Review of John's Colon Cancer Surgery and Colostomy

John, a 20-year-old male with colon cancer, underwent surgery in which a significant portion of his large intestine was removed. Because so much bowel was removed, a colostomy needed to be installed in order for his excretory system to work. The operation was successful, but it is still necessary for John to undergo chemotherapy in order to ensure that no cancer cells are left.

The problem is that John has been very depressed since the surgery, especially about the prospect of wearing a colostomy bag the rest of his life. He is not interested in talking to anyone about anything, including the chemotherapy his surgeon wants him to undergo. He also is not open to caring for his colostomy and the nurse is worried about the possibility of infection at the colostomy site.

The surgeon tried to help John. He had family and friends try to encourage John and even had a former patient talk to John about how the colostomy has not drastically changed his lifestyle. The surgeon is concerned that if this mood persists, John will have a difficult, if not impossible, time with chemotherapy.

All this changes when one day, a family member tells John that colostomies can sometimes be reversed. John, ecstatic, asks his doctor why he didn’t mention this earlier. The surgeon is surprised and agrees and starts to reply, but is interrupted by John and does not say any more.

John undergoes chemotherapy and a year later, the cancer is gone for good. John asks the doctor to remove the colostomy. The doctor tells him that his colostomy actually cannot be removed. John replies that it’s okay because he’s learned to live with the colostomy, and is just glad that the cancer’s gone.

Uncertainties

There are uncertainties relating to chemotherapy. First of all, we do not know whether John would consent to undergo chemotherapy in his depressed state. It is possible given his listlessness that he decides to refuse conventional treatment, even though it is medically necessary and may lead to the cancer coming back. If John does undergo chemotherapy in a depressed state, how would he react, both physically and mentally? Would his immune system break down (leading to physical damage), or would he have a mental breakdown (leading to mental damage)? The severity of the side effects would determine whether nondisclosure is warranted.

We also don’t have a lot of information about John’s reactions. If the doctor does disclose that the colostomy is not reversible, would John continue to be uncooperative about his colostomy care? It is possible that if this mood persists, infection can occur, which leads to another slew of harmful side effects. We also do not know if John is actually as content with keeping the colostomy as he seems to be. We know that he was depressed, and we don’t know how the chemo has affected him. If he still is depressed, then this realization must a crushing blow to him, and he may just be saying that he’s okay with the colostomy, but not actually meaning it.

We do not know much about John’s mental condition. Is his depression impacting his ability to make decisions and if so, is he capable of making rational decisions? We do not know if he is receiving any kind of mental health care such as counseling from psychiatrists or antidepressant drugs.We also do not know whether John’s depression about his colostomy is normal compared with other colostomy patients. This could have affected the surgeon’s decision to not tell John that his colostomy is irreversible, especially given that the surgeon is a specialized professional who has likely dealt with similar situations in the past and may have prior knowledge on how to handle the situation.

We do not know a lot about the physician’s motives and actions. For example, is the physician really acting in the patient’s best interests by recommending chemotherapy, or is it possible that he is more concerned with things such as financial reward? Additionally, the surgeon seems to be the sole medical professional making the decision of disclosure or nondisclosure, so would his response have changed if there were other medical personnel in the room with him? Lastly, what was the physician actually going to say before John interrupted him? Was he intending to tell John that his colostomy was not reversible, but upon seeing his reaction, made a judgment call not to?

There are three principles at play in this case: autonomy, beneficence, and nonmaleficence.

Autonomy means that the patient is able to make his own informed choice about what medical procedures his body goes through. In this case, John needs to have all the facts regarding his situation and needs to be able to decide whether to undergo chemotherapy intentionally, freely, and voluntarily. Nondisclosure by the physician regarding the non-reversibility of his colostomy directly impacts John’s autonomy. By hiding a fact, the doctor does not allow John to make a fully informed decision. John’s autonomy is also limited by his own depression. His preoccupation with his colostomy impacts his competence and how rational he can be, although the severity of his depression symptoms is unclear. Thus it can be argued that John’s depression “waives” his right to make his own decisions and thus justifies the doctor’s nondisclosure.

