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A Case Study in Coercion

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					                                    A Case Study in Coercion

   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.
Case Studies :: Case-2: Credit Card Fraud

          State              : Tamil Nadu
          City               : Chennai
          Sections of Law    : Section of Law: 66 of Information Technology Act
                               2000 & 120(B), 420,467,468,471 IPC.

“The environment that the organisation worries about is put there by the organisation.” -
Weick

Background
The assistant manager (the complainant) with the fraud control unit of a large business process
outsourcing (BPO) organisation filed a complaint alleging that two of its employees had
conspired with a credit card holder to manipulate the credit limit and as a result cheated the
company of INR 0.72 million.

The BPO facility had about 350 employees. Their primary function was to issue the bank's credit
cards as well as attend to customer and merchant queries. Each employee was assigned to a
specific task and was only allowed to access the computer system for that specific task. The
employees were not allowed to make any changes in the credit-card holder's account unless they
received specific approvals.

Each of the employees was given a unique individual password. In case they entered an incorrect
password three consecutive times then their password would get blocked and they would be
issued a temporary password.

The company suspected that its employees conspired with the son (holding an add-on card) of
one of the credit card holders. The modus operandi suspected by the client is as follows.

The BPO employee deliberately keyed in the wrong password three consecutive times (so that
his password would get blocked) and obtained a temporary password to access the computer
system. He manually reversed the transactions of the card so that it appeared that payment for the
transaction has taken place. The suspect also changed the credit card holder's address so that the
statement of account would never be delivered to the primary card holder.

Investigation
The investigating team visited the premises of the BPO and conducted detailed examination of
various persons to understand the computer system used. They learnt that in certain situations the
system allowed the user to increase the financial limits placed on a credit card. The system also
allowed the user to change the customer's address, blocking and unblocking of the address,
authorisations for cash transactions etc.

The team analysed the attendance register which showed that the accused was present at all the
times when the fraudulent entries had been entered in the system. They also analysed the system
logs that showed that the accuser's ID had been used to make the changes in the system.
The team also visited the merchant establishments from where some of the transactions had
taken place. The owners of these establishments identified the holder of the add-on card.

Current status
The BPO was informed of the security lapse in the software utilised. Armed with this evidence
the investigating team arrested all the accused and recovered, on their confession, six mobile
phones, costly imported wrist watches, jewells, electronic items, leather accessories, credit cards,
all worth INR 0. 3 million and cash INR 25000. The investigating team informed the company of
the security lapses in their software so that instances like this could be avoided in the future.

This case won the second runner-up position for the India Cyber Cop Award, for its investigating
officer Mr S. Balu, Assistant Commissioner of Police, Crime, Chennai Police. The case was
remarkable for the excellent understanding displayed by the investigating team, of the business
processes and its use in collecting digital evidence.

				
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