Doing Good and Avoiding Evil
Saul Steinman is a physician in private practice in Timberville, a Middle Western industrial town with some fairly tough neighborhoods. One of the families in his practice has been having no end of trouble with their youngest, Ricky, a boy of high school age who attends school when he feels like it, and spends most of his time on his motorcycle. His parents helped him buy it, on advice that it would help his self-esteem, and have regretted the move ever since: not only does he roar around town when he's supposed to be in school, but he's started drinking fairly heavily, even when operating the motorcycle, and he will not wear a helmet. His mother attends every prayer group her church offers, praying for his safety; his father threatens, his sister pleads, Dr. Steinman has tried to talk to the youngster, but nothing seems of any avail in changing his behavior. Now Steinman gets the phone call at two in the morning: Ricky's been in an accident, plowed into a parked car, he's in the hospital, in a coma, apparently dying, would he come and see what should be done? By the time he gets there, the ER staff have Ricky stabilized, more or less, but tell Steinman privately that there is "massive" brain damage, and they do not expect the boy to live.
Eight months go by. Ricky is still in the coma. The condition he is in, called a "persistent vegetative state (PVS)" by the hospital, is confusing; he breathes on his own (without a respirator), every once in awhile he opens his eyes, moves around, seems to be conscious--but he isn't. He sees nothing, he can't eat (he is completely dependent on a feeding tube), he doesn't react to his surroundings at all. After frequent neurological consults, neither Steinman nor the consultants can say for sure that he will never come out of it, but everyone has about given up hope that he will. More importantly, as Steinman reminds the parents every so often, if he does come out of the coma, he will not be the person they remember; much of the cerebral cortex seems to have been destroyed. He will never be a functional adult. The parents, when they talk to Steinman, are beginning to ask if they should "pull the plug," meaning in this case, take out the feeding tube, discontinue the occasional antibiotics, and simply let him go.
Dr. Steinman knows, as the parents do not, that a new "Right to Life" group has just started up in the town, and will expect to be consulted on this matter. He does not know what weight to give to this expectation. Meanwhile, the boy is using up medical resources, to very little purpose, it could be argued. And there is the inescapable fact that it was Ricky's own negligence that led to this tragedy.
Dr. Steinman is badly troubled. Under the circumstances, what should he say?
George Fredericks, town manager of Beachside, sat in his office overlooking the ocean on a Friday afternoon, trying unsuccessfully to come to a decision. The schedule has him appearing before the Board of Selectmen on Monday night to make a recommendation on beach access, in light of the recent protests from Duncan's Hill and other nearby towns. He simply does not know what to recommend.
The favored town of Beachside has six miles of excellent public beaches in a crowded area of the country, where beach access is worth a great deal of money. Beachside adopted, very early, a policy of excluding all nonresidents from its beaches, and began issuing beach passes for residents and their friends when the town became too large for the beach patrol to tell nonresidents from residents by sight.
When Federal law decreed that all beaches, at least below the high tide mark, had to be open to all on the basis of equal access, Beachside immediately complied with the law and declared the beaches open to all. But the parking lots for the beaches, on town land, were for residents only, and there was no parking allowed on the streets near the water. A scale of monstrous parking fines, well publicized and well enforced, rapidly established that Beachside was serious about the parking restrictions. The nearest legal street parking was about a mile away from the water, making a very long trek for anyone with beach umbrellas or children. The result was, as predicted and desired, that very few non-residents spent very much time on Beachside's beaches.
Duncan's Hill, the nearest inland town, had lodged a protest about a year ago, claiming (correctly) that the intent and effect of Beachside's parking restrictions was to exclude non-Beachside American citizens from their country's seashore, or at least from that part of it that bordered Beachside. George had made a formal reply at that time, pointing out that the seashore was maintained in part by the Federal Government, but that the parking lots were built by the town and maintained entirely at town expense, and Beachside had every right to be exclusive about them. As for the parking restrictions on the street, they were reasonable and necessary for public safety. Now two developments have clouded the picture.
First, many families of the region have branches in both Beachside and Duncan's Hill, both small towns with long histories. Arrangements have been made, not by George, to slip "permanent guest" passes into the hands of many Duncan's Hill residents. There is even a certain amount of pressure to extend beach privileges to all of Duncan's Hill.
