Losing the Peace - ethics question (spoilers)

[kkozoriz1]

I just read this part of Losing the Peace when Crusher is on Pacifica:

“The S’ti’ach have remarkable natural healing powers. When
injured, they can put themselves into a coma-like state, similar to a Vulcan healing trance, and redirect all their metabolic energy toward repairing the physical wounds.”
“But if it’s natural, why wasn’t he healing himself?”
“Because he didn’t want to.” Crusher lifted the bandages, revealing, as she suspected, deep brown gouges in the S’ti’ach’s blue arm, which without doubt had been made by his own claws, trying to slice the brachial arteries.
“The delta-wave inducer puts him in a deeper state of sleep, so that his subconscious mind can’t interfere with his autoimmune functions.”

Wouldn't that be treating a patient against his will? Crusher specifically states the the patient himself was deliberately not using his own healing abilities. Does Crusher have the right to apply treatment to a patient who doesn't want it?

 

[Deranged Nasat]

In this situation, I'm sure she would say she does. Her patient's desire not to recover is a sign of psychological illness - of trauma and despair, not of any reasoned philosophy. As was his initial attempt to take his life. Crusher would say (as would I) that Mr. Sasdren needs help psychologically as well as physiologically. So his desire to die should be "treated" as should his physical injuries.

I suppose if Crusher was Denobulan it might have been time for an ethical dilemma, but as it is she treated him whether he wanted it or not. As I said, he's a victim of intense trauma who isn't in a healthy frame of mind. I agree that this sort of thing always has the potential to edge into some iffy and complex ethical territory, but as it is, in this example, I think the vast majority of people would do what Crusher did. Sasdren isn't in intense ongoing physical pain or suffering in a way that can't be treated or helped; the unbearable situation he's in can be helped with therapy - because it's his state of mind that's to blame. So it seems to me that his decision to die should be blamed on that too, and therefore is "illegitimate". Basically, I'd be 100% behind an attempt to save a suicidal person in this situation.

And as a doctor (and a doctor who doesn't live by any particular cultural code that might impede it, as a Denobulan might) Crusher's instinct is to heal.

Of course, we don't know if S'ti'ach culture has any different views on suicide...then again, Sasdren isn't Crusher's problem anymore. She did her duty and saved him,....Maybe he'll try it again, we don't know.

 

[JD]

^What he said. As far as I know, if you survive a suicide attempt today, they will treat you, and I doubt that that would have changed much by the time of Trek.

 

[Snaploud]

I don't think doctors should ever be obligated to follow the subconscious desires of patients. Conscious, purposely-expressed desires are another matter entirely.

 

[Christopher]

I wouldn't know, but I'd suspect that even a Do Not Resuscitate order in a patient's living will or medical records would not be honored in a case of the attempted suicide of an otherwise healthy individual, because the act would be a clear sign that the patient wasn't of sound mind and judgment.

 

[F. King Daniel]

Even if suicide was considered acceptable among the S'ti'ach (like the Vulcans, IIRC, although I have no idea where I got that from), I'd imagine the person in question has to be of sound mind when they make that choice. Sasdren wasn't.

 

[BillJ]

I wouldn't know, but I'd suspect that even a Do Not Resuscitate order in a patient's living will or medical records would not be honored in a case of the attempted suicide of an otherwise healthy individual, because the act would be a clear sign that the patient wasn't of sound mind and judgment.

My question becomes: If you have truly limited resources, do you have time to be messing around with those who don't want to go on? Shouldn't those resources be used for those who truly want and need it?

 

[Christopher]

Dude, you really need to take an ethics class sometime.

 

[BillJ]

Dude, you really need to take an ethics class sometime.

So you have enough supplies to save one person and you have two that need treatment. Who do you save? The one that wants to live or the one that attempted to kill themselves? Or do you let both die in an attempt to satisfy some ethical obligation?

 

[kkozoriz1]

In Half a Life Timicin left the Enterprise specfically to commit suicide. Shouldn't Crusher have prevented him from doing so in that case? There was no question that he was going to kill himself and Lwaxana even went along with him. If attempted suicide is a sign of an unsound mind, shouldn't she have had him confined? Even the Captain couldn't override her on a medical matter.

In Ethics if Worf had not changed his mind, would Crusher have allowed Alexander to assist Worf with his suicide? Riker only turned it down because Alexander was Worf's closest relative.

The point is, shouldn't the cultural wishes of the being in question be taken into account? How did Crusher know that she wasn't interfering in what could be a religious ceremony for instance?

 

[BillJ]

In Half a Life Timicin left the Enterprise specfically to commit suicide. Shouldn't Crusher have prevented him from doing so in that case? There was no question that he was going to kill himself and Lwaxana even went along with him. If attempted suicide is a sign of an unsound mind, shouldn't she have had him confined? Even the Captain couldn't override her on a medical matter.

