Medical Ethics: Approved Cases for the final paper

Medical Ethics: Approved Cases for the final paper
Table of Contents
Notes: this contains the pre-approved cases for you to discuss in your papers. As term develops, you will also receive new forum cases. These are also permissible topics, even if they are not presently in this document. If you wish to do a case that is neither in this document, nor from the forum, you should contact me about it for approval. Note the cases are categorized by the basic kind of issue they raise. The tles also suggest topics or provide a synopsis of the issue. Also note that I have provided comments or guided the topic in some of the cases; be sure to pay aenon to these notes. Finally, remember you do not need to provide citaons for case details obtained from this packet. For any details you found in other sources, you would need to provide citaons.
You should be able to jump to a topic in the table of contents by holding Ctrl and le kicking on the tle.
Contents
Autonomy
1.) The Dax Case: should Dax Cowart’s treatments have been ceased?
2.) To Dialyze or not to dialyze
3.) Disagreement over treang a 16 year old with Hodgkin’s lymphoma
4.) A difficult case for respect for autonomy (RL from week 4 on the forum)
Miscellaneous
1. Paent’s family in the trauma bay (week 3 forum prompt): should the aending physician let the paent’s wife in?
Confidenality
1.) What should a PT do when she thinks her paent is lying to her physician?
2.) Should a nurse tell other health-care professionals about a paent’s suicide aempt which the paent told the nurse of in confidenality?
Case Overview:
3.) Should a hospital worker whose grandfather was admied overnight look at his grandfather’s records?
Case Overview:
Beginning and End of Life Ethics
1.) The case of Briany Maynard
2.) An 83 year old man requests that a doctor stop his pacemaker; should the doctor do so?
Case Overview:
3.) The case of Helga Wanglie: should paents and/or family be able to demand treatment their doctor believes to be fule?
Case Overview:
4.) Aboron because of Down’s Syndrome
Case Overview:
Health Care and Jusce
1.) How should we raon vaccines?
Case Overview:
2.) Are religious exempons for contracepve treatments jusfiable?
Case Overview:
3.) Do paents have a right to alternave medicine (here acupuncture)?
Case Overview:
Autonomy
1.) The Dax Case: should Dax Cowart’s treatments have been ceased?
Case overview: hps://www.youtube.com/watch?v=lSsu6HkguV8
2.) To Dialyze or not to dialyze
Case overview: a comatose 64 year-old man was brought to the Emergency Room by ambulance. Someone who remained unidenfied had called “911” only to say that he needed immediate dialysis. There was no family with him, and the paent’s records were retrieved from a nearby hospital. His history included Type 2 Diabetes Mellitus for many years with mulple complicaons: end stage renal failure (Stage 5 Chronic Kidney Disease), hemodialysis dependence, bilateral above knee amputaons (AKA), a previous cardiac arrest with post-resuscitaon cerebral anoxia, mulple prior strokes, and heart disease with many admissions for heart failure. He had not dialyzed for nearly one month, and the dialysis unit was also contacted regarding his previous treatments at their facility. Apparently, his course had been complicated by his verbally and physically abusive behavior towards other paents, their families, as well as dialysis center staff. Although he was not disrupve in other environments, when he arrived at the dialysis unit he exhibited mulple dysfunconal and potenally dangerous behaviors. He struck and insulted people in the waing room, he spit at nurses and dialysis technicians while on the machine, and he pulled out his needles when he was unaended. Occasionally, the bleeding from this acvity was substanal and startled other paents. The unit decided to discharge him from their care and to disconnue dialysis.
Aer Emergency Department evaluaon, he was admied to the hospital with a crically elevated potassium level. He was dialyzed emergently one me, and his family was contacted by the primary care team and nephrologist for a conference. His divorced wife and a 28 year-old daughter comprised the paent’s enre family, and neither had obtained legal decision making authority through durable power of aorney. As the paent was not competent to make his own decisions regarding his dialysis and other essenal care, they were queried as to what statements, if any, the paent had made in the past regarding future medical care. They insisted that he be chronically dialyzed despite the preceding history of abusive behavior. They said that “when he wakes up, he says that he wants to dialyze.” He was temporarily dialyzed three mes a week, and an Ethics Consultaon was obtained to assist in decision-making.
