Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true patient care case. You vote on your decision in the case and, next week, we'll reveal how you all made the call. Bioethicist Jacob M. Appel, MD, JD, will also weigh in with an ethical framework to help you learn and prepare.
The following case is adapted from Appel's 2019 book, :
Ian McKenna, MD, runs a dialysis clinic that provides life-prolonging treatments to hundreds of patients each week. Most are very appreciative. Lucinda is the rare exception. She is, in the words of McKenna's head nurse, "the worst patient ever." Lucinda often appears at the clinic drunk, or high on cocaine. Even when she arrives clean and sober, she frequently hurls racist and anti-Semitic comments at the staff and at other patients.
On several occasions, when she was upset, she pulled dialysis tubing out of the arm of the patient in the neighboring bed, so now she must receive treatment alone in the far corner of the clinic under the watch of a nursing assistant. She refuses a psychiatric referral, but she does not appear to be mentally ill, merely an extremely unpleasant person. Still, multiple efforts by McKenna over two years have failed to achieve a working relationship with Lucinda.
One afternoon, when she feels the staff has kept her waiting for treatment too long, Lucinda topples several chairs in the waiting area and breaks a glass coffee table. McKenna has had enough; he decides that he will no longer provide treatment for Lucinda. However, with her history, it's possible that no other hospital or clinic will assume care for her. Of course, she will soon die without dialysis.
See the results and what an ethics expert has to say.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
And check out some of our past Ethics Consult cases: