Chemotherapy Ethical Dilemmas
Adelajda Zhgaba Medical Ethics PHL 211
Ethical considerations in chemotherapy treatment for cancer patients
1. Would it be ethically concerning to accept refusal of chemotherapy treatment from cancer patients, more importantly from teenagers diagnosed with this disease?
According to the National Cancer Institute, approximately 12.7 million people are diagnosed with cancer each year and 7.6 million of them die from this disease. People usually undergo chemotherapy, radiation therapy, immunotherapy and some go towards alternative treatment to prolong their life, ameliorate it or even save it. Lately, there has been a high number of patients who have refused to pursue chemotherapy even though there was a high chance of improvement …show more content…
and benefits from that course. Increasingly providers have been facing rejection, as patients tend to follow other ways of treatment, even though the chances for long-term survival are low for the latter ones as they are not very well established in the medical science or tested for efficacy. (Pickering 2013) Lately, cases of chemotherapy refusal have been occurring even with minors who have been diagnosed with cancer. One of the main issues that arises is if the hospital and the medical staff should treat the minors against their or their parent’s wish or respect their decision? Is it ethical to accept refusal of standard treatment from cancer patients with decision making capabilities, especially when the patients are under 18 years old and their parents are legally responsible to make healthcare decisions for them?
Before proceeding, chemotherapy is a treatment method using drugs to cure cancer.
It works by stopping the cancer cell growth or slowing it down. At the same time, while it is destroying cancer cells, it also harms healthy cells that divide quickly. Damaging the healthy cells causes the patient to have numerous side effects that at times become very severe. However, there are pros to pursuing chemotherapy as numerous regimens are successful and can put the disease in remission despite the side effects. In most cases, chemotherapy can increase the patient’s lifespan and can increase the cancer survival rate. It is a scientific method to address a disease that is evolving daily since research continues to find new results on how cancer cells produce and respond to different …show more content…
treatments.
Despite the high success rate for most of the available chemotherapy regimens, in the last decade people who are cancer patients are refusing to undergo chemotherapy. Refusing treatment means avoiding all the negative side effects and possible risks which might be very severe, uncertainty of success and the long treatment duration. Despite of the pro-chemotherapy evidences, there are also many cons. Patients will have a poor quality of life, weakened immune system and probable recurrence in the future if they pursue chemotherapy. Patients feel more comfortable pursuing an alternative course of treatment. According to Frenkel, when patients refuse conventional treatment, they mention multiple reasons such as fear of adverse effects, uncertainty about treatment effectiveness, hopelessness, loss of control, denial about the illness, dysfunction of the health care system, quality of life after cancer treatment, personal circumstances, goals, beliefs, thoughts, feelings and most importantly issues between the communication of the patient and the physician which Frenkel considers to be crucial in establishing trust and addressing patient’s emotions and decision for care (Frenkel) Huijer, M. & Van Leeuwen, E. (2000). Patient-physician communication is detrimental to how the patient will approach the treatment options especially when the patient is a minor and legal problems might arouse following treatment refusal. In 2015, Cassandra a 17-year-old girl decided to forego chemotherapy after she was diagnosed with Hodgkin’s Lymphoma. The chemotherapy regimen offered an 85% chance of cure, however, she would insist in not receiving any treatment as she believed that her body would be poisoned more with the drugs and she did not want to place more importance on the quantity of life, but rather to the quality of life she would have. Her mother was supportive of the refusal of treatment. Eventually, Cassandra’s case was presented in court as the courts have the right to overrule parents when their medical decisions put the child’s life under threat. Temporary custody was removed from the parent and Cassandra was put in a foster home. The court ruled that Cassandra should continue chemotherapy against her will as she would have a higher chance to live by being treated. (Macklin 2015). There is not an actual law for patients who refuse chemotherapy or standard treatment courses, however, when parents discontinue standard proven treatment in a child with cancer that has a likelihood of long-term cure and survival, referral to the local child protection agency is shown because a parent's incapability to provide adequate care for a child is a criminal offense. Because cure rates for many childhood malignancies are more than 50% with conventional regimens, withholding treatment can be a problematic ethical dilemma for the treatment providers (Hord 2006). While there is no law to force adults to continue with chemotherapy, adult chemotherapy patients sign dozens of medical treatment waivers and documents as they decide to discontinue. Cassandra’s case might be an example of lack of clear communication where the patient is described and explained the science behind the current, alternative, and new medical treatments. If her medical experience was enhanced with friendly staff that showed her an improved quality of life post chemotherapy, then perhaps Cassandra would be more enthusiastic to receive treatment. (Freiden 2015)
Two of the main ethical principles that arise due to this controversy are the respect for autonomy which is the free will and choice of the patient or guardian in case the patient is a minor and the beneficence principle for providing benefit to the patient and nonmaleficence concept of not doing any harm to the patient and his/her family. In cases involving minors, respect for autonomy is not seen in the same way as in adults because young children do not have a proper decisional capacity, which is required for autonomy. As children mature and become teenagers, they usually develop the capacity to make decisions and their involvement related to health care is often wanted, acknowledged, and respected by their parents as well as their physicians. In such cases, decisions should try to be as reasonable and approachable as possible to the child’s wishes and decision (Hord 2006).
