For your culminating assignment, please choose one of the cases from the scenarios below and draft a paper that includes answers to the questions that follow the case. Answers should be thorough and apply knowledge gained from this course. You may utilize any course related resources, as well as any other sources found and cited. Your essay should be free of spelling and grammatical errors. It should flow properly and be clear, concise, and written in a professional manner. You should use headings as described above. You should include a reference page in APA 7th edition format. The reference page does not count toward your pages. You should write for quality and clarity rather than quantity. The following rubric will be used for evaluation. Please ensure you have all categories below. Selection of Scenario (20 points) Scenario is chosen and clearly identified (10 points) Rationale for choosing scenario is provided (10 points) Identification of Ethical Issues (20 points) Main ethical issues/dilemmas in the scenario are clearly identified (10 points) Identification shows depth of analysis and critical thinking (10 points) Application of Ethical Principles (20 points) Response shows understanding of relevant ethical principles (10 points) Ethical principles are thoroughly applied to the scenario (10 points) Quality of Recommendations (20 points) Recommendations follow logically from ethical analysis (5 points) Recommendations are realistic and specific (5 points) Recommendations are actionable with a clear implementation plan (10 points) Communication (20 points) Writing is clear, organized and professional (5 points) APA style formatting is used appropriately (5 points) Grammar, spelling and punctuation are correct (5 points) References are properly cited in APA style (5 points) Ethics Scenarios: Choose one for this project Case 1: A woman enters the emergency room with stomach pain. She undergoes a CT scan and is diagnosed with an abdominal aortic aneurysm, a weakening in the wall of the aorta which causes it to stretch and bulge (this is very similar to what led to John Ritter’s death). The physicians inform her that the only way to fix the problem is surgically, and that the chances of survival are about 50/50. They also inform her that time is of the essence, and that should the aneurysm burst, she would be dead in a few short minutes. The woman is an erotic dancer; she worries that the surgery will leave a scar that will negatively affect her work; therefore, she refuses any surgical treatment. Even after much pressuring from the physicians, she adamantly refuses surgery. Feeling that the woman is not in her correct state of mind and knowing that time is of the essence, the surgeons decide to perform the procedure without consent. They anesthetize her and surgically repair the aneurysm. She survives, and sues the hospital for millions of dollars.
Questions for Case 1: Do you believe that the physician’s actions can be justified in any way? Is there any other information you need to know to make an ethical analysis? [consider the medical decision making capacity questions among other things] How would you apply the 4 goods from Dr. Pellegrino here? Is there anything else that they could have done? Is it ever right to take away someone’s autonomy? (Would a court order make the physicians’ decisions ethical?) What would you do if you were one of the health care workers? Case 2: You are a general practitioner and a mother comes into your office with her child who is complaining of flu-like symptoms. Upon entering the room, you ask the boy to remove his shirt and you notice a pattern of very distinct bruises on the boy’s torso. You ask the mother where the bruises came from, and she tells you that they are from a procedure she performed on him known as “cao gio,” which is also known as “coining.” The procedure involves rubbing warm oils or gels on a person’s skin with a coin or other flat metal object. The mother explains that cao gio is used to raise out bad blood, and improve circulation and healing. When you touch the boy’s back with your stethoscope, he winces in pain from the bruises. You debate whether or not you should call Child Protective Services and report the mother.
Questions for Case 2: What decisions need to go into your consideration of whether or not you call CPS? How would you consider the 4 goods discussed by Dr. Pellegrino in this situation? Should we completely discount this treatment as useless, or could there be something gained from it? When should a physician step in to stop a cultural practice? (If someone answers “when it harms the child” remind that person that there is some pain in many of our medical procedures, for example, having one’s tonsils removed) Should the physician be concerned about alienating the mother and other people of her ethnicity from modern medicine? Do you think that the physician should report the mother?
Case 3: Dax Cowart is a 25-year-old man who had graduated college and was in excellent health. He enjoyed staying active and surfed, rode horses, and played golf, among other things. One day he and his father were looking at some property to possibly buy when their car would not start. As they were trying to work on the car, they did not realize that a nearby refinery had a propane gas leak and there was a pool of the leaking gas where they were trying to start the car. Ultimately, the sparks caused by them trying to start the car along with this gas caused a tremendous explosion. Dax was severely burned, over 65% of his body with large areas being third-degree burns. When he was taken to the hospital, he was in extreme pain despite substantial doses of narcotics. He required numerous surgeries and very painful procedures to treat the burns that were infected. Dax refused all treatments and wanted the doctors to let him die. The doctors obtained consent from his mother who was aware Dax was refusing treatment but she could not believe those were his true wishes. After 10 months of treatments and surgeries that were extremely painful, he was discharged from the hospital. Throughout this time, Dax never stopped refusing treatments, yet his mother continued to consent for him. Nine months into treatments, two psychiatrists were consulted and they determined Dax had capacity to make decisions but the doctors still had his mother sign all consents since he continued to refuse treatments. At discharge, he was blind, partially deaf, and severely disfigured. He had lost all fingers except the stump of one thumb and could only use his right arm. He was in chronic pain. About two years after discharge he did try to commit suicide. However, he persevered and returned to school. About 12 years after the incident he graduated from law school. He began practicing law. He did get married and then divorced twice. He became a speaker and advocate for patients. At this point, he enjoyed life and took pleasure it what he was doing. However, he still holds that he should have been allowed to refuse treatment, and he still believes if the same thing happened again, he would have refused the treatments because of the substantial burdens of pain and agony they caused him.