A review of the past medical history noted that about one year ago, when the paent suffered a heart aack, he also had post-resuscitaon anoxic brain injury. Prior to the episode, he did have bizarre behaviors that were primarily self-directed. (He deliberately slammed his below-the-knee amputaons into the floor to the extent the bleeding necessitated that AKA be done.) Someme aer the brain injury, he began to exhibit the more violent behaviors that were threatening, dangerous, and abusive to others.
An ethics consultant was brought in. The Ethics consultants faced a number of challenges. Since the paent could not communicate, were his former wife and his daughter appropriate surrogates? Were they acng in the paent’s best interests or were they movated by other dynamics in their efforts to connue his dialysis? Was his behavior in the previous dialysis unit appropriately documented and determined to be irreversible? Were there elements of delirium, or had the strokes and anoxic brain injuries made his behavior permanent? Should he be sedated in order to connue chronic dialysis? If not, was disconnuaon of dialysis an ethical opon?
The consultants decided to obtain the relevant informaon regarding the paent and his behavior from three sources prior to rendering their opinion: 1) the dialysis unit staff that cared for him during the preceding year, 2) the nurses and staff who cared for him during the present admission, and 3) his family. The family gave permission to review his dialysis unit records. They only cauoned the ethics consultants that one nephrologist at the unit made the decision to stop dialysis because he was frustrated with the family’s behavior and that he had been rude to them.
The staff members at the unit were consistent in describing the paent’s abusive behavior. Whereas it had begun prior to his cardiac arrest, they agreed that it worsened aerwards. The behavior did not seem to “wax and wane,” but was persistent and potenally dangerous to the paent, other paents, and the health care team. In contrast to the family’s contenon, four rounding nephrologists were involved in the decision to disconnue his dialysis, not merely the one who may have been biased according to the inial family meeng. One nephrologist admied that he could only sedate the paent on high dose, parenteral anpsychoc medicaons and he felt that this opon was untenable for a prolonged period of me. Prior to disconnuing the paent’s dialysis, the unit staff and administraon held a meeng with the family. They apprised the former wife and daughter that, if a family member sat with the paent on dialysis and helped to relax him, they would try to connue his treatments. However, the family connued to “drop him off” at the unit and leave. The unit documented the meengs in wring and officially disconnued the paent’s access to dialysis at their unit. Some staff members alleged that the family profited from the paent’s “Social Security” income and therefore desired to have dialysis connued.
The dialysis nurses who had treated the paent at the hospital aer his recent admission were asked about his behavior. Even though he dialyzed enough (four mes regularly) to reach a comfortable baseline, he was verbally and physically abusive, and he tried to pull out his needles unless he was restrained and heavily sedated. The behavior had only become worse aer he “woke up” aer 1 month without dialysis. No one had been able to hold a meaningful conversaon with him regarding his medical treatment plan.
Aer obtaining this background informaon, the consultants met with the family and recommended no further dialysis. The consultants, primary care team, nephrologists, and nursing staff of the hospital unit unanimously agreed with that decision. The family disagreed with the decision and requested another aempt with sedaon, however they were diplomacally refused.
3.) Disagreement over treang a 16 year old with Hodgkin’s lymphoma
Case overview: A 16 year old Hodgkin lymphoma paent refuses to have his blood specimen drawn, thus canceling his scheduled oncologic treatment. As a 16 year old, he has no legal standing as an adult. His parents are split over his decision. One supports his right to choose; the other wishes the specimen to be drawn and the chemotherapy reinstated. The treang physician is in favor of having the blood sample drawn against the child’s wishes.
