M3 Lesson 1: Reason and Impartiality | While task 1

Students whose first names begin with the letters A, D, G, J, M, P, S, V, Y must present
an argument on the ethics of the case assigned based on the benefits to be acquired.

The Case of George: DNR for an Adult with Down Syndrome

CASE STUDY: WHAT SHOULD WE DO?

BIOETHICS FORUM, SUMMER 1999
BY ROSEMARY FLANIGAN

George is a twenty-three-year-old young man with Down's syndrome.

Until three years ago, he lived at home with his parents and had a part-time job washing dishes
at a restaurant. When George turned twenty, he and his parents decided that living in a group
home would be a good experience for him and he entered into his new life enthusiastically.
George and his parents have a good relationship and they have always encouraged him to be
prudently independent. George has often brought his good friend, Stan, home for supper. They
both live at the home for developmentally disabled young men, and his parents are happy that
he has found a friend.

But one Saturday, George and Stan were waiting for a bus and in the course of some horseplay,
Stan accidentally pushed George too hard and he fell in front of the bus. He suffers from severe
brain injury, has no swallowing reflex and has had a feeding tube placed. A year has passed. The
parents visit George each day at the rehabilitation hospital but he has shown no signs of
consciousness. Stan is devastated by George's condition and the parents permit him to visit
once a week, although the young man would prefer to be there every day.

The doctor has requested a Do Not Resuscitate Order for George and the parents have signed it
although they are not legally declared his guardians. But now they are talking to the doctor
about removing the feeding tube. It is not instrumental in restoring him to any quality of life
and they realize that it would be better that George simply be allowed to die.

George and his parents live in a state that requires "clear and convincing evidence" for
withholding/withdrawing nutrition and hydration, and they are feeling hard pressed to provide
such evidence. They have not talked with George about dying; in the beginning, it was not
relevant; now they wish they had helped him make his advance directive. Even if they have
themselves declared his guardian they live in a state that does not permit guardians to withhold
or withdraw life-sustaining treatment.

They ask you for advice.

Questions

 The conflict in this case is between law and ethics. Address first what is the ethical thing
to do here.

- The ethical to do here is to sign the do not resuscitate order for George because in that
way he will not suffer anymore. Even if I will face challenges as a parent that is not
listed as the guardian but I will only prioritize what benefits my child that is having a
hard time for so long in the hospital that’s why I will find a way to talk to the listed
guardian. As a parent, I will also talk to the guardian that is listed in the hospital
because I only want to make my son happy even if he is that situation and let the
guardian he listed as the one who will sign the order for him.

 Is it ethically appropriate to remove the feeding tube? What is your argument?

- It is ethically appropriate to remove the feeding tube if the guardian that is listed will be
the one to sign it in the hospital allowing them to do it and if it proven by the medical
professionals that the condition of George has zero chance of survival. On the other
hand, if the parents who are not listed as the guardian of George are the ones who will
sign in the hospital regarding the removal of the feeding tube then it is unethical and
also if the doctor proves that there is a chance for George to survive then it really
unethically appropriate. I looked into the possibility that George can still survive his
current condition that’s why it should first be proven by the medical professionals
before giving them the option to remove the ffeding tube because what if George can
still survive but then they remove the feeding tube and the possibility of survival will
lessen and George’s possibility of dying will increase.

 Should the parents ask Stan and the other boys at the group home if George has ever
expressed an opinion on the subject of end-of-life?

- Yes, the parents should ask them because they are the people who are with George
most of the time and they might have talked about the subject of end-of-life with
George. If Stan and the other boys have an important statement about the subject that
George had talked before then it will be a big help for the parents to know what would
benefit George based on his statement when he talked to Stand and the boys.

 Is the ideal here that the parents use a substituted judgment or a best interest
judgment?

(Substituted judgment is one in which the surrogate or proxy decision maker can speak the
judgments previously articulated by the patient; best interest judgment is one in which decision
makers do not know the patient's wishes but choose to do what reasonable people would
decide under like circumstance or in similar positions.)
 - If the parents got an idea once they talked to Stan and the boys that is mostly with
George before the accident about what would George decide if he is in the situation on
end-of-life then it is ideal that the parents should use a substituted judgment because
they have an idea about what George wants for himself. On the other hand, if the
parents has no idea of what George wants, then they should look into the different side
of the situation for example, the possibility of George to survive and to die and what is
the best to do when they knew the that possibility. When they investigated by the help
of the doctors then it would be the best if they decide based on their research on
George’s situation because they would know what would benefit George once they
knew the possibility of surviving and dying.

 Distinguish between competency and decisional capacity. Even if George has been
declared incompetent, could he still have decisional capacity to make out an advance
directive?

- He can’t make out an advance directive verbally because his brain injury might affect
his way of speaking but the people around him should look into his vital signs and
current condition as it can be an advance directive because it shows his capacity of
surviving.

 What kind of ethical reasoning are you using-virtue, principles, consequences?

- The ethical reasoning that I used is by consequences because I am looking into

character’s benefits to be acquired once the people around him will decide whether to
sign the order or not and whether to remove the feeding tube or not. I also considered
the possibilities of George’s survival and what George’s wants if he talked about the
subject of end-of-life with his friends before deciding what advice I should give to his
parents. I also looked into his situation that is very obvious about him close to dying
because there are no sign of improvements in his one year of being comatose that’s
why giving him the benefit of not suffering anymore based on his situation is what I
keep in mind by making an ethical reasoning by consequences.

 If the Disabled Advisory Group for Brain Injury protests your position, can you defend it?

- Yes, I can defend it because I will not stand my position if I didn’t go on thorough
investigation about George’s case. I am able to look into the different sides of the
situation and not stick on one side only because I know that they are different things to
consider when I looked into different sides. As I provide my position about the
situation, I mainly considered the benefits that George should get on his situation
because it must be very hard for him to deal with his severe injury and being comatose
for so long without any improvements.