A Case Study in Coercion

A Case Study in Coercion

Manuel Villanueva

Oakland University, Michigan

Abstract

A case study of a 70-year-old patient finds his doctor responsible in coercing him into having a pacemaker inserted in his body. The doctor threatens to have the patient’s truck driver license revoked if he refuses treatment. Although the patient does not want the pacemaker put in his body, he does not want to lose his truck driver job which is how he supports himself. Ultimately, the patient submits to his doctor’s threats and has the pacemaker inserted into his body. The case is examined finding legal and moral faults with the doctor in his relationship with his patient.

    The exact medication and dosage is uncertain in this case but an assumption will be made regarding both. Mr. Jones, a 70-year-old man, had been to his doctor’s office complaining of dizziness and lightheadedness for several days after taking his new prescription of diltiazem hydrochloride, 180-mg once a day. Mr. Jones told his doctor, Dr. Smith, that his lightheadedness had become so severe that he collapsed hitting his head in the process. After this incident Mr. Jones discontinued taking his new prescription thinking it was responsible for his lightheadedness. Dr. Smith ordered a twelve-lead electrocardiogram (EKG) and diagnosed Mr. Jones as having third-degree atrioventricular (AV) block, a potentially life-threatening bradycardia. Third-degree AV block “is not a stable pacemaker, and episodes of ventricular asystole are common” (American Heart Association, 1994, p. 3-15). Mr. Jones was admitted to the telemetry unit of a metropolitan teaching hospital for monitoring and tests. One day later Tracy, the night shift nurse, received report that Mr. Jones was diagnosed with third-degree AV block. However, Tracy did not recognize Mr. Jones’ cardiac rhythm as being third-degree AV block. A subsequent twelve-lead EKG revealed Mr. Jones as having a right bundle branch block (RBBB), a condition that does not indicate treatment. At that time, Mr. Jones’ heart rate was seventy to eighty beats per minute with an underlying sinus rhythm: not third-degree AV block. Curiously, Tracy asked Mr. Jones why he had been admitted and diagnosed with third-degree AV block; so, Mr. Jones told his story leading up to his doctor’s appointment. Because Mr. Jones was hemodynamically stable, Tracy told Mr. Jones that his heart was working fine other than some minor abnormalities in his heart rhythm. Later, Dr. Brown, the cardiologist on call, sat down with Tracy and explained that Mr. Jones’ third-degree AV block was temporarily induced by his medication. Dr. Brown also said Mr. Jones’ RBBB, although benign in itself, made him extremely susceptible to the medication’s adverse effects. That morning Mr. Jones, feeling well and no longer in third-degree heart block, told his doctor he wanted to go home. On the contrary, Dr. Smith insisted he must stay to have a permanent pace maker inserted in his chest to counter the effects of diltiazem. Upon hearing Dr. Smith’s plans, Mr. Jones refused to have the pacemaker. But Dr. Smith threatened to inform the State License Bureau that Mr. Jones was unfit to drive if he did not agree to have the pacemaker. Dr. Smith stated that Mr. Jones would be a danger to others if he were to pass out and loose control of his truck due to the diltiazem; he gave no reason why Mr. Jones must continue to take diltiazem.

    The following night, Mr. Jones explained to Tracy what had happened. Tracy suggested to Mr. Jones that he could retire from work to avoid having a pacemaker but Mr. Jones said that he needed to work to support himself. Then Tracy commented to Mr. Jones, “I really don’t know why you need that medication. Without it your heart rate and your blood pressure are normal. There are risks involved with having a pacemaker put in. You don’t have to get it if you don’t want to.” Mr. Jones agreed but said he did not want to loose his truck driver’s license. The following day Mr. Jones signed a consent for the procedure and had the permanent pace maker inserted into his chest. Later, Tracy learned that Dr. Smith was upset that she openly questioned Mr. Jones’ need for a pacemaker.