Second, more towns have expressed interest in Beachside's beaches. Especially threatening to the townsfolk are the inquiries from Newtown, a fast-growing exurbanite center to the west, and Oldport, a large dying factory town to the east, with a sizable African American population. Made nervous by these developments, the Beachside Board of Selectmen has asked George to come up with a solution to protect them on their beaches, "just the way it used to be." George knows he can't do that. Realistically, the options seem to be:
After you have thought through the situation from George's perspective, try adopting the perspective of others who will be at that meeting: a White resident of Oldport, an African American resident of Oldport, representatives from Duncan's Hill and Newtown, a lifelong Beachside resident in her 60's, a member of the Board of Selectmen. Can we distinguish racial from socio-economic stereotyping in this case?
Case 3: A case for the ethics committee
(This lengthier case provides the opportunity to try on diverse roles, both familial and professional. Note how different the situation appears from the different role perspectives.)
The scene: Most hospitals have "Ethics Committees," whose job (among others) is to offer advice and consultation to anyone in the hospital who is distressed by the ethical dilemma posed by a case. In the case of Samuel Weston, it is his family who are distressed, and they have asked for an audience with the hospital Ethics Committee, asking others with interests in the case to offer their opinions also. The speaker and narrator is the oldest son of Samuel Weston, the one who requested the meeting. Questions from the members of the Ethics Committee are indicated by parentheses.
Thank you for agreeing to talk to us. My name is Jonathan Weston, and I am the oldest son of Samuel Weston, a patient in this hospital. To make a long and agonizing story very short, after several strokes, my father is now, as they say, "terminally comatose," and some of us think that we ought to pull out all the tubes and call the funeral parlor and the rest of us think that that would be murder, totally inexcusable, and we're not quite sure where to turn right now. I understand that you people are the "Ethics Committee" in this hospital, and that you're supposed to know what to do in these cases. OK, tell us what to do.
Let's fill in some details.
My father was admitted to this hospital on March 3, 1986, when he was 74, almost 75 years old. He was discovered by my mother lying unconscious on the floor in the bathroom. My mother called the police and they brought him here. By evening he had sort of recovered consciousness and knew us, and they'd diagnosed a stroke. There isn't much you can do for a stroke at first, so they just basically took care of him and he got much better. By late April they had him in physical therapy on the Rehabilitation Wing and we were talking about taking him home. He was in very good spirits, joking about fending off rabid dogs with his walker....then he had another stroke in May. The doctors said it was "mild," just a "set-back"....then in July he had another one, and since then he hasn't opened his eyes, or when he does, he doesn't see anything. They say he isn't going to get any better.
For awhile after his third stroke they had him on a respirator, then he "improved" to the point where he can breathe on his own. They're feeding him, and occasionally pumping in antibiotics, with tubes. The doctors say eventually his heart will stop. I have my doubts. His father lived to 98, and Dad's heart has always been enormously strong. With adequate food and water, he might touch 100. The question is, how long should we go on with this treatment? When is enough enough? For the answers that have been proposed, let me introduce the rest of the cast of characters:
Dr. Jerome MacDonald: I've been Mr. Weston's physician for
23 years now, physician and friend, and taken care of the rest of his
family as well. I have nothing but affection for the man, and sympathy
for Flora Weston and the children in this time of grief and anguish.
My role in this situation is now very limited. I cannot, of course,
unilaterally make the decision to withdraw nutrition and hydration.
I can certainly tell the family that according to all the consultants,
their husband and father is surely terminally ill and permanently unconscious,
with no chance of improvement, and I have done that. He is not legally
"brain-dead"--since he's breathing on his own, the brainstem is clearly
alive, and part of the cerebellum as well--but he will not function
as a human being again. Nevertheless, he looks human enough--as a matter
of fact, he looks like Sam Weston, asleep. I know what torment they're
going through, and I sympathize deeply, and I will comply with whatever
decision they can reach as a family.
Flora Weston: I can't believe Sam isn't going to get better.
He got better last time, didn't he? Because we had hope and were willing
to wait! I saw his eyes look at me just three days ago. There has to
be hope. We can't live without hope! I don't know what to do. But please
let's not give up.
Roger Weston, the younger son: This is ridiculous. Dad spends
all his life, sometimes 60 hours a week, just to earn money to leave
to his family, and here we are, just about out of insurance, spending
$1500 a week on his living corpse. Why are we doing this? He's dead,
he's been dead for months! Let's pull out the stupid tubes and let him
go. That's the way he would want it, that's for sure.
