to weaken
faster and be in the hospital constantly. My father would be living with the
grave burden of knowing my mother and I are suffering watching him suffer from
hard treatment and that we would gain financial problems from extensive medical
bills. My father wants to remain as strong as he can at home with my mother and
me. In a sense my father knows what to expect because his brother died of
esophageal cancer, without treatment, so he knows that eventually the cancer
will cause him to not be able to make his own decisions. So, when that time
comes my father wants my mother and I to monitor him and oversee his decisions.
My mother knows it will be hard to watch my father refuse treatment, but she
wants to respect my father’s life choices because he knows what is best for him
and his life. As a nursing student I want to follow my practice and morals by respecting
my father’s values and medical decisions, but as his daughter I know if given
the opportunity to proxy consent for my father’s treatment I would be put in a
tough spot deciding what to do, especially if I knew I could prolong his life.

Am I facing an ethical dilemma here?

Steven is married and has three children,
his two oldest being from his first marriage. He is a hard-working man and
enjoys being kept busy with hobbies and work. My father had bronchitis leading
to the discovery of stage II esophageal cancer and has decided that he would
rather have the fatal pathology take his life than living with the grave burden
it would cause him. Choosing to let the cancer take his life is an easy
decision for him knowing the grave burden outweighs the disease, the grave
burden is why he does not fear death. The grave burden my father would be
living with, if he chose treatment, would be putting my mother and I in a
financial crisis with the ongoing and multiple treatments. Especially with the
potential risk of the cancer coming back regardless of if the treatment worked.
The other part of the grave burden being he does not want to see us suffer
watching him suffer more from the treatment, he’d like to stay out of the
hospital if he can. When it comes to decision making and values, my father
wants my mother and I as his advocates because we know what he wants and what
is best for his life, compared to my older siblings who do not know his values
as well as we do. My mother wants to respect my father’s decisions and choices,
but I am put in an ethical dilemma of signing the consent for treatment. I know
there is a possibility I could prolong his life for a few years, but is that
worth the grave burden on my father based off my own needs? So, is it
permissible, impermissible, or obligatory for me to sign consent as my father’s
proxy to start cancer treatment even though my father refused knowing it would
cause a grave burden on him?

Analysis: Background Information

Proxy consent is when a patient is unable
to give informed consent, another person is called to offer a substitute
informed consent. A proxy consent is ethical when a patient can not offer
consent and the person offering proxy consent must make the decision off what the
patient would choose if she or her were able to. If you do not know what the
person would choose you base it off what a reasonable person would choose. In my
father’s case, he knew when the time came he would not be able to  decide for himself informing us that he would
not want the treatment if we were asked to consent for it.

A fatal pathology is an illness or disease
that effects the persons daily living, and if not treated it will cause death.
The fatal pathology in my father’s case is the stage II esophageal cancer. My
father has recognized that the grave burden is causing more of an effect in his
life than the fatal pathology, this means the moral obligation to treat the
cancer decreases because he can no longer pursue the purpose of life. Since the
moral obligation is decreased we need to take in into count all the basic human
needs, not just the physical, and focus on my fathers psychological, social,
and spiritual/cultural needs as well.

Leading to what a grave burden is and why
it’s okay to allow the fatal pathology to take its course. A grave burden is
when a patient cannot live with the medical therapy anymore, it is not helping
because of the burden it has caused. We want to prolong peoples lives but we
also want to stop the pain and suffering, mentally and physically. So, even if
we can alleviate the fatal pathology it is not obligatory if it is causing the
patient a burden. In my father’s case, it is his decision that the medical
treatment would cause a grave burden because it will cause him to suffer
emotionally having my mother and I see him suffer and knowing the financial
burden it will cause us. Therefore, it would be morally okay to allow my father
to die from the cancer because living with the grave burdens would cause my dad
to lose purpose for living.