Questions: One of the physicians who initially treated him argued that burn patients lose medical decision making capacity when they first enter the hospital because they are in such a great deal of pain. In such cases, what should be done to determine medical decision making capacity, and when should this be done? How often should this evaluation for capacity be done? Also consider this: patients such as Dax with these burns can be in a great deal of pain for a very long time – how do you evaluate capacity in cases where the suffering will be prolonged? One argument by a doctor in the case was that, because Dax could not see a future for himself, this was impacting his decisions. If they could get him well enough to be discharged, he would change his mind. Does this notion of one not being able to see a future for himself have an impact (should it be considered) when determining his competency? Could this inability for Dax to any future for himself have clouded his judgment? (He thought that he would end up on the street corner selling pencils) What if the doctors argued that they knew that it was very likely they would be able to treat Dax’s injuries to the point where he would survive and be discharged to home. While he would have disabilities, they felt that he would have the possibility of living a happy life. With this as their suspected prognosis, if the doctors abided by Dax’s informed refusal for any treatments, would this be equivalent to the doctor’s assisting in suicide? Why or why not? After his recovery, Dax attempted suicide as noted in the case. This was about two years after the incident. What if rather than attempting suicide at home, Dax had returned to the hospital and told the physicians that he wanted to die. He had capacity to make decisions. He was back in school, was married, and was trying to make his life enjoyable but it was too hard. He decided that he wanted to just starve himself to death. But starvation is an extremely painful way to die so he wanted to be admitted to receive pain medications while being allowed to not eat or drink until he died. Could the doctors assist him in committing suicide in this way? Why or why not? Consider the different understandings of dignity we discussed in the modules: what role would the consider of Dax’s dignity have here? How you you consider the 4 goods of medicine in Dax’s case? Is using this idea of the 4 goods helpful in your evaluation? Is there ever a time where it might be acceptable for a physician to override the decision of a patient with capacity? What is the role of patient autonomy in the physician-patient relationships? Are there times when there can be conflict and how should these be handled? Case 4: A woman was diagnosed with motor neuron disease (the same disease that Stephen Hawking has) 5 years ago. This is a condition that destroys motor nerves, making control of movement impossible, while the mind is virtually unaffected. People with motor neuron disease normally die within 4 years of diagnosis from suffocation due to the inability of the inspiratory muscles to contract. The woman’s condition has steadily declined. She is not expected to live through the month, and is worried about the pain that she will face in her final hours. She tells her doctor that she has read on the internet that diamorphine is used in the UK to relieve pain and suffering at the end of life if one begins to suffocate or choke. She saw that it works well in various studies. She cannot believe it is not available in the US, but her brother is able to acquire diamorphine through the black market. She tells her doctor she wants to use diamorphine if she begins to suffocate/choke. She says that she knows it will lessen her pain and understands there is the potential it could hasten her death. She accepts the risks and just does not want to suffer. About a week later, she falls very ill, and is having trouble breathing. Questions for Case 4: What are the ethical considerations in this case in general? Does she have a right to choose to take opioids [in general] for her suffering even though the means here would be illegal? Let’s say the medication was available in the USA and obtaining it was not illegal but the doctor followed the Drug Enforcement Agency’s recommendations that diamorphine does not have a currently accepted medical use and, though could be prescribed, should not be? Does the patient have a right to this medication? What is the role of patient autonomy here? Considering your answers above, now, because she has developed the shortness of breath which indicates that her death is likely now becoming more imminent, does this impact your answer? What role does patient autonomy have here? If she was also on a benzodiazepine for anxiety and requested the opioids to relieve suffering from choking once this symptom was present, does this change your ethical analysis? [Consider that taking opioids with a benzodiazepine does increase the risks for respiratory depression and risks of opioid overdose — all of which could increase the risk of hastening death.] If patient explicitly has no intention of overdosing but just wants to minimizing suffering, how do you consider the ethical analysis of giving her opioids here? Is the short amount of time she has to live ethically relevant? Is there an ethical difference between her dying in 6 hours and dying in a week? What about a year, and how do you draw this distinction? If she expressed a desire to be given a high enough dose of the opioid so that she would overdose and die, how does this change your ethical analysis? Is the right for a patient’s self-determination powerful enough to create obligations on the part of others to aid her so that she can exercise her rights? If she makes this request, what should the clinician do and what would be important elements in the conversation the clinician should have with her? What role should cost play in the decisions related to providing different medical interventions that have the possible effect of hastening death? Does this factor create a conflict of interest for the clinicians? Should the costs of caring for her be taken into account and how is this considered? If medicines offered were intended to hasten death, would patients feel like they needed to consent in order to end their lives to save money? Does this conversation add pressures to the patient by causing patients to have desires to end their lives earlier to save money? If you were the physician, what would you do? Why? Recalling the various approaches to bioethics in Module 2, which school of thought does your response most closely match? What are the ethical implications if your decision is to refer her to another clinician?