Cynthia Weston Green, the older daughter: They're a bunch of
cold-blooded murderers, nothing else! I think I knew Daddy better, and
loved him more, than all of them put together. I know I haven't seen
him much for the last six years when I was in California, but after
my marriage failed I just wasn't financially able to come home when
I wanted, and I know it was stupid to be too proud to ask for the money,
and Daddy has been in my thoughts every minute. I don't care what they
say about his medical condition. He's still my father, I still love
him, and to talk about depriving him of food and water borders on the
sadistic! Where do we get this bit about how it's too troublesome, or
expensive, to feed him with tubes? Wouldn't you feed him if he just
couldn't move his hands, and you had to feed him with a spoon? I seem
to recall that once upon a time I had to be fed with a spoon, as
did Jonathan and Roger, and before that we had to be fed with
tubes, or nipples, and we were pretty expensive and troublesome,
especially Roger, and Daddy fed us, and paid for us, without
complaining. Well, maybe it's time for us to return the favor. Of course
he's going to die some day. But while I live, he's not going to die
because his children decided to starve him to death when he was too
old and sick to complain about it!
Laura Weston, the younger daughter: I'm not sure I know what
Dad would have wanted, but I know that if that were me, in that bed,
I'd want to die. I just wouldn't want to hang around in that state.
That isn't really life. I'm just not interested in the financial aspect
of this dispute. But I know that that is no life to be living, and no
human being should be kept around in that state.
Evelyn Swenson, Samuel Weston's nurse: We are dealing here
with a patient who needs care. That's my department--not the physician's,
who stops by maybe every two weeks to see if he's died yet, and not
the family's, who only gather by the bedside to fight with each other.
I am not only the servant of the whims and interests of family and physician:
I have my own professional ethic to answer to, and that ethic requires
me to render the best available care to every patient. Mr. Weston requires
bathing, turning, changing, nutrition and hydration, all of which is
"nursing care," not "medical care," and which it is my professional
duty and competence to provide. I know it would be convenient for everyone
if Mr. Weston would just die, but I am not allowed to watch third parties
kill a patient for their own convenience. There are lots of places in
this world where helpless elderly people are allowed to starve to death;
this hospital should not be one of them.
Dr. Morton Farrell, administrator of the hospital: You know,
the reason we provide these enormously expensive hospitals and treatments
is so that living people who have suffered some trauma, or have some
acute illness, can be saved--can receive the tremendously complicated
care that will cure them, make them well. Weston isn't going to get
well. He isn't even going to get measurably better. I know we invite
his imminent death--the rest of his death, really--if we take out the
feeding tubes. But what a terrible waste of resources it is to keep
him going like this! When the insurance is gone, the hospital pays through
the nose; the family can be billed, but usually won't pay, and then
the public pays to keep him here. The family complains about the $1500
per week they have to pay. Now that the DRG has expired (the amount
of money that Medicare will pay for patients in his Diagnosis Related
Group--patients who have what he has), it's costing the hospital $5000
per week to keep him, and we can't even bill the family for that! And
for what? I'll be glad to see him out of here, one way or another.
Mr. Gregory Little, Esq., the family attorney: I'm hardly in
a position to say very much, since Mr. Weston, anticipating no such
accident, had no opportunity to set his affairs in order, including
the making of a "Living Will" or assignment of durable power of attorney.
He told me on several occasions that he would not wish to live with
artificial life support, should he be rendered incapable of communicating.
Does nutrition and hydration count as artificial life support? Food
and water seem natural enough, but tubes don't. What counts as artificial
in this case?
Jonathan Weston, again: OK, people, there you have it. I have
to make the decision, except that if I make it the wrong way, some other
family member--not my mother, of course, but my sister or brother easily--will
complain, hold a press conference, probably sue.... What do you think
I should do?
Case 4: The alcoholic in the workplace
(Note: this somewhat longer case demonstrates the peculiar intractability of this type of ethical dilemma. In the "A" portion of the case, the three major principles suggested by your text are in direct opposition. In the "B" portion, the arguments for both sides are drawn from the same principles, not because the principles mean nothing or the participants are arguing incorrectly, but simply because our calculations of benefit are necessarily speculative, our assessments of justice depend on the framework adopted, and our respect for human dignity can be expressed in one of several ways.)A.
A tense meeting in the office of Mr. R. Howard Williams, Vice President for Personnel (Howie, in what follows), on the case of Mr. Francis J. O'Brien, Director of Special Accounts, Finance Department (Frank), on the request of Mr. Joseph Machowski, Vice President for Finance (Joe), of the Allbest Engineering Division. All three parties are present.
Howie: (after good mornings, offerings of coffee etc.) Joe, you're the "complainant," as it were, why don't you present the complaint.
