medical ethics case analysis essay

Case Studies

Case study discussion.

Below is a list of the case study articles that have been published in NIB , each with keywords, a set of discussion questions, and further resources. To search page contents with keywords, select "Control-F" from a PC, or "Command-F" from a Mac.

• Accommodating Religious Beliefs in the ICU: A Narrative Account of a Disputed Death
• When Ethics Consultation and Courts Collide: A Case of Compelled Treatment of a Mature Minor
• Advance Directives, Preemptive Suicide, and Emergency Medicine Decision Making
• Healing the Physician’s Story: A Case of Narrative Medicine and End-of-Life Care
• The Efficacy of Ethics Discernment in the Organizational Context: The Case of Post-Offer Nicotine Screening
• Can We Talk About Sex?
• Should We Tell Annie?: Preparing for Death at the Intersection of Parental Authority and Adolescent Autonomy
• A Case of Deceptive Mastectomy
• Do Everything
• Responding to the Refusal of Care in the Emergency Department
• I Don’t Know Why I Called You
• Undocumented and at the End of Life
• Dax’s Case Redux: When Comes the End of the Day?
• Desperately Seeking a Surrogate— For a Patient Lacking Decision-Making Capacity
• What to Say When: Responding to a Suicide Attempt in the Acute Care Setting
• Conversation and the Jehovah’s Witness Dying From Blood Loss
• Caregivers’ Role in Maternal-Fetal Conflict
• The Surgeon as Stakeholder: Making the Case Not to Operate
• The Enduring Case
• Military Health Care Dilemmas and Genetic Discrimination: A Family’s Experience with Whole Exome Sequencing
• Conflicting Values: A Case Study in Patient Choice and Caregiver Perspectives
• Ethical Dilemmas Relating to the Management of a Newborn with Down Syndrome and Severe Congenital Heart Disease in a Resource-Poor Setting
• System Failure: No Surgeon To Be Found
• Ethical Challenges in the Care of the Inpatient with Morbid Obesity
• A Life Below the Threshold? Examining Conflict Between Ethical Principles and Parental Values in Neonatal Treatment Decision Making
• The Clinical Bioethicist’s Role: Should We Aim to Relieve Suffering?
• To Enroll or Not to Enroll?: A Researcher Struggles with the Decision to Involve Study Participants in a Clinical Trial That Could Save Their Lives
• Sometimes Those Hoofbeats Are Zebras: A Narrative Analysis
• A Jehovah’s Witness Adolescent in the Labor and Delivery Unit: Should Patient and Parental Refusals of Blood Transfusions for Adolescents Be Honored?
• Reframing Medical Appropriateness: A Case Study Concerning the Use of Life-Sustaining Technologies for a Patient With Profoundly Diminished Quality of Life
• "We Didn't Consent to This"
• Screen Shots: When Patients and Families Publish Negative Health Care Narratives Online
• A Personal Narrative on Living and Dealing with Psychiatric Symptoms after DBS Surgery
• The Will Reconsidered: Hard Choices in Living Organ Donation
• Malleable Transplant Criteria: At What Cost?
• Responding to Requests for Aid-in-Dying: Rethinking the Role of Conscience
• Getting to the Heart of the Matter: Navigating Narrative Intersections in Ethics Consultation
• Speaking for Our Father
• Forcible Amputation in Delusional Patients: A Narrative Analysis of Decisional Capacity
• A Health Care Systems Approach to Improving Care for Seriously Ill Patients
• An Ethics of Unknowing: Discerning Ethical Patient-Provider Interactions in Clinical Decision-Making
• How Should Physicians Manage Neuro-prognosis with ECPR?
• The Ethics of Choosing a Surrogate Decision Maker When Equal-Priority Surrogates Disagree
• A Gay Epidemiologist and the DC Commission of Public Health AIDS Advisory Committee
• Shared Decision-Making in Palliative Care: A Maternalistic Approach
• Phantom Physicians and Medical Catfishing: A Narrative Ethics Approach to Ghost Surgery
• It Takes Time to Let Go
• An American’s Experience with End-of-Life Care in Japan: Comparing Brain Death, Limiting and Withdrawing Life-Prolonging Interventions, and Healthcare Ethics Consultation Practices in Japan and the United States
• The Sword of King Solomon
• Appreciating the Dynamicity of Values at the End of Life: A Psychological and Ethical Analysis
• Serendipity and Social Justice: How Someone with a Physical Disability Succeeds in Clinical Bioethics
• The Right to Be Childfree
• Undisclosed Placebo Trials in Clinical Practice: Undercover Beneficence or Unwarranted Deception?
• What Do We Owe to Patients Who Leave Against Medical Advice? The Ethics of AMA Discharges?
•  "Jehovah's Witnesses and the Normative Function of Indirect Consent"
• "Parental Refusals of Blood Transfusions from COVID-19 Vaccinated Donors for Children Needing Cardiac Surgery"
• "Withdrawing Life Support After Attempted Suicide: A Case Study and Review of Ethical Consideration"

1. Accommodating Religious Beliefs in the ICU: A Narrative Account of a Disputed Death

Martin L. Smith, Anne Lederman Flamm

Abstract: Despite widespread acceptance in the United States of neurological criteria to determine death, clinicians encounter families who object, often on religious grounds, to the categorization of their loved ones as “brain dead.” The concept of “reasonable accommodation” of objections to brain death, promulgated in both state statutes and the bioethics literature, suggests the possibility of compromise between the family’s deeply held beliefs and the legal, professional and moral values otherwise directing clinicians to withdraw medical interventions. Relying on narrative to convey the experience of a family and clinical caregivers embroiled in this complex dilemma, the case analyzed here explores the practical challenges and moral ambiguities presented by the concept of reasonable accommodation. Clarifying the term’s meaning and boundaries, and identifying guidelines for its clinical implementation, could help to reduce uncertainty for both health care professionals and families and, thereby, the incremental moral distress such uncertainty creates.

Keywords: Brain death, clinical ethics, ethics consultation, reasonable accommodation, religious conflict

Link to Case on MUSE

Reflection Questions:

• How might have the nurses’ and physicians’ initial frank commentary about Sarah’s condition affected the family’s interpretation of the clinicians’ opinions later on in the care process?
• In what ways might the new hospital have provided support to Sarah’s family in order to avoid the religion vs. medicine standoff that eventually developed?
• How much patience are physicians obligated to have with family members who extensively question the medical decision-making process? Was the hospital staff correct in labeling Rebekah as “manipulative”?
• Is it ethically appropriate for financial considerations to affect the family’s decision-making? Why or why not? To what extent should the healthcare team discuss the financial impact of decisions with families?

Web Resources:

• New York State Department of Health Guidelines for Determining Brain Death. (2011). Retrieved from: http://www.health.ny.gov/professionals/hospital_administrator/letters/2011/brain_death_guidelines.pdf
• Olick, RS, Braun, EA, and Potash, J. (2009). Accommodating Religious and Moral Objections to Neurological Death. The Journal of Clinical Ethics. Retrieved from: http://www.upstate.edu/bioethics/pdf/faculty/olick_accommodating-religious-and-moral-objections-to-neurological-death.pdf
• Breitowitz, YA. Jewish Medical Ethics: The Brain Death Controversy in Jewish Law. Jewish Virtual Library. Retrieved from: https://www.jewishvirtuallibrary.org/jsource/Judaism/braindead.html

2. When Ethics Consultation and Courts Collide: A Case of Compelled Treatment of a Mature Minor

Jeffrey P. Spike

Abstract: A fourteen year old is diagnosed with aplastic anemia. The teen and his parents are Jehovah’s Witnesses. An ethics consult is called on the day of admission by an ethically sophisticated social worker and attending. The patient and his parents see this diagnosis as “a test of their faith.” The ethical analysis focuses on the mature minor doctrine, i.e. whether the teen has the capacity to make this decision. The hospital chooses to take the case to court, with a result that is at odds with the ethics consultation recommendations. Ethics was never deposed or otherwise invited to be involved with the hearing. Thus the larger question of the relation of ethics and law was brought into stark relief.

Keywords: Adolescent, Capacity, Child Neglect, Decision-making Capacity, Ethics Consultation, Informed Consent, Jehovah’s Witnesses, Mature Minor, Religion, Religious Belief, Right to Refuse Treatment, Teen, Teenager

• What is the relationship between law and ethics? When they conflict, which should prevail?
• At one point, the author of this case study says, of trying to convince his young patient of the benefit of treatment: “…but that seemed coercive. In fact, far too many patients act out of fear and accept treatment that has virtually no choice of benefit.” In this case, where Luke would have greatly benefitted from treatment, where is the line to be drawn between thoroughly informing him and coercing him?
• Are there ever circumstances where it might be disadvantageous to have an ethics consultation?
• Anderson & Associates, P.C. (2015). Illinois Recognizes the “Mature Minor Doctrine” in Some Cases. Retrieved from: http://www.andersondivorcelawchicago.com/chicagodivorceattorney/2015/01/29/illinois-mature-minor-doctrine-states/

Pauley, M. (2011). National Health Care Decisions Day, Jehovah’s Witnesses & Mature Minors. Marquette University Law School Faculty Blog. Retrieved from: http://law.marquette.edu/facultyblog/2011/04/14/national-health-care-decisions-day-jehovahs-witnesses-mature-minors/

• Jehovah’s Witnesses: The Surgical/Ethical Challenge. (1981). JW.org. Retrieved from: http://www.jw.org/en/publications/books/blood/jehovahs-witnesses-the-surgical-ethical-challenge/

3. Advance Directives, Preemptive Suicide, and Emergency Medicine Decision Making

Richard L. Heinrich, Marshall T. Morgan, Steven J. Rottman

Abstract: As the United States population ages, there is a growing group of aging, elderly, individuals who may consider "preemptive suicide"(Prado, 1998). Healthy aging patients who preemptively attempt to end their life by suicide and who have clearly expressed a desire not to have life -sustaining treatment present a clinical and public policy challenge. We describe the clinical, ethical, and medical-legal decision making issues that were raised in such a case that presented to an academic emergency department. We also review and evaluate a decision making process that emergency physicians confront when faced with such a challenging and unusual situation.

Keywords: Aging, Autonomy, Advance Directives, Emergency Department, Preemptive Suicide

• Can we rely on the perspective of a patient to trust that a logical decision about preemptive suicide is being made?
• In this case, the family supported the patient’s decision, and thus gave it more credence. When the patient and family disagree, which view should prevail?
• What could the medical team have done prior to providing treatment in order to clarify their patient’s DNR wishes?
• Suicide is currently illegal in the United States. Does the fact that it is illegal mean that it is wrong? Is there an ethical right to suicide, despite the fact that it is illegal?
• Gabbatt, A. (2009). Doctors acted legally in ‘living will’ suicide case. The Guardian. Retrieved from: http://www.theguardian.com/society/2009/oct/01/living-will-suicide-legal
• Tolchin, M. (1989). When long life is too much: suicide rises among elderly. The New York Times. Retrieved from: http://www.nytimes.com/1989/07/19/us/when-long-life-is-too-much-suicide-rises-among-elderly.html?pagewanted=all&src=pm
• Appleby, J. (2014). ‘Prophylactic’ Suicide. The New York Times, Sunday Review. Retrieved from: http://www.nytimes.com/2014/11/16/opinion/sunday/prophylactic-suicide.html

4. Healing the Physician’s Story: A Case of Narrative Medicine and End-of-Life Care

Lori A. Roscoe

Abstract: Telling stories after a loved one’s death helps surviving family members to find meaning in the experience and share perceptions about whether the death was consistent with the deceased person’s values and preferences. Opportunities for physicians to evaluate the experience of a patient’s death and to expose the ethical concerns that care for the dying often raises are rare. Narrative medicine is a theoretical perspective that provides tools to extend the benefits of storytelling and narrative sense–making to physicians. This case study describes narrative writing workshops attended by physicians who care for dying patients. The narratives created revealed the physicians’ concerns about ethics and their emotional connection with patients. This case study demonstrates that even one–time reflective writing workshops might create important opportunities for physicians to evaluate their experiences with dying patients and families.

Keywords: Death and Dying, End–of–Life Issues, Healthcare Professionals, Narrative Inquiry, Stories, Storytelling

• This piece extensively discusses the effects that narrative medicine can have for a practicing physician. What potential effects can it have on the other side of the doctor-patient interaction?
• What does the Japanese physician’s story suggest about the role that culture plays in the doctor-patient experience?
• Is it possible for a physician to be truly empathetic with his or her patients? Why or why not?
• Should medical schools across the country include narrative medicine in their curriculum? Why or why not?
• Chen, PW. (2008). Stories in the Service of Making a Better Doctor. The New York Times. Retrieved from: http://www.nytimes.com/2008/10/24/health/chen10-23.html?pagewanted=all
• Geisler, SL. (2006). The Value of Narrative Ethics to Medicine. The Journal of Physician Assistant Education. Retrieved from: http://www2.paeaonline.org/index.php?ht=action/GetDocumentAction/i/25232

5. The Efficacy of Ethics Discernment in the Organizational Context: The Case of Post-Offer Nicotine Screening

David M. Belde

Abstract: This article examines the efficacy of an ethics discernment process in the organizational context, a practice referred to in the paper as "mission due diligence." This type of ethics discernment is a structured process intended to awaken the ethical concerns that a particular issue raises within moral agents and to give voice, directly and indirectly, to those who will be impacted by, and responsible for, strategic decision-making. The efficacy of this particular ethics discernment practice is contingent upon several realities, including, but not limited to 1) the timing in which it is undertaken, 2) the degree of importance and relevance attributed to it, and 3) the skills of the person leading it. This case report examines how this process was used to highlight and address the ethical issues related to a new hiring policy, namely, a mandatory nicotine screening test for prospective employees in the healthcare context. Framed by the Bon Secours Virginia Health System hiring process, the author explores the importance of diligently focusing on ethical considerations in the organizational realm while still maintaining true to the virtues of the network.

Keywords: Ethics Discernment, Nicotine Screening, Organizational Ethics

• The author says, “Virtually all organizational ethics programs have to grapple with their overall importance and relevance within an organization.” How much authority should an ethics program within a hospital be afforded?
• If an employer can show sufficient empirical results for why a drug test is necessary, is it warranted? Do the sufficient reasons have to be related to the patients’ best interests?
• What are the different ways that Catholicism affects the ethical considerations in this case? What role does religion play in ethical consultations in general?
• Why does the author say balancing advocacy and inquiry are so important?
• Tucker, M & Salazar, L. (2014). Cotinine testing may violate the American with Disabilities Act (ADA), the ADA Amendments Act (ADAAA), and state laws. Wells Fargo Insights. Retrieved from: https://wfis.wellsfargo.com/insights/clientadvisories/pages/cotininetestingmayviolateadaandotherlaws.aspx
• Our Values. Bons Secours Health System. Retrieved from: http://hso.bonsecours.com/about-us-our-mission-our-values.html
• Framework for Ethical Discernment. (2014). The Taylor University Center for Ethics. Retrieved from: http://ethics.taylor.edu/framework-for-ethical-discernment/

6. Can We Talk About Sex?

Mindy B. Statter

Abstract: A three–year–old female undergoes elective inguinal hernia repair and unexpectedly is found to have testes in the hernia sacs. A recommendation is made not to disclose the patient’s genotype to her mother. This case study addresses the ethical conflict of whether to disclose the patient’s male genotype to the parent that has been raising the child as female.

Keywords: Autonomy, Beneficence, Complete Androgen Insensitivity Syndrome, Disclosure, Informed Consent, Intersex, Nonmaleficence

• In what—if any—circumstances is it ethically acceptable to withhold medical information about a child from the primary caretaker?
• Now that disclosure of a CAIS diagnosis is mandatory, what responsibility would a parent potentially have to override a doctor’s recommendations for gender maintenance?
• This case highlights the ethical risks and potential consequences later in life of not disclosing a patient’s CAIS diagnosis and treatment. Conversely, what would the consequences be for disclosing?
• Ignoring the medical precedents set now, do you believe the doctor in this case should have felt remorse for not disclosing the full nature of the girl’s condition to her mother? Would her mother have been equipped to handle that knowledge at that time?
• Dreger, AD. (1998). “Ambiguous Sex”—or Ambivalent Medicine? The Hastings Center Report. Retrieved from: http://www.isna.org/articles/ambivalent_medicine
• Intersex Conditions, Human Diversity Resources. UConn Health Center. http://uchc.libguides.com/humandiversity/intersex
• Georgiann Davis. "Normalizing Intersex: The Transformative Power of Stories." Narrative Inquiry in Bioethics 5.2 (2015): 87-89. Project MUSE. Web. 8 Dec. 2015

7. Should We Tell Annie?: Preparing for Death at the Intersection of Parental Authority and Adolescent Autonomy

Erica K. Salter

Abstract: This case analysis examines the pediatric clinical ethics issues of adolescent autonomy and parental authority in medical decision–making. The case involves a dying adolescent whose parents request that the medical team withhold diagnosis and prognosis information from the patient. The analysis engages two related ethical questions: Should Annie be given information about her medical condition? And, who is the proper decision–maker in Annie’s case? Ultimately, four practical recommendations are offered.

Keywords: Adolescent, Decision-making Capacity, End of Life Care, Mature Minor, Parental Consent

• At what age do teens develop the ability to make autonomous decisions for themselves? What factors unique to adolescence might enhance or detract from this ability?
• What factors should be considered in deciding whether an adolescent should be given decision-making authority? Why?
• Is it ever appropriate for medical practitioners to lie to a child (or actively conceal the truth from a child)? Why or why not?
• Was it appropriate of the new attending doctor to call the palliative care physician? How could that miscommunication have been prevented?
• Hill, JB. (2012). Medical Decision Making by and on Behalf of Adolescents: Reconsidering First Principles. Faculty Publications. Retrieved from: http://scholarlycommons.law.case.edu/cgi/viewcontent.cgi?article=1081&context=faculty_publications
• Leonard, K. (2015). Case Sparks Debate About Teen Decision Making in Health. U.S. News and World Report. Retrieved from: http://www.usnews.com/news/articles/2015/01/22/case-sparks-debate-about-teen-decision-making-in-health

8. A Case of Deceptive Mastectomy

Rebecca Volpe, Maria Baker, George F. Blackall, Gordon Kauffman, Michael J. Green

Abstract: This paper poses the question, “what are providers’ obligations to patients who lie?” This question is explored through the lens of a specific case: a 26–year–old woman who requests prophylactic bilateral mastectomy with reconstruction reports a significant and dramatic family history, but does not want to undergo genetic testing. Using a conversational–style discussion, the case is explored by a breast surgeon, genetic counselor/medical geneticist, clinical psychologist, chair of a hospital ethics committee and director of a clinical ethics consultation service.