Analysis on stage II esophageal cancer and
how it progresses, as stated by the Cancer.Net Editorial Board: “Stage IIA has
either condition: The tumor is located in the upper
or middle part of the esophagus, and the cancer is in either of the 2 outer
layers of the esophagus or The tumor is located in the lower part of the
esophagus, and the cancer is in either of the 2 outer layers of the esophagus.
The tumor cells are less differentiated.” And “Stage IIB: has either of these
conditions: The tumor is located in the upper or middle part of the esophagus,
and cancer is in either of the 2 outer layers of the esophagus. The tumor cells
are less differentiated, or Cancer is in the inner layers of the esophagus and
has spread to 1 or 2 lymph nodes near the tumor.”


Level I is focused around one’s own
self-interest, they obey commands to avoid punishments. Obedience can lead to
gaining awards and favors to be returned. If I acted on level one reasons I may
sign the consent, so I don’t get blamed for my father’s death by my siblings
because I had the chance to sign. Another reason I may sign the consent would
be because I am not emotionally ready to see my father die because I don’t want
to suffer knowing I could have potentially saved him. Reasons I may not sign
the consent would be avoiding my mother being angry at me because I do not want
her mad at me when I knew what his requests were. Another reason I might not
sign the consent would be because I would not be able to watch my father get
even more ill from the chemo, knowing it would pain me to see him loose his
energy at an even faster rate. I want to avoid bad punishments by not signing,
but I also have the chance of being a hero if I sign the consent. Therefore, if
I acted at Level I my rewards and punishments would be clashing, meaning I
would never be happy with either decision I make. So, acting at Level I shows a
conflict of self-interests which will lead to no consensus.

Level two is focused on the social roles,
fitting into society and pleasing the people around us. You focus your actions
around the people you see as more of an authority over others, wanting to maintain
good relationships and approval from society. Reasons I might sign the consent would
be because as my father’s daughter I see this as the best option of protecting
my father from death. Another reason I might sign the consent, so my siblings
would approve of my decision to sign. I might not sign the consent because as a
proxy I need to sign the consent respecting my father’s wishes because I knew
his intentions on treatment before he was unable to speak or decide for himself.
Another reason being I can avoid disappointing my father and not loosing his
trust by signing when I knew his request. Therefore, acting at level two leads
to social role conflicts because there are no clear solutions between the
choices. Since there are no clear solutions that means acting at level 2 will
lead to no consensus. 

Level 3 thinking is based off the morality
of universal principles. You obey rules that are given, and you apply the
universal more principles to your situation. Level three thinking mainly
focuses its decisions on the principle of respects for persons. Respect for
persons requires us to respects all people in included, so the decision can be
acceptable and free of conflict. In the case of my father I need to be
respecting the people involved, which is my father, and even my mother because
she is respecting his decision. So, if I do not sign the consent for my father
to start treatment I will be avoiding conflict and the abuse of power I am
given with the option to sign.

the Proposed Course of Action: Seven Moral Principles

The principle of respect for persons is
treating people with the respect that you would treat yourself, respecting
their dignity and their worth as a person. I need to respect my father as a
person, agreeing that he knows what’s best for himself when meeting his four
basic needs: physiological, physical, social, and spiritual/cultural. Just like
I know what’s best for me and my four basic human needs. I need to respect my
father’s psychological needs in knowing that he would be living with a graven
burden if I agreed to sign for him to start treatment when he does not want it.
I know my father deserves respect for his decisions and what he believes in
best for him. if I were to sign the consent for treatment I would be violating
the principle of respect for persons and my father’s dignity.

The principle of non-malevolence states
that we need to avoid harming people, no matter what we are doing. In my
father’s case of the grave burden causing him to not want treatment, it would
be the fatal pathology harming my father. But, if I were to agree to sign the
consent I would be harming my father, not the cancer or treatment. Meaning I
would be violating the principle of non-malevolence because I would be
violating my fathers four basic human needs, especially his psychological. 