The principle of beneficence holds that the sole goal of the physician is to heal the patient. The doctor needs to look out for the well-being of the patient, and in this case, this involves ensuring that John is cancer-free and mentally healthy. From a viewpoint of beneficence, the doctor did the right thing in not disclosing that John’s colostomy was not reversible. This action led to psychological relief in John, which allowed him to undergo chemotherapy successfully and ultimately become cancer-free. However, it is not clear whether John is content with living with his colostomy, so his mental health may be impacted.

Nonmaleficence means that the physician is not intentionally creating harm. In this case, regardless of what the doctor chooses to do, there is the possibility of harm. If the doctor does reveal that the colostomy is not reversible, John’s depressed mood will continue and his colostomy may become infected. If he chooses to undergo chemotherapy while depressed, he could potentially be harmed mentally and/or physically. He may suffer a mental breakdown, or his immune system may be compromised. If John chooses not to undergo chemotherapy, then cancer has a chance of coming back. However, if the doctor hid this information, John may be damaged psychologically. He may feel mental anguish, and the physician-patient trust may be damaged as well. There is potential harm in both decisions, but choosing nondisclosure leads to less harm than choosing disclosure.

Possible Case Resolutions

1. The doctor corrects John immediately and tells him that his colostomy is not reversible.
2. The doctor lies to John and tells him that his colostomy is reversible even though it is not.
3. Our resolution:The doctor does not confirm what type of colostomy John has and allows John to assume that his colostomy is reversible.

We believe that this decision is the best choice out of all three resolutions. My argument will be structured by defending our resolution against the other two possible resolutions.

In a comparison between our resolution and resolution #1, the primary conflict is between the principles of autonomy vs beneficence/nonmaleficence, and beneficence/nonmaleficence should be prioritized over autonomy. We believe that in this case, it is more important for the doctor to provide the best possible care to the patient and avoid the most harm than it is for the patient to make his own choice. We have two reasons for this. First, the potential benefits are much greater if the doctor hides the fact that John’s colostomy is not reversible. The chemotherapy will completely cure John of cancer, providing an enormous physical benefit that is not certain in the case of disclosure. If the doctor discloses that John’s colostomy is not reversible, resulting in John staying depressed, a slew of negative effects may result. If John chooses to undergo chemotherapy, in a depressed state, there is a high chance that he will be hurt physically or mentally. Additionally, if John is depressed enough, he will likely continue his poor treatment of his colostomy, which may lead to infection. He may even refuse chemotherapy, which provides the opportunity for the cancer to recur.

John also benefits in terms of mental health. It is possible (although not certain) that withholding the information provided a measure of psychological relief and gave him enough time to learn to cope with the colostomy. The patient may experience some psychological anguish from holding out hope that his colostomy was reversible, which may negatively impact the relationship he has with his physician. However, the pros of nondisclosure still far outweigh the cons.

Lastly, John’s autonomy may be compromised by his depression. John is so hung up on the idea that he will have to carry around a colostomy bag for the rest of his life that he is not focused on the bigger goal: beating cancer. His apathy, which may lead to him refusing chemotherapy, means that he is not fully competent to make his own decisions. Because John’s autonomy is being limited by his own mental state, autonomy takes a lower priority than beneficence.

In the comparison between our resolution and resolution #2, the main point lies in the difference between overt lying and deception (withholding information). We hold that deception is a better alternative than lying. According to the readings, deception is the “deliberate withholding of information where the person not informed is misled into drawing a false conclusion.” (Ellin, 78)However, deception is permitted if several criteria are met:

1. When the withheld information may be detrimental to medically necessitated treatment. The knowledge that John’s colostomy is not reversible may continue John’s depression and even cause him to refuse medically necessary chemotherapy. Another way of looking at this is that withholding information is okay if that information will end up injuring the patient, and John may experience physical and mental harm if he remains depressed. This concept is known as therapeutic privilege.
2. The withheld information does not improve the patient’s life. The colostomy is not reversible regardless of when the physician tells John.

Therefore, we believe that withholding information is acceptable in this case, but overt lying is not. One may argue that lying and deception are one and the same, since they are done with the same intention and result in the same outcome. However, drawing from the Ellin reading, we can argue that “the liar is more responsible for the harm caused than is the mere deceiver.” (81) The surgeon was able to withhold the information because the patient did not ask, so part of the blame can be shifted to the patient. In other words, the patient is more responsible for bringing about his own deception than if he had been lied to by the surgeon.