If you write on this case, do not limit yourself to considering the child’s legal status. This is a course on medical ethics, not medical law. It is coherent that our current laws are unjust, and that sixteen year old children’s parents should have less legal authority than they current do. So, this case is here parally to get you to think more about what (legal) medical rights children ought to have, not simply which legal rights they do have.
4.) A difficult case for respect for autonomy (RL from week 4 on the forum)
Case overview: at 80, R.L. lives with his wife in a rerement community. He has always valued his independence, but recently he has been having trouble caring for himself. He is having difficulty walking and managing his medicaons for diabetes, heart disease, and kidney problems.
His doctor diagnoses depression aer nong that R.L. has lost interest in the things he used to enjoy. Lethargic and sleepless, R.L. has difficulty maintaining his weight and talks about killing himself with a loaded handgun. He agrees to try medicaon for the mood disorder.
Two weeks later, before the effect of the medicine can be seen, R.L. is hospitalized for a heart aack. The heart is damaged so severely it can’t pump enough blood to keep the kidneys working.
Renal dialysis is necessary to keep R.L. alive, at least unl it’s clear whether the heart and kidneys will recover. This involves moving him three mes a week to the dialysis unit, where needles are inserted into a large artery and a vein to connect him to a machine for three to four hours.
Aer the second treatment, R.L. demands that dialysis be stopped and asks to be allowed to die.
Some Addional Reflecons:
R.L.’s was an actual case that presented his physicians with a common dilemma in treang paents with serious illnesses: Had depression rendered him incapable of making a legimate life-and-death decision?
When paents agree to undergo or refuse medical treatment, they are supposed to reach the decision by a process called informed consent. The doctor discloses informaon about the medical condion, treatment opons, possible complicaons, and expected outcomes with or without treatment.
To give informed consent or refusal, the paent must be acng voluntarily and must have the capacity to make the decision. That means the paent must be able to understand the informaon, appreciate its personal implicaons, weigh the opons based on personal values and life goals, and communicate a decision. From an ethical point of view, informed consent is based on the philosophical principles of autonomy and beneficence. In R.L.’s case, these two principles are in conflict. First, R.L.’s prognosis is unclear, and the physician does not know if the benefits of dialysis will outweigh the burdens. Under normal circumstances, this decision would be made by R.L., but the physician suspects the paent’s capacity for autonomous decision making is impaired by depression.
Depression is a mood disorder that can profoundly affect a person’s ability to think posively, experience pleasure, or imagine a brighter future. Depressed people frequently have lile energy, poor appetes, and disturbed sleep. They may have difficulty concentrang, or they may be troubled by feelings of guilt and hopelessness. Preoccupaon with death is common and, in some cases, may include contemplang suicide.
Because R.L. was suicidal before his heart aack, no one was sure whether his refusal of dialysis represented an authenc exercise of his right to stop life­saving treatment or a convenient means to passively end his life. On the other hand, if the doctor connued dialysis, he would be denying R.L. the same right to refuse treatment that another paent who was not depressed would have.
When paents ask to have life-sustaining treatment withheld, doctors have been taught to consider whether depression is driving the request, because the condion lis in two-thirds of those who are treated with an-depressant medicaons. The presumpon is that once the problem has cleared, the paent will look at treatment decisions differently.
Recent research has challenged that presumpon by showing depressed paents don’t necessarily choose to hasten death in the first place and they oen make the same decisions aer they recover from depression.
Thus, depressed paents may be able to give informed consent, but doctors and loved ones must consider whether the decision to refuse medical treatment is logical, internally consistent, and conforms with past life choices and values.
In R.L.’s case, the doctor, in consultaon with a psychiatrist, decided to connue the course of an depressant medicaon to see if, when it began to take effect, R.L. would change his mind about treatment. In the meanme, his dialysis was connued.
Aer five weeks, R.L. showed no improvement, and he began to refuse medicaons and food. If R.L. was to be kept alive, he would need to be given a feeding tube. Legally, this might be defensible insofar as there is a plausible case for R.L’s not being competent (though remember the worry, menoned previously, that we shouldn’t hasten to conclude depression necessarily prevents people from acng on their deeper values). In such a case, the decision would be his wife’s. But, ethically, the issues may not be so clear.
