Cases in Medical Ethics

Student-Led Discussions
     

Chris Cirone

I was a Hackworth Fellow for the Markkula Center for Applied Ethics at Santa Clara University.
I was also a pre-medical student, and am currently attending the Loyola University Chicago
Stritch School of Medicine. During my senior year at Santa Clara, I led discussions on medical
ethics with students interested in medicine. The purpose of these discussions was two-fold. First,
they were created to help bring current ethical issues onto our campus. Second, they were
intended to help students who were interested in a career in the health sciences determine
whether or not medicine is their correct calling. Most of the discussions followed a simple
format. One to two cases were formulated for the students to read. Then I presented the students
with various questions related to some of the ethical issues contained in the situations described.
The following cases are the ones that I presented to the groups. Each case also has a short history
and summary of the ethical issues being reviewed. The questions I asked of the students are
included as well. These cases and questions are public domain, and can be re-used or modified
for educational purposes. I hope that you find them useful, and that they spawn the same
thoughtful enjoyment in you as they did in me.

Note: The cases were not based on specific events. However, it is possible that they share
similarities with actual events. These similarities were not intended.

Autonomy

Autonomy essentially means "self rule," and it is a patient's most basic right. As such, it is a
health care worker's responsibility to respect the autonomy of her patients. However, at times this
can be difficult because it can conflict with the paternalistic attitude of many health care
professionals. The following two cases address patient autonomy. The first involves the rights of
an individual to decide her own fate, even against her physicians' judgments. The second case
involves the rights of a parent to care for her child in the manner that she sees fit.

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 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:

 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?

Autonomy Part 2

Maintenance of patient autonomy is one of the major ethical focuses of physicians. Therefore, a
second discussion was also held that focused primarily on patient autonomy. This discussion also
took a superficial look at euthanasia. For this discussion, a 58 minute video, Dax's Case
(produced by Unicorn Media, for Concern for Dying ; produced by Donald Pasquella, Keith
Burton ; directed by Donald Pasquella New York : Filmakers Library, c1984) was used. The
video tells the story of Dax Cowart, a man who was severely burned by an accidental propane
explosion. The burns disabled Dax, and the physicians forced treatment on him. Though he
survived the treatment, he still argues that he should have been allowed to refuse it so that he
could die. The video is very useful; however, the videos of Dax's burn treatments are very
graphic and the video should be reviewed before it is shown to a group of students.

Questions:

 In the video, one of the physicians says that burn patients are incompetent to make
decisions when they first enter the hospital because they are in such a great deal of pain.
However, patients such as Dax can be in a great deal of pain for a very long time. In such
cases, what should be done to determine competence, and when should this be done?
 Do you think the fact that Dax could not see a future for himself should have been taken
into account when determining his competency? Could this have clouded his judgment?
(He thought that he would end up on the street corner selling pencils)
 Do you think that the fact that Dax was going to recover, and had the possibility of living
a happy life, made not treating Dax like suicide… or murder? What if he did not have this
possibility?
 After his recovery, Dax attempted suicide. Should the physicians have let him die? Is it
ever correct for a doctor to allow a patient to kill himself?
 Do you ever think that it is correct for a physician to break a competent patient's
autonomy? If so, is this one of those cases?
 Do you think that in this case, that the ends justified the means?

Euthanasia

The word "euthanasia" draws its roots from Greek meaning "good death." As it is used in this
discussion, it means "the act of ending the life of a person suffering from either a terminal
illness, or an incurable disease." The AMA is against physicians assisting in euthanasia. There is
currently only one state in the US that allows for euthanasia, and that is Oregon, where in 1997,
the "Death With Dignity Act" went into effect. Euthanasia advocates stress that it should be
allowed as an extension of a person's autonomy. Those who are against euthanasia often say that
it can lead to the devaluation of human life, and to a slippery slope in which the old and disabled
will be killed on the whims of healthy people. We examined one case and the Oregon law to
view the ethics of euthanasia.

Case One:
A woman was diagnosed with motor neurone 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 neurone 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 asks her doctor to give her diamorphine for pain if she begins to suffocate or
choke. This will lessen her pain, but it will also hasten her death. About a week later, she falls
very ill, and is having trouble breathing.

Questions for Case 1:

  Does she have a right to make this choice, especially in view of the fact that she will be
dead in a short while (say six hours)? Is this choice an extension of her autonomy?
 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?
 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? She clearly cannot kill herself.
She can't move, but should someone be FORCED to help her, or to find someone to help
her?
 Should the money used to care for this woman be taken into account when she is being
helped? Do you think that legalizing euthanasia could create conflicts of interest for the
patient/ or the doctor? Will people feel that they need to end their lives earlier to save
money?
 Ask each student: If you were the physician, what would you do? Note: if you would pass
her off to another doctor knowing he or she would do it, does this free you from you
ethical obligations?