The beneficence and nonmaleficence concepts are not very clear as they relate to many cancer treatments which might be or not be successful. To decide if a treatment is beneficial to the patient, all the emotional and physical harms versus the positive outcomes should be weighed. The emotional difficulties are experienced not only from the minor or adult with cancer but also from the family members. If the treatment is successful and there is cure to the disease, the whole experience concludes to be beneficial for everyone, however, if the treatment is unsuccessful and it fails, the entire course ends to be harmful to the patient and family members (Hord 2006).
In conclusion, over the past several years, the wishes and desires of the patient and family has been part of the decision-making process for undergoing chemotherapy or not.
There are cases of parents refusing treatment on behalf of their children with cancer who have a cure rate of more than 50% with conventional therapy treatments and if left untreated, it puts the child at considerable risk. At this point, physicians are obliged to seek legal intervention. Despite the decision that patients make after balancing the pros and cons, the chance of their recovery and prolonging their life, there should always be support from the physician. However, there is at times lack of communication between patients and physicians regarding treatment regimens. They fail to integrate the balancing of pros and cons with the personal perspective of the patient so this makes it difficult to develop a relationship for both
sides.
In my opinion, I think the autonomy of the patients should be respected as their decisions are based on their moral values, personal beliefs, and rationality. The physicians should always try to communicate at best with their patients so there is a complete understanding of the situation and prognosis of the disease, but I do not think that they should force patients with them being adults or minors to undergo or forego chemotherapy. I happen to be in a real situation regarding this topic when my dad was diagnosed with Stage III pancreatic cancer. He started chemotherapy and after 5 sessions, he decided to stop as the treatment was not successful. In contrary, the cancer had metastasized to the liver. After many consultations and close conversations with his medical oncologist, he decided to stop treatment. Chemotherapy was only making him feel weaker in terms of the immune system, he had loss of appetite, fatigue, nausea and vomiting. My dad was having severe side effects that were affecting his quality of life. Even though, his medical oncologist insisted on trying another treatment option, my father opposed as he did not want to waste any time feeling sick without having a reassurance that the new regimen would be effective. As the time went on he had more complications from the progression of the disease, however, I can say that at the time when he was not undergoing any treatment, he enjoyed his time with his family and friends without suffering from any side effects. My father’s example shows a good way to approach and handle ethically treatment options for cancer patients, of all ages.
References:
1. Pickering, Lisa. “The Ethics of Chemotherapy.”
Guardian Liberty Voice, http://guardianlv.com/2013/11/the-ethics-of-chemotherapy/
2. Frenkel, Moshe. “Refusing Treatment.” The Oncologist, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662856/pdf/onc634.pdf.
3. Huijer, Marli., Van Leeuwen, Evert. “Personal values and cancer treatment refusal.” Journal of Medical Ethics, http://jme.bmj.com/content/26/5/358.full.
4. Macklin, Ruth. “The Ethical Dilemma of Forced Chemotherapy on a Teen.” Albert Einstein College of Medicine, http://blogs.einstein.yu.edu/the-ethical-dilemma-of-forced-chemotherapy-on-a-teen/.
5. Hord, Jeffrey. “Do parents have the right to refuse standard treatment for their child with favorable-prognosis cancer?” American Society of Clinical Oncology, http://ascopubs.org/doi/full/10.1200/jco.2006.06.4709.
6. Freiden, Joyce. “Forcing Teen to Have Chemo Not Troubling to Ethicists.” MedPage Today,
http://www.medpagetoday.com/publichealthpolicy/ethics/49519.