    One identifiable dilemma in this situation is the violation of Mr. Jones’ right to autonomy. Although Mr. Jones ultimately yielded to his doctors’ treatment, Mr. Jones did not truly give his informed consent into taking the medication, diltiazem, or in having a pacemaker inserted into his body. Indeed, Mr. Jones was not able to make a voluntary decision concerning his treatment because he was threatened with having his means of support taken away from him if he did not agree to treatment. Authors Appelbaum, Lidz, and Meisel (1987) state, “wills are voided if the testator was subjected to undue influence, criminal confessions are voided if coerced, and contracts entered into under duress are voidable. So to with consent to medical care” (p. 61). Dr. Smith could have persuaded Mr. Jones into agreeing to treatment by offering him a rational argument. Instead, Mr. Jones was coerced into treatment by being presented with a scenario that he would find irresistible. “Coercion and manipulation invalidate consent because they interfere with free choices” (Lo, 1995, p. 28). As a result, Mr. Jones’ autonomy had been compromised. “In order to be able to choose freely, one must not be under too much pressure from the outside. Law has two terms that characterize such pressures: coercion and undue influence. The presence of either invalidates the legal character of any effort at producing autonomous expressions, including the granting of consent” (Appelbaum et al., 1987, p. 24). Furthermore, Mr. Jones was not presented with a reasonable explanation to make an informed decision about his treatment: “The duty of disclosure, or the duty to inform, is the truly distinguishing and innovative aspect of the informed consent doctrine” (Appelbaum et al., 1987, p. 57).

    One fact that may shed light onto this case is the reason Mr. Jones was taking diltiazem, especially such a large dose despite the fact his blood pressure and heart rate were within normal limits in the absence of this medication. Diltiazem is a calcium channel blocker that is typically used to treat hypertension and cardiac arrhythmias (Gerald & O’Bannon, 1988, p. 347). Because diltiazem caused a potentially life-threatening effect on Mr. Jones, it is said to have a poor therapeutic index in this case. “The therapeutic index provides a quantitative measure of the relative safety of a given medication. It is the ratio of the dose that produces toxic effects to the dose required to produce the intended clinical response” (Gerald & O’Bannon, 1988, p. 31). In order to legitimately give diltiazem, the “ratio must be greater than 1 if the drug is to possess any clinical value” (Gerald & O’Bannon, 1988, p. 31). If diltiazem causes a potentially life-threatening effect on Mr. Jones then we must assume that this drug has been given to treat an equally life-threatening condition. In this case, 180-mg of diltiazem produced a potentially life-threatening arrhythmia while the same 180-mg of diltiazem was prescribed to treat an unknown condition. The therapeutic index appears to be one-to-one which indicates it is not appropriate to give. In fact, any prescribed medication given to Mr. Jones producing third-degree (AV) block would be considered inappropriate. Above all other ethical guidelines in medicine a physician has an obligation to do no harm: “If physicians cannot benefit patients, they at least should not harm them or make the situation worse. When benefits and burdens are evenly balanced, physicians should err on the side of not intervening” (Lo, 1995, p. 37). Another question is why did Mr. Jones’ doctor choose not to inform his patient of any alternatives except to have a pacemaker and remain on diltiazem. Dr. Smith has chosen to exercise medical paternalism which will be discussed later.

    According to the latest draft of the American Nurses Association’s Code of Ethics for Nurses, Tracy is morally bound to ensure her patients' autonomy:

Patients have the moral and legal right to determine what will be done with their own person; to be given accurate information in a manner that they can understand and all the information necessary to make an informed judgment; to be assisted with weighing the benefits, burdens and available options in their treatment, including the choice of no treatment; to accept, refuse or terminate treatment without undue influence, duress, coercion or penalty; and to be given necessary support throughout the decision-making and treatment process (American Nurses Association [ANA], 2000, p. 6).

    Dr. Smith took every right mentioned above away from Mr. Jones and Tracy had a professional obligation to correct this situation. Mr. Jones chose not to be treated; that is his right. As a nurse, Tracy has a primary moral obligation to serve her patients' interests; not the doctors' or the hospital's but her patients’ interests. "The nurse's primary commitment is to the patient, whether an individual, family, group or community" (ANA, 2000, p. 9).

