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Manifestation of Ethical and Legal Challenges in a case pertaining to permanent unconscious patient. 

Ethical/legal issues that have surfaced in the given case are as follows

1. No ventilator support or other life support for the subject as expressed by her in the living will she had drawn up with her husband

The issue presents interplay of Clinical ethics as well as law. The given information indicates that the 72 year old lady had a cerebral hemorrhage which caused severe damage to her brain and made her ventilator dependent. Now, her condition involves ethical implications of medical technologies; techniques; treatments along with policies pertaining to the line of action in delivering the health care (Brock & Mastroianni, 2013). All these imply that there is a clinical ethical issue associated with the scenario.

As the case involves a "living will" that was drawn between the subject and her husband a year prior to the event, law also gets associated with it. The "living will" would bring into the picture established and enforceable social rules, a violation of which may result into creation of civil or criminal liability (Brock & Mastroianni, 2013). A will would also have several vested interests associated with it. As established and enforceable social rules are very much involved, there is an obvious association of law. Hence, interplay of clinical ethics and law in this particular issue.

2. The disapproval by the subject's husband to withdraw life support inconsistent with the patient's wishes expressed in her living will

The husband of the subject is the surrogate decision making authority and along with the patient had drawn up a "living will", a year before the event which specified that the patient was against any artificial life support in case of a terminally ill condition. However, the patient's husband insisted later on that the patient had not intended for the document to be used in the prevailing circumstance when discussed the living will. He was not giving his consent despite being made aware of the fact that the subject would not gain normal functioning of the brain. On the contrary, he put forth that condition of the subject is not imminently terminal. All these manifest some sort of inconsistency.

The issue is legal/ethical one as "advance directive" enables a patient to use several legal documents while competent to record his or her future wishes in the event that patient loses his or her decision making capacity. A "living will" is such a legal document which contains the records of a person's desire regarding future medical treatment when the concerned person will not be having any capacity either physical or mental to take any decision mostly in case of terminal illness or permanent unconsciousness (Brock & Mastroianni, 2013). However, it is noteworthy to mention that most likely the patient's husband has been chosen by her as a decision maker, thereby, executing "durable power of attorney for health care or health care proxy" giving the patient's husband to make informed consent.
A very important aspect in this regard is the variation in state laws. State laws are subject to variations on the conditions that can be covered in an "advance directive" pertaining to the concerned individual (Brock & Mastroianni, 2013). In addition, it is imperative to ensure that the document is effective viz. number of witnesses and the circumstances under which it can be put on practice and the procedural requirements that entail all these (Brock & Mastroianni, 2013). The given situation is a clear case in which the authenticity of the advance directives has been questioned even though it forms a very strong basis for the appropriate treatment of the patient which in turn has the patient's expressed wishes as the basis (Brock & Mastroianni, 2013). In this case, the surrogate decision making authority has very clearly expressed that the advance directive is not applicable in the given circumstances, thereby raising ethical as well as legal issue.

3. Discord between the patient's adult Children and her husband regarding continuation of the ventilator support or other artificial life support

Being the next legal kin and the surrogate decision making authority, the patient's husband understood that the patient would not be able to recover any meaningful brain function but still he felt that the living will did not apply as the condition was not imminently terminal as according to him; his wife is not in a permanent unconscious condition. The immediate family members of the patient had contrary views.
There is an ethical dilemma. As per the living will which is nothing but an advance directive, the couple's adult children are correct. On the other hand, as state laws are subject to variations on the conditions that can be covered in an "advance directive" pertaining to the concerned individual, the effectiveness of the procedural requirements also get challenged (Brock & Mastroianni, 2013). More so, the patient's husband is unable to understand fully the medical condition coupled with his emotional attachment to the subject might be forcing him to challenge the advance directive. All these give rise to ethical/ legal issue.

Handling of No ventilator support or other life support for the subject as expressed by her in the living will she had drawn up with her husband

As many people would not want to see their near and dear ones depart forever, such a will may often be tweaked by virtue of emotional attachment with the patient. The ethical implications of medical technologies; policies, and treatments have a bearing upon the whole gamut of clinical ethics here. Through in-house or on-call trained ethicists the given issue could be handled. The utilitarian approach which does most good and/ least harm can be utilized to reduce the ill consequences (Velasquez et al., 2015).

Handling of the disapproval by the subject's husband to withdraw life support inconsistent with the patient's wishes expressed in her living will 

Being the surrogate decision making authority, the husband is entitled to take certain decisions on behalf of the patient who is not having the capacity to take any decision. The subject's husband is contradicting the advance directive which is the living will. This may be because of his lack of understanding of the condition of the patient in depth though he understood that there will be negligible brain function recovery. This may be because of the emotional attachment the person is having with the patient. On the other hand, by objecting the refusal to withdraw the life support, the immediate family members of the patient are abiding by what the patient actually desired.

It is important to consider three important aspects viz. the option that will cause more benefit than harm; the option that will respect the rights of all the stakeholders, and the option that best serves the interest of the community as a whole (Velasquez et al., 2015). The patient's husband must abide by the patient's living will as it would be like respecting patient's wishes, and also the wishes of her immediate family members. By utilizing this utilitarian approach which deals with consequences, the patient's sufferings would also cease to exist, thereby, causing more good than harm for most of the stakeholders. The right's approach encourages respecting moral rights of the affected individuals as human beings have the right to choose freely what exactly is to be done with their lives. As a part of this approach, it is the duty of the patient's husband to respect the patient's right. By utilizing the virtue approach, patient's husband must ponder upon the aspects viz. self-centricity of his current act which may be inconsistent with the patient's husband acting at his best(Velasquez et al., 2015).

Handling discord between the patient's adult Children and her husband regarding continuation of the ventilator support or other artificial life support

The patient's husband must abide by the wishes of the immediate family members as it would be like adhering to the patient's living will. By utilizing this utilitarian approach which deals with consequences, the patient's sufferings would also cease to exist, thereby, causing more good than harm for most of the stakeholders. The right's approach encourages respecting moral rights of the affected individuals as human beings have the right to choose freely what exactly is to be done with their lives. As a part of this approach, it is the duty of the patient's husband to respect the patient's right. Majority of the stakeholders in the decision making process are in favor of withdrawing life support consistent with the patient's wishes which would be good for everyone as espoused by the common good approach (Velasquez et al., 2015).

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