Assignment 1, Group 15

Members: Aimee Allworth, Rachael Anderson, Kalina Nguyen, Nicholas Rintala, and
Jessica Wang
Ethics Consultation for Daxs Case
(a) Four Box Method
Medical Indications
Dax is a 26 year old Caucasian male, presumably was healthy before this incident.
Diagnosis: Patient came into the hospital with severe burns on 65% of his body
including on his hands and ears, loss of eyesight due to burned eyes and third
degree burns on the face, and in shock. He also has developed a dropped foot
(damage to his right foot that causes abnormality in his gait). He also suffers from
insomnia, severe depression from losing his father, and pain from his injuries.
Prognosis: The efficacy of curing the patient's burns through fluid replacements, skin
graftings, whirlpool tankings (in a Hubbard Tank with chlorox and water), operations
to remove dead skin, and the administration of antibiotics is high. There is a small
chance that the left eye may be able to heal and see again. Attaining any form of
original normalcy for the patient is futile, but it is likely that the patient will live if given
treatments.
Treatments and & Goals of Therapy: Amputation of heavily charred fingers and the
right eye, heavy doses of narcotics to reduce pain as much as possible, regular deep
cleansing of the skin, skin grafts. The left eye stitched shut in an attempt to avoid
further pain. Patient also receives psychoanalytic therapy and antidepressants for
depression and insomnia.
Patient Preference
Autonomy principle: Patient requested to be shot to death immediately following
incident and continued requests for death and stopping treatments throughout
hospital stay. When these requests were not honored, Dax requested repeatedly to
be provided with a gun and assistance from the nurse to help him die. After
realization of lack of physical mobility, he consented to some treatment for the
purpose of regaining mobility in arms and legs.
Capacity of choice: Initially questionable because patient was in excruciating pain
and so mental capability to make decisions about wanting to live may have been
impaired. Patient initially lacked ability to refuse therapy due to lack of physical
mobility to resist and, following initial reparative procedures, now has capability to
decide whether or not to continue treatment. After the first series of treatments,
patient was declared mentally competent by psychiatric evaluations performed by Dr.
White and another practicing psychiatrics physician.
Informed consent/refusal: It is certain Dax knew that he would never regain his
original life back due to the extent of his medical condition. He knew he would have
to sustain pain throughout treatments and be deformed for the rest of his life. It is
uncertain whether or not he was informed that he his treatment has a high chance of

saving his life and that he would be able to live for years to come following his
treatments.
Surrogate decision maker: Ada Cowart (his mother) gave permission for the
physicians to treat all of Dax's injuries and keep him alive when Dax was first
admitted and rendered incompetent. She often went along with the doctors
suggestions without consulting Dax because she admitted she did not fully
understand Daxs condition or the treatments.
Advance Directives: There are no known advanced directives in this case.
Quality of Life
Evaluation: Plastic surgeon resident indicated to patient that reparative surgery
would be continuous and take many years, and so Dax would be in medical care for
a long time. Dax must be moved to multiple treatment centers, which places him far
from friends, family, and home town. Dax used to be handsome as proclaimed by
family friends and rather athletic. Quality of life is greatly lowered by blindness,
disability, and deformity. He will need assistance to do simple bodily functions. Dax
also openly fears that his deformity will prevent him from marrying and living the life
he wanted.

Contextual Features
Family: Mother refuses to end Daxs treatment regardless of her sons requests
because of her religious (Catholic) beliefs.
Cost of care: Treatment involves moving Dax to multiple locations and different
providers far from hometown. Family is willing to support treatment and after-care
costs. Family lawyer also brought a law suit against the company responsible for the
propane leak, and the cost of care is also being covered by that company.
Allocation of Resources: Doesnt seem to be a problem here.
Confidentiality and Protection of Others: Also not an issue.
Law: Daxs providers themselves could face legal prosecution from the hospital if
they left their patient to die. Daxs family lawyer wants to keep Dax alive to bring a
stronger law suit on the propane company.
Conflicting providers: Multiple providers have had differing opinions on the case.
Many (his mom and the doctors and nurses) feel it would be a violation of their duties
as health care providers to stop treating Dax and let him die in their hands when they
have means of providing treatment. Dr. White (the psychiatrist) expresses the most
difficulty in seeing Dax's treatment continue despite his wishes for death and, at the
end of a memoir he wrote called Dax's Case 12 Years Later, Dr. White speaks about
how wonderful and caring an act it was of the renown Sigmund Freud's doctor to
administer a deathly dose of morphine when Freud had no more quality of
life. Perhaps in retrospect Dr. White supported Daxs pleas to let him die.

Patients culture and religious affiliation: Unsure if Dax shared the same religious
beliefs as his mother, but patient preferences are clear.
(b) Consensus ethics recommendation about whether or not to proceed with
proposed treatments:
Our group is at a consensus that Daxs requests to stop treatments should be
honored and the physicians should not proceed with any further procedures.
(c) Argument for the consensus recommendation
The four ethical principles are beneficence, nonmaleficence, autonomy, and
justice. The ethical principles that seem particularly at stake in Daxs case are those
of autonomy, nonmaleficence, and beneficence.
The principle of autonomy dictates that one ought to give competent and
well-informed patients the right to exercise their autonomy and make their own
decisions. In Daxs case, although he was initially rendered incompetent during the
initial stages of his treatment, after his evaluation with two psychiatrists who declared
him sane and sound of mind, the doctors ought to recognize Dax as an autonomous
individual. His wishes to discontinue treatment should be honored, but his health
care providers should not feel the need to comply with Daxs request for assisted
suicide with a gun because this request is not within the health providers job. It is
their job, however, to ensure that Dax knows all the consequences of discontinuing
treatment and the benefits he could gain from receiving treatment.
The principle of nonmaleficence states that physicians and health care providers
ought to do no harm and omit anything that would hurt the patient. In this case,
although the treatments could save Daxs life, they cause Dax excruciating pain
which he would have to endure many times over a time span in years. In addition to
physical pain, he is also in constant mental and emotional distress from the
repercussions of losing his father and the event that lead to his painful injuries. It is
known he has depression and insomnia and often requires large doses of narcotics.
It is clear that the patient is in very deep distress, and giving him more treatments
would only cause him more pain than relief.
Lastly, the principle of beneficence states that health care providers ought to do
good and only good and that their actions should be in the patients best interest.
Despite the prognosis that the patient would be able to regain some level of
independence and likely to live for years to come upon completion of all treatments,
the process of administering those treatments would span over years of being in the
hospital and countless procedures that cause the patient pain. The patient would
have to live with the emotional and mental aftereffects of having gone through so
much pain for the rest of his life. Most importantly, the patient himself has requested
discontinuation of his treatments and was evaluated to be competent and sane. The
patients own arguments for discontinuing treatments include the fear of having to
endure the painful treatments, the fear of which he considers a greater harm than
being left alone and dying. Hence, the providers would be doing the most good by
honoring Daxs wish to stop treatment.