My PATIENT ALICE Elder Law: An Ethical Analysis • Robert L. Barrow JC, MD, FCLM, MRO •
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y patient Alice (not her real name) is eighty -nine years old and has anhritis in her hip. She is now on ca.lcium supplementation and is on a synthetic hormone replacement. She has very well controlled high blood pressure. She acrually gets around well but, and I quote, "Nor like I used to." Unci I recendy (relatively speaking), she lived independenrly in California. A!; her mobility declined, she moved to Arkansas CO be closer [Q her widowed daughter. She is still very competent at handling her own affairs, but as the years pass, she is relying on the judgement of her daughter increasingly. AJice is happy spending time with her daughter and enjoys her grandchildren, some of whom are actually approaching middle age. She has witnessed the advance of human capability from the airplane (0 interplanetary travel. From radio on [0 television and now the Internet, she has seen
Dr. Barrow is a physician as well as an anomey.
His West Linle Rock dinic provides both acute and chronic medical care. He also provides expert consultation service in '-----------' the field oflega! medicine and has recently accepted a position to be Of Counsel at the Baber Law Firm in conjunction with his Legal Medicine speciality.
our ability to communicate with one another increase in bandwidth. She has also seen the wars of a hundred years and the increase of our ability to kill one another extended from machine guns and nerve gas to the thermonuclear bomb. The intrusion of the Flu Pandemic of 1918 and polio in the early fifties left her with memories of dead and crippled people young and old. She knows about the emergence of AIDS. She accurately remembers the great depression. That made a more meaningful impression on her than did the development of the transistor or the laser. As a direct consequence, she is very fiscally conservative while, at the same time, very daring in her embrace of the new. Consequently, she is nor totally dependent on Social Security. Is this a story with a happy ending? Well, that entirely depends on your viewpoint. Alice will not live many more years. Her remaining years will be a slow contraction of her world as her options are reduced by the degradation of her mental and physical capabilities. The biggest Medico-Legal hurdles she will face are going to concern avoidance of being taken advantage of or physically! mentally abused by her family, business contacts and other strangers including the government. Additionally, she is going to want to have some say in what her final days and hours will be like. She will want to have some power in terms of what things will be done to her during the endstage of her final illness. She will want to retain as much control of her assets as possible without day
to day responsibility. These are the same problems that all people face except that they have increased urgency as the options narrow and the income becomes more fixed. All of the issues can be ethically defined in terms of the concepts of "beneficence" and "autonomy". Beneficence is what our ethical point of view requires us to do and decide for other people who are less able to do or decide for themselves. Autonomy is the aspect ofour ethicaJ point of view which requires us to let people do what they want and decide for themselves. The rwo positions are mutually exclusive and these competing interests must constantly be balanced in the light of knowledge and experience. Although it has often been said that senior citizens are in their second childhood, this is true only for those whose capabilities have declined to the point where beneficence is the only ethical position. As long as a person retains a minimum of competence. the concept of autonomy requires us to leave well enough alone. Where do you draw the line? As Hypocrites taught us, "First, do no harm." If not acting in someone's best interest allows him or her to come to harm, it is imperative to act. Even this maxim needs to be tempered by allowing autonomy wherever it is at all possible. This should be tempered by good sense. One of my patienrs (nor Alice) with emphysema continued smoking until she required hospitaJization for a period of over a month. During this time she was treated with potent steroids, and she became psychotic. Evenrually, she recovered her sense but left the hospital on oxygen. Is it ethical not to allow her to smoke? She is no longer able m drive so her cigarettes would have to be bought by someone else. Restricting her access to cigarettes is a matter of informing her children that further smoking would likely soon return her to the hospital with no guarantee of recovery. She was also unable to smoke during the six-week visit to the hospital so she was fully withdrawn from the nicotine. I define procuring cigarettes for this woman as codependency. In this instance, beneficence wins. In other circumstances, if the woman were able to supply her own desire for cigarettes, I would be able to discourage her but would not be able to use beneficence for her benefit. Autonomy My Patient Alice Continued on page 40