By Ryan Pferdehirt, DBe and Tarris (Terry) Rosell, PhD, DMin, HEC-C

April 2024

Bioethics case study on moral culpability for respecting patients’ autonomy.

A 55-year-old patient, Steve, who identifies as male is suffering from respiratory distress and end stage renal disease. Steve was admitted to the hospital a few days ago and has seen considerable improvement with treatment. He is now ready for discharge. The patient is vociferously requesting to be discharged back to home, but the primary attending believes Steve would benefit by going to a skilled nursing facility for a short period. Disposition to SNF is probably not absolutely essential, just strongly recommended. If Steve were to go home instead, it would be against medical advice (AMA), but would not constitute an unsafe discharge.

This patient has a long history of IV drug abuse but communicates to the health team that his recent hospitalization has brought some clarity in that regard, and he vows to “give up doing drugs.” He says the desire to go back home is because that’s where he feels most comfortable. Steve’s physician believes that discharging back to home this soon will risk substance use recidivism. During an ethics consultation, the physician states that she does not want to be morally responsible for her patient when he goes home, goes back to street drugs, overdoses and dies. What then should be done?