Miscellaneous
1. Paent’s family in the trauma bay (week 3 forum prompt): should the aending physician let the paent’s wife in?
Case Overview: A 28-year-old man is involved in a motor vehicle collision on a country road in rural North Carolina. He was driving a large SUV and restrained by a seatbelt. According to witnesses, the driver appeared to lose control of the vehicle while driving over an icy overpass. At inial assessment by emergency medical service (EMS) professionals, the paent was obtunded and hypotensive, for which he was emergently intubated; his passenger was pronounced dead at the scene. Shortly aer intubaon, the paent suffered a cardiac arrest. EMS performed eight minutes of cardiopulmonary resuscitaon before his spontaneous return of circulaon. The paent was brought via helicopter to a level I trauma center.
In the trauma bay, the team performs a primary survey (a specific, targeted exam done in the trauma bay to idenfy life-threatening injuries) during which the paent requires bilateral thoracotomy tube inseron and central line placement. Aer placement of the le chest tube, a liter of blood immediately drains into the device’s collecon chamber. Aer further examinaon, the team finds evidence of severe chest trauma: wide chest wall ecchymosis (severe bruising), subcutaneous crepitus (air under the skin suggesng traumac injury to the lung), and extensive bilateral rib fractures. Extended focused assessment of sonography in trauma (FAST) exam (a quick abdominal ultrasound to idenfy intra-abdominal hemorrhage aer traumac injury) reveals no intra-abdominal fluid collecons; however, the paent has what appears to be blood in the pericardial sac and a large undrained hemothorax (collecon of blood) in the le chest. A massive transfusion protocol is iniated to try to compensate for his blood loss. Nevertheless, he remains hypotensive and tachycardic. The trauma team plans for exploratory thoracotomy to idenfy and treat a suspected intrathoracic injury. As the trauma team begins coordinang with members of the operang room staff, the on-call chaplain approaches the senior aending physician with a request. The paent’s wife, who has just arrived at the hospital, has asked for permission to come to the trauma bay to see her husband prior to surgery.
The aending physician looks at her paent and at members of the trauma team engaged in a flurry of movement as they prepare the paent for immediate transport to the operang room. With tubes protruding from the paent at nearly every orifice and a pool of blood expanding beneath his stretcher, the aending physician observes a scene that could be traumazing to even a seasoned clinician and wonders how to respond to the chaplain.
Confidenality
1.) What should a PT do when she thinks her paent is lying to her physician?
Case Overview: aer suffering a back injury at work, Lowell Baxter has completed three weeks of physical therapy. While unable to work, Lowell has been going three mes per week to see therapist Eve Nye who has been working for three months at a new clinic and is sll learning the ropes.
Aer Mr. Baxter’s ninth treatment, his physician, Dr. Felton Cranz, explained that he had made good progress. Lowell no longer needed PT but was unable to return to his physically demanding job. He connued the home exercise regimen that Ms. Nye had given him. Dr. Cranz, who was not adverse to ordering addional physical therapy if necessary, told Lowell to call him if he had any further problems.
One month later, Mr. Baxter called Dr. Cranz’s office and told the nurse that there had been “a flare up” in his lower back. Aer talking with the doctor, the nurse called Lowell and told him that Dr. Cranz ordered another round of PT -3 mes per week for 3 weeks -that he should begin right away.
During his third session, while telling Eve about his recent acvies, Lowell menoned that he slipped and fell on a rainy night while coaching his daughter’s soccer team. He said that this happened “a couple of days” before the “flare up”. Eve asked if he told his doctor about this latest fall. Surprised at the queson, Lowell replied, “Well, no. Why would I? Anyway, I was having some painful twinges in my back before I slipped. Besides I fell on the so grass. I’m sure I didn’t hurt myself when I slipped. Dr. Cranz is always so busy and I don’t need to waste his me with this. He told me aer I finished my sessions a month ago that I might need another round of PT anyway. I feel beer aer our therapy sessions ….So, how about those Sharks -the men in teal?”
