Hospital Social Work

Ethics

In a previous issue of Health & Healing, my co-worker, Aubrey Baker eloquently pointed out some of the ethical situations that hospital based social workers face. In my own practice in the Emergency Department, ethical considerations are a daily occurrence. One dilemma we are often confronted with is the conflict between an individual's self-determination and freedom of choice versus the patient's best interest as assessed by the medical team (of which I am a part). One case in particular stands out, which I would like to share with you, since the ramifications surrounding the outcome resound within me to this day.

Miss X was a 16-year-old female who was brought into the emergency department after having lost large quantities of blood over a two week period. A surgeon was called and a D & C was seen as the only option to stop the bleeding. While this type of surgery at 16 is rare, it is not unheard of. However, Miss X did not want to receive blood products due to her religious beliefs. Normally this wouldn't be a problem, particularly when the patients are over the age of majority. However, since Miss X was 16 years old, there were legal considerations.

... I feel like I contributed to saving a life. But to this day, I am not comfortable with an outcome that should have brought me good feelings.

After ruling out all possible alternatives to surgery, Child Welfare was contacted. I was told that apprehension was possible but that even Child Welfare could not force Miss X to have blood products. Only a Judge could order the involuntary use of blood products if he/she determined it was in the best interest of the child. I was thus faced with a seemingly unresolvable dilemma: whether to let a 16 year old exercise self-determination by refusing to allow a life saving operation, or to use legal means to force her to undergo an operation that the medical team felt was in her best interest.

A Judge was contacted and a hearing was arranged for 8:30 that evening at the hospital. Housekeeping, security, and even the Site Administrator were contacted to facilitate finding an appropriate venue that could hold all the people that would attend this hearing. There were to be 14 people there including a lawyer representing the young lady, numerous medical staff, the child welfare worker, and of course the patient, the Judge, and myself. Once the hearing began, the various parties began to present their positions to the Judge. The Judge had to take the following points of view into consideration;

• the 16 year old patient who chose to follow the teachings of her faith;
• the parents who agreed to her choice;
• the doctor who wished to save her life through the use of blood products;
• the Child welfare worker who represented the interests of the child within the boundaries of the law;
• and myself, who was there to represent the best interests of the patient by giving her the opportunity to make an informed decision.

The hearing lasted one hour and during its course Miss X was to have her beliefs tested to the limit. Though she had been raised with the faith most of her life, it was only at the age of sixteen, 6 months previous to her admission to hospital, that she chose this religious path for herself. She listened to the various sides during the hearing, but in the end chose to stand by her beliefs.

Despite this, the Judge, after hearing that Miss X would likely die if the surgeon was not allowed to administer blood products, felt that the use of blood products was in the patient's best interest. He, therefore, ordered the use of blood products as a last resort. The surgery proceeded and blood did, in fact, have to be used to save Miss X's life.

My actions as a social worker are to act in my patients' best interest. It is my belief that only the patient can determine what is in their best interest. If they choose to have no intervention, then so be it, as long as they have had the opportunity to hear all sides of the argument and they still choose to go against the medical perspective. This can be a difficult perspective when working in a hospital though, since the facility and those serving in it are there to save lives, not to end them, or stand by and watch while one dies.

I was able to learn from this experience. The most important lesson was a reaffirmation that the patients' "best interests" are not viewed the same by all involved. In the end, I feel like I contributed to saving a life. But to this day, I am not comfortable with an outcome that should have brought me good feelings.

Health & Healing Spring / Summer 2000

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