Oregon's Death With Dignity Act:

We discussed the following questions pertaining to the Death With Diginity Act.

Death With Dignity Questions:

 Look at the requirements for the request. Do you see any problems with them? (The
woman from case 1 would not qualify.)
 Why would they put in these guidelines? Should they be there, if they keep a competent
person like the woman above from living her autonomy? (Is it to protect the doctors so
they will not have to GIVE the medication?)
 Is there a moral difference between prescribing the drug and actually giving it to the
patient? If not, why put in the rules?
 Why do you think they wouldn't let a person who is terminally ill and in pain with
possibly more than 6 months receive assistance in dying? Say someone is diagnosed with
HIV?
 Does the justification of euthanasia necessarily justify the assisted suicide of a healthy
person?
 Do you think a weakness of this law is the probability of patients being influenced by
family members? (For example, for financial or other reasons?) Note: Approximately
60% of Oregonians in 2000 said (before they died) that they used the prescription at least
in some part due to fear of being a burden on their family.
 The AMA says that euthanasia is fundamentally incompatible with the physician's role as
healer. What do you think about this statement? Why should a physician have to be the
one who does this?

Assisted Reproduction:
This is a difficult subject because it involves reproductive issues. In our culture, reproductive
liberty, the freedom to decide when and where to conceive a child is highly protected, and this
can make these cases much more difficult.

Case 1:
There are two types of surrogacy. One type involves a surrogate mother who uses her own egg
and carries the baby for someone else. The other type is a "gestational surrogacy" in which the
mother has no genetic tie to the child she carries. In the case presented, a gestational surrogate is
used.

A woman, after a bout with uterine cancer had a hysterectomy (surgical removal of the uterus).
Before, its removal, however, she had several eggs removed for possible fertilization in the
future. Now married, the woman wishes to have a child with her husband. Obviously she cannot
bear the child herself, so the couple utilizes a company to find a surrogate mother for them. The
husband's sperm is used to fertilize one of the wife's eggs, and is implanted in the surrogate
mother. The couple pays all of the woman's pregnancy-related expenses and an extra $18,000 as
compensation for her surrogacy. After all expenses are taken into account the couple pays the
woman approximately $31,000 and the agency approximately $5,000. Though the surrogate
passed stringent mental testing to ensure she was competent to carry another couple's child, after
carrying the pregnancy to term, the surrogate says that she has become too attached to "her" child
to give it up to the couple. A legal battle ensues.

Questions for Case 1:

 In the United States it is illegal to pay a person for non-replenishable organs. The fear is
that money will influence the poor to harm their bodies for the benefit of the rich. Do you
see a parallel between this case and this law? Can allowing surrogate mothers to be paid
for their troubles allow poorer women to be oppressed?
 Does paying the surrogate harm her and/or the child's dignity?
 Is it selfish/conceited for this couple to want children of their own genetic make-up? If
yes, does this change if you can "easily" have a child? (Note: Over 100,000 children in
the U.S. are waiting to be adopted. However, most are older, have several siblings, or
have special needs.)
 On their website, the AMA says "that surrogacy contracts [when the surrogate uses her
own egg], while permissible, should grant the birth mother the right to void the contract
within a reasonable period of time after the birth of the child. If the contract is voided,
custody of the child should be determined according to the child's best interests." Do you
see any problems with this? (What's a reasonable time? In a way can you steal the
surrogate's child?)
 One of the main arguments against the use of surrogate mothers is that carrying and
giving birth to a child is such an emotional event that it is impossible to determine if the
surrogate will be able to give up the child. Though adults enter into the contract, the child
could ultimately suffer if a long custody battle ensues (as it could in states where
surrogacy contracts hold no legal value, such as Virginia). With the possibility of such
battles, do you think it is acceptable for parents to use a surrogate mother?
  Do you think that if the surrogate is awarded the baby, this could cause emotional harm
to the child?
 Who do you think should receive the child, and why?

Case 2:

A married couple wishes to have a child; however, the 32 year old mother knows that she is a
carrier for Huntington's disease (HD). HD is a genetic disorder that begins showing signs at
anywhere from 35-45 years of age. Its symptoms begin with slow loss of muscle control and end
in loss of speech, large muscle spasms, disorientation and emotional outbursts. After 15-20 years
of symptoms HD ends in death. HD is a dominant disorder which means that her child will have
a 50% chance of contracting the disorder. Feeling that risking their baby's health would be
irresponsible, the couple decides to use in vitro fertilization to fertilize several of the wife's eggs.
Several eggs are harvested, and using special technology, only eggs that do not have the
defective gene are kept to be fertilized. The physician then fertilizes a single egg, and transfers
the embryo to the mother. Approximately 9 months later, the couple gives birth to a boy who
does not carry the gene for the disorder.

