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INTRODUCTION
Moral courage has received growing attention from scholars who have further developed a shared understanding of the notion and refined its role in normative frameworks. This improved understanding of moral courage promises to offer guidance in navigating difficult ethical dilemmas in a number of professional realms, including medicine. In this article we apply a multitiered framework of moral courage to an ethics consultation involving a rapidly decompensating patient in the intensive care unit (ICU). We argue that this framework provides the conceptual resources to address the morally salient features of the ethics consultation case, and thus can assist clinicians and other medical professionals in resolving dilemmas involving moral distress stemming from wayward authoritative commands. The case is as follows.
Mr. S. was a 75-year-old man in the ICU of a Veterans Administration (VA) medical center who had fulminant liver failure, acute renal failure requiring continuous dialysis, and cardiomyopathy requiring vasopressors. In addition, he had been intubated for respiratory failure. Mr. S. had been nonresponsive for most of his ICU stay.
He had been admitted weeks earlier from a nursing home for a non-STEMI (a non-ST segment elevation myocardial infarction), and had a history of dementia, liver cirrhosis, and esophageal varices, all attributable to alcohol abuse. His condition had continued to decline, including episodes of gastrointestinal and urogenital hemorrhage and acute urinary obstruction, requiring several blood transfusions.
There was a well-documented history of financial and physical abuse by the patient's family, and the previous spring, when he still had capacity to make such decisions, Mr. S. strongly voiced his wish that his family not be contacted or involved in his medical care. The note further documented Mr. S's understanding that VA policy states that, in case of both lack of capacity and lack of surrogates, the chief of staff should make decisions for the patient.
The ethics team was consulted to assist with goals of care decisions, when the ICU team felt that Mr. S.'s decline had become irreversible. Hospital policy is clear that first there must be agreement among the entire medical team that the medical situation is irreversible, followed by a discussion and a vote of concurrence by the ethics committee, which in turn must be approved by the director of the medical...