When Ms. Nye saw Mr. Baxter on his fih visit, he complained of increased pain with radiaon down his le leg. During her evaluaon, Eve concluded that his pain was different from the pain he experienced aer the first fall and was almost ceranly related to the second fall. She explained this to Lowell and suggested to him that he talk to his doctor to ensure that he received the appropriate treatment. Lowell insisted that he did want to bother his doctor with this.
Now, on his seventh visit, Mr. Baxter is visibly fagued and short-tempered. He complains of weakness and numbness in the le leg. Eve strongly encourages him to talk with Dr. Cranz. He adamantly refuses.
“Well, perhaps I should talk with Dr. Cranz for you. I could tell him about your fall at the soccer game and this onset of numbness and weakness in your leg. You know, Dr. Cranz looks at the notes I write.”
“No,” blurts Mr. Baxter. “I don’t want you to say anything. It’s none of your business! This is my injury, and I don’t want to bother him with this. You have to respect my wishes. Your job is to do therapy; not to interfere. Now, let’s get on with it!”
2.) Should a nurse tell other health-care professionals about a paent’s suicide aempt which the paent told the nurse of in confidenality?
Case Overview: the paent Mr Green is a 57 year old gentleman with aggressive prostate cancer who is took care of by the nursing team in the oncology department of a general hospital in Brisbane, QLD, Australia. Mr Green was diagnosed with prostate cancer seven years ago but refused medical and surgical treatment at the me. He chose to seek alternave treatment and did not follow up with the urologist over that seven year period. Mr Green has now presented with anemia and hypoproteinemia. Aer several diagnosc tests over a period it was discovered that the cancer had metastasized to his bones, it had spread locally to his lymph nodes and the primary tumor was invading the bladder and parally obstrucng the le kidney. Mr Green had several admissions over a two month period for various reasons. On the last admission Mr Green was told that he may only have 4–6 weeks (previously it was 6–12 months) to live aer a cystoscopy showed further extensive growth of the tumor, it was determined that any further surgical/medical intervenon would not be appropriate in this case and that a palliave care regimen was the next step. At this point the paent reported to the health care team that he had resigned himself to the fact that he was going to die. Mr Green pulled one of the author’s colleagues aside and confided to the nurse that he planned to kill himself and that is was a secret that the nurse was not to tell anyone.
The major ethical queson of this case can be idenfied as if the nursing staff should tell other health care team members about paent’s suicide aempt without paent’s consent.
3.) Adolescent confidenality surrounding aboron decisions.
Case Overview: some Fridays are more memorable than others. This one started with a pile of phone messages, and my nurse said that the one on top was urgent. The paent—age seventeen—said she had to come in immediately and talk: “I’m desperate. And please do not let my mom know. I might be pregnant, I need your help.” The paent’s mother had also called. I requested that the nurse make arrangements without nofying the mother, as I would call later.
The paent arrived during my lunch hour, since it was the only me available, and was franc, as she was certain that she was pregnant. Her menstrual period was late, and, indeed, urine tesng confirmed her pregnancy. Based on the ming of her last period she was about eleven or twelve weeks along. The paent said that her mom would pressure her to get an aboron. We talked for a long me about what she wanted, if the father of the child was to be involved, and the challenges to be faced. I also informed the paent that her mother was already aware of something as she had also called to talk to me. I asked how she would like me to handle things with her mother since I would need to return her phone call from earlier in the day. The paent already knew that her mother was suspicious and recognized that the discussion was both necessary and appropriate. The paent was willing to see a counselor and an obstetrician on the following Monday for confirmaon of dates via ultrasound. She wanted me to help her speak with her mother and said that I could invite her to come in Monday for a joint discussion. The paent thought leng things sele over the weekend was the best course of acon. The immediate next step was for me to tell her mother that we would all talk the following week and that her daughter was medically fine and geng all the care she needed.