In Ethics if Worf had not changed his mind, would Crusher have allowed Alexander to assist Worf with his suicide? Riker only turned it down because Alexander was Worf's closest relative.

The point is, shouldn't the cultural wishes of the being in question be taken into account? How did Crusher know that she wasn't interfering in what could be a religious ceremony for instance?

I don't think you could stop either one in the instances listed above as they are cultural norms for the societies they come from (they don't consider wishing to commit suicide a sign of mental illness). I put Losing the Peace down after the re-hash of the Thalaron debate from Destiny so I don't know if the actions by the character in question are within their cultural norms.

 

[Deranged Nasat]

Interesting discussion.

In Half a Life Timicin left the Enterprise specfically to commit suicide. Shouldn't Crusher have prevented him from doing so in that case? There was no question that he was going to kill himself and Lwaxana even went along with him. If attempted suicide is a sign of an unsound mind, shouldn't she have had him confined? Even the Captain couldn't override her on a medical matter.

But Timicin was in sound mind. He wasn't suffering from trauma or extreme depression or any of the issues Sasdren was presumably going through. His reasons were cultural, not due to psychological troubles. He was engaging in ritual that is very dear to the Kaelon society. I guess we'd say that it wasn't a case of "I want to die!" but of "I'm choosing death over the alternatives". I think that's the key. The first statement is a sign of a problem psychologically, the second a reasoned position. When the Ranger rammed the Borg cube at Khitomer in Gods of Night, its command crew chose death over the alternatives. Timicin did the same. Sasdren isn't the same because he isn't choosing death so much as he wants to die. And wanting to die as a default way to escape your problems is a sign of an unsound mind. I hope I phrased that in a way that makes sense.

In Ethics if Worf had not changed his mind, would Crusher have allowed Alexander to assist Worf with his suicide? Riker only turned it down because Alexander was Worf's closest relative

I'm guessing she'd have made quite a fuss over it. I suppose she might say "if this were a Klingon ship, go ahead, but in a Federation sickbay I, as the ranking medical official, refuse to permit it". Or something. It's not quite the same as the Timicin situation because Worf is actually her patient, Timicin wasn't. So she has a duty and obligation to interfere with Worf if her ethics suggest she should, I'd imagine. It's certainly a complex situation, but I think Crusher would be firmly against the suicide option so long as the patient was under her perview. Don't quote me or anything, I'm no authority on medical practice and associated ethics.

The point is, shouldn't the cultural wishes of the being in question be taken into account? How did Crusher know that she wasn't interfering in what could be a religious ceremony for instance?

Well, I don't think a doctor can do that. She has to heal her patients, not leave them dying while she searches the database for "S'ti'ach wrist-slitting ceremonies". I suppose like any way of life it has the potential to cause problems, but a doctor has to live by a "heal first, worry about complications later" code.

 

[kkozoriz1]

Timicin had requested asylum and later changed his mind. It appears that he wasn't quite as sure as you're making it out to be. His daughter basically guilted him into it.

A doctor, even now, has to take the patients wishes into account. You cannot force an Jehovah's Witness to accept a blood transfusion although a court can allow one where a minor is involved since they cannot make an informed decision on their own.

 

[Deranged Nasat]

Timicin had requested asylum and later changed his mind. It appears that he wasn't quite as sure as you're making it out to be. His daughter basically guilted him into it.

Oh, I'm not denying that he was largely guilted into it by his family and his society, but I think that's a separate issue from whether or not he was making a choice with sound mental faculties.

A doctor, even now, has to take the patients wishes into account. You cannot force an Jehovah's Witness to accept a blood transfusion although a court can allow one where a minor is involved since they cannot make an informed decision on their own.

Okay, good point , but that's in a far more stable social environment than a refugee camp in the aftermath of a major conflict. Crusher doesn't have time to contact S'ti'ach'aas and ask for detailed cultural/legal information about suicide and choice, etc, or the cultural implications of subconscious resistance to healing trance. She has a patient in front of her who is in need of medical care. So she feels has an obligation to help him. If angry S'ti'ach show up afterwards moaning about her actions, that's a secondary issue for another time, presumably, and, I'd argue, possibly a largely disconnected issue. She did what her own code of conduct dictated she do - help the sick and injured recover. And, Sasdren is free to go once he's healed. If he refuses psychological help and decides to go off somewhere and try again, there's not much Crusher can do.

Again, I think we all have to acknowledge that we're potentially skirting around some very complex issues, but I still think the Sasdren case is quite clear-cut. He had tried to take his life - and seemingly was in a state of mind where he wanted to die - as a response to a traumatic situation. That's almost certainly a sign of mental illness. So his desire to die is a symptom just as much as his slit wrists. And as a doctor in a difficult situation, an emergency refugee camp, Crusher has to just get down to the healing and help people. Doctors can't be effective at their job if they're constantly second-guessing along the lines of "but what if S'ti'ach don't agree with overriding suicidal outlooks?"