Joe: Sure. Frank
and I have been working together, more or less, for over seven years
now, and I have a great deal of respect for him as a person, Frank,
I want to say that right now. But in the last seven or eight months
there's been nothing but trouble, and if it were up to me we'd have
let you go by now, I guess you know that. There was the time in April
when we needed the data on the Stoddard account for the planning meeting,
and it was your responsibility to get it there, and you were nowhere
to be found, and neither was the data. Then there were the long lunch
hours that we only found out about when your secretary was sick and
the substitute found out that she was supposed to cover for you from
one to two-thirty in the afternoon! Whatever else you can do with secretaries
in these liberated days, you can't ask them to lie for you--it's just
not fair. Then you were due for the Department meeting in early May
which we hoped to be able to pick up the pieces from the April fiasco,
and you checked out "sick" two hours before the meeting. All the rest
of us had to stay half the night getting the paperwork done around you.
Howie: That's one
of the reasons why we're here. Joe, as a good supervisor, you have documented
performance and stopped there. But I have to look into causes and cures.
I know you've been happy with Frank's work in the past, and that you
would be happy to keep him on if he could be restored to full performance.
I also know that it would cost the company almost $100,000, all things
considered, to separate Frank, hire a successor, and train him or her
to do Frank's job. And I suspect that Frank would rather keep his job
than be fired! So we serve everyone's interests if we get Frank working
well again. And I think we can do that.
Frank: Finally I get a word in edgewise? Thanks. I have very little to say. Joe, you and I have not gotten along, and it's not entirely your fault. I thought when I joined on here that the Finance division was a short assignment until a position opened up in Marketing, where I can use some creativity in my job. I've repeatedly put in for the switch but no one can quite find the way to get me over there. I'm sorry if my work doesn't seem to be a model of good attitude, but that's why. And when you look at all the stuff you've got in black and white, there really isn't much there. I did miss a deadline or two, but every one of my counterparts in other Departments has, too. You guys call these meetings out of the blue, demand full reports from all of us, and then get all huffy when we can't supply them just like that. Sorry about that missed meeting; you have me dead to rights there. I just forgot about it. One meeting in nine years? And you were going to fire me? I think after nine years I deserve an occasional long lunch, and if you believe that secretarial scuttlebutt about "forcing me to lie for him," you're dumber than I think. As for the Mondays, I have a nasty case of gastroenteritis that has a way of flaring up after a weekend's eating and drinking; sorry about that too. Yes, drinking, Howie, and whatever you may have heard from the nosy neighbors, I'm not a drunk, and I have problems enough without well-intentioned busybodies trying to reform my life for me. I value my privacy, and my freedom to choose my own lifestyle, and I think, as an adult, I'm entitled to them. What I do on my own time is my own affair. I may change the medication for the gastroenteritis, or I may not. I will try not to be late or absent any more. But you don't have enough in that file to fire me, and you don't have any right to run my life for me, no matter what your opinions of me may be. I'd appreciate it if you'd leave me alone.
Incidentally, Frank did, eventually, opt for the rehabilitation route. That was not the end of the story; it continues in what follows.
Mr. R. Howard Williams, Vice President of Personnel (Howie in what follows), presenting the case to the committee: Gentlemen, thank you for agreeing to help us decide this case. It concerns the Director of Special Accounts in the Finance Department, Francis J. O'Brien, who has been with the company for a little over nine years. Frank was diagnosed alcoholic about a year ago, went through a course of rehabilitation at our expense, seemed all right and returned to work; now he's drinking again. He's been suspended without pay for one week, by which time we have to decide whether to put him through rehabilitation again or terminate his employment here for good. As you may know, this case has been placed before your committee at the request of Robbins Brown, President of this Division, and...
Mr. Joseph Machowski, Vice President of Finance (Joe in what follows), interrupting: Howie, can we make this quick? I've got two more meetings this morning and a desk full of work.
Howie: OK, Joe, why don't you go first? You're Frank's direct superior, after all.
Joe: Thanks, I
guess. I am not, for starters, familiar with this procedure. We have
here a case of a bad actor, we've done everything we can for him, and
why Rob Brown wants you to get involved in the case is beyond me. Anyway,
Frank was hired nine years ago to fill a low-level vacancy in the finance
department. He's pretty good with numbers and in a few years was promoted
to credit manager. He was perfectly competent to manage the accounts,
but couldn't get along with his supervisor, so we moved him into an
auditing position. He claimed that with his winning personality he should
be in marketing, but Sandy Levine, then VP of Finance, argued that his
talents seemed better suited to finance, so he stayed in our division.