Things seemed to have the potenal to move forward, and just as I was about to take a quiet moment at the end of the day to call the teenager’s mother, the assistant medical director for our mul-specialty clinic stormed into my office. He irately informed me that there had been a severe paent complaint that he needed to address with me immediately. Apparently, a paent of mine was being denied access to care in violaon of her reproducve rights, and what did I think I was doing? A mother who had called about her daughter was livid because she was certain her daughter was almost at the twelve-week limit when an aboron could be done locally and with less risk to her daughter. She said that she had informed the director “that the treang physician was making things worse.” Somewhat shaken, I asked the name of the paent, and, sure enough, it was the adolescent female with whom I had spoken this morning. I informed my medical director that I had seen the paent, that she was pregnant, and that she had told me she wanted to keep the baby. When he heard about the proposed plan of acon, he felt less concerned about the issue of “denial of access to care” and—given the full picture—did not have risk management concerns at this me.
Beginning and End of Life Ethics
1.) The case of Briany Maynard
Case Overview: hp://www.cnn.com/2014/10/07/opinion/maynard-assisted-suicide-cancer-dignity/index.html
2.) An 83 year old man requests that a doctor stop his pacemaker; should the doctor do so?
Case Overview: Mr. Perry (not his real name) was 83 years old and had several medical problems. He had spent the past several months in and out of hospitals and rehab. Prior to that, he lived independently in a small Midwestern town. Widowed many years ago, he subsequently enjoyed the company of a lovely lady friend who lived down the street from the Perry home. He had five adult children and numerous grandchildren.
Life should have been relavely good for this octogenarian. But life was not good. Not anymore. “My body is all worn out. I’m worn out. Don’t want to do this anymore, Doc. They say I can’t go home and be safe. And I’m NOT going to a nursing home. No way! Just stop that lile gadget that shocks me and the part that keeps my heart going. I want them stopped. Yes, the pacemaker, too. A magnet will stop it, right? Just do it. Please.”
Mr. Perry had a cardiac resynchronizaon therapy defibrillator (CRT-D) implanted a few years ago. It included an electrical pacing component for heart rhythms, on which the paent was 100% dependent. The defibrillator had shocked him, more than once, just before he came to the hospital E.R. with this request. That was the last straw for Mr. Perry. No more shocks for him. No nursing home or rehab or hospitalizaons or medicaons. And no more mechanical pacing either. “I’m red of fighng.”
Deacvang an internal defibrillator is one thing. The paent’s cardiologist didn’t need an ethics consultaon for that decision. “If he doesn’t want to be shocked again, that’s his decision. And if it went off again aer he’d requested it stopped, that could be a kind of torture,” she reasoned. Deacvaon happened quickly aer admission from the Emergency Department. A “Do Not Aempt Resuscitaon” order was placed in the chart.
But the pacemaker, also? He wanted it stopped. Ought we do so? Would that be ethically respecul of this paent’s autonomy? Or would it be physician-technician assisted suicide?
3.) The case of Helga Wanglie: should paents and/or family be able to demand treatment their doctor believes to be fule?
Case Overview: on December 14, 1989, Helga Wanglie, 86, fell in her Minneapolis home and broke her hip. Aer the fracture was successfully set at Hennepin County medical Center (HCMC), she was discharged to a nursing home. She was readmied to HCMC on January 1, 1990, when she developed respiratory failure and was placed on a respirator. During the next five months repeated aempts to wean Mrs. Wanglie from the respirator were unsuccessful; she was conscious, aware of her surroundings, and could recognize her family.
On May 7, 1990, she was transferred to another facility that specializes in the care of respiratordependent paents. While there and sll unable to be weaned from the respirator, she experienced a cardiopulmonary arrest and was taken to another acute care hospital in St. Paul. Diagnosis now showed severe and irreversible brain damage. The hospital ethics commiee discussed with the family the possibility of liming further life-sustaining treatment because of her dismal prognosis. The family resisted the idea and requested that Mrs. Wanglie be transferred back to HCMC where they felt she had received excellent care.
