Autonomy vs. Beneficence 

There is a Spanish-speaking-only 14-year-old pregnant patient who comes into the ED with her older brother for vaginal bleeding. The brother states that his schizophrenic sister is refusing her medication for a few days now. During the story, Dr. Shah sees puncture marks and bruises on her arm that the brother quickly states are because she sells herself for drugs. Suspecting that the brother may not be trustworthy, Dr. Shah calls in a certified clinical interpreter. Through the interpreter, the patient states she is being sexually trafficked and forcibly drugged by the man claiming to be her “brother”. She also states that she is non-schizophrenic and is experiencing a miscarriage. Her “brother” says she is lying and usually has delusions of persecution. Dr. Shah read a similar situation occurring before where the clinician decided to trust the brother only to find out later that the patient was a human traffic survivor. Dr. Shah now wonders what he should do.

 Dr. Shah has a dilemma of autonomy vs. beneficence. The patient states she is being held against her will and is sex trafficked but, the brother says she has schizophrenia. Dr. Shah now has to choose whether to treat the patient based on her story or treat her schizophrenic episode and let her leave with her “brother”. Should he believe the patient and plan his care plan around her HPI or should he believe the brother who is not only her guardian but also states that the patient is not sound of mind to make her own decisions? 

Dr. Shah should trust her autonomy and continue providing the standard of care that the patient needs based on her story. The patient has the moral right, the values, and the right to make decisions on her health. Although the patient is a minor she still needs to be added to the decision-making process regarding her health. To protect her autonomy, Dr. Shah should have seen the patient alone with a translator. According to Dovydaitis et al. seeing the patient alone can build trust and rapport with the patient leading to more effective care. The patient told Dr. Shah that she is being sex trafficked and held against her will meaning Dr. Shah was under a legal obligation in NYS to call Child Protective Services (CPS) and should call the National Hotline for Sex Trafficking. The patient has a higher risk of being harmed because she told Dr. Shah about her situation in front of her “brother”. Dr. Shah should also be aware that the dynamic between the patient and her brother is negative and that Dr. Shah’s job is to advocate for the patient (AMA J Ethics). In Dr. Shah’s choosing to believe and respect the patient’s autonomy, he is shielding the patient from being harmed. 

There is so much going on in this story, she only speaks Spanish, she is underaged and her puncture wounds imply that she is a drug user. All of these can lead to implicit bias and believing the “brother’s” story of her being a schizophrenic patient that sells herself for drugs. Some argue that wanting to do what is right for the patient, Dr.Shah should choose to believe the brother especially since she is underaged and he is her guardian making him legally able to decide her care. Also, in accepting the “brother’s” story, Dr. Shah will be providing optimal care in managing her schizophrenia and other symptoms. Others argue that the patient does not have the mental capacity to make her own decisions as she is a schizophrenic minor. Therefore, Dr. Shah choosing to treat the patient according to her brother’s statement is for the patient’s benefit.  

There are flaws in both of those counterarguments. Now that the patient herself stated she is being sexually trafficked asking her brother for informed consent can be detrimental to the patient getting the care she needs. Dr. Shah can decide to override the guardian’s decisions regarding her care since he finds her brother not trustworthy. Deciding to believe the patient and respecting her autonomy does not mean Dr. Shah cannot add a psychiatric evaluation to her care plan.

In conclusion, Dr. Shah should choose to believe the patient. In respecting the patient’s autonomy, Dr. Shah will also be doing what is best for the patient. There does not need to be a conflict with the patient’s autonomy and beneficence if Dr. Shah decides to believe the patient. Dr. Shah can still provide a psychiatric evaluation to ensure if the patient is or is not schizophrenic. Also, a minor does have patient autonomy and needs to be added to the decision-making process of their health chiefly because Dr. Shah is questioning the brother’s intentions. Dr. Shah should respect the patient’s autonomy and believe in her story. 

References: 

AMA J Ethics. 2017;19(1):23-24. doi: 10.1001/journalofethics.2017.19.1.ecas3-1701.

AMA J Ethics. 2016;18(1):12-17. doi: 10.1001/journalofethics.2017.18.1.ecas2-1601.

Dovydaitis T. (2010). Human trafficking: the role of the health care provider. Journal of midwifery & women’s health, 55(5), 462–467. https://doi.org/10.1016/j.jmwh.2009.12.017

Informed consent for minors in research studies. Johns Hopkins Medicine, based in Baltimore, Maryland. (2017, June 14). Retrieved June 23, 2022, from https://www.hopkinsmedicine.org/institutional_review_board/guidelines_policies/guidelines/informed_consent_minors 

Renee, A. (2017, July 25). When can the government override a parent’s medical decision in the U.S.? abc10.com. Retrieved June 23, 2022, from https://www.abc10.com/article/news/local/when-can-the-government-override-a-parents-medical-decision-in-the-us/103-459250777