Ethical considerations in chemotherapy treatment for cancer patients
1. Would it be ethically concerning to accept refusal of chemotherapy treatment from cancer patients, more importantly from teenagers diagnosed with this disease?
According to the National Cancer Institute, approximately 12.7 million people are diagnosed with cancer each year and 7.6 million of them die from this disease. People usually undergo chemotherapy, radiation therapy, immunotherapy and some go towards alternative treatment to prolong their life, ameliorate it or even save it. Lately, there has been a high number of patients who have refused to pursue chemotherapy even though there was a high chance of improvement …show more content…
and benefits from that course. Increasingly providers have been facing rejection, as patients tend to follow other ways of treatment, even though the chances for long-term survival are low for the latter ones as they are not very well established in the medical science or tested for efficacy. (Pickering 2013) Lately, cases of chemotherapy refusal have been occurring even with minors who have been diagnosed with cancer. One of the main issues that arises is if the hospital and the medical staff should treat the minors against their or their parent’s wish or respect their decision? Is it ethical to accept refusal of standard treatment from cancer patients with decision making capabilities, especially when the patients are under 18 years old and their parents are legally responsible to make healthcare decisions for them?
Before proceeding, chemotherapy is a treatment method using drugs to cure cancer.
It works by stopping the cancer cell growth or slowing it down. At the same time, while it is destroying cancer cells, it also harms healthy cells that divide quickly. Damaging the healthy cells causes the patient to have numerous side effects that at times become very severe. However, there are pros to pursuing chemotherapy as numerous regimens are successful and can put the disease in remission despite the side effects. In most cases, chemotherapy can increase the patient’s lifespan and can increase the cancer survival rate. It is a scientific method to address a disease that is evolving daily since research continues to find new results on how cancer cells produce and respond to different …show more content…
treatments.
Despite the high success rate for most of the available chemotherapy regimens, in the last decade people who are cancer patients are refusing to undergo chemotherapy. Refusing treatment means avoiding all the negative side effects and possible risks which might be very severe, uncertainty of success and the long treatment duration. Despite of the pro-chemotherapy evidences, there are also many cons. Patients will have a poor quality of life, weakened immune system and probable recurrence in the future if they pursue chemotherapy. Patients feel more comfortable pursuing an alternative course of treatment. According to Frenkel, when patients refuse conventional treatment, they mention multiple reasons such as fear of adverse effects, uncertainty about treatment effectiveness, hopelessness, loss of control, denial about the illness, dysfunction of the health care system, quality of life after cancer treatment, personal circumstances, goals, beliefs, thoughts, feelings and most importantly issues between the communication of the patient and the physician which Frenkel considers to be crucial in establishing trust and addressing patient’s emotions and decision for care (Frenkel) Huijer, M. & Van Leeuwen, E. (2000). Patient-physician communication is detrimental to how the patient will approach the treatment options especially when the patient is a minor and legal problems might arouse following treatment refusal. In 2015, Cassandra a 17-year-old girl decided to forego chemotherapy after she was diagnosed with Hodgkin’s Lymphoma. The chemotherapy regimen offered an 85% chance of cure, however, she would insist in not receiving any treatment as she believed that her body would be poisoned more with the drugs and she did not want to place more importance on the quantity of life, but rather to the quality of life she would have. Her mother was supportive of the refusal of treatment. Eventually, Cassandra’s case was presented in court as the courts have the right to overrule parents when their medical decisions put the child’s life under threat. Temporary custody was removed from the parent and Cassandra was put in a foster home. The court ruled that Cassandra should continue chemotherapy against her will as she would have a higher chance to live by being treated. (Macklin 2015). There is not an actual law for patients who refuse chemotherapy or standard treatment courses, however, when parents discontinue standard proven treatment in a child with cancer that has a likelihood of long-term cure and survival, referral to the local child protection agency is shown because a parent's incapability to provide adequate care for a child is a criminal offense. Because cure rates for many childhood malignancies are more than 50% with conventional regimens, withholding treatment can be a problematic ethical dilemma for the treatment providers (Hord 2006). While there is no law to force adults to continue with chemotherapy, adult chemotherapy patients sign dozens of medical treatment waivers and documents as they decide to discontinue. Cassandra’s case might be an example of lack of clear communication where the patient is described and explained the science behind the current, alternative, and new medical treatments. If her medical experience was enhanced with friendly staff that showed her an improved quality of life post chemotherapy, then perhaps Cassandra would be more enthusiastic to receive treatment. (Freiden 2015)
Two of the main ethical principles that arise due to this controversy are the respect for autonomy which is the free will and choice of the patient or guardian in case the patient is a minor and the beneficence principle for providing benefit to the patient and nonmaleficence concept of not doing any harm to the patient and his/her family. In cases involving minors, respect for autonomy is not seen in the same way as in adults because young children do not have a proper decisional capacity, which is required for autonomy. As children mature and become teenagers, they usually develop the capacity to make decisions and their involvement related to health care is often wanted, acknowledged, and respected by their parents as well as their physicians. In such cases, decisions should try to be as reasonable and approachable as possible to the child’s wishes and decision (Hord 2006).
