Thursday, January 17, 2008

NYS Supreme Court Case Stirs Ethical Debate

As is being being reported in numerous outlets, the NYS Supreme Court will be hearing a civil case filed against NewYork-Presbyterian Hospital by a construction worker who underwent an involuntary rectal examination as part of his trauma assessment. The plaintiff is claiming assault, battery, and false imprisonment for being restrained, sedated, and examined against his wishes. The hospital's response, of course limited due to HIPAA requirements, is that the plaintiff was brought to the ER with head trauma, was combative, and needed to have severe head trauma ruled out. (Apparently a rapid way to assess injury to the nerves of the spinal cord is to check rectal sphincter tone.) The plaintiff resisted, was sedated, and when brought out of sedated, punched a doctor in anger, and was arrested for assault.

None of this in itself is particularly new or newsworthy; it is a continuing debate of what constitutes emergency care, standard care, informed consent, and what it means to have decision making capacity. These debates have been going on for years, and will likely continue for as long as any of us can envision.

No, the interesting thing actually comes from the commentary at City Room, the NYTimes local blog. Reading through the comments gives an eye-opening view into the way the general public perceives medicine, emergency medical care, and doctors. The most fascinating, and oft-repeated claim, is that if the patient (plaintiff) could be be arrested for assault, then he was obviously competent to decide his medical care - that, as one commenter put it,
if the patient’s competence is questioned regarding his ability to make an informed decision, then it’s inconsistent to charge that same incompetent person with assault.

Of course, the best retort to that (also brought up in comments) is that a drunk person is not competent to make decisions - yet is still responsible for the actions they take while drunk. (Also of note is that no one claiming specific background and training in medical ethics has spoken up in the thread. For those of you reading this, with the limited information available, what's your take on the situation?)

Obviously the message of personal autonomy and the basic idea of informed consent has permeated our society, but at a very simplistic level that might actually cause more misunderstanding and difficulty when treating emergency medical cases than potential good. The question becomes then, how do we increase the general knowledge level of the lay person while still emphasizing autonomy, while simultaneously acknowledging the education and superior knowledge of the physician without falling back on paternalism?

For anyone interested in this line of thought, the comments in that thread are well worth the read, and the contemplation.

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