The family thought the suggeson of withdrawal of life-sustaining technologies reflected moral decay in our culture and hoped instead for a miracle. Mr. Wanglie said that only God can take life and that doctors should not play God.
By late 1990 repeated evaluaons by neurology and pulmonary medicine services at Hennepin County Medical Center confirmed the diagnosis of permanent unconsciousness (persistent vegetave state) and permanent respirator dependency because of chronic lung disease.
The hospital staff concurred that they had erred inially on the side of connuing treatment in order to provide me for the family to come to see the fulity of the treatment being offered Mrs. Wanglie; but the months passed and several conferences with the family proved to widen the ri between the medical judgment that the use of the respirator could not serve the paent’s interests and the determinaon of the Wanglie family to do nothing which would shorten Mrs. Wanglie’s life.
4.) Aboron because of Down’s Syndrome?
Case Overview: this should be taken to be more about the general ethical status of seeking an aboron specifically because one does not want to give birth to a child with Down’s Syndrome. As you likely know, this has been a significant issue in Ohio of late. Here is a relevant overview piece from the New York Times: hps://www.nymes.com/2007/05/13/weekinreview/13harm.html
Health Care and Jusce
1.) How should we raon vaccines?
Case Overview: Alison is a 19-year-old university student with moderately severe asthma. She was hospitalized once when she was twelve and caught a bad cold, and she has had some serious aacks in the past few years. If Alison were to catch the flu, it would likely cause an even more severe inflammaon of the lungs than a cold, leading to even more severe asthma aacks 1. Alison would be unable to breathe and her fast-acng inhaler might not be enough to clear her airways. Geng a flu vaccine is Alison’s best defense against geng the flu in the first place; it can cut her risk of geng the flu by up to 90 percent. When she was a child, her mother always took her to get her flu vaccine, and since she has been away at school she has been careful to get her own yearly vaccinaon. Unfortunately, this year there is a shortage, making it difficult to obtain the seasonal flu vaccine. Influenza vaccines are not considered very profitable to make, because they are expensive and any extra has to be thrown away at the end of the flu season, since a new vaccine must be produced every year. Consequently, not many companies produce the flu vaccine. Given that no single person or agency is in charge of ensuring that the United States has an adequate supply of influenza vaccines, it is not surprising that shortages do occur. This year, one of the companies, in charge of producing nearly half of the United States’ supply, had a bacterial contaminaon that forced them to shut down all vaccine producon.
Alison is very afraid of catching the flu. Her worst asthma aacks have been when she had a cold, and she is terrified of not being able to breathe. Alison wants to be sure to sll get her yearly flu vaccine, but there is currently no system in place to ensure that at-risk populaons receive the limited supply of vaccines available. It is enrely dependent on each clinic to try to raon their limited supply. To do this, some clinics aempt to use medical necessity criteria, which are challenging to define; Medicare defines medical necessity as “services or supplies that are needed for the diagnosis or treatment of your medical condion and meet accepted standards of medical pracce.” This is a subjecve standard, and is frequently assessed by an insurance company that never sees the paent, to determine if payment will be issued. Alternavely, many clinics avoid the issue by using a loery. The most common method of distribuon, however, is a “first-come first-served” basis, with some consideraon of medical necessity requirements.
In Santa Clara county in the 2009 H1N1 vaccine distribuon, the inial shipment to arrive was a nasal form of the vaccine, so it was limited to healthy children 2 years and older, especially those younger than 10 years who are recommended to receive two doses; and healthy household contacts (2 -49 years) of infants younger than 6 months 2. The next shipments of the injecon vaccine were then directed towards high risk groups such as pregnant women, household contacts and caregivers for children younger than 6 months of age, health care professionals, all people from 6 months of age to 24 years old (due to their parcular vulnerability to H1N1), and people aged 25 to 64 who have medical condions such as asthma that put them at a higher risk of complicaons from the flu.