The principle of benevolence is used to
promote the wellbeing of others, we need to act towards the needs of others. I
need to act toward the needs of my father, supporting him in his decision of
not starting treatment so he does not live the rest of his life with a grave
burden. If I do not consent, physically the fatal pathology will take his life
but psychologically I will be preventing the grave burden of him worrying about
our suffering and the finances the chemo therapy will cause. If I agree to sign
the consent, then I will not be promoting the best wellbeing for my father. What’s
also important for me to think about is that I am going though nursing school
and they teach us the importance of being an advocate for my patients. So, even
if my father is not my patient I need to be an advocate for him, promoting
what’s best for him and what he wants for his life. It is in my morals as nurse
student and person to respect and be an advocate for those that need me. Therefore,
if I sign the consent I am violating the principle of benevolence because I am
not promoting what my father wants for his four basic needs.

The principle of integrity focuses on
respect for one’s self and the decisions they make, also respecting yourself
and your decisions you make as well. This principle focuses on the consistency
of our decisions, so we don’t become hypocrites with the decisions we make. As
a future nurse I am meant to be an advocate for my patients, basing my care off
their decisions and their integrity. If I disrespect my father’s integrity I am
disrespecting my own because if one of my patients told me that they did not
want anyone to sign for them I would respect that because that is their
decisions and it should be just as easy to respect for my father. Based off
these morals, I am violating my own integrity and being a hypocrite if I don’t
act off my father’s decisions, meaning I am doing it for my own benefit and not
his. If I disagree with his decisions I would be questioning and violating his integrity
and his cultural values and beliefs. I do not have to compromise my own
beliefs, but I need to respect my father integrity for what he believes in. I
want what’s best for my father, which means I need to respect his decisions and
his integrity. Therefore, if I sign the consent I am not only violating the
principle of integrity I am violating my father’s integrity and my own
integrity as well.

The principle of justice focuses on
treating human beings fairly. Justice can be difficult because we may have to
act against what someone values or believes. In the case of my father I can not
sign the consent for treatment because I know his views and values, I need to
treat him fairly. I need to treat my father fairly because it will bring
justice to him knowing he gets to live the rest of his life the way he wants to,
not living with the grave burden of what me and my mother will live with. I
need to remain unbiased and fair, even if he is my father because everyone
needs to be treated fairly towards their needs. Meaning if I sign the consent I
would be violating the principle of justice because I would not be treating my
father in the appropriate and fair way, know justice would be brought towards
his needs.

The principle of utility has the intention
of producing the best outcome and choosing the most good. We need to find
several good sources that can offer different actions in the problem, or in
solving the problem. For my father’s situation utility does not apply because
there is only one option and that is not to sign the consent. It would be
impermissible to sign because that is not an option to my father, I do not have
any other good choice. So, I need to respect my father and his choice to not
have treatment. If I do not sign the consent I am doing the best that I can,
and that is respecting my father and his decisions.

The principle of double effects is
treating people with respect and making sure the bad does not out weigh the
good. In my father’s case double effect does not apply because it would be
impermissible for me to sign. I would be causing a bad consequence if I sign
because I would be going against my father’s decision, meaning I would be
outweighing the good even if that means allowing the fatal pathology to take my
father’s life. If I respect his decision, the fatal pathology taking his life
is unintended. Signing would outweigh the good, meaning double effect does not


Is it permissible, impermissible, or
obligatory for me to sign consent as my father’s proxy to start cancer
treatment even though my father refused knowing it would cause a grave burden
on him? It would be impermissible for me to sign the consent because I have
violated the seven moral principles, meaning I have violated my fathers four
basic human needs and what he values. As a proxy and most importantly a
daughter, I need to look at how this decision will benefit him, meaning I need
to respect my father’s dignity and morals by not signing the consent when the
opportunity is handed to me. If I think at level three I will be obeying the
rules and applying the moral principles that bring no conflict to my father’s
decision, respecting him as a person. Therefore, I will not sign the consent, allowing
my father to alleviate his grave burden and meet his needs in the way that will
give his life purpose.