Keywords: Clinical Ethics, Deceit, Lying, Provider/Patient Relationship, Providers’ Obligations

• Do you believe that the patient-doctor relationship should be reciprocal? Does the Hippocratic Oath mandate that doctors uphold their duties regardless of patient behavior?
• This case study asks us to consider typical signals that the doctors relied on when initially deciding whether or not to trust the patient. They cite qualities like her attractiveness, her maturity, and her husband’s support in order to explain their initial trust. Should they have been more skeptical in the beginning? Why were they so willing to believe the patient’s story at face value?
• Aside from the guilt that the surgeon himself would likely have felt, what might have been some potential consequences for the ethics team and hospital in general if the surgery had been successfully performed? What if it had gone badly?
• Polta, A. (2014). Lying to the Doctor. Center for Advancing Health, Prepared Patient Blog. Retrieved from: http://www.cfah.org/blog/2014/lying-to-the-doctor
• Ludwig, M & Burke, W. (2013). Physician-Patient Relationship. Ethics in Medicine, University of Washington School of Medicine. Retrieved from: http://depts.washington.edu/bioethx/topics/physpt.html
• Observer Staff. (2000). What Should Plastic Surgeons Do When Crazy Patients Demand Work? Observer. Retrieved from: http://observer.com/2000/07/what-should-plastic-surgeons-do-when-crazy-patients-demand-work/

9. Do Everything

H. Rex Greene

Abstract: A 57–year–old with an incurable cancer suffered an abdominal catastrophe, putting him in the ICU, comatose with no chance of survival. His attending oncologist had only met him once and had no knowledge of his goals of care. Lacking an advance directive the staff turned to his family, who said, “Do everything.” This loaded statement was thought to be a demand for futile care even though it ultimately proved a reflection of their emotional response to a terrible, unanticipated event, not an irrational demand for useless care. A sympathetic exploration of the patient’s goals and expectations with his family using Buckman’s SPIKES format disclosed that their major concern was that he not die on his wife’s birthday. The family agreed to withdraw him from ventilator support the following day. Unraveling a medical conflict requires a sensitive process of shared decision–making based on a transparent process of clinical reasoning that synthesizes patient and family values with medical knowledge and ethical duties. Properly done, the outcome usually is a satisfactory experience for all concerned.

Keywords: Abandonment, Advance directives, Catastrophic Illness, Clinical Reasoning, Conflict Resolution, Decisional Capacity, Do Everything, Futility, Paternalism, Shared Decision Making, SPIKES, Substituted Judgment

• This case explains that responding appropriately to a request to “do everything” requires doctors to ensure that patients’ families “know the medical facts, delivered in a kind, caring fashion.” Sometimes, it can take many meetings over several days for the family to absorb the medical facts. How should decisions be made in the meantime?
• The conclusion of this case seems to reaffirm that emotion is more important than reason when approaching difficult conversations with patients’ families. Should emotion-based education and empathy training be offered in the modern medical school curriculum? Is it even possible to train physicians to be more emotionally intelligent?
• Why is the establishment of the goal of treatment so important to the unity of a patient, their family, and their doctor? What are the barriers to establishing goals of care?
• Baile, WF. et al. (2000). SPIKES—A Six Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist. Retrieved from: http://theoncologist.alphamedpress.org/content/5/4/302.full
• Medical Futility. (2007). ACOG Committee Opinion No. 362. American College of Obstetricians and Gynecologists. Obstet Gynecol. Retrieved from: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Ethics/Medical-Futility
• Enhancing Communication and Coordination of Care. (2013). Cardinal Glennon. Retrieved from: http://www.cardinalglennon.com/Documents/Forms/AllItems.aspx?RootFolder=http%3a%2f%2fwww%2ecardinalglennon%2ecom%2fDocuments%2femergency-medicine&FolderCTID=0x0120000161C93D9B68B34BA6E74A98204CE2A1

10. Responding to the Refusal of Care in the Emergency Department

Jennifer Nelson, Arvind Venkat, Moira Davenport

Abstract: The emergency department (ED) serves as the primary gateway for acute care and the source of health care of last resort. Emergency physicians are commonly expected to rapidly assess and treat patients with a variety of life–threatening conditions. However, patients do refuse recommended therapy, even when the consequences are significant morbidity and even mortality. This raises the ethical dilemma of how emergency physicians and ED staff can rapidly determine whether patient refusal of treatment recommendations is based on intact decision–making capacity and how to respond in an appropriate manner when the declining of necessary care by the patient is lacking a basis in informed judgment. This article presents a case that illustrates the ethical tensions raised by the refusal of life–sustaining care in the ED and how such situations can be approached in an ethically appropriate manner.

Keywords: Decision–making Capacity, Emergency Department, Emergency Physician, Informed Consent, Treatment Refusal

• Does coming to the Emergency Department constitute implied consent to treatment? Why would a patient come to the ED if not to receive potentially life-sustaining treatments at a physician’s recommendation?
• If it is evident that a patient lacks decision-making capacity, is it paternalistic to administer life-saving treatment even if the patient refuses?
• In this case, would it be ethically appropriate for the physicians to consult the patient’s family, in order to bring in one more agent of authority?
• Cooper, S. (2010). Taking No for an Answer—Refusal of Life-Sustaining Treatment. AMA Journal of Ethics/Virtual Mentor. Retrieved from: http://journalofethics.ama-assn.org/2010/06/ccas2-1006.html
• ACEP Code of Ethics for Emergency Physicians. (2008). Retrieved from: https://www.acep.org/Clinical---Practice-Management/Code-of-Ethics-for-Emergency-Physicians/

11. I Don’t Know Why I Called You

Jeffrey S. Farroni, Colleen M. Gallagher

Abstract: This case study details a request from a patient family member who calls our service without an articulated ethical dilemma. The issue that arose involved the conflict between continuing further medical interventions versus transitioning to supportive or palliative care and transferring the patient home. Beyond the resolution of the ethical dilemma, this narrative illustrates an approach to ethics consultation that seeks practical resolution of ethical dilemmas in alignment with patient goals and values. Importantly, the family’s suffering is addressed through a relationship driven, humanistic approach that incorporates elements of compassion, empathy and dialog.

Keywords: End of life, Empathy, Relationships, Clinical Ethics

• How can healthcare providers and ethicists strike a balanced middle-ground between being too detached and too empathetic? Which side of this split should they err on? Why?
• In this case, how did the patient’s family’s expectations influence the decision-making of the ethicist and the doctors?
• How can an ethicist’s varied background bring new knowledge and insight to a collaborative ethical deliberation?
• Shelton, WN & White, BD. (2015). Realistic Goals and Expectations for Clinical Ethics Consultations: We Should Not Overstate What We Can Deliver. The American Journal of Bioethics. Retrieved from: http://www.tandfonline.com/doi/pdf/10.1080/15265161.2014.974773
• American Society for Bioethics and Humanities Clinical Ethics Task Force. Improving Competence in Clinical Ethics Consultation: A Learner’s Guide. Retrieved from: http://www-3.unipv.it/centrodibioetica/resources/Improving_Competence_in_Ethics.pdf

12. Undocumented and at the End of Life

Annette Mendola

Abstract: Three of the most contentious issues in contemporary American society—allocation of medical resources, end of life care, and immigration—converge when undocumented immigrant patients are facing the terminal phase of chronic illness. The lack of consistent, pragmatic policy in each of these spheres leaves us with little guidance for how to advocate for undocumented patients at the end of life. Limited resources and growing need compound the problem. Care for patients in this unfortunate situation should be grounded in clinical and economic reality as well as respect for the dignity of the individual to avoid exacerbating inequalities.

Keywords: Allocation of Resources, Dialysis, ESRD, End–of–Life Care, Undocumented Patients

• How does Henri’s lack of citizenship or permanent residence in the United States limit not only his access to, but his knowledge of, the full range of medical options available to him? Does this make him vulnerable, and therefore deserving of increased protections, in a way that other patients are not?
• Was it Henri’s right to refuse hospice, considering the lack of other options available? Why or why not?
• Should the ethics consulting team have made more of an effort to communicate to Henri that Lucia was no longer willing to be his caregiver? Why would this matter?
• Is a partial treatment of a severely ill patient worth the effort, or just a waste of time and resources? What is the apparent stance of the ethics committee on this question?
• Kimball, C. “End-of-Life Health Care Disparity: A Case Study”. Nursing Economics. Retrieved from: https://www.nursingeconomics.net/necfiles/news/End-Of-Life_Care_Kimball.pdf
• Ortega, AM. (2014). “Stay or Go? Terminally Ill Undocumented Immigrants Face Dilemma”. New America Media. Retrieved from: http://newamericamedia.org/2014/01/undocumented-and-dying-latinos-may-find-comfort-in-final-journey-home.php

13. Dax’s Case Redux: When Comes the End of the Day?

Ashley R. Hurst, Dea Mahanes, Mary Faith Marshall

Abstract: Forty years after Dax Cowart fought to have his voice heard regarding his medical treatment, patient autonomy and rights are at the heart of patient care today. Yet, despite its centrality in patient care, the tension between a severely burned patient’s right to stop treatment and the physician’s role in saving a life has not abated. As this case study explores, barriers remain to hearing and respecting a patient’s treatment decisions. Dismantling these barriers involves dispelling the myths that burn patients must grin and bear intense pain to recover and that a patient’s choice to discontinue treatment equals physician failure. Moreover, in these situations, sustained, direct engagement between physician and patient can reduce the moral distress of all involved and enable physicians to hear and better accept when a patient is calling for the end of the day.

Keywords: Dax Cowart, Ethics Consultation, Moral Distress, Palliative Care, Patient Autonomy

• Communication between a patient and his or her care team is crucial in cases like this. Why did the avenues of communication break down in this piece? What could have been done to improve the relationship between the patient and the medical team?
• What obligation did the physicians have to be visiting the patient and witnessing the implications of his wound care? If their behavior had been different, how might that have changed the course of treatment for the patient?
• Was the sheer number of people in the room for the patient’s first consult coercive? What could have been done differently to understand both the patient’s wishes and the team’s perspective earlier in the process?
• Does the possibility of a high quality of life post-treatment warrant or justify doctors’ prescribing painful treatment over a patient’s objections?
• “Dax’s Case” preview. (1984). Retrieved from: http://search.alexanderstreet.com/view/work/1630976
• Kavan, MG, Elsasser, GN, Barone, EJ. (2012). The Physician’s Role in Managing Acute Stress Disorder. Am Fam Physician. Retrieved from: http://www.aafp.org/afp/2012/1001/p643.html
• Requests to Die: Non-Terminal Patients. Mhhe. Retrieved from: http://novella.mhhe.com/sites/dl/free/0078038456/1037408/Pen38456_Ch02.pdf

14. Desperately Seeking a Surrogate— For a Patient Lacking Decision-Making Capacity

Martin L. Smith, Catherine L. Luck

Abstract: Our hospital’s policy and procedures for “Patients Without Surrogates” provides for gradated safeguards for managing patients’ treatment and care when they lack decision–making capacity, have no advance directives, and no surrogate decision makers are available. The safeguards increase as clinical decisions become more significant and have greater consequences for the patient. The policy also directs social workers to engage in “rigorous efforts” to search for surrogates who can potentially provide substituted judgments for such patients. We describe and illustrate the policy, procedures, and kinds of expected rigorous efforts through our narration of an actual but disguised case for which we provided clinical ethics guidance and social work expertise. Our experience with and reflection on this case resulted in four recommendations we make for health care facilities and organizations that aim to provide quality care for their own patients without surrogates.

Keywords: Clinical Ethics, Decision–Making Capacity, End–of–Life Decisions, Ethics Committee, Ethics Consultation Service, Patients Without Surrogates, Rigorous Efforts, Social Work, Surrogate Decision Maker, Unbefriended Patient, Unrepresented Patient

• While this author cautions against using social media to determine a surrogate, do you think it could be a reliable method of determining a close relationship?
• Does your state allow non-family members to serve in the role of surrogate decision-maker?
• If there had been sufficient grounds for Sally to be Jacob’s surrogate, do you think she would have come to the same conclusions as Jacob’s brother? Could the process have been expedited, and yet be just as reliable?
• Stanford Hospitals and Clinics. (2009). Health Care Decisions for Patients Who Lack Capacity and Lack Surrogates. Retrieved from: http://www.thaddeuspope.com/images/Stanford_Health_Care_Decisions_For_Patients_Who_Lack_Capacity_and_Surrogates_7_09.pdf
• Varma, S & Wendler, D. (2007). “Medical Decision Making for Patients Without Surrogates”. Arch Intern Med. Retrieved from: http://ogg.osu.edu/site_documents/sage/course3/wk8_varma.pdf

15. What to Say When: Responding to a Suicide Attempt in the Acute Care Setting

Arvind Venkat, Jonathan Drori

Abstract: Attempted suicide represents a personal tragedy for the patient and their loved ones and can be a challenge for acute care physicians. Medical professionals generally view it as their obligation to aggressively treat patients who are critically ill after a suicide attempt, on the presumption that a suicidal patient lacks decision making capacity from severe psychiatric impairment. However, physicians may be confronted by deliberative patient statements, advanced directives or surrogate decision makers who urge the withholding or withdrawal of life sustaining treatments based on the patient’s underlying medical condition or life experience. How acute care providers weigh these expressions of patient wishes versus their own views of beneficence, non–maleficence and professional integrity poses a significant ethical challenge. This article presents a case that exemplifies the medical and ethical tensions that can arise in treating a patient following a suicide attempt and how to approach their resolution.

Keywords: Advanced Directives, Critical Care, Life–sustaining Treatment, Suicide, Surrogate Decision Maker

• Can suicide ever be a rational, autonomous decision? Why or why not?
• How can patient/family relationships pose a challenge for doctors trying to establish the best course of action for a patient?
• How did the family’s perspective affect the patients’ treatment in this case? Was the outcome of their input positive or negative?
• In the absence of both a clear patient advance directive and familial knowledge of patient preferences, how should medical decisions be made? What did the doctors do in this case?

Web resources:

• Carrigan, CG & Lynch, DJ. (2003). Managing Suicide Attempts: Guidelines for the Primary Care Physician. Primary Care Comparnion to The Journal of Clinical Psychiatry. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419387/
• Sokol, D et al. (2011). Ethical dilemmas in the acute setting: a framework for clinicians. BMJ. Retrieved from: http://www.medicalethicist.net/documents/Tattoo%20BMJ%20PDF.pdf
• Forster, PL & Wu, LH. Assessment and Treatment of Suicidal Patients in an Emergency Setting. Gateway Psychiatric Services. Retrieved from: https://www.gatewaypsychiatric.com/pdf/Assessment%20and%20Treatment%20of%20Suicidal%20Patients%20in%20an%20Emergency%20Setting.pdf

16. Conversation and the Jehovah’s Witness Dying From Blood Loss

D. Malcolm Shaner, Jateen Prema

Abstract: Religious belief can complicate the usual management of seriously ill patients when the patient is a Jehovah’s Witness and the treatment is a blood transfusion. This narrative highlights critical points in a discussion of two cases wherein the process to promote an exercise of free will also becomes an exercise for the ethics consultant and healthcare team. Despite a medical care program’s carefully considered additions to an electronic healthcare record, additional conversation, investigation, preparation, and an open mind are required. Helping conflicted family members and considering whether and in what context to contact the Jehovah’s Witness Hospital Liaison Committee complicates the approach.

Keywords: Blood Transfusion, Jehovah’s Witness, Religious Rights

• Consider the differences between the two cases with regard to how the hospital handled the patient requests. What did the hospital do well, and what could it have improved?
• In Case 1, what was the effect of attempting the surgery once the patient had changed his mind? How did that change influence the perspective of both the doctors and the patient’s mother?
• In Case 1, was the medical officer’s frankness with the patient appropriate, taking into consideration the beliefs that the patient already expressed?
• How did the doctors in Case 2 actively facilitate moral decision making on the part of the patient?
• Panico, ML et al. (2011). “When a Patient Refuses Life Saving Care”. Am J Kidney Dis. Retrieved from: http://www.medscape.com/viewarticle/751273
• Robinson, BA. (2010). “Jehovah’s Witnesses’ (WTS) opposition to blood transfusions”. Ontario Consultants on Religious Tolerance. Retrieved from: http://www.religioustolerance.org/witness11.htm

17. Caregivers’ Role in Maternal-Fetal Conflict

Abstract: The case, which occurred in a public hospital in Turkey in 2005, exhibits a striking dilemma between a mother’s and her fetus’ interests. For a number of reasons, the mother refused to cooperate with the midwives and obstetrician in the process of giving birth, and wanted to leave the hospital. The care providers evaluated the case as a matter of maternal autonomy and asked the mother to give her consent to be discharged from the hospital, which she did despite the fact that her cervix was fully open. She left the hospital and gave birth shortly thereafter. Subsequently, the baby died two days later. In light of contemporary ethical principles, the mother’s competency could be debatable due to the physical and psychological conditions the mother confronted. Furthermore, protection of the fetus’ life should have been taken into account by the caregivers when making a decision concerning discharging of the mother.

Keywords: Ability to Consent, Autonomy, Beneficence, Decision Making Capacity, Ethical Dilemma, Fetal Beneficence, Fetal Rights, Maternal Autonomy, Maternal–Fetal Conflict, Pregnancy

• Did the mother have the right to demand to leave? Would your answer to this question change if discharging the mother endangered the fetus? Why or why not?
• Was the mother in a position to make an autonomous choice? Other than autonomous patient decision-making, are there models of decision-making that might have been considered in this case? How might they be applied?
• How could the care team have done better? Should a hospital have policies to help prevent or address such a situation? If so, what would these policies look like?
• Schetter, CD & Tanner, L. (2012). Anxiety, depression, and stress in pregnancy: Implication for mothers, children, research, and practice. Current Opinion in Psychiatry. Retrieved from: http://health.psych.ucla.edu/CDS/documents/DunkelSchetterTanner-2012COPsychiatry.pdf
• Post, LF. (1996). Bioethical Consideration of Maternal-Fetal Issues. Fordham Urban Law Journal. Retrieved from: http://ir.lawnet.fordham.edu/cgi/viewcontent.cgi?article=2171&context=ulj

18. The Surgeon as Stakeholder: Making the Case Not to Operate

Abstract: Surgeons are in a unique position, serving as gatekeepers to the operating room. They determine if operations are possible, are indicated, and have a reasonable risk–to–benefit profile. When an operation is indicated and the patient is amenable to it, the conversation between surgeon and patient is usually straightforward. On the other hand, when a patient’s co–morbidities substantially increase the risk of operative intervention, surgeons often question the utility of offering their services. These situations become immensely more difficult when patients have the expectation of being offered surgical treatment. This case describes the clinical encounter between an endocrine surgeon and an 83–year–old woman who has been incidentally found to have adrenal metastasis from melanoma. The patient wants an operation that the surgeon is reluctant to offer because of her frailty and high operative risk. The case focuses on the ethical dilemma that arises when a patient wants an operation that a surgeon does not want to perform.

Keywords: Metastatic Melanoma, Palliative Care, Respect for Autonomy, Shared Decision–Making, Surgical Ethics

• What reasons are acceptable for refusing to operate on a patient? Why?
• How should surgeons approach situations in which they are consulted for operative interventions that they do not want to provide?
• When surgeons think the risk of surgery is too great and not justified but patients think the risks are worthwhile, whose assessment should prevail? Why?
• Louden, K. (2015).“Risk Calculator Does Not Alter Surgeons’ Choice to Operate". Medscape. Retrieved from: http://www.medscape.com/viewarticle/852708
• Kasman, DL. (2004).“When is Medical Treatment Futile?: A Guide for Students, Residents, and Physicians." Journal of General Internal Medicine. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1492577/

19. The Enduring Case

Craig M. Nelson

Abstract: In clinical ethics an enduring case takes on a life of its own and comes to closure over a long period of time. This essay describes the evolution of such a case over a 1–year period. The case involves a 90–year old male patient with multiple chronic medical conditions who lacked decision–making capacity, was a resident of a long–term care facility, and did not have known previously expressed wishes regarding medical treatment. The ethics consultation initially revolved around this question: What method or process must be employed so that medical treatment decisions could be ethically reviewed and could include a shared decision–making process for Mr. Smith? This case analysis describes the evolution of this case and argues that the good of the patient must remain paramount throughout an enduring case.

