Health Care Ethics
Appendix of Cases for Discussion
CASE
# 1
An
82 year old woman whom you have treated for minor illnesses and moderate
hypertension for 16 years has always been fiercely self-sufficient and
independent. On a routine physical exam you discover bilateral cataracts that
have appeared and grown quite rapidly. She listens attentively as you explain
the condition and what is involved in cataract surgery. However when you broach referring her to an ophthalmologist,
she refuses adamantly, but offers no reason. You are startled because her
choice seems so out of character. Then you:
What are the ethical
principles/guidelines involved in each scenario? Which do you judge best and
why? Can you think of an ethically better way to go?
CASE
#2
A family physician and PA have just set-up
practice in an isolated area where people have long lacked reasonably
accessible health care. The PA is seeing a family for the first time, and
learns that the parents believe that the risks of immunizations outweigh the
potential benefits. They believe that they can adequately protect their
children by the lifestyle they have adopted (vegetarian diet, organically grown
food, exercise, home schooling). Consider
the following three scenarios:
What are the ethical
principles/guidelines involved in each scenario? Which do you judge best and
why? Can you think of an ethically better way to go?
CASE
#3
A 34 year old woman lawyer who is being
considered for a judgeship comes to your office and says that she is HIV+ and
wants help with the best treatment regimen available. She tells you that she
had a relationship with a man “last year” somewhat in reaction to discovering
that her husband had been unfaithful. Her friend called her recently to tell
her he had discovered that he was HIV+; so she had gotten herself tested
anonymously in another city. She does not want her husband to know because she
fears he would not be able to keep the matter confidential, and she feels no
obligation to tell him because he too took the risk of being unfaithful. And,
she says, she will insist on condom use on some pretext in any further sexual
intercourse they may have with one another.
Is it ethically permissible
to breach confidentiality and inform this woman’s spouse of his danger? Yes? or No? State your
reasons, citing the ethical guidelines/principles you are using.
Is there an ethical obligation that
you breach confidentiality and inform this woman’s spouse of his danger? Yes? or
No? State your reasons, citing the ethical guidelines/principles you are using.
CASE
#4
A
34 year old very successful business woman, who has been your patient for some
time, suffers a psychotic episode with paranoid ideation. She is convinced that
her business partner has stolen a lot of money from her even though an
accountant she secretly hired to check the books says they are in perfect
order. She shows you a gun she has acquired and tells you she intends to
confront her partner and if not convinced of his innocence kill him.
Is it ethically permissible
to breach confidentiality and inform this woman’s partner of his danger? Yes?
or No? State your reasons, citing the ethical principles/guidelines you are
using.
Is there an ethical obligation
that you breach confidentiality and inform this woman’s partner of his danger?
Yes? or No? State your reasons, citing the ethical principles/guidelines you
are using.
CASE
#5
A
thirty-one year old man, whom you have seen a couple of times for minor
problems comes to you with “just bothersome” symptoms of some twitching of his
hands and legs. After a physical exam and some neurological consultation your
suspicion of Huntington’s Disease is confirmed. When you ask him about his
family history, he says he knows nothing of it since he was abandoned and
adopted as an infant. You explain that Huntington’s is a genetic disease
inherited from one parent with a one in two chance that the child in each
pregnancy will inherit it, but in which the first symptoms occur only in adult
life (30’s to50’s). He is terribly
shaken because, as he reminds you, he has two children, a 5yo boy and a 3yo
girl and he and his wife have just learned, to their joy, that she is again
pregnant—six or seven weeks. Both he and his wife, who is also your patient,
hold a very strong moral belief that abortion is wrong, he says, and even if
they could know that the just conceived child were affected, he feels sure
neither of them would consider abortion. He begs you not to tell his wife so as
to spare her for a time the mental anguish he is now experiencing and afford
her the unadulterated enjoyment of the children for the years that may be
possible before his increasing symptoms will force a revelation. It is, after
all, his information to give or withhold, he contends when you advance some
reasons she should know. He adds hopefully that perhaps there will be a more
effective treatment by then.