The beneficence and nonmaleficence concepts are not very clear as they relate to many cancer treatments which might be or not be successful. To decide if a treatment is beneficial to the patient, all the emotional and physical harms versus the positive outcomes should be weighed. The emotional difficulties are experienced not only from the minor or adult with cancer but also from the family members. If the treatment is successful and there is cure to the disease, the whole experience concludes to be beneficial for everyone, however, if the treatment is unsuccessful and it fails, the entire course ends to be harmful to the patient and family members (Hord 2006).
In conclusion, over the past several years, the wishes and desires of the patient and family has been part of the decision-making process for undergoing chemotherapy or not.
There are cases of parents refusing treatment on behalf of their children with cancer who have a cure rate of more than 50% with conventional therapy treatments and if left untreated, it puts the child at considerable risk. At this point, physicians are obliged to seek legal intervention. Despite the decision that patients make after balancing the pros and cons, the chance of their recovery and prolonging their life, there should always be support from the physician. However, there is at times lack of communication between patients and physicians regarding treatment regimens. They fail to integrate the balancing of pros and cons with the personal perspective of the patient so this makes it difficult to develop a relationship for both
sides.
In my opinion, I think the autonomy of the patients should be respected as their decisions are based on their moral values, personal beliefs, and rationality. The physicians should always try to communicate at best with their patients so there is a complete understanding of the situation and prognosis of the disease, but I do not think that they should force patients with them being adults or minors to undergo or forego chemotherapy. I happen to be in a real situation regarding this topic when my dad was diagnosed with Stage III pancreatic cancer. He started chemotherapy and after 5 sessions, he decided to stop as the treatment was not successful. In contrary, the cancer had metastasized to the liver. After many consultations and close conversations with his medical oncologist, he decided to stop treatment. Chemotherapy was only making him feel weaker in terms of the immune system, he had loss of appetite, fatigue, nausea and vomiting. My dad was having severe side effects that were affecting his quality of life. Even though, his medical oncologist insisted on trying another treatment option, my father opposed as he did not want to waste any time feeling sick without having a reassurance that the new regimen would be effective. As the time went on he had more complications from the progression of the disease, however, I can say that at the time when he was not undergoing any treatment, he enjoyed his time with his family and friends without suffering from any side effects. My father’s example shows a good way to approach and handle ethically treatment options for cancer patients, of all ages.
References:
1. Pickering, Lisa. “The Ethics of Chemotherapy.”
Guardian Liberty Voice, http://guardianlv.com/2013/11/the-ethics-of-chemotherapy/
2. Frenkel, Moshe. “Refusing Treatment.” The Oncologist, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3662856/pdf/onc634.pdf.
3. Huijer, Marli., Van Leeuwen, Evert. “Personal values and cancer treatment refusal.” Journal of Medical Ethics, http://jme.bmj.com/content/26/5/358.full.
4. Macklin, Ruth. “The Ethical Dilemma of Forced Chemotherapy on a Teen.” Albert Einstein College of Medicine, http://blogs.einstein.yu.edu/the-ethical-dilemma-of-forced-chemotherapy-on-a-teen/.
5. Hord, Jeffrey. “Do parents have the right to refuse standard treatment for their child with favorable-prognosis cancer?” American Society of Clinical Oncology, http://ascopubs.org/doi/full/10.1200/jco.2006.06.4709.
6. Freiden, Joyce. “Forcing Teen to Have Chemo Not Troubling to Ethicists.” MedPage Today,
http://www.medpagetoday.com/publichealthpolicy/ethics/49519.