Keywords: Ethical Appropriateness, Ethical Process, Moral Community, Treatment Planning

• What kinds of processes might help an incapacitated patient’s voice be heard, especially when the patient’s values were never formally documented?
• Why might it be important to try to give voice to an incapacitated patient’s values?
• What went well with the process in this clinical ethics consultation? Might there be opportunities for improving the processes deployed in this case, and if so, what might they be?
• Ten Myths About Decision-Making Capacity: A Report by the Natioanl Ethics Committee Of the Veterans Health Administration. (2002). Retrieved from: http://www.ethics.va.gov/docs/necrpts/nec_report_20020201_ten_myths_about_dmc.pdf
• California Advance Health Care Directive Probate Code Section 4701. Retrieved from: https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=PROB&division=4.7.&title=&part=2.&chapter=2.&article=

20. Military Health Care Dilemmas and Genetic Discrimination: A Family’s Experience with Whole Exome Sequencing

Benjamin M. Helm, Katherine Langley, Brooke B. Spangler, Samantha A. Schrier Vergano

Abstract: Whole–exome sequencing (WES) has increased our ability to analyze large parts of the human genome, bringing with it a plethora of ethical, legal, and social implications. A topic dominating discussion of WES is identification of “secondary findings" (SFs), defined as the identification of risk in an asymptomatic individual unrelated to the indication for the test. SFs can have considerable psychosocial impact on patients and families, and patients with an SF may have concerns regarding genomic privacy and genetic discrimination. The Genetic Information Nondiscrimination Act of 2008 (GINA) currently excludes protections for members of the military. This may cause concern in military members and families regarding genetic discrimination when considering genetic testing. In this report, we discuss a case involving a patient and family in which a secondary finding was discovered by WES. The family members have careers in the U.S. military, and a risk–predisposing condition could negatively affect employment. While beneficial medical management changes were made, the information placed exceptional stress on the family, who were forced to navigate career–sensitive “extra–medical" issues, to consider the impacts of uncovering risk–predisposition, and to manage the privacy of their genetic information. We highlight how information obtained from WES may collide with these issues and emphasize the importance of genetic counseling for anyone undergoing WES.

Keywords: Genetic Discrimination, Genetic Information Nondiscrimination Act of 2008 (GINA), Genetic Testing, Incidental Findings, Military, Secondary Findings

• It is clear that this type of genetic testing is revolutionizing diagnoses, but it comes with ethical concerns. Do the advantages of WES outweigh the possible disadvantages? Why or why not?
• Do you agree that pre–test conversations should be required in every scenario? Why or why not?
• When the SCN5A gene mutation was found, should the father have told his superiors? Why or why not?
• The SCN5A mutation is probabilistic–not all individuals who have the mutation will develop symptoms. However for some patients, the only presenting feature is sudden cardiac death. What are some reasons patients might have for—and against—wanting this information?
• National Human Genome Research Institute. (2014a). Fact sheet: Genetic discrimination. Retrieved from: http://www.genome.gov/10002077
• Majewski, J. et al., (2011). What Can Exome Sequencing Do For You? Journal of Medical Genetics. Retrieved from: http://www.medscape.com/viewarticle/749695_1
• Collins, F. (2007). The threat of genetic discrimination to the promise of personality medicine. Testimony to the United States House of Representatives Committee on Ways and Means. Retrieved from: http://waysandmeans.house.gov/Media/pdf/110/3-14-07/CollinsTestimony.pdf

21. Conflicting Values: A Case Study in Patient Choice and Caregiver Perspectives

Margot Eves, Phoebe Day Danziger, Ruth M. Farrell, Cristie M. Cole

Abstract: Decisions related to births in the “gray zone" of periviability are particularly challenging. Despite published management guidelines, clinicians and families struggle to negotiate care management plans. Stakeholders must reconcile conflicting values in the context of evolving circumstances with a high degree of uncertainty within a short time period. Even skilled clinicians may struggle to guide the patient in making value–laden decisions without imposing their own values. Exploring the experiences of one pregnant woman and her caregivers, this case study highlights how bias may undermine caregivers’ ability to meet their obligation to enhance patient autonomy and the moral distress they may experience when a patient’s values do not align with their own. Management strategies to mitigate the potential impact of bias and related moral distress are identified. The authors then describe one management strategy used in this case, facilitated ethics consultation, which is focused on thoughtful consideration of the patient’s perspective.

Keywords: Bias, Ethics Consultation, “Gray Zone", Moral Distress, Perspective–Taking

• How can we distinguish between concerns that reflect bias versus concerns that reflect legitimate differences in values?
• Does it matter if a patient’s choices reflect bias, or do patients have the right to have their decisions respected even if they are based on potentially unsubstantiated biases or beliefs?
• Given the controversial nature of the patient’s viewpoint regarding life with disabilities, did the providers have an obligation to try to mitigate the patient’s bias? Why or why not?
• What are some of the ways that the providers could have tried to address the patient’s biases regarding life with a disability? For example, should the patient have been offered the opportunity to speak to parents of children with disabilities, specifically those disabilities more likely to be a result of complications from prematurity? Would it be ethically permissible to require that she do so?
• Are there other, more effective ways to support professionals who take care of patients whose values and choices differ so significantly from their own?
• Lyerly, AD. (2008). Reframing neutral counseling. Virtual Mentor. Retrieved from: http://virtualmentor.ama–assn.org/2008/10/ccas3–0810.html
• Guttmacher Institute. (2015). State policies in brief: An overview of abortion laws. New York: Guttmacher Institute. Retrieved from: http://www.guttmacher.org/statecenter/spibs/spib_OAL.pdf

22. Ethical Dilemmas Relating to the Management of a Newborn with Down Syndrome and Severe Congenital Heart Disease in a Resource-Poor Setting

Ama K. Edwin, Frank Edwin, Summer J. McGee

Abstract: Decision-making regarding treatment for newborns with disabilities in resource-poor settings is a diffi cult process that can put parents and caregivers in confl ict. Despite several guidelines that have helped to clarify some of the medical decision-making in Ghana, there is still no clear consensus on the specifi c moral criteria to be used. This article presents the case of a mother who expressed her wish that her child with Down syndrome should not have been resuscitated at birth. It explores the ethical issues at stake in both her misgivings about the resuscitation and her unwillingness to consider surgical repair of an atrioventricular (AV) canal defect. Knowing that children born with Down syndrome are able to pursue life’s goals, should our treatment of complete AV canal defect in such children be considered morally obligatory, even in resource-poor settings like Ghana?

Keywords: Atrioventricular Septal Defect, Down Syndrome, Ethical Duty, Newborn, Withholding Treatment

• What is the difference between a substantiated concern and one that reflects bias? How can providers assess the difference?
• The mother’s views about the relative lack of value of a person with disabilities are controversial and seem to reflect an unfair or unfounded bias. In light of this, did the provider have an obligation to try to address the mother’s bias?
• If health care providers had an obligation to try to mitigate or address the mother’s bias, how should they have attempted to do so? Should the mother have been required to speak to other parents of children with disabilities?

23. System Failure: No Surgeon To Be Found

Carol Bayley

Abstract: A woman admitted to the emergency room of a hospital died because no surgeon could be found to stop the bleeding from injuries she sustained in a farming accident. The case points to ethical shortcomings both institutionally and professionally. The call system is inadequate, and physician fears of being sued or insufficiently compensated contribute to the overall problem. Potential responses include the institutional equivalent of a root cause analysis and an understanding of the pressures brought to bear on physicians to treat emergencies.

Keywords: Emergency Call, Institutional Ethics, John Glaser, Organizational Ethics, Root Cause Analysis

• Do you think a physician has an ethical obligation to try to help a patient who will otherwise die, even when the patient’s problem is not within the physician’s specialty? If so, how do you ground this obligation? If not, why not?
• If physicians have such an obligation, what ought they to do when they face barriers to fulfilling it?
• People often see themselves in the best light; it’s very human to see one’s self favorably, and to try to explain away one’s own responsibility when an error occurs. In light of this natural tendency, what structures could be set into place to help physicians and other stakeholders take responsibility in these types of situations?

24. A Life Below the Threshold?: Examining Conflict Between Ethical Principles and Parental Values in Neonatal Treatment Decision Making

Thomas V. Cunningham

Abstract: Three common ethical principles for establishing the limits of parental authority in pediatric treatment decision–making are the harm principle, the principle of best interest, and the threshold view. This paper considers how these principles apply to a case of a premature neonate with multiple significant co-morbidities whose mother wanted all possible treatments, and whose health care providers wondered whether it would be ethically permissible to allow him to die comfortably despite her wishes. Whether and how these principles help in understanding what was morally right for the child is questioned. The paper concludes that the principles were of some value in understanding the moral geography of the case; however, this case reveals that common bioethical principles for medical decision–making are problematically value-laden because they are inconsistent with the widespread moral value of medical vitalism.

Keywords: Harm Principle, Best Interests, Threshold View, Neonatal Decision Making, Values, Medical Vitalism

• How should the ethicist think through the relationship between apparently competing bioethical views in particular clinical circumstances?
• Should there be a competency evaluation for parents, guardians, surrogates, or other proxy medical decision makers?
• Should society develop policies to limit health care in circumstances where there is an appreciable likelihood of extremely poor outcomes?

25. Ethical Challenges in the Care of the Inpatient with Morbid Obesity

Paul L. Schneider, Zhaoping Li

Abstract: Objective: To provide a thorough analysis of the range of ethical concerns that may present in relation to the care of the morbidly obese inpatient over the course of several years of care. Methods: A narrative of the patient’s complex medical care is given, with particular attention to the recommendations of three separate ethics committee consultations that were sought by his health care providers. An ethical analysis of the relevant issues is given within the Principles of Biomedical Ethics framework, highlighting the principles of autonomy, beneficence, non–maleficence, and justice. Results: The case study presents a patient with morbid obesity, obesity hypoventilation syndrome, and numerous ICU admissions. The first ethics consultation was requested regarding the permissibility of forcing bariatric surgery on him against his will. The second consultation was regarding a request by nursing staff to no longer attempt to mobilize him. The third was regarding the patient’s refusal to be discharged. Conclusions and Recommendations: The care of inpatients with morbid obesity presents a unique set of practical and ethical challenges to health care personnel. A disciplined approach to ethical analysis using the Principles of Biomedical Ethics framework may be helpful in dealing with these challenges. Recommendations for improvement are made for the individual and local settings, as well as nationally.

Keywords: Autonomy, Beneficence, Ethics, Justice, Morbid Obesity, Non–Maleficence, Paternalism, Professionalism

• Sometimes in health care there is a mismatch between a units’ ideal admission criteria and the actual patients admitted. Is it appropriate to try to help health care workers feel more comfortable with patients who are not ideal in some way? If so, are there limits to this approach?
• A “hard paternalism” approach in this case might have involved placing this patient on a locked unit so that he could not have restaurant deliveries. Given his dire clinical circumstances, could this have been ethically supported?
• Do you agree that providers were overly reliant on the principle of autonomy in allowing this patient to be poorly compliant with dietary therapy in the on–campus nursing home? If not, can you suggest alternate rationales?

26. The Clinical Bioethicist’s Role: Should We Aim to Relieve Suffering?

Deborah L. Kasman

Abstract: Bioethics consultants arrive at their profession from a variety of prior experiences (e.g., as physicians, nurses, or social workers), yet all clarify ethical issues in the care of patients. The integrated bioethicist’s role often extends beyond case consultations. This case presents a young person suffering a prolonged and gruesome end–of–life journey, which raised questions regarding the bioethicist’s role in alleviating suffering as part of the health care team. The case is used to illuminate forms of suffering experienced by patients, families, and health care providers. The question arises as to whether it is in the ethicist’s jurisdiction to alleviate suffering, and if the answer is “yes,” then whose suffering should be addressed? The discussion addresses one approach taken by an integrated bioethicist toward promoting delivery of ethical and compassionate care to the patient.

Keywords: Clinical Ethics Consultation, Healing, Meaning in Death, Provider Well–Being, Suffering

• Is relief of suffering part of a clinical ethics consultation? Should it be? Why or why not?
• How do you respond to suffering? What are your most productive responses? Unproductive responses?
• Should a clinical ethicist be involved in clinical care without maintaining direct patient contact? If patients/families refuse ethics involvement, what role can the clinical ethicist play in promoting ethical medical decision–making?
• When a clinical ethicist is also trained as a licensed health provider (e.g., physician, nurse, chaplain, or social worker), can prior clinical experience affect the ethicist’s role in responding to suffering? Can this be an advantage, a hindrance, or both?

27. To Enroll or Not to Enroll?: A Researcher Struggles with the Decision to Involve Study Participants in a Clinical Trial That Could Save Their Lives

Roberto Abadie

Abstract: Hundreds of thousands of clinical trials are conducted annually around the world, working to further scientific knowledge and expand medical treatment. At the same time, clinical trials also present novel challenges to researchers who have access to large pools of research participants and are routinely approached by pharmaceutical companies seeking to recruit subjects for clinical trials. This case study discusses the ethical dilemmas faced by a community health investigator who received an invitation to enroll people who inject drugs (PWID) into a clinical trial of a drug that promised a new treatment option for Hepatitis C. The author elaborates on the ethical tensions that he confronted between “doing good” and “avoiding harm. The paper suggests that issues of distributive justice should also be considered, particularly when the drugs being tested might eventually command prices that place them out of reach of the population enrolled in the trial. This case does not attempt to provide an ethical road map to assist researchers in similar circumstances, but rather to illustrate some of the considerations involved in making a decision about whether or not to participate in clinical trials research.

Keywords: Beneficence, Clinical Trials, Enrollment, Justice, Non-Maleficence

• Since they were originally formulated a few decades ago, the principle of respect for autonomy seems to have gained priority in detriment of the principle of justice. With drug prices reaching exorbitant levels—more than eighty thousand dollars for a full HCV treatment—placing access beyond the reach of many, shouldn’t bioethicists reconsider the way we think about justice?
• The principle of beneficence establishes the requirement of a social good, as one of if its main criteria. But drug prices seem to benefit the pharmaceutical industry while depriving many of much needed drugs. With this in mind, how do you think we should interpret this principle?
• Imagine you or somebody you know has the opportunity to participate in a clinical trial. What elements would you need in order to make an informed decision? And an ethical one?

28. Sometimes Those Hoofbeats Are Zebras: A Narrative Analysis

Abstract: The case of BB, an 11-year-old girl who was hospitalized because of sudden odd seizure-like symptoms and catatonic affect, highlights several ethical issues and communication problems. The correct diagnosis was initially missed, partly because physicians are trained to think of the most common explanation for a patient’s symptoms; the medical education truism “when you hear hoofbeats, think horses, not zebras” was not helpful in BB’s case. The common habit of medical professionals to not revisit a diagnosis once one is established also led to missed opportunities to provide appropriate care for this young patient. The difficulty nurses and/or family members have in questioning a diagnosis and treatment plan are also discussed.

Keywords: Clinical Ethics, Ethical Focus, Case Study, Communication, Medical Error, Moral Distress, Two-Challenge Rule

• Hospitals are generally reluctant to admit patients known to have problematic behavior or unknown diagnoses, yet in this case, having a new physician on her case was the key to making an accurate diagnosis. How might transfers between medical facilities be reimagined to improve patient care, rather than being seen as “dumping” of undesirable problematic patients and families?
• What interventions or changes in protocol might empower nurses and family members to productively question a physician’s diagnosis and treatment plan for a patient?

29. A Jehovah’s Witness Adolescent in the Labor and Delivery Unit: Should Patient and Parental Refusals of Blood Transfusions for Adolescents Be Honored?

Johan Christiaan Bester, Martin Smith, Cynthia Griggins

Abstract: A 15-year-old was admitted to the labor and delivery unit for induction of a 41-week-gestation pregnancy. Her parents, members of Jehovah’s Witnesses, and the patient, who had been studying the religion but had not yet been baptized, were adamant that no blood transfusions would be accepted even if a life-threatening hemorrhage were to occur. In our analysis, we examine the underlying ethical conflict and issues raised by this case. We considered two important ethical questions in analyzing the dilemma: first, whether adolescents are capable of providing autonomous and authentic refusals for lifesaving interventions; and second, whether parents can refuse such interventions for their adolescent children based on their religious beliefs. We provided justifications for not considering the adolescent’s refusal as autonomous and for overruling the parental refusal, concluding that there was ethical support for providing potentially lifesaving transfusions should they become clinically indicated. We also suggested strategies to avoid blood loss and the need for transfusions in order to respect the stated values and preferences of the patient and her family to the greatest degree possible. In order to protect the privacy of the patient and her family, details in this case have been changed and no identifiable information has been used.

Keywords: Best Interests, Blood Transfusions, Jehovah’s Witnesses, Principlism, Religious Conflict

• The authors have defended a principle that it should generally be presumed that adolescents lack the necessary decision–making capacity to provide autonomous refusals for life–saving treatments, unless convincing evidence to rebut this presumptionis present. Do you agree with this principle, and if so, why? What would count as convincing evidence? If not, what reasons can you provide for dismissing this principle?
• In the article a threshold is described for parental decision–making. Beyond that threshold, it is the duty of clinicians to challenge the parental decision, and the duty of the state to overrule the parental decision. Do you agree that the threshold to overrule parental decision–making was reached in this case? Why or why not? What might have changed your view?
• Different jurisdictions have reached different conclusions in cases regarding the authority of adolescents to refuse life–saving treatments. States also have different stances on the “mature minor” rule. How does the neurodevelopment and cognitive development evidence the authors briefly discuss in the article influence your thinking on these issues, and specifically on whether states should have a “mature minor” rule and how they should interpret and apply it?

30. Reframing Medical Appropriateness: A Case Study Concerning the Use of Life-Sustaining Technologies for a Patient With Profoundly Diminished Quality of Life

Colleen M. Gallagher, Elijah Weber, Nisha Rathi

Abstract: This case study considers the clinical ethics issues of medical appropriateness and quality of life for patients who are critically ill. The case involves a terminally ill cancer patient with a profoundly diminished quality of life and an extremely poor prognosis; his spouse desires to bring him home, where she will arrange to keep him alive for as long as possible via life-sustaining interventions. The analysis engages with the complicated notion of medical appropriateness, both in general and as it pertains to life-sustaining interventions in a critical care setting, and considers the ethical implications of the various ways in which one might understand this concept. It also addresses the significance of quality-of-life determinations, emphasizing the role of individualized values in determining the importance of quality of life for clinical decision-making. The discussion concludes with a description of the two strategies employed by the ethics team in helping to alleviate the medical team’s concerns about this case.

Keywords: Case Study, Method, Clinical Ethics Focus

• Is the goal of keeping a terminally ill patient, with a profoundly diminished quality of life, alive for as long as possible via life-sustaining technologies a medically appropriate goal of care?
• Is “medical appropriateness” a useful term for conducting an ethical analysis of a particular case?
• What is the ethical significance of a profoundly diminished quality of life for determining goals of care for a particular patient?
• Do quality of life considerations ever outweigh patient or surrogate decision-maker preferences regarding the ethical justifiability of continuing with life-sustaining interventions?