What do you do? Why?
What ethical guidelines/principles are you referencing in making your decision?
CASE
#6
Your
inner city practice has been seeing members of a group of immigrant
Afghanistanis who are Muslims. You have come to know and have developed
considerable respect for a number of them. One day an extremely bright 12yo
girl whom you have seen for several minor problems comes to you bringing along
her 16yo sister. The younger girl still wears western dress, but the 16yo is
wearing the long dress, head covering, and facial veil of purdah (the
requirement that women of marriageable age be completely covered). The 12yo
tells you with great urgency and earnestness that she has brought her sister
who is “a little bit slow mentally” to get “the shot that keeps you from
getting pregnant”[Depo-Provera]. She says that she knows that her sister is
being taken advantage of sexually by a man who works at the place they are sent
together to market regularly. She has been unable to convince her sister that
she must end this relationship, and she fears for her life because in their
cultural-religious context back home the male relatives of a woman who has been
sexually active outside of marriage may ritualistically kill her as a matter of
family honor. Even though it is illegal it is essentially never prosecuted and
punished in the part of Afghanistan they come from. She says one of her
brothers would do it she is sure; and the rest of the family would be sure he
was out of the country before the killing could become known and reported. But
she thinks no one will suspect anything as long as her sister doesn’t get
pregnant. And no one will tell her family for fear of getting killed for making
such an assertion to them. Her sister’s responses to your questions and
remonstrations are simple statements: “No one knows.” “I OK.” “No baby. No
baby!” A serum pregnancy test is negative.
What do you do? Why?
What ethical principles/guidelines are you referencing as you make your
decision?
[N.B.
This is a made-up story, and while I know that such happenings are very
real in parts of the world, I believe that they are in no way of the essence of
Islam, but rather, as stated, a sort of cultural-religious practice.
–HMM]
CASE
#7
A baby born to parents new to your practice at
8:45 one Saturday night when you are on call shows classic signs of Down’s
Syndrome. You speak at some length with the distressed parents, empathizing
with their shock and disbelief, and reassuring them that children with Down’s
Syndrome can lead happy fulfilling lives. You promise to return and talk with
them the next day. By late morning on Sunday, the baby is vomiting forcefully.
Your suspicion of duodenal atresia is confirmed by x-ray. When you explain the
situation and the need for surgery to her parents, they categorically refuse
saying they don’t want her to have the pain of surgery, and that they believe that
this circumstance is a sign of God’s will that they “let her go”.
What do you do? What
ethical principles/guidelines help you make a decision?
CASE #8
An elderly widower with moderately-severe
Alzheimer's is moved to your town and into a nursing home where you provide
care, and you are asked by his son to become his primary health care provider.
This son has been designated by his siblings to be their father’s surrogate decision-maker. As you talk with him
about his father’s care, he tells you that a well-reputed neurologist had
suggested a very promising, but still-listed-as-experimental drug for his
father. He says that it made him very nervous and he would tend to choose a
better-studied medication for himself, but that he’d approved the “experimental-drug”
option for his father because “Dad was always a risk-taker when there was the
chance of a really good pay-off.” He adds that “while Dad’s care is expensive
in this new setting, he has good health insurance, and it offers him maximum
safe freedom, sociability, and frequent visits from his children, all of which
he seems to derive pleasure from.”
What do you think of
this son’s ability as a surrogate decision-maker?
Does he understand that
his role is to make choices as he thinks his Dad would have chosen?
Are his decisions
informed (in the ethical sense of the word)?
Do you think they are
beneficent?
Is there a reasoned
process of decision-making discernable?
Is he acting in good
faith (without conflict of interest) on his father’s behalf?