 Is this a case of eugenics? "Eugenics" is defined as "the hereditary improvement of the

human race controlled by selective breeding" (dictionary.com)
 Would it be acceptable for the parents to select for sex as well, or should they only select
an embryo that does not have HD? How would this be different?
 Is it ethical for this couple to have a baby when the mother could begin showings signs of
HD when the baby is just a few years old?
 With this technology possible, would it be ethical for this couple to have a child without
genetically ensuring it would not have the disease? What if we did not have this
technology, would it be ethical for a known carrier to have a child? (If not, how far
should this carry? a carrier for cystic fibrosis ( which is recessive)? )
 Weighing everything we have discussed, do you believe the couple acted ethically?

Response To Bio-Terrorism

The possibility of terrorists using biological weapons on the citizens of the United States has
been a major topic in the press for the last several years. Smallpox has been speculated to be the
perfect biological terror agent because of the potency of the virus, and because of the lack of
herd immunity present in the US population. The following case presents a possible way in
which the virus could be released in the population and a possible response. The questions
following the case involve the ethics surrounding the government's response.

Smallpox Facts:

 Smallpox initially has flu-like symptoms, which are recognizable 7-19 days after
exposure. After 2-4 days of flu-like symptoms, the fever begins to decrease, and pox will
form.
 An infected person is contagious one day before the characteristic pox appear.
  Approximately 30-50% of unvaccinated people exposed to smallpox will contract the
disease.
 The mortality rate for smallpox was approximately 20-40%.
 The vaccine that was used was approximately 90% effective.
 It is possible that if terrorists were to use the smallpox virus, that they would genetically
modify it. If this were the case, then the vaccine may not prevent all of the disease
symptoms for those vaccinated.

Facts gathered from: http://www.vbs.admin.ch/ls/e/current/fact_sheet/pocken/

Case:

Date: June 22, 2005. A 27-year-old man is brought into a New York City emergency room with
a 101-degree fever, and what he believes is chickenpox (Varicella). After a brief examination,
the 35-year-old physician is puzzled because the pox do not appear to be typical of the varicella-
zoster virus. Worried, he calls in another physician for her opinion. She takes one look at the
patient, determines he has small pox, and immediately orders him to be quarantined. She notifies
the Centers for Disease Control and Prevention (CDC) and asks them what should be done.
While doing background on the patient, he tells the physicians that he is a flight attendant and
that he has flown to Orlando, FL, Los Angeles, CA, Chicago, IL, and Seattle, WA in the past few
weeks while working. Though he is given excellent treatment, and had been in perfect health a
few days earlier, the patient dies 7 hours after admittance to the hospital.

The CDC decides that mandatory small pox vaccines will be administered to all workers in the
NYC hospital, and to all patients who were in the ER. His co-workers are all given mandatory
vaccines as well, as are all people living in his apartment complex. They also ship stored
quantities of the vaccine to all of the cities where the man had flown to for work. The vaccines
are offered to citizens of these cities. Finally, all people, along with their families who had been
on the man's flights in the weeks preceding the appearance of the disease are forced to receive
the vaccine.

Questions:
Note: The flight attendant was most likely given small pox by a bio terrorist who flew on his
plane sometime during the past week/week and a half. The terrorist would have been contagious
but would not have shown symptoms. Virtually every person the man came into contact with
would have gotten the virus.

 Is it ethical for the CDC to force people to get the vaccine?

 An LA woman on the flight is religiously opposed to vaccines. Under California law she
can normally refuse vaccines on religious or personal grounds. However, the government
says she must receive the vaccine or face mandatory quarantine. What do you think of
this?
 Do you think that for more common diseases, for example measles, that it is ethical for
the state to allow people to refuse vaccines (even for religious grounds)? What if their
 refusal can harm others who cannot have the vaccine, such as people who are
immunocompromised like AIDS patients?
 Is it ethical for someone to refuse the vaccine?
 You had driven down to Los Angeles 5 days ago to visit a friend for the weekend. While
in town, you visited many tourist attractions. You are worried and you try to get the
vaccine, but are denied it because of limited resources. What do you think of this?
 Citizens begin calling for the mandatory quarantining of people directly exposed to the
victim, i.e those living in his apartment complex, those working in the ER, those who
flew on the plane in the prior week. What do you think of this?
 The smallpox vaccine, like many other vaccines (example: oral polio vaccine) can
actually transmit the virus to others. In light of this, is it ethical for people to get the
vaccine? (Note: they are vaccinating those who may not want to be vaccinated)
 Today, should health care workers be allowed/forced to get the smallpox vaccine? What
about non-health care worker citizens?