31. "We Didn't Consent to This"

Shalini Dalal, Jessica A. Moore, Colleen M. Gallagher

Abstract: Patients and their families have identified the need for ongoing and effective communication as one of the important aspects of medical care, especially when the cessation of disease–modifying therapies is being considered at the end–of–life (EOL). Despite recognizing that this communication is extremely important, clinicians are uneasy and find themselves inadequately trained to “break bad news” and manage emotional responses from the patient/family. The inherent difficulties in accurately predicting prognosis and discussing potential complications make these conversations even more challenging. In most circumstances, patients and their families want to know the truth about their disease and what will be done to make them feel better, and to receive enough information to help them choose a course of action. For many terminally ill patients and their families who have elected to transfer to the palliative care unit (PCU) for EOL care, the assumption is that most of these conversations have already been held, and the ongoing focus becomes managing these patients’ physical and psychological sources of distress, validating their and their families’ emotional responses and preparing them for what is to come. This case report illustrates the need for cultural understanding and clear communication among physicians, members of the clinical team, and patients and their family members.

Keywords: Communication, Cultural Competence, End–of–Life, Palliative Care

• What can/should one do to determine if communication of a poor prognosis has been provided in a manner and to the extent that the patient or surrogate decision–maker wants and allows him/her to make a fully informed decision? How can one go about exploring the extent of patient/family understanding and goals/expectations? What would you do if you discovered that the poor prognosis has not been explained in enough detail to facilitate informed decision–making?
• What resources are available in your institution to help health care providers improve upon their cultural competence with the patient populations seen most often in your area? What resources are available to assist in the care, real–time, of patients from various faith traditions and cultures in your hospital?
• Have you experienced a situation similar to the one presented here? What did you do in that case or would you do in future cases to improve communication and outcomes? Is this a personal practice, or has it been implemented as a “standard practice/ process” in your group, when applicable?

32. "Screen Shots: When Patients and Families Publish Negative Health Care Narratives Online"

Marleen Eijkholt, Jane Jankowski, Marilyn Fisher

Abstract: Social media sites and their relationship to health care is a subject of intense debate. Common discussions regarding social media address patient privacy, or e-professionalism. This case study explores the tensions that arise for health care providers when negative patient statements surface in social media and blog forums. Recognizing that patients and families often find relief in sharing personal illness narratives, we contemplate if, and how, individual health care professionals and institutions should address complaints aired in public, unmoderated media. Our discussion begins by presenting a case of a family blogging on the Internet to share grievances (to deidentify the case, we have changed some details). Next, we offer an exploration of the impact on health care delivery when professionals become aware of specific criticisms published online. Strategies for managing electronic criticisms are then proposed. We conclude by proposing a novel E-THICS approach to address negative patient expressions via electronic word of mouth (eWOM). Our examination of this evolving issue focuses on maintaining satisfactory relationships between health care providers and patients/families when dealing with health care narratives published in open online media.

Keywords: Care-Ethics, Ethics, Internet, Negative Comments, Online, Patient Blogs, Social Media

• What strategies does your institution offer to deal with publicly displayed negative comments from patients?
• To what extent should institutional support be offered to HCPs in interacting with negative eWOM?
• Should providers communicate their distress to a patient (or to family members) about negative expressions in narrative formats, and if so, how can this be done?

33. "A Personal Narrative on Living and Dealing with Psychiatric Symptoms after DBS Surgery"

Frédéricand Gilbert, John Noel M. Viaña

Abstract: Although deep brain stimulation (DBS) may result in dramatic motor improvement in people with Parkinson's disease (PD), it has been correlated with a number of postoperative psychiatric side effects. We report a case of a person with PD experiencing depression and hypomania following DBS surgery. We provide a detailed report of the patient's personal experiences dealing with and managing these psychiatric side effects for three years. Providing a personal narrative focusing on detailed patient subjective experiences complements reports that give insight into the short- and long-term effects of DBS on established psychiatric measures and neurologic activity. But, most importantly, such a qualitative approach provides prospective patients and clinicians with a broader ethical picture of real-life challenges faced and coping strategies employed by PD patients treated with DBS who are experiencing psychiatric adverse events. This case study reinforces the ethical need to disclose the potential risk of harm to prospective patients as well as the importance of establishing a multidisciplinary postoperative supportive group.

Keywords: Deep Brain Stimulation, Identity, Neuropsychiatric Effects, Parkinson's Disease, Self, Side Effects

• What obligations do DBS providers and researchers have to offer follow-up care aimed at addressing potential personality and behavior changes that can cause patients distress?
• What are the trade-offs between the motor ben-efts of DBS and the potential psychological harm induced by treatments?
• Should decision aids be developed to help patients weigh the pros and cons? What would you put into such a decision aid?
• Should family members have a greater voice in DBS decision-making than in ordinary healthcare decision-making given the potential impact of DBS on personality and behavior?

34. "The Will Reconsidered: Hard Choices in Living Organ Donation"

Robert M. Guerin, Elizabeth O’Toole, Barbara Daly

Abstract: In the following article, we illustrate an interview between a living donor advocate and a potential living organ donor in which the donor faced a hard choice: the reasons to donate and the reasons not to donate were equally persuasive. In the discussion that follows, we analyze the act of willing, what differenti-ates coercion and willing, and how the case study highlights a different, but by no means rare, instance in which donors feel paralyzed by the choice at hand. In such cases, we suspect that donor advocates either do not approve the potential donor for transplantation or simply remain neutral. But we think that this approach benefits neither the donor nor the recipient. We conclude this study with recommendations for living donor advocates, providing questions that might solicit donors’ deeper values and suggesting that in these situations donors may benefit from additional time for reflection.

Keywords: Coercion, Donor Advocate, Hard Choice, Living Donor, Self, Willing, Persuasive Communication, Shared Decision Making, Competing Values

35. "Malleable Transplant Criteria: At What Cost?"

Angel Alsina, Rebekah Apple, Nyingi Kemmer and James P. Orlowski

Abstract: An 18-year-old male who had been diagnosed at age 7 with a rare, progressive liver disease was referred to the transplant center and received a transplant, even though he did not meet the center’s criteria for a patient with hepatopulmonary syndrome (HPS). Complications required relisting the patient urgently, but he eventually fully recovered; total hospital charges for his treatment exceeded $5 million. Reflection upon the case resulted in analysis of two ethical questions: primarily, clinician obligation to balance the provision of actuarially fair health care to society against the healing of a single patient; secondarily, the effects of malleable transplant criteria on trust in the patient selection process. We affirmed that physicians should not be principally responsible for justifying financial investment to society or for upholding beneficence beyond the individual physician and patient relationship in order to contain costs. We concluded, however, that such instances, when combined with manipulation of transplant center criteria, pose a potential threat to public trust. We therefore suggested that transplant centers maintain independent ethics committees to review such cases.

Keywords: Beneficence, Organ Donation, Organ Transplant, Rationing, Transplant Criteria, Ethics Committees, Hospital Charges, Moral Obligations, Hepatopulmonary Syndrome

• The authors mention rationing and affirm the tenet that it is unethical to withhold care because of exorbitant costs. What are the ethical implications of this practice, given that the United States has acknowledged the current system as unsustainable? Would you defend providing heroic, expensive care to every patient, regardless of the effect such behavior would have on the future of health care?
• The authors noted the difference between the allocation of organs and patient selection. A number of ethical principles are applied to donation and transplantation, and they often contradict each other. Is it possible to reconcile utilitarianism and deontology? What other principles collided in this case, and how could these conflicts have been avoided?
• A recent study in JAMA found that “prices of labor and goods, including pharmaceuticals and devices, and administrative costs appeared to be the main drivers” of high health care costs in the United States (Papanicolas, Woskie, & Jha, 2018, p. 1024). Growing attention is being paid to the income of nonclinical health care professionals, and Commins (2018) noted that compensation for nonclinician chief executive officers in over 20 US health systems almost doubled between 2005 and 2015. How much of an issue is compensation for nonclinicians, given the rising amount of health care spending in the country? Would adjustments to administrative costs necessarily result in more money being spent on patient care?

36. "Responding to Requests for Aid-in-Dying: Rethinking the Role of Conscience"

Elizabeth R. Brassfield, Manisha Mishra, and Mara Buchbinder

Abstract: This case study illustrates the complex role that a physician’s conscience can play in end-of-life care. We examine a case from Vermont in which a terminally ill patient requests aid-in-dying from her primary care physician under the state’s “Patient Choice and Control at End of Life” Act (Act 39). The physician feels conflicted: she is opposed to prescribing death-hastening medication but does not want to abandon her patient. Much of the medical ethics literature on conscience focuses on whether health care professionals should be permitted to abstain from providing morally contested medical services. Our analysis highlights the interplay of conflicting values that inform the physician’s engagement with aid-in-dying, demonstrating that the issue is often more nuanced than the question of whether or not a physician can (or should) opt out.

Keywords: Conscience; End-of-Life Care; Medical Ethics; Nonabandonment; Patient-Provider Relationship; Physician Aid-in-Dying/Physician-Assisted Suicide; Terminal Illness

• How does Dr. Jones’s response to Mary challenge conventional bioethical views of conscientious objection?
• What are the limits of a commitment to nonabandonment?
• Given a more robust understanding of the role of conscience in medical care, what form, if any, should protections for conscience take?

37. "Getting to the Heart of the Matter: Navigating Narrative Intersections in Ethics Consultation"

Leslie A. Kuhnel

Abstract: Ethics consultants can apply a narrative ethics approach to address ethical challenges that arise in critical situations. This approach recognizes how those involved in the narrative make sense of, keep faith with, and try on new identities and new understanding of their stories. This case study explores the ways in which the stories of patient, provider, and clinical ethics consultant intersect, and considers how the organic nature of the narrative ethics approach allows ethics consultants to navigate the stories of multiple stakeholders as they grapple with complex health care decisions. This essay also suggests that clinical ethics consultants applying the lens of narrative ethics have an obligation to approach consultations with courage, professional humility, intellectual curiosity, and an appreciation for the narratives of as many of the stakeholders as possible (including one’s own).

Keywords: Ethics Consultation, Intersecting Stories, Narrative Ethics

Discussion Questions:

• When have you experienced making sense, keeping faith, and trying on in your own personal or professional health care encounters?
• What narrative traps have you experienced in the course of clinical ethics consultation?
• How has your own personal narrative shaped your perceptions of this case?

38. "Speaking for Our Father"

Nico Nortjé

Abstract: A living will is a document in which an individual can communicate his or her health care choices to loved ones in the event that he or she is unable to do so directly. Many surrogate decision-makers use living wills as guides; however, the existence of such documents does not entirely relieve them of their burden. Surrogate decision-makers often need to consider the impact of the personal and family burdens entailed by their decisions, and the stress accompanying these burdens regularly creates high levels of anxiety and depression. This stress can be exacerbated when two surrogate decisionmakers are at loggerheads as to the best way forward. This case study illustrates the effects of stress accompanying disagreement among surrogate decision-makers—here, the patient’s adult sons—and demonstrates that a process of listening can help the bioethicist identify the values that are important to the patient and, consequently, to the surrogate as well, and use these values to help address the issue.

Keywords: Ethics, Intensive Care Unit, Living Will, Medical Power of Attorney, Surrogate Decision-Making

• Have you experienced similar cases where parties disagreed as to what was best for the patient? What did you do?
• Do you think it is better for surrogate decisionmakers to have leeway in interpreting the wishes of a patient, or should they have explicit instructions?
• There may be disagreement and tension within the health care team as to the best way forward. How can you assist team members in presenting a unified message to the family?

39. "Forcible Amputation in Delusional Patients: A Narrative Analysis of Decisional Capacity"

Lori A. Roscoe, David P. Schenck, Joel L. Eisenberg

Abstract: This case study concerns the predicaments faced by two women who each had been advised by her physicians to have a gangrenous foot amputated to prevent the potentially fatal spread of infection. In both cases, the determination of the patients' decisional capacity was a critical component in judging whether or not to honor their medical treatment decisions. The communicative complexity of navigating a double bind, a situation in which a person confronts a choice between two undesirable courses of action, is also discussed. The patients in these cases had no medically appropriate choice that also respected other valued outcomes, such as independence, a sense of dignity, or control over one's destiny. Taken together, these cases raise issues about the context-specific meaning of decisional capacity and its role in informed consent.

Keywords: Decisional Capacity, Double Bind, Amputation, Communication

• Under what circumstances might a decision to amputate over the patient's objections be appropriate?
• Under what circumstances can a delusional or cognitively impaired patient give informed consent for medical treatment?
• Suppose the patient was not delusional but nonetheless believed that merely washing the wound with soap and water would make it better. Would it then be ethical to perform the amputation against her will? What role does rationality play in determining competence and giving informed consent?
• How can a patient's wishes be acknowledged in a plan for treatment, even if she or he is deemed to lack decisional capacity?

40. "A Health Care Systems Approach to Improving Care for Seriously Ill Patients"

Lisa Soleymani Lehmann, Jill Lowery, Virginia Ashby Sharpe, Kenneth A. Berkowitz

Abstract: Health care systems can go beyond advance care planning to create mechanisms for eliciting and documenting the goals of care and life-sustaining treatment decisions of patients with serious life-limiting illnesses. These systems can help ensure that patients receive care that is consistent with their values and preferences. We describe a case in which even though a patient with a serious illness had completed an advance directive and had discussed preferences with family, clinicians failed to identify the patient's authentic preferences for life-sustaining treatment. We offer a stepwise framework for communication with seriously ill patients and describe a systems approach to transforming the process of eliciting, documenting, and honoring patients' life-sustaining treatment preferences in the U. S. Veterans Health Administration.

Keywords: Advance Care Planning, Communication, End-of-Life Care

41. "An Ethics of Unknowing: Discerning Ethical Patient-Provider Interactions in Clinical Decision-Making"

Abstract: There is an irreducible amount of uncertainty in clinical decision-making. Both health care providers and patients experience anxiety elicited by clinical uncertainty, and this can lead to missed opportunities for healthy shared decision-making. In order to improve the patient-provider relationship and the ethical qualities of decision-making, the provider first needs to recognize where his/her "unknowing" exists. This article presents a model for a unique ethics of unknowing by identifying three levels at which the provider's knowledge or lack thereof impacts clinical decision-making. The model illuminates ethical choices that providers can make to promote healthy patient-provider relationships. The means by which an ethics of unknowing informs shared decision-making in patient care will be exemplified through a case study of one patient's encounters with several physicians while making difficult decisions throughout her breast cancer journey.

Keywords: Clinical Ethics, Uncertainty, Epistemology, Shared-Decision Making, Patient-Provider Relationship, Patient Care, Medical Decision-Making, Breast Cancer

42. "How Should Physicians Manage Neuro-prognosis with ECPR?"

Ian J. McCurry, Jason Han, Andrew Courtwright

Abstract: Rapidly advancing technologies in the field of extracorporeal cardiopulmonary resuscitation (ECPR) have presented a new challenge in accurate neuroprognostication following cardiac arrest. Determination of brain state informs the prognostic picture and allows providers to begin effective communication regarding likelihood of meaningful neurological recovery as defined by patients or family members. The evolving role of sedation during ECPR and its impacts on ethical tension in decision-making is reviewed. Work surrounding the advancing field of neuroprognostication after cardiac arrest and hypothermia is summarized and implications of premature withdrawal of life-sustaining treatments are discussed. Advances that improve predictive value for neurological recovery are utilized in affirming and discussing the implications for end-of-life wishes of individuals in the setting of intensive resuscitative therapies.

Keywords: End Of Life, Resuscitation, Ethics, Critical Care, ECMO

43. "The Ethics of Choosing a Surrogate Decision Maker When Equal-Priority Surrogates Disagree"

Matthew Shea

Abstract: When decisionally incapable patients need a surrogate to make medical decisions for them, sometimes the patient has not appointed a healthcare agent and there is intractable disagreement among potential surrogates of equal priority, legal rank, or relation to the patient (e.g., child vs. child, sibling vs. sibling). There is no ethical, legal, or professional consensus about how to identify the appropriate surrogate in such circumstances. This article presents a case study involving an elderly female patient whose four children disagree about whether to continue life-sustaining treatment for their mother, along with an ethical analysis of various strategies for selecting the appropriate surrogate in cases of conflicting equal-rank family members. It critically examines three different strategies—chance, majority rules, and quality of relationship with the patient—and defends the third approach.

Keywords: Surrogate Decision Making, Equal-Priority Surrogates, Family Disagreement, Conflict Resolution, Substituted Judgment, Clinical Ethics, Ethics Consultation

44. "A Gay Epidemiologist and the DC Commission of Public Health AIDS Advisory Committee"

Steven S. Coughlin, Paul Mann, and Bruce Jennings

Abstract: Based upon the lead author's deep personal and professional experience, this case narrative illustrates the importance of engagement between public health practitioners and members of affected populations and their advocates. The case underscores the need to build strong coalitions to address serious public health and social issues. It also illustrates how decisions about control groups in research raise ethical issues. In addition, the case illustrates the reality that public health and social services are sometimes inadequate in the face of dire circumstances. Justice in public health has both a distributive aspect (how to allocate limited resources and distribute potential benefits as fairly as possible) and a procedural dimension (ensuring public participation, especially of those most affected). Frameworks for public health ethics, which post-date the events detailed in the autobiographical case narrative, highlight both distributive justice and procedural justice.

Keywords: African Americans, AIDS, HIV, Community Prevention, Prevention, Public Health, Social Justice

45. "Shared Decision-Making in Palliative Care: A Maternalistic Approach"

Laura Specker Sullivan, Mary Adler, Joshua Arenth, Shelly Ozark, and Leigh Vaughan

Abstract: During goals of care conversations, palliative care clinicians help patients and families determine priorities of care and align medical care with those priorities. The style and methods of communicating with families and negotiating a care plan can range from paternalistic to entirely patient driven. In this paper, we describe a case in which the palliative care clinician approached decision-making using a paradigm that is intuitive to many clinicians and which seems conceptually sound, but which has not been fully explored in the bioethics literature. This paradigm, termed maternalism, allows the clinician to direct decision-making within a relationship such that best interests and autonomy are mutually reinforced, thus reflecting relational autonomy as opposed to individual autonomy. We explore whether this method is appropriate in this case and explain how it captures significant ethical features of the case that might be missed by other approaches.

Keywords: Shared Decision-Making, Palliative Care, End of Life, Paternalism, Relational Autonomy

46. "Phantom Physicians and Medical Catfishing: A Narrative Ethics Approach to Ghost Surgery"

Saljooq M. Asif

Abstract: The concerns raised by ghost surgery, an unethical practice in which someone other than the surgeon who obtains consent performs an operative procedure without the patient’s knowledge, have long been ignored by bioethics and other related disciplines. Indeed, ghost surgery is neither tracked nor studied in the United States, and the practice itself remains underreported. Ghost surgery represents a corporeal transgression as well as a relational rift: what was communicated by physicians is rendered null and void, and the surgical narrative that patients thought they knew is disrobed as a lie and revealed to be a catfish. In order to combat this practice and prevent any form of medical catfishing, physicians must guarantee effective communication and transparency and view themselves as storytellers alongside their patients. By following such a framework, physicians can ideally end the simulation and suture an ethic of accountability within a co-constructed narrative.