    Here are Tracy’s personal values in this dilemma. Tracy has strong feelings about interfering with someone’s autonomy, including her own. She finds the doctor's attitude offensive and demeaning in this matter. The doctor did not approach Mr. Jones as his personal advocate. Instead, the doctor dictated what treatment Mr. Jones was to accept along with threatening Mr. Jones into compliance. Also, Dr. Smith was upset with Tracy’s interference in Mr. Jones’ willingness to comply with treatment. Tracy has witnessed numerous procedures performed on patients at her teaching hospital just for the sake of learning. Tracy has also seen several complications of having a pacemaker and feels there should be some legitimate reason for having one. Tracy’s personal values move her towards opposing Dr. Smith’s plans for a pacemaker in this case.

    The moral position of Dr. Smith is in question as he has chosen to exercise medical paternalism in this case. Over all other persons, including Mr. Jones, Dr. Smith believes he knows what is best for Mr. Jones. Also, it is clear Dr. Smith feels he is protecting society by imposing medical treatment on Mr. Jones. There are several reasons why the practice of medical paternalism is looked down upon in medicine. One reason is “critics of medical paternalism point out that value judgments are unavoidable in clinical decisions and that physicians have no expertise to make them” (Lo, 1995, p. 39). Mr. Jones should be able to decide what treatment is right for him because he must live with the consequences of accepting or declining treatment. It is his life, not the doctors’. Another reason is that practicing medical paternalism encourages a patient to relinquish the duty of caring for himself. Author Bernard Lo (1995) states, “patients who sense that they have no decision-making power will not seek an active role” (p. 40). Dr. Smith has now created an environment where Mr. Jones has become a passive participant in order to avoid further conflict and maintain this one-sided relationship. “In Contrast, if patients are empowered to participate in their care, they generally become more active in asking questions, seeking information, and taking responsibility for difficult choices” (Lo, 1995, p. 40). Let us assume Dr. Smith is correct: Mr. Jones needs to take diltiazem and have a pacemaker. Despite this fact, Dr. Smith was morally and legally wrong in the manner he approached Mr. Jones. Take for example a similar scenario, an employer has threatened his employee to sign a waiver or be fired. The employee is frightened and worried about losing her job so signing the waiver becomes “the only reasonable thing to do” (Fingarette, 1997). That was an example given by philosopher Herbert Fingarette to describe one of the many legal interpretations of coercion. Coercion is not acceptable in law nor is it acceptable in medicine.

    Here is Tracy’s moral position. Just as deontologists Immanuel Kant believed “that we should never impose anything on a person against her [or his] will,” Tracy believes her patients should not be forced into treatment (Graber, 1998, p. 521). Tracy has identified that Dr. Smith has coerced Mr. Jones into accepting treatment. "Such coercion would undermine patients' abilities to pursue rational courses of action that are consistent with their ethical systems" (Appelbaum et al., 1987, p. 26). Second, Tracy suspects that Mr. Jones was not presented with all possible alternatives to taking diltiazem and having a pacemaker inserted in his body. "If the physician, who is aware of the medical situation, fails to share such facts with the patient, who presumably is not, the latter will be unable to make a reasoned choice and therefore unable to act autonomously" (Appelbaum et al., 1987, p. 27). Although Tracy was opposed to Mr. Jones having a pacemaker and taking diltiazem, all she did was state this fact to Mr. Jones when he should have taken a proactive role as her patient’s advocate.

    Whatever moral position Mr. Jones held in this case was suppressed by Dr. Smith’s coercion and medical paternalism. We can assume that Mr. Jones is a rational and reasonable being and by his initial refusal of treatment we can see that he was acting autonomously.