CASE
#9
A
12 year old boy whose parents are Christian Scientists, and who has shared his
parents faith practice all his life, becomes sick with bone pain and abdominal
pain, pallor, and frequent respiratory infections. Gradually, he becomes too
weak to attend school. He tells one of his friends that he is scared and wants
to find out what is wrong with him, but doesn’t want to disappoint his parents
by seeing a physician against their wishes and religious beliefs. The friend,
who has been your patient since birth and is now a rather mature 14 year old
boy, comes to you and proposes that he bring his sick friend to talk with you
while the boy’s parents are at work.
What is your response?
What ethical guidelines/principles do you reference in making a decision?
CASE
#10
In
your pediatric/adolescent group practice you notice that a colleague of yours
habitually discusses prescription refills in the waiting-room when parents drop
into the office, even when other parents and children are present. You also
notice that everyone in the office has become careless with remarks in the
corridors just outside patient-care rooms; e.g. “Joshua’s strep
test is positive.” or “Do we have any samples of Tofranil?” or “Do you have Dr.
______’s (an obstetrician) telephone number handy?”
Are these behaviors of
concern to you ethically? Why?
CASE
#11
In
your family practice, you care for a young mother and her two sons, both of
whom have classic hemophilia. The four-year old has had multiple bleeds and
qualifies for SSI (Social Security Disability Income). His infant brother has a
similar moderate factor VIII deficiency. Their single, financially struggling
mother, whose husband has deserted the family and who has impressed you with
her care of and for the children asks you to certify the baby for SSI although
he hasn’t yet met the criteria for doing so.
What is your response?
On which ethical principles/guidelines is it based?
CASE
#12
You
are newly employed at a nursing home where you are assigned as medication nurse
for two floors. On one of them is an extremely obese 55 year old woman with
muscular dystrophy. She has lower back pain for which she has a standing
analgesic order; however she frequently complains of “breakthrough pain” and
requests more pain medication. She also has a standing order for this
situation, which is an injection of sterile saline, which the other nurses
inform you, “always works like a charm. She sleeps, and so can other patients
in nearby rooms!”
Do you see any ethical
difficulty with this practice? If so, what? And what do you do?
CASE
#13
You
have worked for 13 years at a certain hospital. One of your friends from
nursing school days also works there and has recently been made nursing
supervisor. You are happy for her because she’s been having a difficult time financially
for the past couple of years. Her husband had just left her two years ago when
she was in a multiple car smashup, sustaining a back injury that required two
operations. As medication nurse, you have the only key to the narcotics cabinet
on your floor. Several times over about a month, the narcotics count is
slightly off…just a pill or two missing each time. You think initially that
possibly during a particularly hectic period you forgot to record a dose; but
after the second time you know that that’s not so .You recall that several
times when you were in the middle of a procedure with a patient, your friend
has asked for your narcotics key, saying that a patient elsewhere on the floor
is in pain and she’ll just give him/her the ordered pain medication “to help
you out”. You enquire discreetly among some of the other medication nurses, and
learn that they two have occasionally come up a pill or two short on their
narcotics counts recently.
What do you do? What
ethical guidelines/principles help ypu to a decision?
CASE
#14
A
17-year-old honor student senior, who is about to graduate from high school
comes to you with a girlfriend who waits in the lobby for her. She is
approximately eight weeks pregnant; the father is her steady boyfriend of the
past two years, whom she plans to marry at the end of college. They have been
accepted at the same college. Both families are happy. They slipped-up in their
use of birth control. A child now would mess up all their plans. They have
decided an abortion would be best. (She fights back tears as she tells you
this.) His mother knows and is supportive of the decision. Her mother is
recovering from a mild heart attack and her parents believe abortion is wrong.
She is afraid to tell them because she doesn’t want them to have the grief of
knowing about the abortion; she thinks it may anger them toward her boyfriend;
and she fears the news of the pregnancy may adversely affect her mother’s
health. She asks you to refer her to someone for an abortion.
What do you do? How do
you formulate the ethics of the situation?