Keywords: Ghost Surgery, Narrative Ethics, Accountability, Catfishing, Medical Harm

47. "It Takes Time to Let Go"

Tiffany Meyer, Laura Walther-Broussard, Nico Nortjé

Abstract: Futile or nonbeneficial treatment is often a source of contention between care teams and family members of ICU patients. This narrative describes such a case at a cancer center. In the midst of the COVID-19 crisis, the psychosocial team had to act as a bridge between a patient's surrogate decision maker and the care team. In light of COVID-19 visitor restrictions, the psychosocial team, the surrogate/family, and the care team had to respectfully work towards what was best for the patient.

Keywords: Nonbeneficial treatment, COVID-19, Psychosocial team, Values, Goals of Care

48. "An American’s Experience with End-of-Life Care in Japan: Comparing Brain Death, Limiting and Withdrawing Life-Prolonging Interventions, and Healthcare Ethics Consultation Practices in Japan and the United States"

Alexander A. Kon, Keiichiro Yamamoto, Eisuke Nakazawa, Reina Ozeki-Hayashi, Akira Akabayashi

Abstract: American and Japanese laws, customs, and practices in end-of-life decision-making differ significantly. We present a case with which one of the authors was involved to illustrate some of the key legal and cultural differences in the declaration of brain death, limiting and withdrawing life-prolonging interventions, and healthcare ethics consultation practices. The analysis presented facilitates understanding of similarities and differences between Japanese and American healthcare ethics specifically in regards to end-of-life care. Further, the analysis provides insights that can aid in developing policies and practices in regions where multiple cultures coexist.

Keywords: Brain Death, Organ Transplantation, Withholding Treatment, Japan, Ethics Consultation

49. "The Sword of King Solomon"

Maria Susana Ciruzzi

Abstract: Conjoined twin pregnancies are one of the greatest dilemmas we face in healthcare practice. Thanks to scientific knowledge and evolution, technology and the higher level of wealth in our society, conjoined twins have a chance to survive, albeit with the risk of major consequences on their lifespan and quality of life. Particularly, in the case of newborns with extreme prematurity or congenital malformations, special care must be taken in the use of treatments that offer little to no benefit. This is especially the case with procedures and techniques of unproven efficacy that could create unfounded expectations and hopes in parents and health professionals. It is within this conceptual framework that the author presents a case submitted to a bioethics committee at a pediatric hospital in a Latin American metropolis and analyzes the ethical challenges posed to the treating team and the consensual approach determined by the team.

Keywords: Conjoined Twins, Parental Decision Making, Do No Harm Principle, Ethical Dilemma, Quality of Life

50. "Appreciating the Dynamicity of Values at the End of Life: A Psychological and Ethical Analysis"

Austin Burns, Natalie Hardy & Nico Nortjé

Abstract: It can be difficult for families to accept when loved ones experience a change in saliency of values due to serious illness and inevitable death. When patients lose decision-making capacity, family members often refuse to withdraw care and insist on the continuation of non-beneficial treatment. Through a joint ethical and psychological analysis, this case study examines the narrative of a husband and wife, wed for over 50 years, and how the patient’s values, his life’s story, and the wife’s interpretation of his preferences were reconciled to achieve a resolution that respected the patient’s autonomy and previously expressed wishes.

Keywords: Ethics, Anticipatory Grief, Serious Illness, Decision-Making, Values

51. "Serendipity and Social Justice: How Someone with a Physical Disability Succeeds in Clinical Bioethics"

Kevin T. Mintz

Abstract: Trainees with disabilities in health-related professions are often subjected to structural ableism in medicine: the discriminatory manifestation of lowered expectations towards people with disabilities by medical professionals. In this case study, I reflect on my experiences as the first individual with significant disabilities to be offered a postdoctoral fellowship in clinical bioethics at the National Institutes of Health. I focus on the following question: What arrangements need to be in place in order for someone with my level of disability to thrive as a clinical bioethicist? By telling my story, I show how the process of accommodating trainees with disabilities often requires creative problem-solving and a considerable amount of institutional resources. I also describe the team-based method that my mentors and I developed to enable me to complete rotations on the NIH’s bioethics consultation service. If more trainees with disabilities are to succeed in clinical bioethics trainee programs, the field will have to grapple with how to develop an infrastructure for providing disability-related support across training programs. This article is the beginning of a dialogue about how to build such an infrastructure.

52. "The Right to Be Childfree"

Andrea Eisenberg & Abram L. Brummett

Abstract: In this manuscript, we start with a real life account of an Ob/Gyn experience with a young patient from the childfree movement requesting permanent sterilization. A narrative ethics approach invites the reader to experience the encounter in an immersive way for this growing issue. This approach allows readers to reflect on their reaction to the patient and consider how that can affect other patient encounters. Additionally, it explores the stigma these young patients encounter making a permanent decision to never have children. In the commentary, we explore the ethical issues in this case including why we question the permanent decision to refrain from having children. We also discuss informed consent and patient education along with the various approaches to physician-patient relationships with an emphasis on shared decision making, which allows space for both patient and physician to question and reason through their health decisions.

Keywords: Childfree, Permanent Sterilization, Shared Decision Making, Regret, Narrative Ethics

53. "Undisclosed Placebo Trials in Clinical Practice: Undercover Beneficence or Unwarranted Deception?"

Daniel Edward Callies

Abstract: A placebo is an intervention that is believed to lack specific pharmacological or physiological efficacy for a patient’s condition. While placebo-controlled trials are considered the gold standard when it comes to researching and testing new pharmacological treatments, the use of placebos in clinical practice is more controversial. The focus of this case study is an undisclosed placebo trial used as an attempt to diagnose a patient’s complex and unusual symptomology. In this case, the placebo was used not just as a treatment, but as a diagnostic intervention in order to determine the best course of treatment for a patient. Could the deceptive use of a placebo be justified in clinical practice on the grounds of beneficence?

Keywords: Placebo, Beneficence, Deception, Trust, Disclosure

54. " What Do We Owe to Patients Who Leave Against Medical Advice? The Ethics of AMA Discharges?"

Leenoy Hendizadeh, Paula Goodman-Crews, Jeannette Martin, Eli Weber

Abstract:  Discharges against medical advice (AMA) make up a significant number of hospital discharges in the United States, and often involve vulnerable patients who struggle to obtain adequate medical care. Unfortunately, much of the AMA discharge process focuses on absolving the medical center of liability for what happens to these patients once they leave the acute setting. Comparatively little attention is paid to the ethical obligations of the medical team once an informed decision to leave the acute care setting AMA has been made. Via a case narrative, we offer an ethical framework that we believe can help guide an ethically defensible AMA discharge process. By emphasizing our duty to provide the best care possible under the circumstances, we contend, our ethical obligations to promote the patient’s best interests can still be met despite their decision to leave the acute setting against medical advice.

Keywords:  Beneficence, Narrative Ethics, Case Study, AMA Discharges, Shared Decision-Making

  Link to Case on MUSE

55. "Jehovah's Witnesses and the Normative Function of Indirect Consent"

Joanna Smolenski

Abstract:  In this case study, I consider Mr. A, a Jehovah's Witness with chronic vertebral osteomyelitis in need of surgical debridement. Prior to proceeding to the OR, he was unwilling either to explicitly consent to or refuse blood transfusion, while indicating he was open to transfusion intraoperatively, if the team judged it necessary. Ethics was consulted to determine if it would be morally justifiable for the team to proceed with blood transfusion during the course of surgery without Mr. A's documented consent to being transfused. I argue that in this case, what might be termed indirect consent—namely, delegating decision-making regarding some possible course of action without explicitly consenting to the course of action itself—may be sufficient for discharging the clinician's ethical obligation to obtain consent. Identifying information has been changed or omitted to protect patient confidentiality.

Keywords:  Blood Transfusions, Jehovah's Witnesses, Informed Consent, Indirect Consent, Self-Sovereignty

56. "Parental Refusals of Blood Transfusions from COVID-19 Vaccinated Donors for Children Needing Cardiac Surgery"

Daniel H. Kim, Emily Berkman, Jonna D. Clark, Nabiha H. Saifee, Douglas S. Diekema, Mithya Lewis-Newby

Abstract: There is a growing trend of refusal of blood transfusions from COVID-19 vaccinated donors. We highlight three cases where parents have refused blood transfusions from COVID-19 vaccinated donors on behalf of their children in the setting of congenital cardiac surgery. These families have also requested accommodations such as explicit identification of blood from COVID-19 vaccinated donors, directed donation from a COVID-19 unvaccinated family member, or use of a non-standard blood supplier. We address the ethical challenges posed by these issues. We describe the current screening and safety processes for standard blood donation and explore the importance of donor anonymity and challenges with directed donation and non-standard blood suppliers. We present an ethical framework using the Best Interest Standard, the Zone of Parental Discretion, and the Harm Principle when considering these refusals. Finally, we provide recommendations for how to approach these requests as they potentially become more commonplace in pediatrics.

Keywords:  Medical Ethics, Critical Care, Pediatrics, Innovation, Cardiac Surgery, Cardiac Catheterization

57. “Withdrawing Life Support After Attempted Suicide: A Case Study and Review of Ethical Consideration"

David A. Oxman & Benjamin Richter

Abstract: Ethical questions surrounding withdrawal of life support can be complex. When life support therapies are the result of a suicide attempt, the potential ethical issues take on another dimension. Duties and principles that normally guide clinicians’ actions as caregivers may not apply as easily. We present a case of attempted suicide in which decisions surrounding withdrawal of life support provoked conflict between a patient’s family and the medical team caring for him. We highlight the major unresolved philosophical questions and contradictory normative values about suicide that underlie this conflict. Finally, we show how these considerations were practically applied to this particular case.

Keywords: Medical Ethics, Critical Care, Life Support Therapies, Suicide

• Cases in Medical Ethics: Student-Led Discussions
• Markkula Center for Applied Ethics
• Focus Areas
• Bioethics Resources

Cases in Medical Ethics

Student-led discussions.

A selection of medical ethics cases designed to help determine whether medicine is the correct calling for pre-medical students.

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 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.

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?

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 : Filmmakers 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.

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?

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.

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?

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/

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?

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The Cambridge Medical Ethics Workbook: Case studies, Commentaries and Activities: M Parker, Donna Dickenson. Cambridge University Press, 2001,  29.95, pp 359. ISBN 0521788633

2003, Journal of Medical Ethics

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Paul Macneill

Elisa Rapaport

Fields such as medical ethics have long suffered from a disconnect between theory and application. “Real-world” practitioners understand the day-to-day realities that inspire and inhibit their actions, and “ivory tower” scholars sometimes fall into the trap of presuming that non-scholars cannot understand theory or, worse yet, that ethical theory need not be informed by practical experience. There are plenty of applied ethicists across disciplines bridging this divide, yet problems persist amongst faculty who underestimate the interest and capacity of medical and nursing students, and even amongst academic administrators who presume ethics is too obscure a topic to warrant seminar-style discussion. For many nurses, philosophy is intimidating. Yet with each new semester I find that most of my nursing students need not have worried about how they might grasp what are foreign-sounding terms like deontology, teleology, and utilitarianism. They already understand the concepts and have employed them in their lives — usually both personally and professionally. I have also found that most nurses could themselves populate a textbook with true-life examples demonstrating every such concept I challenge them to consider. Like most philosophers, I bring a blend of critical analysis, theory, and logical consistency to the courses I teach. My goal is to expose medical professionals to the processes that guide their decision-making, to the historical context of patient autonomy, and to potential dilemmas that await them in their careers as they strive for professional excellence. It is not enough to memorize cases, dates, theorists, and terminology. For the experience to truly be transformative – to successfully equip and empower students to reflect on the implications of their actions on patients, colleagues, and the profession in general – the union of theory and practice is essential. The process is most effective when students are encouraged to share and reflect on their experiences in the context of improving their moral decision-making. With such input, those scholars tweaking the theoretical approaches to today’s problems can better grasp the feasibility of their theories. The theories can evolve and as originally hoped, influence behavior, when given the opportunity to be taken seriously in the lives of the moral agents. The field of bioethics and philosophy in particular could benefit from listening to the professionals who are living ethical dilemmas every day. This paper will provide a series of brief excerpts from student stories demonstrating the relevancy of moral theory as typically applied to issues in health care. It is an example of an on-going conversation amongst disciplines that we must engage in at the academic level in order to truly appreciate and fulfill the promise of humanity in medicine.

Persona y Bioética

Pablo Requena

Clinical ethics refers to an emerging field in clinical medicine that focuses on the process of ethical decision making in the clinical setting. It has developed as a result of a growing awareness that modern medicine – characterized by technological progress, cultural diversity, and social challenges – is posing a range of new “ethical dilemmas” that medical science alone cannot solve. For this reason, clinical ethics is often linked to “ethics consultation”, which consists in services provided by an individual ethicist, ethics team or committee to address the ethical issues involved in a specific clinical case. Although at the beginning clinical ethics mainly developed as a methodological analysis to arrive at justifying clinical ethical decisions, it has quickly become clear that the difficulty in clinical decision making is only one aspect of wider ethical problems pertaining to the doctor-patient relationship as a whole and, probably, to the core value of the medical profession. The principlism method is usually presented as the most popular methodological approach to the analysis of clinical cases. However, strong criticism against this model has been raised, and other alternative approaches are referred to, such as the casuistry model. Recently, significant contributions have been made by the narrative medicine and virtue ethics approaches. According to these methodologies, a sound anthropology as well as a good relationship with the sick person are key elements required of any person engaged in a medical practice that aims to be genuinely appropriate from an ethical perspective. La ética clínica es un prominente campo de la medicina clínica cuyo objeto de estudio es el proceso decisional ético en la práctica médica. En los últimos decenios se ha desarrollado enormemente debido a la toma de conciencia de los dilemas éticos que lleva consigo la práctica moderna, y cuya solución no encuentra respuesta en la sola ciencia médica. La ética clínica está ligada a la “consulta ética”, que se realiza a un experto o a un comité ético. Desde el principio de la ética clínica ha sido claro que el análisis metodológico del proceso decisional es sólo una parte de cuadro más amplio que tiene que considera los aspectos éticos de la relación médico-paciente. El método más utilizado para el análisis del caso clínico es el principialismo, al que sigue por importancia la casuística bioética. Junto a las ventajas de estos modelos, desde su origen han recibido fuertes críticas, lo que ha condicionado la búsqueda de vías alternativas. Recientemente la medicina narrativa y la perspectiva ética de las virtudes han desarrollado una reflexión significativa en este sentido, proponiendo una metodología que apoya en una antropología bien fundada, que propone un modo adecuado de relación con la persona enferma en su singularidad.

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Medical Ethics Issues: Position Papers & Resources

In addition to the ACP Ethics Manual, ACP publishes ethics position papers on a broad range of health care ethics issues including clinical ethics, professionalism, the delivery of health care, teaching, medical research, human rights and other topics. ACP ethics policy is approved by the Board of Regents and serves as the basis for the development of ACP ethics education and practice resources and legislative, regulatory and policy implementation activities.

Current ACP Ethics Policies and Resources

New determination of death and organ transplantation, position papers.

• Standards and Ethics Issues in the Determination of Death: A Position Paper From the American College of Physicians (September 4, 2023)
• Ethics, Determination of Death, and Organ Transplantation in Normothermic Regional Perfusion (NRP) with Controlled Donation after Circulatory Determination of Death (cDCD): American College of Physicians Statement of Concern (April 17, 2021)

Comments and Letters

• ACP letter to the Uniform Law Commission Committee about updating the Uniform Determination of Death Act (UDDA) (June 7, 2023)
• Does Normothermic Regional Perfusion Violate the Ethical Principles Underlying Organ Procurement? Yes. (Chest. 2022;162(2):288-90)
• Rebuttal From Dr. DeCamp et al. (Chest. 2022;162(2):292-3)

NEW Disability

• ACP Letter Regarding Discrimination on Basis of Disability in Health and Human Service Programs Proposed Rule 2023 (November 13, 2023)

NEW Electronic and Online Professionalism

Ethics manual, electronic patient-physician communication, electronic health records, telemedicine, and online professionalism.

• Initiating and Discontinuing the Patient–Physician Relationship
• The Medical Record
• Boundaries and Privacy

Case Studies

• Lab Results Reporting, Ethics, and the 21st Century Cures Act Rule on Information Blocking CME/MOC

Ethics, Electronic Health Record Integrity and the Patient-Physician Relationship CME/MOC (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2021)

Ethics, Professionalism, and the Physician Social Media Influencer CME/MOC (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

”Doctor, Can’t You Just Phone a Prescription In?” and Other Ethical Challenges of Telemedicine Encounters CME/MOC (ACP Ethics Case Studies Series. MOC and CME by Medscape. 2019)

Maintaining Medical Professionalism Online: Posting of Patient Information CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Addressing a Colleague's Sexually Explicit Facebook Post CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Copied and Pasted and Misdiagnosed (or Cloned Notes and Blind Alleys) CME (ACP Ethics Case Studies Series. CME by Medscape. 2015)

American College of Physicians Ethical Guidance for Electronic Patient-Physician Communication: Aligning Expectations (J Gen Intern Med. published online 22 June 2020)

Ethical Implications of the Electronic Health Record: In the Service of the Patient (J Gen Intern Med. 2017;32:935-9)

Policy Recommendations to Guide the Use of Telemedicine in Primary Care Settings (Ann Intern Med. 2015;163:787-9)

Online Medical Professionalism: Patient and Public Relationships (Ann Intern Med. 2013;158:620-7)

NEW End-of-Life Care

• Care of Patients Near the End of Life
• Show Codes, Slow Codes, Full Codes, or No Codes: What Is a Doctor to Do? CME/MOC (ACP Ethic Case Studies Series, MOC and CME by Medsape. 2023)

2011 Letter and 2009 letter to Congressman Blumenauer regarding ACP’s support for legislation to pay for voluntary end-of-life care consultations (see H.R. 1898, the Life Sustaining Treatment Preferences Act of 2009).

• Ethics, Determination of Death, and Organ Transplantation in Normothermic Regional Perfusion (NRP) with Controlled Donation after Circulatory Determination of Death (cDCD): American College of Physicians Statement of Concern

End-of-Life (PEACE) Brochures (ACP. 2014) The PEACE brochures were developed by the Patient Education Work Group, which was convened in conjunction with the Consensus Panel project. Order copies of printed brochures

• Improving Your End-of-Life Care Practice
• Living with a Serious Illness: Talking with Your Doctor When the Future is Uncertain
• When You Have Pain at the End of Life
• Making Medical Decisions for a Loved One at the End of Life

ACP-ASIM End-of-Life Care Consensus Panel Papers (1999-2001) ACP convened this Greenwall Foundation supported consensus panel to develop ethical, policy, and clinical recommendations for physicians and other clinicians on end-of-life decisions.

Physician's Guide to End-of-Life Care Edited by Lois Snyder, JD, and Timothy Quill, MD, FACP (ACP Books. 2001)

Advance Directive Forms for Your State Contact Caring Connections, a program of the National Hospice and Palliative Care Organization (NHPCO).

National Healthcare Decisions Day, April 16 Details and resources on NHDD and the importance of advance care planning.

