Decision making capacity

Initial Post: A 60-year-old homeless man, “Jesse”, is found confused and in distress by a passerby who calls 911. Paramedics bring the man to the hospital. Jesse’s feet and legs are swollen and covered in ulcers and dead tissue—diagnosed as osteomyelitis, or infection of his legs. His past medical history is established to include chronic obstructive pulmonary disease (COPD), chronic foot infections, alcoholism, and tobacco use. In addition to this, clinicians find a mass in Jesse’s lung that could either be TB or cancer. Physicians recommend a biopsy. The infections in this patient’s legs are so severe that a double amputation is also recommended.

Jesse says “No!” to amputation, but reluctantly agrees to a biopsy of the lung mass. Jesse had been able to identify his location in a hospital but not why, or what could happen as a result of not going along with medical recommendations for treatment. He had stated to the clinical team that he just wants to leave the hospital and die. But does he? Maybe. In a previous hospital admission, the chart indicates that Jesse had refused surgery as treatment for recurring infection in his legs, and physicians believed he had done so with decisional capacity.

Jesse’s support system initially seems to consist only of a couple recent acquaintances at the homeless shelter (who don’t have telephones and cannot be reached) and a dog that Jesse says is his best friend. A hospital social worker searches for any next of kin, someone who knows Jesse and might be willing and able to make decisions as a surrogate. Social work eventually finds an out-of-town brother and an estranged sister. Neither have seen their brother in many years, and anyway are unwilling to make decisions on his behalf. The attending physician wonders aloud what should be done for Jesse now, and who can decide? An ethics consultation is requested.

1. Does Jesse have decision making capacity?

2. How might strong or weak paternalism apply?

3. If Jesse had a living will, would it help in this case? Why or why not?

4. What moral methodology helps you respond to this case and what recommendations would you provide?

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