The patient, Mrs. Z., is a sixty-year-old woman who received a kidney transplant approximately one year earlier. Her current hospitalization is for a urinary tract infection and dehydration. She had a similar hospitalization three months ago. She is characterized in the medical record as “non-compliant” with her medicines, and she does not drink enough fluids to maintain her hydration. In order to treat her infection and to rehydrate her, the hospital staff would like to place a peripherally inserted central catheter (PICC) line and also additional IV lines. These would need to remain in place for several days. The patient refuses the placement.

The ethics consultant interviewed Mrs. Z and found her very difficult to engage in any sustained conversation. Mrs. Z would only offer that she “didn’t want any tubes” and that the reason was because “they hurt.” She repeated this line over and over when questioned. When asked whether she understood that these interventions might help her get better and that a lack of treatment could lead to her getting worse, she would say, “I don’t want to talk about that.” She would repeat these sentences or something similar in response to virtually any questions.

She has a husband, whom she married about five years ago, and who is currently in a rehabilitation facility after suffering a stroke. He has difficulty speaking, but when contacted by telephone, he said that he thought, “everything should be done.” Hospital staff also contacted her twenty-four-year-old son, who is going to school in another state and was her kidney donor. He says his mother’s mental status has never been completely right since the transplant and deteriorates significantly when she gets an infection and is dehydrated. He says that she has been negative about treatment since the transplant but would likely have wanted this care if she were her “old self”. Armed with this information, the ethics consultant asked Mrs. Z if she could say how her son felt about her decisions or why he thinks she should agree to the PICC line and IV line placements. In response, she would turn away in bed and sometimes cover her head with the sheet.

Questions:

1. Do you think Mrs. Z has the capacity to make decisions about her care? Why or why not?
2. If Mrs. Z does not have decision-making capacity, who is the more appropriate surrogate decision-maker; her husband or her son? Specifically, what effect on being able to act as the surrogate decision-maker is created by either the husband’s stroke or the fact that the son is the donor of Mrs. Z.’s kidney?
3. Can a surrogate consent to restraining the patient to treat her?
4. Should Mrs. Z receive treatment for her dehydration and infection despite refusing this care?
5. If Mrs. Z is treated despite her refusal, would you characterize this as “weak” paternalism or “strong” paternalism?