• Expert Witnesses

To Be or Not to Be: Should I Serve as an Expert Witness? CME (ACP Ethics Case Studies Series. CME by Medscape. 2014)

Guidelines for the Physician Expert Witness (Ann Intern Med. 1990;113:789)

NEW Family Caregivers

Ethical Guidance on Family Caregiving, Support, and Visitation in Hospitals and Residential Health Care Facilities, Including During Public Health Emergencies (J Gen Intern Med. 2023 Mar 20:1–8)

Family Caregivers, Patients and Physicians: Ethical Guidance to Optimize Relationships (J Gen Intern Med. 2010;25:255-60)

Family Caregivers, Patients and Physicians: Ethical Guidance to Optimize Relationships (ACP. 2009) (This publication is a longer version of the position paper above.)

Information Resources for Physicians Supporting Family Caregivers (ACP. 2010) This appendix of resources was developed in conjunction with the ACP position paper to help physicians manage relationships with patients and caregivers.

When the Family Caregiver Is a Physician: Negotiating the Ethical Boundaries CME/MOC (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

Genetic Testing and Precision Medicine

• Precision Medicine, Genetic Testing, Privacy, and Confidentiality

ACP Comments on privacy protection and human genome sequencing (May 24, 2012) ACP provided comments to the Presidential Commission for the Study of Bioethical Issues regarding the ethical implications of evolving notions of privacy and access in relation to the integration of large-scale human genome sequencing into research and clinical care.

Position Papers and Statements

Ethical Considerations in Precision Medicine and Genetic Testing in Internal Medicine Practice Ann Intern Med.2022;175:1322-1323

Genetic Testing and Reuniting Families (July 10, 2018)

Global Health Clinical Experiences

• Cultural Humility and Volunteerism

Ethical Obligations Regarding Short-Term Global Health Clinical Experiences (Ann Intern Med. 2018;168:651-7)

NEW Health and Human Rights

"Health and human rights are interrelated. When human rights are promoted, health is promoted ... Physicians have important roles in promoting health and human rights and addressing social inequities." (Ethics Manual, seventh edition).

• Obligations of the Physician to Society

Health as a Human Right (Ann Intern Med. doi:10.7326/M23-1900)

ACP's Human Rights Page : ACP policy statements and letters of support, as well as documents related to College advocacy for the humane treatment of prisoners and detainees.

NEW Health Information Privacy, Protection, and Use

• Confidentiality
• Research Sections within the Research chapter include “Use of Human Biological Materials in Research” and “Internet and Social Media Research”.

Maintaining Medical Professionalism Online: Posting of Patient Information (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Confidentiality and Privacy: Beyond HIPAA to Honey, Can We Talk? (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Ethical Guidance for Physicians and Health Care Institutions on Grateful Patient Fundraising: A Position Paper From the American College of Physicians (Ann Intern Med.doi:10.7326/M23-1691)

Health Information Privacy, Protection, and Use in the Expanding Digital Health Ecosystem: A Position Paper of the American College of Physicians (Ann Intern Med.2021;174:994-998)

NEW Pandemics and Ethics -->

Health care system catastrophes.

• The Patient-Physician Relationship and Health Care System Catastrophes
• Medical Risk to Physician and Patient

When Resources Are Limited During a Public Health Catastrophe: Nondiscrimination and Ethical Allocation Guidance CME/MOC (ACP Ethics Case Studies Series. MOC and CME by Medscape. 2023)

Pandemic Treatment Resource Allocation Ethics and Nondiscrimination (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

Stewardship of Health Care Resources: Allocating Mechanical Ventilators During Pandemic Influenza (ACP Ethics Case Studies Series. 2017)

ACP supports ACIP recommendation for additional mRNA COVID-19 vaccine dose and WHO call for equitable global vaccine distribution (August 17, 2021)

ACP Statement on Global COVID-19 Vaccine Distribution and Allocation: On Being Ethical and Practical (June 8, 2021)

ACP's Policy Statement on the Ethical Allocation of Vaccines During Pandemics Including COVID-19 (November 23, 2020)

A Wake-up Call for Healthcare Emerging Ethical Lessons from Covid-19 (Modern Healthcare, June 16, 2020)

Non-Discrimination in the Stewardship of Healthcare Resources in Health System Catastrophes, including COVID-19 Pandemic (March 26, 2020)

Internists Say Harassment Based on Race or Ethnic Origin is Never Okay (March 31, 2020)

Universal Do-Not-Resuscitate Orders, Social Worth, and Life-Years: Opposing Discriminatory Approaches to the Allocation of Resources During the COVID-19 Pandemic and Other Health System Catastrophes (Ann Intern Med.2020;173:230-232)

NEW Patient–Physician Relationship

Patient-physician relationship.

• The Physician and the Patient
• Initiating and Discontinuing the Patient-Physician Relationship
• Third-Party Evaluations
• Providing Medical Care to One’s Self; Persons With Whom the Physician has a Preexisting Close Nonprofessional Relationship or a Reporting Relationship; and VIPs
• Sexual Contact between Physician and Patient
• Gifts from Patients

Confidentiality and privacy, disclosure of medical errors, and informed and surrogate decision making

• Informed Decision Making and Consent
• Making Decisions Near the End of Life

The Doctor Will See You Shortly. The Ethical Significance of Time for the Patient–Physician Relationship (J Gen Intern Med. 2005;20:1057-62)

Ethics and Time, Time Perception, and the Patient–Physician Relationship (ACP. March 2003) (This publication is a longer version of the position paper above.)

• Patient Prejudice? The Patient Said What?... and What Comes Next CME (ACP Ethics Case Studies Series. CME by Medscape. 2022)

Confidentiality and Privacy: Beyond HIPAA to Honey, Can We Talk? CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Preventive Health Screening, Ethics, and the Cognitively Impaired Patient CME (ACP Ethics Case Studies Series. CME by Medscape. 2015)

The Difficult Patient: Should You End the Relationship? What Now? An Ethics Case Study CME (ACP Ethics Case Studies Series. CME by Medscape. 2014)

Must You Disclose Mistakes Made by Other Physicians? CME (ACP Observer. November 2003)

Physicians and Society

• Relation of the Physician to Government
• Strikes and Other Joint Actions by Physicians

Physician Work Stoppages and Political Demonstrations—Economic Self-Interest or Patient Advocacy? Where Is the Line? CME (ACP Ethics Case Studies Series. CME by Medscape. 2010)

• Physician-Assisted Suicide and Euthanasia
• Toolkit on Issues in Delivering Patient-Centered End-of-Life Care and Responding to a Request for Physician-Assisted Suicide (Member login)

Ethics and the Legalization of Physician-Assisted Suicide (Ann Intern Med. 2017;167:576-8)

Physician–Industry Relations

• Conflicts of Interest
• Sponsored Research

Physician Open Payments (Sunshine Rule) This ACP webpage provides guidance and related tools for physicians on the Physician Payment Sunshine Rule (also referred to as the National Physician Payment Transparency Program, or Open Payments). The Open Payments system, implemented by the Centers for Medicare and Medicaid Services (CMS) in 2015, provides a mechanism for the public reporting of physician and teaching hospital financial relationships with industry.

Physician–Industry Relations. Part 1: Individual Physicians (Ann Intern Med. 2002;136:396-402)

Physician–Industry Relations. Part 2: Organizational Issues (Ann Intern Med. 2002;136:403-6)

NEW Practice Models, the Business of Medicine and the Changing Practice Environment

• The Changing Practice Environment
• Financial Arrangements

Ethics, Professionalism, Physician Employment and Health Care Business Practices CME/MOC

Banning Harmful Health Behaviors as a Condition of Employment: Where There's Smoke There's Fired? CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Wellness Programs and Patient Goals of Care CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Obligations and Opportunities: The Role of Clinical Societies in the Ethics of Managed Care (J Am Geriatr Soc. 1998;46:378-80)

Ethical and Professionalism Implications of Physician Employment and Health Care Business Practices CME (Ann Intern Med. published online 15 March 2021)

Assessing the Patient Care Implications of “Concierge” and Other Direct Patient Contracting Practices (Ann Intern Med. 2015;163:949-52)

The Patient-Centered Medical Home: An Ethical Analysis of Principles and Practice (J Gen Intern Med. 2013;28:141-6)

Ethical Considerations for the Use of Patient Incentives to Promote Personal Responsibility for Health: West Virginia Medicaid and Beyond (ACP. 2010)

Pay-for-Performance Principles That Promote Patient-Centered Care: An Ethics Manifesto (Ann Intern Med. 2007;147:792-4)

Pay-for-Performance Principles that Ensure the Promotion of Patient Centered Care—An Ethics Manifesto (ACP. 2007) (This publication is a longer version of the position paper above.)

Medical Professionalism in the Changing Health Care Environment: Revitalizing Internal Medicine by Focusing on the Patient–Physician Relationship (ACP. 2005)

Ethics in Practice: Managed Care and the Changing Health Care Environment (Ann Intern Med. 2004;141:131-6)

Selling Products Out of the Office (Ann Intern Med. 1999;131:863-4)

Prescription Drug Abuse

Prescription Drug Abuse (Ann Intern Med. 2014;160:198-200)

NEW Professionalism

American College of Physicians Pledge (ACP. 1982 [updated; original 1924]) The ACP Pledge is taken by new Fellows at Convocation at each Internal Medicine annual meeting. The Pledge affirms the physician’s membership in an ethical and moral community dedicated to healing, comfort, and altruism.

Physician Charter on Professionalism

Medical Professionalism in the New Millennium: A Physician Charter (Ann Intern Med. 2002;136:243-6)

• Professionalism

Ethical and Professionalism Implications of Physician Employment and Health Care Business Practices (Ann Intern Med. published online 15 March 2021)

• ACP Professional Accountability Principles (ACP. March 2018)

Professional Attire and the Patient-Physician Relationship CME/MOC (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

Addressing a Colleague's Unprofessional Behavior During Sign-Out CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Dealing with the "Disruptive" Physician Colleague CME (ACP Ethics Case Studies Series. CME by Medscape. 2009)

Professional Well-being and Ethics

• The Impaired Physician

Physician Suicide Prevention: The Ethics and Role of the Physician Colleague and the Healing Community CME/MOC

When an Aging Colleague Seems Impaired CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Physician Suicide Prevention and the Ethics and Role of a Healing Community: An American College of Physicians Policy Paper (J Gen Intern Med. 2021 Sep;36(9):2829-2835)

Physician Impairment and Rehabilitation: Reintegration Into Medical Practice While Ensuring Patient Safety (Ann Intern Med. 2019;170(12):871-879.)

ACP’s Physician Well-being and Professional Satisfaction initiative aims to foster a culture of wellness, reduce administrative burdens on physicians, improve practice efficiency and enhance individual physician well-being. The project website includes tools and programs for individual members, their practices, and ACP Chapters.

Research Ethics and Human Subjects

Research Sections within the chapter include “Protection of Human Subjects,” “Use of Human Biological Materials in Research,” “Placebo Controls,” “Innovative Medical Therapies,” “Scientific Publication,” “Sponsored Research” and “Public Announcement of Research Discoveries.”

Responsible Conduct of Research (RCR) Project

Under a grant from the Association of American Medical Colleges and the DHHS Office of Research Integrity, ACP Ethics staff has implemented member education and support programs on the responsible conduct of office-based research. Workshops have been presented at ACP's annual meeting as well as at several ACP chapter meetings.

Research in the Physician's Office: Navigating the Ethical Minefield (Hastings Cent Rep. 2008)

Volunteering for a Research Study? Talk with Your Doctor About What You Should Know This patient education brochure provides information and guidance to patients who are considering volunteering for a research study. The brochures are designed to facilitate conversations between doctors and their patients. They are intended for distribution in doctors’ offices and come in packages of 50. Access the brochure order form .

Author! Author! Who Should Be Named in a Published Study? An Ethics Case Study CME (ACP Ethics Case Studies Series. CME by Medscape. 2014)

When are Industry-Sponsored Trials a Good Match for Community Doctors? CME (ACP-ASIM Observer. 2001)

Research Ethics Training Resources

• Revised Common Rule Educational Materials , Department of Health and Human Services
• The Research Clinic , Office of Research Integrity, Department of Health and Human Services
• Responsible Conduct of Research (RCR) , Research Ethics and Compliance Training, CITI Program
• Responsible Conduct of Research Training , Office of Intramural Research, National Institutes of Health
• HIPAA Training and Resources , Department of Health and Human Services
• Online Ethics Center for Engineering and Science , Center for Engineering Ethics and Society, National Academy of Engineering
• World Association of Medical Editors (WAME)
• Council of Science Editors (CSE)
• European Association of Science Editors (EASE)

ACP supports National Academies’ call for withdrawal of Notice of Proposed Rulemaking (NPRM) for ‘Common Rule’ and for appointing a new commission (Dec. 31, 2015) ACP issued a statement in support of the National Academies' call for withdrawal of the Common Rule NPRM and for appointing a new research ethics commission.

ACP Comments on Notice of Proposed Rule Making (NPRM) (Dec. 31, 2015) ACP submitted comments to the Office for Human Research Protections of the U.S. Department of Health and Human Services on the Notice of Proposed Rule Making, "Federal Policy for the Protection of Human Subjects," also known as the Common Rule. ACP also submitted an earlier round of comments on the proposed rule making on Oct. 25, 2011.

Stewardship of Health Care Resources

"Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly in practicing high-value care. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient puts the patient first but also respects the need to use resources wisely and to help ensure that resources are equitably available" (Ethics Manual, seventh edition).

Conflicting duties? The physician's primary duty, first and foremost, is to the individual patient. She or he must advocate for the patient—in a health care system that grows more and more complex by the year—based on the best interests of the patient. But the physician also should use health care resources responsibly and efficiently. Are these duties in conflict? The Ethics Manual and ethics case studies explore these issues and provide help in sorting them out.

Is it rationing? Parsimonious care is not rationing. The goal of medical parsimony is to provide the care necessary for the patient's good on the basis primarily of evidence-based medicine. Although this may have the welcome side effect of preserving resources, reducing resource use is not the intent. It is this difference in intent and action that helps provide a foundation for the ethical distinction between parsimonious medicine and rationing.

• Resource Allocation

ACP’s High Value Care Project aims to improve health, avoid harms, and eliminate wasteful practices. The project website offers learning resources for clinicians and medical educators, clinical guidelines, best practice advice, case studies and patient resources on a wide variety of related topics.

Patient Requests for Specific Care: 'Surely You Can Explain to My Insurer That I Need Boniva?' CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Who Should Get What? Mammography and the Stewardship of Health Care Resources CME (ACP Ethics Case Studies Series. CME by Medscape. 2012)

The following ethics case studies were developed through an award from the ABIM Foundation's Putting the Charter into Practice project. Watch a video report of the ACP's work on this project presented by Dr. David Fleming, former President of the College.

Stewardship of Health Care Resources: Allocating Mechanical Ventilators During Pandemic Influenza CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Stewardship of Health Care Resources: Responding to a Patient's Request for Antibiotics (ACP Ethics Case Studies Series. CME by Medscape. 2014)

Teaching, Training and the Hidden Curriculum

• Attending Physicians and Physicians-in-Training

Resident Duty Hours: To Hand Over or Gloss Over? CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Hidden Curricula, Ethics, and Professionalism: Optimizing Clinical Learning Environments in Becoming and Being a Physician (Ann Intern Med. 2018;168:506-8)

CME/MOC activities based on this ACP position paper are available:

Annals offers two CME/MOC activities:

Ethics, Professionalism, and the Hidden Curriculum (Click on “CME/MOC” on the left sidebar.)

Annals On Call – Hidden Curriculum

In this Curbsiders Podcast , Sanjay Desai, MD, coauthor of ACP’s position paper and Internal Medicine program director at Johns Hopkins, reviews several cases that illustrate how institutional norms can shape the practice of medicine. Detailed summaries of the cases discussed are available here .

Archived Ethics Position Papers

Health Information Technology & Privacy (July 2011)

Cognitively Impaired Subjects (November 1989)

• Ethics Position Papers by Publication Date

Home Essay Examples Health Medical Ethics

Case Study: Medical Ethics

• Category Health
• Subcategory Medicine
• Topic Medical Ethics

 This essay will discuss and analyse a given case study and the ethical and theoretical implications of the case study scenario. Moreover the essay will analyse ethical principles and theoretical concepts with acknowledgment to individuality, rights, responsibilities and duty of care. The essay will also identify and discuss relevant legislation, policies and procedures.

Ethics is defined as system of moral principles that determinate human behaviour, how person makes decisions and the way they conduct activities.The concept of ethics has been shaped by cultures, creed, philosophies and it is designed to help individuals to distinguish what is “right” and what is “wrong”. The focus of ethics is what is good for the individual and society, also referred as a moral philosophy, a teaching on morals, their principles, norms, and rules of conduct. Ethics or moral philosophy examines theories of what human beings are capable of , along with what they must do to live an ethically good life.According to Beauchamp and Childress (2013), health care ethics or bioethics, requires health care professionals to adhere to four principles- respect autonomy, ensuring non-maleficence practice ,beneficence, and justice.Medical ethics, such as medical deontology, is a discipline and system of ethical principles and rules that are responsible for the application of humane, human-related, values ​​and moral views in medical and healthcare practice.

Our writers can write you a new plagiarism-free essay on any topic

As a scientific discipline, bioethics encompasses practice, including clinical practice and the application of these rules, as well as research in the field of medical history as well as history of medical ethics, and interdisciplinary research with philosophical and sociological focus.Therefore medical ethics is closely connected to all aspects of medical and healthcare practice, the standards it sets are encompassing across the healthcare field.Bioethics has evolved from medical ethics, and it applies to all healthcare professionals within the healthcare sector and organisations, such as doctors, nurses, clinical staff and healthcare providers and it is related to the service users and care provision. Although ethical theories provide framework and guidelines on what is ethical and how to imply ethics in decision making process, recognising what is “right” and what is “wrong” ethical decision can be difficult. Healthcare professionals can encounter complicated issues in the decision making process between two possible options, neither of which is absolutely acceptable from an ethical perspective, and it is referred as ethical dilemma.

Healthcare professionals unavoidably face difficult ethical issues and decisions during their practice for instance the case study of “Child B: a case of just care?” (Sellman, 1997) In 1995 the case emphasises the difficulties and challenges in treating patients with illnesses that could be life-threatening. Child B is a 10-year-old girl with leukaemia who was denied funding for a second bone marrow transplant in 1995.The case was widely reported at the time and brought to the fore the dilemmas of regulation at the United Kingdom National Health Service. In fact, the paediatricians who cared for child B based their decision on clinical rather than financial considerations, and media coverage of the case failed to review the complexity of the issues involved. The case also demonstrates the difficulty of determining the best interests of children and obtaining their consent to treatment. There was a disagreement between the child B father and the paediatricians, who spoke to her about how her best interests could be served, and this led to a collapse of confidence and the search for additional opinions. This highlighted the rise of consumerism in healthcare and the challenge for physicians and managers to justify their decisions and to explain the reasons for those decisions. A common theme in child B case is the need for greater openness in prioritisation decisions and stronger patient safeguards.

