Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether it was ethical to force a mentally disabled man to donate stem cells.
Yes: 40%
No: 60%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in with an excerpt adapted from his book, .
U.S. law recognizes very few circumstances in which people owe duties to provide assistance to others without voluntary agreements to do so. Certain relationships do impose obligations, such as financial support for spouses and children.
Most states require individuals who begin to help a stranger during an emergency to continue rendering such assistance, to the best of their abilities, until help arrives -- as "partial rescues" run the risk of scaring off other would-be rescuers. Otherwise, only a handful of states compel innocent bystanders to offer emergency assistance.
Courts have generally proven unwilling to force individuals to provide sick relatives with medical aid, such as organs or tissues, even when these individuals are uniquely situated to help. In one notorious case, David Shimp refused to give bone marrow to his cousin Robert McFall, who suffered from aplastic anemia, despite an estimated 50-60% chance of saving McFall's life. Although Judge John Flaherty Jr. derided Shimp's conduct as "morally indefensible," he did not compel the donation -- and McFall died of his disease.
Similarly, in another high-profile case, Tamas Bosze, the father of a boy with leukemia, was unable to convince a judge to order bone marrow testing on his other two children, the boy's half-siblings.
More challenging are cases where the potential donor is cognitively impaired to the point where he cannot understand what is being asked of him. In the scenario of Morty and Lou, Lou may cry out against doctors, but conjecturing on whether he would consent to a brief medical procedure in order to continue to enjoy the occasional company of his brother is a purely speculative endeavor.
No consensus exists on how to handle such situations. Doctors can sometimes turn to the patient's closest relative for guidance, but in Lou's case, that relative has an obvious conflict of interest.
One Kentucky court in 1969 went so far as to order Jerry Strunk, a cognitively impaired 27-year-old, to donate a kidney to his brother. More often, a complex cost-benefit analysis comes into play -- one that weighs the hardship to the potential donor, the stakes for the potential recipient, and the emotional benefit that the recipient's survival affords the donor.
In this case, Morty's life hangs in the balance while the costs to Lou are low, so the doctors might be able to justify obtaining a court order for the procedure. Yet one ought not lose sight of Lou's vulnerability as a person unable to fend for himself.
As the potential medical risks of an intervention rise, the arguments for invading a person's bodily integrity prove increasingly more challenging to justify.
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:
Confront Mentor Over Abusive Research?