When we promoted him to Director of Special Accounts, he still said
he wanted to be in marketing, but there wasn't a position open. In his
present job he has a lot of freedom of action, so I'm not on top of
how his performance went from day one, but about a year and a half ago
it started to go directly down hill--missed deadlines, missed meetings,
absenteeism, just very poor. Disciplinary notices didn't do too much
good. Eventually Howie got hold of the case, got the Employee Assistance
counselors involved, and they made some progress: he admitted he'd been
drinking a lot and agreed to go into a detox and rehab program, followed
up with AA meetings, get the family in on it, all that stuff. Well,
it worked for awhile, then he started fighting with his wife again,
missed a couple of reports, refused to admit there was anything wrong
when I called him on them, then showed up in the office drunk after
lunch on Tuesday. That was the last straw. We sent him home then and
there and notified him of the suspension the next day. Now what do we
do with him? I say fire him:
Howie: Thanks, Joe. Donna, why don't you take the story from here? Donna Reed is our substance abuse counselor.
Donna: You have to try to understand the situation from Frank's point of view. He's been here for nine years, he's undoubtedly done a good job--his file is full of commendations, up until the last few years-- but he hasn't gotten into the department he wants, and he thinks his talents are not being fully used. He was saddled with an incompetent supervisor for awhile, and still resents that. Maybe he could have been more philosophical about his treatment by the company--but then his wife started bugging him about how he should get promoted faster, and should make more money, and he found himself torn between his loyalty to the company and his loyalty to his family. Then his teenagers had problems and that was worrying him too. The drinking didn't seem so serious to him--just a temporary reaction to stress--but he was willing to try rehabilitation, and did, and it seemed to work. If his wife hadn't started in on him again, he might have stayed sober indefinitely. But she's been working with Alanon counselors recently, and she and Frank both think that a short stay in that rehab center will get him back on his feet for good this time. I think it's very hopeful, and I think the committee ought to advise sending him back to the center. What do you think, Mr. Williams?
Howie: I think I'm with you, Donna. The way I see it, we're responsible for the man. Nine years isn't a whole life, but it's a sizable chunk out of a manager's career. We had to have known how much it frustrated him to be kept where we could use him, in the finance department, not in marketing where he wanted to be. We let this behavior start, and let it go because we were too busy to catch it, and now I think we owe him that second chance:
[Note: this case deliberately employs portraits that might be regarded by some as racial stereotypes in order to draw attention to problematic, and very real, interracial perceptions.]
Yussuf Amani is a Syrian who owns a small grocery store in Chicago. Soon after setting up the store, the purchase of which had consumed all his savings, Yussuf discovered that the neighborhood, largely African American, was anything but friendly to foreigners. Business was good enough during the day, but night brought gangs of toughs, with unsubtle efforts to extort protection money, which Yussuf would not pay. Soon Yussuf began noticing that much too much merchandise was missing without being paid for--too much to be accounted for by the usual neighborhood children stealing gum and the occasional welfare family, at the end of its funds, making off with some cans of tunafish. Yussuf started rigging his store for protection. Buzzers announced the entrance and exit of customers, gates made sure that any who left the store passed under his eyes. The customers resented the security measures, but Yussuf felt he had no choice. The shoplifting decreased. Then the holdups began. After the first armed holdup, Yussuf put bulletproof shields around the cashier's area and around a back counter where his assistant could be stationed to call the police. The next several holdups became very interesting contests: could the police get there before Yussuf had to give the robbers any money? Yussuf was losing less on the holdups, but the resentment of the neighborhood was increasing. Then the muggings began. The first time Yussuf was attacked on his way home, he wrote it off to the normal risks of life in the city. The second time, he realized they were after him. At this point Yussuf realized he had some decisions to make:
Should he sell the store, at a loss if necessary, reconcile himself to working for other people all his life, go look for a job somewhere? That would mean the end of his dreams for himself, his family, his children. Maybe the Land of Opportunity isn't for everyone?
Should he tighten security, arrange to travel with others when he is on the street, settle in for the long haul? After all, in all this violence, business remains good. He can prosper, but only in the atmosphere of an armed camp.
Above all, should he get a gun? He probably cannot get one legally, but illegal handguns are easily available, and from an early stint in the Syrian armed forces, he knows how to use one well. Not that he looked forward to shooting anyone, but with a handgun he could hold robbers in his store before the police got there, and the reputation for carrying a handgun, which would spread like wildfire, would be his best protection from mugging.
Materials prepared by Lisa H. Newton, Ph.D. 1998
|Cases: [1-5 | 6-10 | 11-15 | 16-23 ]|
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