The case of child B raised ethical and practical dilemmas amongst other issues such as the right of the child to be involved into the decision making process to some extend, difficulties to determinate ‘best interests’ of the child and the strong legal profile of the case. Predictably the ethical arguments that emerged were predominantly deontological and utilitarian associated to duty and the greater good. Deontological ethical theory encompasses the duty-based approach to moral principles, not the morality of the results of the decision. This approach is also called ‘non-Consequentialist’, in view of the fact that ethics must be driven by duty, not consequences.Deontology was developed by the German philosopher Immanuel Kant. His theory focus on the motives of actions and whether a given action is motivated by duty even if that produces a inadequate result and consequences are irrelevant to a deontological theory. In the case of child B clinical and medical professionals involved in her care came to agreement with the decision not to continue further treatment for her progressive condition. They came to the decision in compliance with the Guidelines for Professionals Practice clause of the Code of Professional Conduct to advocacy as promoting and protecting the interest of patients or service users. (UKCC,1996)

However advocacy defined as paramount to the patient best interest personal professional judgment may differ. For instance one health care professional could have different opinion than other, and the parents of the child in this case disagreed with their decision not to continue any further treatment. However in this case the father of the child was not satisfied with the health care professionals advocacy and decided personally to advocate for his daughter rights.

On the utilitarian ethical theory side in this case health authorities denied recourse allocation for further treatment on the foundations that the resources could be used more effectively elsewhere, where a greater amount of good can be achieved. Utilitarianism is an ethical theory that determines right from wrong by focusing on results and it is a form of consequentialism. Utilitarianism holds that the most ethical choice is the one that will provide the greatest for the greatest number. In the case of child B the health care provision and decision making process can be argued that non of the ethical theories implied approaches were beneficial to the care that the child received.

Moreover according to the Convention on the Rights of the Child 1989 states that every child has the right of equal protection of their civil rights , and freedom of discrimination on the basis of the child’s race, age, gender , identity , ethnicity, sexuality or other characteristics. Furthermore the children’s rights highlight that every child has the rights to care, health care, protection from abuse.The United Kingdom Children Act 2004 main and most important purpose is to ensure and provide the best levels of care and protection. The interests of children are paramount in their welfare and safeguarding, and anyone working or caring for children has this responsibility.Therefore in relation to child B case can be said that decisions made in regards the health care provision for the child were complex and could not satisfied all parities involved.

Respecting the dignity and integrity of individuals is part of a holistic approach of health care professionals. Acknowledging the physical and emotional effects that further treatment would have on child B the medical and clinical professionals recommended palliative care approach.Their view was that in regards to the medical history of child B it was unlikely to benefit from further intensive treatment.

The child B case was a case of strong legal profile as the father of the child refused to accept the decision of the health care professional and took the Health Authority to the High Court. The courts ultimately supported the decision of the Health Authority on the grounds that any further treatment will be detrimental to the child. Due to the publicity of the case of child B an anonymous benefactor funded the experimental and costly treatment. However the treatment the child undertaken was considered experimental as only very few children underwent.

It is where can be said that the health care professionals and clinical professionals had their reasons to rase the medical issues regarding the treatment and argue the best interest of the child could be met and that the treatment will be beneficial. However evidence suggest that the treatment had prolonged the life of child B a year longer than anticipated.

Child B case raised practical issues from the health care sector such as allocation of resource of on service provision and the need for a fair, rigours relevant and regulated decision making process.  

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Medical Ethics: Review Case Study

Ethics refers to the issue of morality. Thus, it entails what ought to happen. However, ethics may mean two different things to healthcare providers’ verses patients. For patients, ethics is about how they want to receive treatment, as well as allowed to make their own decision pertaining to their health issues. However, according to the professional offering the healthcare, ethics refers to adherence to standard of ethics promulgated by accredited bodies such as the American Nursing Association or the American Medical Associations for physicians. Codes of ethics guide profession’s goals, values, as well as determining the degree of loyalty in serving the public and the community. The American Nursing Association developed a code of ethics to guide nurses towards ethical treatment for their patients. Similarly, the law requires professionals such as nurses or physicians to abide to certain laws by meeting reasonable treatment standards. Failure for the medical staffs to apply due care in the treatment process can lead to a medical malpractice lawsuit.

Therefore, the decision of the 12 years old boy to terminate chemotherapy together with the consent of his parents to try an alternative course of chemotherapy is not reasonable for the nurses to stop giving the boy chemotherapy as directed by the physician. From an ethics point of view, the nurse is required to go ahead and give the boy chemotherapy as directed by the physician. This complies with the code of ethics that requires registered nurses to have duty of care towards their patients by offering safe and competent care. Therefore, the action of the nurse to precede offering chemotherapy to the boy who is suffering from cancer is in accordance to the professional ethics of observing competence in service delivery. However, the action of the healthcare providers contravenes the law. This is because the law gives even the minors the freedom to choose the kind of treatment fit for them. Therefore, the 12 years old boy can challenge the healthcare providers in the court for continuing offering him chemotherapy despite his decision to stop it (Hawkins, 1996). In addition, the nurse will break the ethical principle of valid consent by continuing chemotherapy despite the boy decision to terminate it. Nurses are required to get consent before giving any treatment of care (Guido, 2009).

Antidepressants are drugs that a qualified medical practitioner can prescribe to treat depression, improve sleep, mode, concentration or appetite. Therefore, the physician is acting as per the law by prescribing antidepressant drug to new resident joining the nursing home. The antidepressant drug will help the new residents to settle more easily in their new environments. The drug will assist them by improving their moods, sleep and concentration (Siribaddana, 2012). However, the method that the physician is using in lying that the antidepressant is a pill is unethical. It is responsibility for physicians, as well as nurses to tell patients the truth. This is important in enhancing the trust between patients and healthcare providers. Not telling the patients the truth brings a great harm to the patients. Telling lies to patients undermine patients’ autonomy and leads to loss of trust, which is imperative in the healing process. Patients have the right to know the truth from their health care providers. Physicians and nurses should therefore, give the patients true information pertaining to their health issue. Although, the law does not consider telling lies as an illegal act for healthcare providers, it is an unethical conduct. The Natural Law theory states that lying violates an objective moral standard. It argues that telling the truth is essential in building and sustaining human relations. It claims that human beings are relational and the failure to tell the truth hinders human relations.

Because of the importance that accompanies telling the truth, physicians, as well as nurses should make it their responsibility to tell their patients the truth at all times. In the second scenario, the physician and the nurse fail in meeting the code of ethics that requires medical professionals to get informed consent. The code requires patients to get accurate information about their illness and intended treatment. Moreover, it requires the healthcare providers to make the patient understand about the proposed treatment. Thus, the physician should take time and explain to the new residents the benefit of the drug he/she is prescribing them. Alternatively, the nurse can explain to the new residents that taking the drug is important in helping them in settling more easily in their new homes by giving them appetite, helping them concentrate as well as having a good mood. It is equally important in informing the new residents of any side effects that may arise from using the drug. This will be important in establishing a strong relationship between the medical staffs and the residents, which will facilitate subsequent interactions. However, telling lies to the new residents may result to lack of trust when they find out that the medical staffs have not been honest. Although the law does not consider telling lies as illegal for healthcare providers, it is unethical behavior, which should end (Drane, 2012).

In conclusion: healthcare providers should ensure that they act legally, as well as ethically in their day-to-day endeavors. Acting legally and ethically is imperative in building essential relations with the patients, which facilitates medication, as well as help them to avoid possible lawsuits for malpractice.

Reference List

Drane, J. (2012). Honesty in Medicine: should doctors tell the truth? Web.

Guido, G. (2009). Legal & Ethical Issues in Nursing (5 th ed). New York: Prentice Hall Hawkins, S. (1996). Protecting the Rights and Interests of Competent Minors in Litigation Medical Treatment Disputes . Web.

Siribaddana, P. (2012). Moral, ethical and legal issues regarding prescription medication . Web.

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• v.61(1); Jan-Mar 2020

A research on abortion: ethics, legislation and socio-medical outcomes. Case study: Romania

Andreea mihaela niţă.

1 Faculty of Social Sciences, University of Craiova, Romania

Cristina Ilie Goga

This article presents a research study on abortion from a theoretical and empirical point of view. The theoretical part is based on the method of social documents analysis, and presents a complex perspective on abortion, highlighting items of medical, ethical, moral, religious, social, economic and legal elements. The empirical part presents the results of a sociological survey, based on the opinion survey method through the application of the enquiry technique, conducted in Romania, on a sample of 1260 women. The purpose of the survey is to identify Romanians perception on the decision to voluntary interrupt pregnancy, and to determine the core reasons in carrying out an abortion.

The analysis of abortion by means of medical and social documents

Abortion means a pregnancy interruption “before the fetus is viable” [ 1 ] or “before the fetus is able to live independently in the extrauterine environment, usually before the 20 th week of pregnancy” [ 2 ]. “Clinical miscarriage is both a common and distressing complication of early pregnancy with many etiological factors like genetic factors, immune factors, infection factors but also psychological factors” [ 3 ]. Induced abortion is a practice found in all countries, but the decision to interrupt the pregnancy involves a multitude of aspects of medical, ethical, moral, religious, social, economic, and legal order.

In a more simplistic manner, Winston Nagan has classified opinions which have as central element “abortion”, in two major categories: the opinion that the priority element is represented by fetus and his entitlement to life and the second opinion, which focuses around women’s rights [ 4 ].

From the medical point of view, since ancient times there have been four moments, generally accepted, which determine the embryo’s life: ( i ) conception; ( ii ) period of formation; ( iii ) detection moment of fetal movement; ( iv ) time of birth [ 5 ]. Contemporary medicine found the following moments in the evolution of intrauterine fetal: “ 1 . At 18 days of pregnancy, the fetal heartbeat can be perceived and it starts running the circulatory system; 2 . At 5 weeks, they become more clear: the nose, cheeks and fingers of the fetus; 3 . At 6 weeks, they start to function: the nervous system, stomach, kidneys and liver of the fetus, and its skeleton is clearly distinguished; 4 . At 7 weeks (50 days), brain waves are felt. The fetus has all the internal and external organs definitively outlined. 5 . At 10 weeks (70 days), the unborn child has all the features clearly defined as a child after birth (9 months); 6 . At 12 weeks (92 days, 3 months), the fetus has all organs definitely shaped, managing to move, lacking only the breath” [ 6 ]. Even if most of the laws that allow abortion consider the period up to 12 weeks acceptable for such an intervention, according to the above-mentioned steps, there can be defined different moments, which can represent the beginning of life. Nowadays, “abortion is one of the most common gynecological experiences and perhaps the majority of women will undergo an abortion in their lifetimes” [ 7 ]. “Safe abortions carry few health risks, but « every year, close to 20 million women risk their lives and health by undergoing unsafe abortions » and 25% will face a complication with permanent consequences” [ 8 , 9 ].

From the ethical point of view, most of the times, the interruption of pregnancy is on the border between woman’s right over her own body and the child’s (fetus) entitlement to life. Judith Jarvis Thomson supported the supremacy of woman’s right over her own body as a premise of freedom, arguing that we cannot force a person to bear in her womb and give birth to an unwanted child, if for different circumstances, she does not want to do this [ 10 ]. To support his position, the author uses an imaginary experiment, that of a violinist to which we are connected for nine months, in order to save his life. However, Thomson debates the problem of the differentiation between the fetus and the human being, by carrying out a debate on the timing which makes this difference (period of conception, 10 weeks of pregnancy, etc.) and highlighting that for people who support abortion, the fetus is not an alive human being [ 10 ].

Carol Gilligan noted that women undergo a true “moral dilemma”, a “moral conflict” with regards to voluntary interruption of pregnancy, such a decision often takes into account the human relationships, the possibility of not hurting the others, the responsibility towards others [ 11 ]. Gilligan applied qualitative interviews to a number of 29 women from different social classes, which were put in a position to decide whether or not to commit abortion. The interview focused on the woman’s choice, on alternative options, on individuals and existing conflicts. The conclusion was that the central moral issue was the conflict between the self (the pregnant woman) and others who may be hurt as a result of the potential pregnancy [ 12 ].

From the religious point of view, abortion is unacceptable for all religions and a small number of abortions can be seen in deeply religious societies and families. Christianity considers the beginning of human life from conception, and abortion is considered to be a form of homicide [ 13 ]. For Christians, “at the same time, abortion is giving up their faith”, riot and murder, which means that by an abortion we attack Jesus Christ himself and God [ 14 ]. Islam does not approve abortion, relying on the sacral life belief as specified in Chapter 6, Verse 151 of the Koran: “Do not kill a soul which Allah has made sacred (inviolable)” [ 15 ]. Buddhism considers abortion as a negative act, but nevertheless supports for medical reasons [ 16 ]. Judaism disapproves abortion, Tanah considering it to be a mortal sin. Hinduism considers abortion as a crime and also the greatest sin [ 17 ].

From the socio-economic point of view, the decision to carry out an abortion is many times determined by the relations within the social, family or financial frame. Moreover, studies have been conducted, which have linked the legalization of abortions and the decrease of the crime rate: “legalized abortion may lead to reduced crime either through reductions in cohort sizes or through lower per capita offending rates for affected cohorts” [ 18 ].

Legal regulation on abortion establishes conditions of the abortion in every state. In Europe and America, only in the XVIIth century abortion was incriminated and was considered an insignificant misdemeanor or a felony, depending on when was happening. Due to the large number of illegal abortions and deaths, two centuries later, many states have changed legislation within the meaning of legalizing voluntary interruption of pregnancy [ 6 ]. In contemporary society, international organizations like the United Nations or the European Union consider sexual and reproductive rights as fundamental rights [ 19 , 20 ], and promotes the acceptance of abortion as part of those rights. However, not all states have developed permissive legislation in the field of voluntary interruption of pregnancy.

Currently, at national level were established four categories of legislation on pregnancy interruption area:

( i )  Prohibitive legislations , ones that do not allow abortion, most often outlining exceptions in abortion in cases where the pregnant woman’s life is endangered. In some countries, there is a prohibition of abortion in all circumstances, however, resorting to an abortion in the case of an imminent threat to the mother’s life. Same regulation is also found in some countries where abortion is allowed in cases like rape, incest, fetal problems, etc. In this category are 66 states, with 25.5% of world population [ 21 ].

( ii )  Restrictive legislation that allow abortion in cases of health preservation . Loosely, the term “health” should be interpreted according to the World Health Organization (WHO) definition as: “health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” [ 22 ]. This type of legislation is adopted in 59 states populated by 13.8% of the world population [ 21 ].

( iii )  Legislation allowing abortion on a socio-economic motivation . This category includes items such as the woman’s age or ability to care for a child, fetal problems, cases of rape or incest, etc. In this category are 13 countries, where we have 21.3% of the world population [ 21 ].

( iv )  Legislation which do not impose restrictions on abortion . In the case of this legislation, abortion is permitted for any reason up to 12 weeks of pregnancy, with some exceptions (Romania – 14 weeks, Slovenia – 10 weeks, Sweden – 18 weeks), the interruption of pregnancy after this period has some restrictions. This type of legislation is adopted in 61 countries with 39.5% of the world population [21].

The Centre for Reproductive Rights has carried out from 1998 a map of the world’s states, based on the legislation typology of each country (Figure ​ (Figure1 1 ).

The analysis of states according to the legislation regarding abortion. Source: Centre for Reproductive Rights. The World’s Abortion Laws, 2018 [ 23 ]

An unplanned pregnancy, socio-economic context or various medical problems [ 24 ], lead many times to the decision of interrupting pregnancy, regardless the legislative restrictions. In the study “Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008” issued in 2011 by the WHO , it was determined that within the states with restrictive legislation on abortion, we may also encounter a large number of illegal abortions. The illegal abortions may also be resulting in an increased risk of woman’s health and life considering that most of the times inappropriate techniques are being used, the hygienic conditions are precarious and the medical treatments are incorrectly administered [ 25 ]. Although abortions done according to medical guidelines carry very low risk of complications, 1–3 unsafe abortions contribute substantially to maternal morbidity and death worldwide [ 26 ].

WHO has estimated for the year 2008, the fact that worldwide women between the ages of 15 and 44 years carried out 21.6 million “unsafe” abortions, which involved a high degree of risk and were distributed as follows: 0.4 million in the developed regions and a number of 21.2 million in the states in course of development [ 25 ].

Case study: Romania

Legal perspective on abortion

In Romania, abortion was brought under regulation by the first Criminal Code of the United Principalities, from 1864.

The Criminal Code from 1864, provided the abortion infringement in Article 246, on which was regulated as follows: “Any person, who, using means such as food, drinks, pills or any other means, which will consciously help a pregnant woman to commit abortion, will be punished to a minimum reclusion (three years).

The woman who by herself shall use the means of abortion, or would accept to use means of abortion which were shown or given to her for this purpose, will be punished with imprisonment from six months to two years, if the result would be an abortion. In a situation where abortion was carried out on an illegitimate baby by his mother, the punishment will be imprisonment from six months to one year.

Doctors, surgeons, health officers, pharmacists (apothecary) and midwives who will indicate, will give or will facilitate these means, shall be punished with reclusion of at least four years, if the abortion took place. If abortion will cause the death of the mother, the punishment will be much austere of four years” (Art. 246) [ 27 ].

The Criminal Code from 1864, reissued in 1912, amended in part the Article 246 for the purposes of eliminating the abortion of an illegitimate baby case. Furthermore, it was no longer specified the minimum of four years of reclusion, in case of abortion carried out with the help of the medical staff, leaving the punishment to the discretion of the Court (Art. 246) [ 28 ].

The Criminal Code from 1936 regulated abortion in the Articles 482–485. Abortion was defined as an interruption of the normal course of pregnancy, being punished as follows:

“ 1 . When the crime is committed without the consent of the pregnant woman, the punishment was reformatory imprisonment from 2 to 5 years. If it caused the pregnant woman any health injury or a serious infirmity, the punishment was reformatory imprisonment from 3 to 6 years, and if it has caused her death, reformatory imprisonment from 7 to 10 years;

2 . When the crime was committed by the unmarried pregnant woman by herself, or when she agreed that someone else should provoke the abortion, the punishment is reformatory imprisonment from 3 to 6 months, and if the woman is married, the punishment is reformatory imprisonment from 6 months to one year. Same penalty applies also to the person who commits the crime with the woman’s consent. If abortion was committed for the purpose of obtaining a benefit, the punishment increases with another 2 years of reformatory imprisonment.

If it caused the pregnant woman any health injuries or a severe disablement, the punishment will be reformatory imprisonment from one to 3 years, and if it has caused her death, the punishment is reformatory imprisonment from 3 to 5 years” (Art. 482) [ 29 ].

The criminal legislation from 1936 specifies that it is not considered as an abortion the interruption from the normal course of pregnancy, if it was carried out by a doctor “when woman’s life was in imminent danger or when the pregnancy aggravates a woman’s disease, putting her life in danger, which could not be removed by other means and it is obvious that the intervention wasn’t performed with another purpose than that of saving the woman’s life” and “when one of the parents has reached a permanent alienation and it is certain that the child will bear serious mental flaws” (Art. 484, Par. 1 and Par. 2) [ 29 ].

In the event of an imminent danger, the doctor was obliged to notify prosecutor’s office in writing, within 48 hours after the intervention, on the performance of the abortion. “In the other cases, the doctor was able to intervene only with the authorization of the prosecutor’s office, given on the basis of a medical certificate from hospital or a notice given as a result of a consultation between the doctor who will intervene and at least a professor doctor in the disease which caused the intervention. General’s Office Prosecutor, in all cases provided by this Article, shall be obliged to maintain the confidentiality of all communications or authorizations, up to the intercession of any possible complaints” (Art. 484) [ 29 ].

The legislation of 1936 provided a reformatory injunction from one to three years for the abortions committed by doctors, sanitary agents, pharmacists, apothecary or midwives (Art. 485) [ 29 ].