    The following value conflicts existed in this case. First, Dr. Smith felt he knew what was best for Mr. Jones to the point that coercion was used. Dr. Smith also felt Mr. Jones, without a pacemaker, was a danger to others on the road. Second, Mr. Jones did not know why he had to take diltiazem or have a pacemaker and certainly did not want either but he did not want to loose his truck drivers’ license. Lastly, Tracy did not see the need for Mr. Jones having a pacemaker or the need of him taking diltiazem. In order to have resolved these conflicts, Dr. Smith should have refrained from practicing medical paternalism and using coercion and instead presented Mr. Jones with all the information necessary to make a rational informed decision.

    Mr. Jones, having possession of all his cognitive abilities, should be free to decide what choices to select concerning his health. Dr. Smith may have advocated that Mr. Jones not drive and may even see fit to report him to the State but was wrong in using this threat to compromise his ability to freely choose treatment. "Advocacy, however, must not be permitted to turn into coercion. Unfortunately, the line between persuasion and coercion is exceedingly fine, and physicians must be extremely sensitive to overstepping it" (Appelbaum et al., 1987, p. 199).

    Two possible outcomes that might have occurred in this case could have been taken to resolve this dilemma. One, as suggested earlier, Dr. Smith could have decided to give Mr. Jones all the information necessary to make an informed decision. Dr. Smith may have even persuaded Mr. Jones by presenting a reasonable argument for having a pacemaker ultimately allowing Mr. Jones to decide what action to take. Second, Dr. Smith could have consulted an ethics committee for advice on how to handle this situation: “Clinical ethics committees…can remedy such problems, by providing multidisciplinary consultation (but not, they are clear, ‘prescriptions’ for action) concerning clinical ethics issues, whether case-related or more general and in doing so benefiting patients, families, and health care staff…” (Gillon, 1997, p. 203). Dr. Smith, Mr. Jones, and Tracy could have all been present at the committee and shared their point of views hopefully coming to a mutual agreement.

    Given a choice on selecting a possible outcome for this case, Tracy would choose to have Dr. Smith present Mr. Jones with all the information to make an informed decision. Although consulting an ethics committee would have been a reasonable choice, Tracy is confident that Mr. Jones would have made a rational decision had he been properly informed and not coerced. Regardless of what decision Mr. Jones would have made, Dr. Smith should have respected it. “Patients have the moral and legal right to determine what will be done with their own person” (ANA, 2000, p. 6). Mr. Jones deserves to have his autonomy respected.

    In conclusion, Dr. Smith took the decision making process away from Mr. Jones by threatening to take away his means of support. Under coercion, Mr. Jones submitted to taking diltiazem and having a pacemaker inserted into his body not because he felt this treatment was needed but because he wanted to keep his job. An injustice was made by not providing Mr. Jones the opportunity to make a rational decision concerning his health. Although Dr. Smith may have advocated that Mr. Jones have a pacemaker, he crossed moral and legal boundaries by imposing the device with a threat. Consequently, Mr. Jones’ autonomy and legal rights were violated.

References

    American Nurses Association. (2000). Code of ethics for nurses: Draft nine. [on-line]. Available: http://www.ana.org/ethics/code9.pdf

    Appelbaum, P. S., Lidz, C. W., & Meisel, J. D. (1987). Informed consent: Legal theory and clinical practice. New York: Oxford University Press.

    Cummins, R. O. (Ed.). (1994). Textbook of advanced cardiac life support. Dallas, TX: American Heart Association.

Fingarette, H. (1997). Coercion, coercive persuasion, and the law. [on-line]. Available: http://www.lermanet.com/cos/Robbins.html

    Gerald, M. C., & O’Bannon, F. V. (1988). Nursing pharmacology and therapeutics. (2nd ed.). Englewood Cliffs, NJ: Prentice Hall Incorporated.

    Gillon, R. (1997). Clinical ethics committees: Pros and cons. Journal of Medical Ethics, 23 (4), 203-204.

    Graber, G. C. (1998). Basic theories in medical ethics. In J. F. Monagle & D. C. Thomasma (Eds.), Health care ethics: Critical issues for the 21st century. (pp. 515-526). Gaithersburg, MD: Aspen Publishers Incorporated.

    Lo, B. (1995). Resolving ethical dilemmas: A guide for clinicians. Baltimore: Williams & Wilkins.