CASE #15
A 17-year-old girl who has a congenitally
malformed fifth thoracic vertebra began having difficulty walking when she was
four years old. Despite multiple back surgeries, she has gradually become paraplegic,
and has lost bowel and bladder control; she has an ileal-loop bladder. She has
lived since she was five years old with her paternal French-speaking
grandmother who is devoted to her, but her parents who live in a town at some
distance and almost never see her have legal custody of her. She is very
intelligent, and makes honor grades in high school. She has a lively
personality, is popular among her classmates, and takes part in all school
social activities. Her local orthopedist has become her primary care doctor,
and he admits her with a high fever and severe anemia. He asks you to consult.
You find a urinary tract infection requiring gentamycin therapy; the anemia is
compatible with anemia of chronic infection. “Elaine” refuses to have an IV
placed. When the nurses try anyway, assuming she is just upset, she becomes
adamant, throwing the IV bottle across the room, snatching the tubing, and
declaring, “I won’t! I’ve had enough IV’s!! You can’t make me!!! My mother said
I don’t have to have it if I don’t want it!!!!” In fact that is what her
parent’s say when contacted. “Whatever ‘Elaine’ says,” they say. They make the
trip to the hospital reluctantly when the administration insists that they come
to sign paperwork. Meanwhile the grandmother pleads with ‘Elaine’, says
innumerable rosaries, and beseeches everyone involved in her care to “save
her”, saying, “Elaine, she don’t know what she’s saying. She is afraid like
little child of the needle. She don’t believe she will die. Don’t let my baby
die. Make her take the medicine.” All this goes on over several days. Your
attempts to persuade and to reason with ‘Elaine’ are met with passionate
outbursts: “I don’t care if I die! I’m not going to die! You can’t make me! I
won’t! I won’t!! I won’t!!!”
What are
the ethical considerations you see in this situation? How do you think it
through? What do you end up doing?
[There is an interesting “post-script” to this
story as I was had occasion to talk with “Elaine” and ask her views about what
I actually did some years later. I’d be glad to share that with anyone after
they think the case through for themselves.]
CASE #16
“Keith” is a seriously brain damaged, severely
micro-cephalic, globally retarded three year old boy whom you have cared for
since age six months when his single mother left his original pediatric care
provider, angry over the poor prognosis he had given her for any significant
improvement in “Keith’s” functioning. His story has a soap-opera aura about it,
but is unmitigated tragedy. His mother, wanting a baby, but not wanting any
ongoing relationship with a man, had moved out of her home state, secured a job
as an executive secretary, and developed an affair with the best-looking, most
intelligent, married man she could find. She was careful to not tell
anyone where she was from, and once she knew she was pregnant she returned
home, leaving no word behind. She had gone into severe eclampsia during labor.
Her obstetrician delayed coming in to the hospital; a second one was called,
but had to travel over an hour through a blizzard, and she ended up delivering
a severely oxygen deprived infant vaginally. She understands that his problem
is “cerebral palsy”, but has read that physical therapy can help children with
cerebral palsy and she works faithfully with “Keith” convinced that he will
eventually be normal. You have always told her the truth, but gently and in
small doses. One evening, about eight o’clock, you get a frantic call from her,
saying that she’s been sick, and has missed some of Keith’s feedings and he is
almost unresponsive. When you see him, you find that he is not only severely
dehydrated, but also seriously hypothermic with a rectal temperature of 95.6
degrees F. Just as you are writing orders for his care in ICU at your local
community hospital, the head nurse on the evening shift tells you that there is
only one available bed there, and that one of the surgeons is requesting it for
a seven year old girl whom he’s just operated on for blunt trauma to the
abdomen and a compound fracture of one leg. Her prognosis is good.
What do
you do? The bed was already assigned to “Keith”. Do you inform his mother of
the situation? Do you involve her in the decision to give up “Keith’s” ICU bed
or not? What ethical principles/guidelines help you?