Case Report: Case report: Administration of anticoagulant therapy after neuro-anesthesia procedure for hemorrhagic stroke patients with COVID-19 complications and its ethical and medicolegal consideration

Background: Ethical dilemmas can occur in any situation in clinical medicine. In patients undergoing neuro-anesthesia for surgical procedure evacuation of intracerebral hemorrhage with a history of hemorrhagic stroke, anticoagulants should not be given because they can cause recurrent bleeding. Meanwhile, at the same time, the patient could also be infected with coronavirus disease 2019 (COVID-19), one of treatment is the administration of anticoagulants. Methods: A case report. A 46-year-old male patient was admitted to hospital with a loss of consciousness and was diagnosed with intracerebral hemorrhage due to a hemorrhagic stroke and was confirmed positive for COVID-19. Giving anticoagulants to patients is considered counterproductive so, an ethical dilemma arises. For this reason, a joint conference was held to obtain the best ethical and medicolegal solutions for the patient. Results: By using several methods of resolving ethical dilemmas such as basic ethical principles, supporting ethical principles, and medicolegal considerations, it was decided that the patient was not to be given anticoagulants. Conclusions: Giving anticoagulants to hemorrhagic stroke patients is dangerous even though it is beneficial for COVID-19 patients, so here the principle of risk-benefit balance is applied to patients who prioritize risk prevention rather than providing benefits. This is also supported by the prima facie principle by prioritizing the principle of non-maleficence rather than beneficence, the minus malum principle by seeking the lowest risk, and the double effect principle by making the best decision even in a slightly less favorable way as well as the medicolegal aspect by assessing patient safety and risk management.

The Doctrine of Double Effect

The aim of the article is to present some of the differences and similari- ties in various versions of the double effect principle (DDE or PDE). The following formulations will be analyzed: that of Thomas Aquinas and two contemporary ap- proaches, namely those of Mangan and Boyle. It will be shown that the presented modern versions vary significantly and the distinction between their intended and only predicted effects is far from clear. As a result, the different contemporary for- mulations of DDE lead to contradictory conclusions, with some justifying what the others condemn. Moreover, it will be demonstrated that, unlike Aquinas, contem- porary authors mostly concentrate on unintentionality condition while neglecting the proportionality requirement. So, unlike Aquinas, they only take into account a narrow scope of cases, where the evil effect occurs with certainty, which leads to a complicated and intricate hypothetical intention test like Donagan’s. It will be shown that, besides its theoretical indistinctness, DDE lead to serious pragmatic risks. It can be quite easily misused as a kind of psychological mechanism to protect self-esteem from a sense of guilt since wrong-doing is treated as merely a predicted unintended effect.

Double effect, principle of

‘Double effect’ refers to the good and bad effects which may foreseeably follow from one and the same act. The principle of double effect originates in Aquinas’ ethics, and is supposed to guide decision about acts with double effect where the bad effect is something that must not be intended, such as the death of an innocent person. The principle permits such acts only if the bad effect is unintended, not disproportionate to the intended good effect, and unavoidable if the good effect is to be achieved. The principle has wide relevance in the moral evaluation of acts which have foreseen double effects. Controversy arises over the identification of the agent’s intention in difficult cases, and over the use of the principle to resolve issues such as abortion, euthanasia, the use of pain-relieving drugs which hasten death, self-defence, and the killing of certain sorts of non-combatants in war.