To ensure that is she is among the lucky few who receive a vaccinaon this year, Alison gets up at 4:00 in the morning on a Friday and drives to the nearest clinic, which opens at 6:00 a.m. This clinic is the only clinic within 50 miles of Alison’s home to have received any vaccine supply, so everyone from the surrounding area is also coming here for their supply. Arriving shortly aer 4:30 a.m., she is number 62 in line for the vaccine. If she does not make it to the front of the line before all the shots are gone, she will not receive a vaccine. If she makes it to the front, but is determined not to be “enough” at-risk because she is not a senior, she will not receive a vaccine. Seniors are especially at risk for contracng pneumonia or bronchis given their generally lowered levels of acvity and weaker immune systems.
Alison finds herself in line behind a sixty-three year old man who doesn’t have any money to pay for the vaccine, but is not yet eligible for Medicare. Seniors are generally considered one of the high-priority groups for geng the flu vaccine, because they tend to have weaker immune systems and therefore develop more complicaons that are frequently fatal. He tells Alison that he is nervous that he will be turned away because he cannot pay, even though he is very close in age to the at-risk populaon. He also menons his daughter who wanted to bring her two young children to try and get the vaccine, but she works at a nearby canning factory and couldn’t get the me off to bring them to the clinic. Up at the front of the line there is some commoon over a young man being turned away because he is not considered at-risk. He can be heard shoung, “I’ll pay anything, just give me the vaccine!”
2.) Are religious exempons for contracepve treatments jusfiable?
Case Overview: On July 6, 2002, a University of Wisconsin-Stout student, went to the K-Mart in Menomonie, Wisconsin, to fill her prescripon for oral contracepves, birth control pills. The only pharmacist on duty, Neil Noesen, asked if she intended to use the prescripon for contracepon. When she replied in the affirmave, Noesen, a Roman Catholic, refused to fill the prescripon, explaining that to do so would be against his religious beliefs. She thought that he was kidding.
But Noesen was very serious. As a devout Catholic, he had concluded that he could not dispense contracepves. He also refused to transfer the prescripon or tell her how or where she could get the prescripon filled, all of which, he explained later, would, in his view, constute parcipang in wrongful behavior. Significantly, prior to employment at K-Mart, Noesen had informed the district manager that he would not dispense contracepves; however, he did not menon that he would refuse to refer or to transfer prescripons.
The queson for this case is whether a religious or conscienous exempon should be offered in cases like this one. Exempons of this kind offer legal protecon for persons who would otherwise be violang a general mandate. Another famous issue of this kind arose in the legal bale Burwell v. Hobby Lobby, wherein Hobby Lobby sought an exempon so they would not have to pay penales for refusing to cover four methods of birth control.
3.) Do paents have a right to alternave medicine (here acupuncture)?
Case Overview: Mr. Chen, a 40 year-old paent originally from China, has had lumbar problems for one year. The condion includes dull pain in his right leg and the inability to sit sll for long periods. X-ray examinaon reveals a prolapsed lumbar disc. He has been treated with convenonal pain medicaon with minimal effect.
His physician, Dr. Robert Olson, recommends back surgery, but Mr. Chen is reluctant to take this opon. Instead, he asks the doctor to refer him to an acupuncturist because his insurance coverage requires physician’s approval for “alternave” therapy. He menons to the physician that he has tried acupuncture before, and it has helped him.
But Dr. Olson is skepcal about any kind of alternave therapy. This derives partly from his belief that allopathic medicine, the approach taught in Western medical schools, is the most efficacious because it has been scienfically proven through clinical trials. He has also had extensive posive experience with surgical treatment for Mr. Chen’s condion. In his view, other forms of medicine are at best placebos, and he does not see it as his duty to recommend them. He refuses to order the acupuncture.
Did the physician act ethically?
This case illustrates a common scenario in doctors’ offices. Many paents seek alternave therapies because convenonal medicine has not brought them sasfacon. Must their physicians make these referrals?

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