 

[Sci]

Dude, you really need to take an ethics class sometime.

So you have enough supplies to save one person and you have two that need treatment. Who do you save? The one that wants to live or the one that attempted to kill themselves? Or do you let both die in an attempt to satisfy some ethical obligation?

Typical medical ethics says that you devote your resources towards saving the patient with a greater medical probability of surviving. Prior suicide attempts on the part of either patient are irrelevant.

 

[Christopher]

Sci's right. Suicidal urges as a result of trauma are themselves a symptom of illness, an illness that threatens the patient's life. If there's a burst vessel bleeding into the patient's brain, the doctor's not going to throw up her hands and refuse to treat it. So why should a disruption in the cognitive and emotional processing of the brain be allowed to kill the patient? Depression isn't a lifestyle choice, it's a behavioral disorder, a medical condition that needs to be treated. It's grossly wrong to equate suicidal tendencies with, say, the wish of a terminal patient to die with dignity rather than have their life uncomfortably prolonged with feeding tubes, respirators, or the like.

 

[kkozoriz1]

Don't forget that this was happening on Pacifica, a Federation member planet. Surely they would have as good a computer system as the Enterprise would. It's not like they were in the middle of nowhere, cut off from all communication. Also, the S'ti'ach wasn't in immediate danger of dying. Crusher simply put the delta wave inducer on him, she didn't medicate him or close an open wound.

 

[kkozoriz1]

Sci's right. Suicidal urges as a result of trauma are themselves a symptom of illness, an illness that threatens the patient's life. If there's a burst vessel bleeding into the patient's brain, the doctor's not going to throw up her hands and refuse to treat it. So why should a disruption in the cognitive and emotional processing of the brain be allowed to kill the patient? Depression isn't a lifestyle choice, it's a behavioral disorder, a medical condition that needs to be treated. It's grossly wrong to equate suicidal tendencies with, say, the wish of a terminal patient to die with dignity rather than have their life uncomfortably prolonged with feeding tubes, respirators, or the like.

This is true as far as humans go. We're dealing with an alien species. They can enter a healing trance. That's pretty darn alien if you ask me. Who's to say that among S'ti'ach this isn't considered normal or even ethical? His refusal to enter the healing trance could be taken as a "do not resuscitate" notice. If a human had such a declaration, as we can have now, would Crusher ignore it?

 

[Sci]

Sci's right. Suicidal urges as a result of trauma are themselves a symptom of illness, an illness that threatens the patient's life. If there's a burst vessel bleeding into the patient's brain, the doctor's not going to throw up her hands and refuse to treat it. So why should a disruption in the cognitive and emotional processing of the brain be allowed to kill the patient? Depression isn't a lifestyle choice, it's a behavioral disorder, a medical condition that needs to be treated. It's grossly wrong to equate suicidal tendencies with, say, the wish of a terminal patient to die with dignity rather than have their life uncomfortably prolonged with feeding tubes, respirators, or the like.

This is true as far as humans go. We're dealing with an alien species. They can enter a healing trance. That's pretty darn alien if you ask me. Who's to say that among S'ti'ach this isn't considered normal or even ethical? His refusal to enter the healing trance could be taken as a "do not resuscitate" notice. If a human had such a declaration, as we can have now, would Crusher ignore it?

An episode of VOY established that even in the 24th Century, medical ethics are that you treat the patient most likely to survive, period. (That's why the Doctor went on the fritz -- he had two patients with an equal chance of survival, and he treated Harry, his friend, instead of the other patient.)

And being as how the S'ti'ach are Federation Members and have been known to the Federation since the TOS era, I'm sure that Crusher would know if his behavior was considered the same as a DNR notice. Since she didn't treat it like a DNR, I'd interpret that as meaning that his refusal to enter a healing trance is not consider a S'ti'ach DNR equivalent.

 

[Christopher]

His refusal to enter the healing trance could be taken as a "do not resuscitate" notice.

No, it absolutely could not, because it's not written down in a signed, legally binding form. Trust me, I've had direct, recent personal experience with exactly this subject. In order for a DNR to be recognized, it must have been agreed to by the patient in advance while the patient was clearly capable of making an informed decision, or by someone whom the patient authorized to make that decision while the patient was capable of making an informed decision. The scenario you're talking about is one where the patient is unconscious and clearly incapable of making an informed decision about his medical care.

Besides, the whole DNR issue doesn't even apply in this case, because Crusher isn't employing any "heroic measures" to keep the patient alive. All she's doing is inducing sleep in order to allow his body to repair itself. So there's no resuscitation of any kind involved. A DNR is something that applies in a situation where the patient would be unable to recover or survive without medical treatment. That is simply not the case here. The patient was fully capable of recovering and leading a full life.

What Crusher did is analogous to nothing more than sedating a delirious patient to keep him from tearing his IV out. There's no way in hell that constitutes a violation of a DNR order. There is no ethical dilemma here. She was totally in the right.