Patient Autonomy, Beneficence, Nonmaleficence, and Justice in the Film, Wit

The film opens on the morose face of Dr. Harvey Kelekian. He glares directly into the lens and states, matter-of-factly, “You have cancer. Miss Bearing, you have advanced metastatic ovarian cancer,” as if we the viewer were his patient,‘ He informs his patient of this tragic news devoid of empathy or compassion, as she stares back dazed at this revelation. Vivian Bearing, a middle-aged, Ph.D. of medieval poetry at a prominent university, ultimately accepts an aggressive regimen of cancer treatment, This scene sets the tone for the healthcare provider/patient interactions throughout the film.

This interaction, as well as others during the film provides an ideal opportunity to explore four basic principles of bioethical decision making. They include patient autonomy, beneficence, nonmaleficence, and justice. Patient autonomy is a patient’s right to make informed healthcare decisions for him or herself, including the right to establish a healthcare proxy and draft a living will.

From the outset of the film there are key points through the course of her care where Vivian is deprived her right to autonomy.

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For instance during their consultation, Dr. Kelekian coldly speeds through his diagnosis, then outlines his course of treatment without Vivian’s thoughts or concerns taken into consideration She is denied an opportunity to make a truly informed healthcare decision for herself; her course of treatment is already predetermined. Furthermore, the consultation scene also illustrates the guidance—cooperation model of the physician-patient relationship. In this case, the physician tells the patient what to do and the patient obeys.

In contrast, the ideal patient-centered relationship allows for mutual participation.

Later in the film, Vivian‘s pain grows so severe she becomes, in a sense, incapacitated. At this point Dr. Kelekian again denies Vivian‘s autonomy; between the choice of pain management and morphine induced coma, he takes a paternalistic approach unilaterally opting for morphine induced coma over Vivian’s implied preference for pain management. This action by Dr. Kelekian illustrates the activity-passivity model of the physician—patient relationship. The doctor does something to the patient and the patient is unable to respond.‘ In this regard, Vivian, incapacitated by pain, cannot appropriately respond to Dr. Kelekian’s action, Drr Kelekian’s and Drr Jason Posner’s care for Vivian Bearing lacked consideration of the bioethical principle of beneficence. Beneficence is a deed or deeds that is done for the welfare of others. The ideal of beneficent actions is to prevent harm or to improve the situation of others through kindness, mercy, and charity.

Vivian is confronted several times in the film by a lack of beneficence at the hand of healthcare professionals. One instance of this is her interaction with the imagining tech, in her first meeting he hostilely asks her for her name and the name of her physician, this interaction lacked kindness or concern. Most of Vivian‘s interactions with Dr. Posner lack any semblance of beneficence. For example, Vivian‘s first encounter with Dr, Posner, he too portrays a cold detached demeanor, then leaves her exposed in a vulnerable position in a pair of stirrups to look for last minute assistance. When it came to his physical exam he also lacked care or gentleness leaving his patient physically uncomfortable. Perhaps the only healthcare professional in the film that showed some level of beneficence was Nurse Susie Monahan, Lying in bed, alone in the dark, Vivian struggles against succumbing to her doubts and fear and in that moment nurse Monahan is there to support her, offer kindness and comfort in the form of a Popsicle.

In the time spent with Vivian, nurse Monahan express empathy, thereby providing therapeutic benefit by reducing Vivian’s anxiety which fosters trust and sharing between the two. Nurse Monahan goes so far as to restore some of Vivian’s autonomy. She urges Vivian‘s to consider her end-of-life care and Do Not Resuscitate (DNR) options, something that both Dr, Kelekian and Dr. Posner neglect to address, Related to the principle of beneficence is nonmaleficence. Non-maleficence means to do no harm or evil. Physicians ideally must refrain from providing ineffective treatments or acting with malevolence toward patients}4 In the case of Wit, adhering to this principle is like walking a tightrope when considering cancer treatment. One can argue that cancer treatment inflicts pain and harm with its severe side effects, yet these treatments can also save lives. The relevant issue in regards to Vivian is whether the benefits outweigh the burdens.

In Vivian’s case, she suffers from advanced stage four metastatic ovarian cancer which is terminal. For Vivian the benefits do not outweigh the burdens, Ending Vivian’s aggressive treatment, which will ultimately not be effective, would be an action of nonmaleficence. However, this is not what is done by her physicians, There is in fact a conflict of interest on the part of Dr. Kelekian. He pushes full dose treatments consistently, not for the benefit of Vivian but for the pursuit of scientific advancement and academic notoriety. The bioethical principle ofjustice deals with issues of treating patients equally. Physicians should treat patients similarly and allocate limited resources justly."Although the film does not show that Vivian’s cancer treatment was a scare resource or that there was unfair disparities; continued full dose administration of the medications violates the principle of justice.

Vivian had extremely low chances of survival, therefore the use of full dose cancer medication was an inefficient allocation of resources that added no true benefit for the patient. Throughout the film Vivian endured encounters with healthcare professionals who, for the most part, neglected consideration of the four basic principles of bioethical decision making According to the Association of American Medical Colleges (AAMC) Professionalism Task Force, physicians’ are entrusted with the professional duty to serve individuals and communities at large, and in doing so, prioritize the interests of those they serve above their own. Paramount to this is the consideration and understanding of the four basic principles of bioethical decision making: patient autonomy, beneficence, nonmaleficence, and justice. Examining the film Wit with an emphasis on the principles of bioethical decision making provides an ideal opportunity to explore and foster understanding of these principles,