Abortion on demand has been legalized for the first time in Romania in the year 1957 by the Decree No. 463, under the condition that it had to be carried out in a hospital and to be carried out in the first quarter of the pregnancy [ 30 ]. In the year 1966, demographic policy of Romania has dramatically changed by introducing the Decree No. 770 from September 29 th , which prohibited abortion. Thus, the voluntary interruption of pregnancy became a crime, with certain exceptions, namely: endangering the mother’s life, physical or mental serious disability; serious or heritable illness, mother’s age over 45 years, if the pregnancy was a result of rape or incest or if the woman gave birth to at least four children who were still in her care (Art. 2) [ 31 ].

In the Criminal Code from 1968, the abortion crime was governed by Articles 185–188.

The Article 185, “the illegal induced abortion”, stipulated that “the interruption of pregnancy by any means, outside the conditions permitted by law, with the consent of the pregnant woman will be punished with imprisonment from one to 3 years”. The act referred to above, without the prior consent from the pregnant woman, was punished with prison from two to five years. If the abortion carried out with the consent of the pregnant woman caused any serious body injury, the punishment was imprisonment from two to five years, and when it caused the death of the woman, the prison sentence was from five to 10 years. When abortion was carried out without the prior consent of the woman, if it caused her a serious physical injury, the punishment was imprisonment from three to six years, and if it caused the woman’s death, the punishment was imprisonment from seven to 12 years (Art. 185) [ 32 ].

“When abortion was carried out in order to obtain a material benefit, the maximum punishment was increased by two years, and if the abortion was made by a doctor, in addition to the prison punishment could also be applied the prohibition to no longer practice the profession of doctor”.

Article 186, “abortion caused by the woman”, stipulated that “the interruption of the pregnancy course, committed by the pregnant woman, was punished with imprisonment from 6 months to 2 years”, quoting the fact that by the same punishment was also sanctioned “the pregnant woman’s act to consent in interrupting the pregnancy course made out by another person” (Art. 186) [ 26 ].

The Regulations of the Criminal Code in 1968, also provided the crime of “ownership of tools or materials that can cause abortion”, the conditions of this holding being met when these types of instruments were held outside the hospital’s specialized institutions, the infringement shall be punished with imprisonment from three months to one year (Art. 187) [ 32 ].

Furthermore, the doctors who performed an abortion in the event of extreme urgency, without prior legal authorization and if they did not announce the competent authority within the legal deadline, they were punished by imprisonment from one month to three months (Art. 188) [ 32 ].

In the year 1985, it has been issued the Decree No. 411 of December 26 th , by which the conditions imposed by the Decree No. 770 of 1966 have been hardened, meaning that it has increased the number of children, that a woman could have in order to request an abortion, from four to five children [ 33 ].

The Articles 185–188 of the Criminal Code and the Decree No. 770/1966 on the interruption of the pregnancy course have been abrogated by Decree-Law No. 1 from December 26 th , 1989, which was published in the Official Gazette No. 4 of December 27 th , 1989 (Par. 8 and Par. 12) [ 34 ].

The Criminal Code from 1968, reissued in 1997, maintained Article 185 about “the illegal induced abortion”, but drastically modified. Thus, in this case of the Criminal Code, we identify abortion as “the interruption of pregnancy course, by any means, committed in any of the following circumstances: ( a ) outside medical institutions or authorized medical practices for this purpose; ( b ) by a person who does not have the capacity of specialized doctor; ( c ) if age pregnancy has exceeded 14 weeks”, the punishment laid down was the imprisonment from 6 months to 3 years” (Art. 185, Par. 1) [ 35 ]. For the abortion committed without the prior consent of the pregnant woman, the punishment consisted in strict prison conditions from two to seven years and with the prohibition of certain rights (Art. 185, Par. 2) [ 35 ].

For the situation of causing serious physical injury to the pregnant woman, the punishment was strict prison from three to 10 years and the removal of certain rights, and if it had as a result the death of the pregnant woman, the punishment was strict prison from five to 15 years and the prohibition of certain rights (Art. 185, Par. 3) [ 35 ].

The attempt was punished for the crimes specified in the various cases of abortion.

Consideration should also be given in the Criminal Code reissued in 1997 for not punishing the interruption of the pregnancy course carried out by the doctor, if this interruption “was necessary to save the life, health or the physical integrity of the pregnant woman from a grave and imminent danger and that it could not be removed otherwise; in the case of a over fourteen weeks pregnancy, when the interruption of the pregnancy course should take place from therapeutic reasons” and even in a situation of a woman’s lack of consent, when it has not been given the opportunity to express her will, and abortion “was imposed by therapeutic reasons” (Art. 185, Par. 4) [ 35 ].

Criminal Code from 2004 covers abortion in Article 190, defined in the same way as in the prior Criminal Code, with the difference that it affects the limits of the punishment. So, in the event of pregnancy interruption, in accordance with the conditions specified in Paragraph 1, “the penalty provided was prison time from 6 months to one year or days-fine” (Art. 190, Par. 1) [ 36 ].

Nowadays, in Romania, abortion is governed by the criminal law of 2009, which entered into force in 2014, by the section called “aggression against an unborn child”. It should be specified that current criminal law does not punish the woman responsible for carrying out abortion, but only the person who is involved in carrying out the abortion. There is no punishment for the pregnant woman who injures her fetus during pregnancy.

In Article 201, we can find the details on the pregnancy interruption infringement. Thus, the pregnancy interruption can be performed in one of the following circumstances: “outside of medical institutions or medical practices authorized for this purpose; by a person who does not have the capacity of specialist doctor in Obstetrics and Gynecology and the right of free medical practice in this specialty; if gestational age has exceeded 14 weeks”, the punishment is the imprisonment for six months to three years, or fine and the prohibition to exercise certain rights (Art. 201, Par. 1) [ 37 ].

Article 201, Paragraph 2 specifies that “the interruption of the pregnancy committed under any circumstances, without the prior consent of the pregnant woman, can be punished with imprisonment from 2 to 7 years and with the prohibition to exercise some rights” (Art. 201, Par. 1) [ 37 ].

If by facts referred to above (Art. 201, Par. 1 and Par. 2) [ 37 ] “it has caused the pregnant woman’s physical injury, the punishment is the imprisonment from 3 to 10 years and the prohibition to exercise some rights, and if it has had as a result the pregnant woman’s death, the punishment is the imprisonment from 6 to 12 years and the prohibition to exercise some rights” (Art. 201, Par. 3) [ 37 ]. When the facts have been committed by a doctor, “in addition to the imprisonment punishment, it will also be applied the prohibition to exercise the profession of doctor (Art. 201, Par. 4) [ 37 ].

Criminal legislation specifies that “the interruption of pregnancy does not constitute an infringement with the purpose of a treatment carried out by a specialist doctor in Obstetrics and Gynecology, until the pregnancy age of twenty-four weeks is reached, or the subsequent pregnancy interruption, for the purpose of treatment, is in the interests of the mother or the fetus” (Art. 201, Par. 6) [ 37 ]. However, it can all be found in the phrases “therapeutic purposes” and “the interest of the mother and of the unborn child”, which predisposes the text of law to an interpretation, finally the doctors are the only ones in the position to decide what should be done in such cases, assuming direct responsibility [ 38 ].

Article 202 of the Criminal Code defines the crime of harming an unborn child, pointing out the punishments for the various types of injuries that can occur during pregnancy or in the childbirth period and which can be caused by the mother or by the persons who assist the birth, with the specification that the mother who harms her fetus during pregnancy is not punished and does not constitute an infringement if the injury has been committed during pregnancy or during childbirth period if the facts have been “committed by a doctor or by an authorized person to assist the birth or to follow the pregnancy, if they have been committed in the course of the medical act, complying with the specific provisions of his profession and have been made in the interest of the pregnant woman or fetus, as a result of the exercise of an inherent risk in the medical act” (Art. 202, Par. 6) [ 37 ].

The fact situation in Romania

During the period 1948–1955, called “the small baby boom” [ 39 ], Romania registered an average fertility rate of 3.23 children for a woman. Between 1955 and 1962, the fertility rate has been less than three children for a woman, and in 1962, fertility has reached an average of two children for a woman. This phenomenon occurred because of the Decree No. 463/1957 on liberalization of abortion. After the liberalization from 1957, the abortion rate has increased from 220 abortions per 100 born-alive children in the year 1960, to 400 abortions per 100 born-alive children, in the year 1965 [ 40 ].

The application of provisions of Decrees No. 770 of 1966 and No. 411 of 1985 has led to an increase of the birth rate in the first three years (an average of 3.7 children in 1967, and 3.6 children in 1968), followed by a regression until 1989, when it was recorded an average of 2.2 children, but also a maternal death rate caused by illegal abortions, raising up to 85 deaths of 100 000 births in the year of 1965, and 170 deaths in 1983. It was estimated that more than 80% of maternal deaths between 1980–1989 was caused by legal constraints [ 30 ].

After the Romanian Revolution in December 1989 and after the communism fall, with the abrogation of Articles 185–188 of the Criminal Code and of the Decree No. 770/1966, by the Decree of Law No. 1 of December 26 th , 1989, abortion has become legal in Romania and so, in the following years, it has reached the highest rate of abortion in Europe. Subsequently, the number of abortion has dropped gradually, with increasing use of birth control [ 41 ].

Statistical data issued by the Ministry of Health and by the National Institute of Statistics (INS) in Romania show corresponding figures to a legally carried out abortion. The abortion number is much higher, if it would take into account the number of illegal abortion, especially those carried out before 1989, and those carried out in private clinics, after the year 1990. Summing the declared abortions in the period 1958–2014, it is to be noted the number of them, 22 037 747 exceeds the current Romanian population. A detailed statistical research of abortion rate, in terms of years we have exposed in Table ​ Table1 1 .

The number of abortions declared in Romania in the period 1958–2016

Source: Pro Vita Association (Bucharest, Romania), National Institute of Statistics (INS – Romania), EUROSTAT [ 42 , 43 , 44 ]

Data issued by the United Nations International Children’s Emergency Fund (UNICEF) in June 2016, for the period 1989–2014, in matters of reproductive behavior, indicates a fertility rate for Romania with a continuous decrease, in proportion to the decrease of the number of births, but also a lower number of abortion rate reported to 100 deliveries (Table ​ (Table2 2 ).

Reproductive behavior in Romania in 1989–2014

Source: United Nations International Children’s Emergency Fund (UNICEF), Transformative Monitoring for Enhanced Equity (TransMonEE) Data. Country profiles: Romania, 1989–2015 [ 45 ].

By analyzing data issued for the period 1990–2015 by the International Organization of Health , UNICEF , United Nations Fund for Population Activity (UNFPA), The World Bank and the United Nations Population Division, it is noticed that maternal mortality rate has currently dropped as compared with 1990 (Table ​ (Table3 3 ).

Maternal mortality estimation in Romania in 1990–2015

Source: World Health Organization (WHO), Global Health Observatory Data. Maternal mortality country profiles: Romania, 2015 [ 46 ].

Opinion survey: women’s opinion on abortion

Argument for choosing the research theme

Although the problematic on abortion in Romania has been extensively investigated and debated, it has not been carried out in an ample sociological study, covering Romanian women’s perception on abortion. We have assumed making a study at national level, in order to identify the opinion on abortion, on the motivation to carry out an abortion, and to identify the correlation between religious convictions and the attitude toward abortion.

Examining the literature field of study

In the conceptual register of the research, we have highlighted items, such as the specialized literature, legislation, statistical documents.

Formulation of hypotheses and objectives

The first hypothesis was that Romanian women accept abortion, having an open attitude towards this act. Thus, the first objective of the research was to identify Romanian women’s attitude towards abortion.

The second hypothesis, from which we started, was that high religious beliefs generate a lower tolerance towards abortion. Thus, the second objective of our research has been to identify the correlation between the religious beliefs and the attitude towards abortion.

The third hypothesis of the survey was that, the main motivation in carrying out an abortion is the fact that a woman does not want a baby, and the main motivation for keeping the pregnancy is that the person wants a baby. In this context, the third objective of the research was to identify main motivation in carrying out an abortion and in maintaining a pregnancy.

Another hypothesis was that modern Romanian legislation on the abortion is considered fair. Based on this hypothesis, we have assumed the fourth objective, which is to identify the degree of satisfaction towards the current regulatory provisions governing the abortion.

Research methodology

The research method is that of a sociological survey by the application of the questionnaire technique. We used the sampling by age and residence looking at representative numbers of population from more developed as well as underdeveloped areas.

Determination of the sample to be studied

Because abortion is a typical women’s experience, we have chosen to make the quantitative research only among women. We have constructed the sample by selecting a number of 1260 women between the ages of 15 and 44 years (the most frequently encountered age among women who give birth to a child). We also used the quota sampling techniques, taking into account the following variables: age group and the residence (urban/rural), so that the persons included in the sample could retain characteristic of the general population.

By the sample of 1260 women, we have made a percentage of investigation of 0.03% of the total population.

The Questionnaires number applied was distributed as follows (Table ​ (Table4 4 ).

The sampling rates based on the age, and the region of residence

Source: Sample built, based on the population data issued by the National Institute of Statistics (INS – Romania) based on population census conducted in 2011 [ 47 ].

Data collection

Data collection was carried out by questionnaires administered by 32 field operators between May 1 st –May 31 st , 2018.

The analysis of the research results

In the next section, we will present the main results of the quantitative research carried out at national level.

Almost three-quarters of women included in the sample agree with carrying out an abortion in certain circumstances (70%) and only 24% have chosen to support the answer “ No, never ”. In modern contemporary society, abortion is the first solution of women for which a pregnancy is not desired. Even if advanced medical techniques are a lot safer, an abortion still carries a health risk. However, 6% of respondents agree with carrying out abortion regardless of circumstances (Table ​ (Table5 5 ).

Opinion on the possibility of carrying out an abortion

Although abortions carried out after 14 weeks are illegal, except for medical reasons, more than half of the surveyed women stated they would agree with abortion in certain circumstances. At the opposite pole, 31% have mentioned they would never agree on abortions after 14 weeks. Five percent were totally accepting the idea of abortion made to a pregnancy that has exceeded 14 weeks (Table ​ (Table6 6 ).

Opinion on the possibility of carrying out an abortion after the period of 14 weeks of pregnancy

For 53% of respondents, abortion is considered a crime as well as the right of a women. On the other hand, 28% of the women considered abortion as a crime and 16% associate abortion with a woman’s right (Table ​ (Table7 7 ).

Opinion on abortion: at the border between crime and a woman’s right

Opinions on what women abort at the time of the voluntary pregnancy interruption are split in two: 59% consider that it depends on the time of the abortion, and more specifically on the pregnancy development stage, 24% consider that regardless of the period in which it is carried out, women abort a child, and 14% have opted a fetus (Table ​ (Table8 8 ).

Abortion of a child vs. abortion of a fetus

Among respondents who consider that women abort a child or a fetus related to the time of abortion, 37.5% have considered that the difference between a baby and a fetus appears after 14 weeks of pregnancy (the period legally accepted for abortion). Thirty-three percent of them have mentioned that the distinction should be performed at the first few heartbeats; 18.1% think it is about when the child has all the features definitively outlined and can move by himself; 2.8% consider that the difference appears when the first encephalopathy traces are being felt and the child has formed all internal and external organs. A percentage of 1.7% of respondents consider that this difference occurs at the beginning of the central nervous system, and 1.4% when the unborn child has all the features that we can clearly see to a newborn child (Table ​ (Table9 9 ).

The opinion on the moment that makes the difference between a fetus and a child

We noticed that highly religious people make a clear association between abortion and crime. They also consider that at the time of pregnancy interruption it is aborted a child and not a fetus. However, unexpectedly, we noticed that 27% of the women, who declare themselves to be very religious, have also stated that they see abortion as a crime but also as a woman’s right. Thirty-one percent of the women, who also claimed profound religious beliefs, consider that abortion may be associated with the abortion of a child but also of a fetus, this depending on the time of abortion (Tables ​ (Tables10 10 and ​ and11 11 ).

The correlation between the level of religious beliefs and the perspective on abortion seen as a crime or a right

The correlation between the level of religious beliefs and the perspective on abortion procedure conducted on a fetus or a child

More than half of the respondents have opted for the main reason for abortion the appearance of medical problems to the child. Baby’s health represents the main concern of future mothers, and of each parent, and the birth of a child with serious health issues, is a factor which frightens any future parent, being many times, at least theoretically, one good reason for opting for abortion. At the opposite side, 12% of respondents would not choose abortion under any circumstances. Other reasons for which women would opt for an abortion are: if the woman would have a medical problem (22%) or would not want the child (10%) (Table ​ (Table12 12 ).

Potential reasons for carrying out an abortion

Most of the women want to give birth to a child, 56% of the respondents, representing also the reason that would determine them to keep the child. Morality (26%), faith (10%) or legal restrictions (4%), are the three other reasons for which women would not interrupt a pregnancy. Only 2% of the respondents have mentioned other reasons such as health or age.

A percentage of 23% of the surveyed people said that they have done an abortion so far, and 77% did not opted for a surgical intervention either because there was no need, or because they have kept the pregnancy (Table ​ (Table13 13 ).

Rate of abortion among women in the sample

Most respondents, 87% specified that they have carried out an abortion during the first 14 weeks – legally accepted limit for abortion: 43.6% have made abortion in the first four weeks, 39.1% between weeks 4–8, and 4.3% between weeks 8–14. It should be noted that 8.7% could not appreciate the pregnancy period in which they carried out abortion, by opting to answer with the option “ I don’t know ”, and a percentage of 4.3% refused to answer to this question.

Performing an abortion is based on many reasons, but the fact that the women have not wanted a child is the main reason mentioned by 47.8% of people surveyed, who have done minimum an abortion so far. Among the reasons for the interruption of pregnancy, it is also included: women with medical problems (13.3%), not the right time to be a mother (10.7%), age motivation (8.7%), due to medical problems of the child (4.3%), the lack of money (4.3%), family pressure (4.3%), partner/spouse did not wanted. A percentage of 3.3% of women had different reasons for abortion, as follows: age difference too large between children, career, marital status, etc. Asked later whether they regretted the abortion, a rate of 69.6% of women who said they had at least one abortion regret it (34.8% opted for “ Yes ”, and 34.8% said “ Yes, partially ”). 26.1% of surveyed women do not regret the choice to interrupted the pregnancy, and 4.3% chose to not answer this question. We noted that, for women who have already experienced abortion, the causes were more diverse than the grounds on which the previous question was asked: “What are the reasons that determined you to have an abortion?” (Table ​ (Table14 14 ).

The reasons that led the women in the sample to have an abortion

The majority of the respondents (37.5%) considered that “nervous depression” is the main consequence of abortion, followed by “insomnia and nightmares” (24.6%), “disorders in alimentation” and “affective disorders” (each for 7.7% of respondents), “deterioration of interpersonal relationships” and “the feeling of guilt”(for 6.3% of the respondents), “sexual disorders” and “panic attacks” (for 6.3% of the respondents) (Table ​ (Table15 15 ).

Opinion on the consequences of abortion

Over half of the respondents believe that abortion should be legal in certain circumstances, as currently provided by law, 39% say it should be always legal, and only 6% opted for the illegal option (Table ​ (Table16 16 ).

Opinion on the legal regulation of abortion

Although the current legislation does not punish pregnant women who interrupt pregnancy or intentionally injured their fetus, survey results indicate that 61% of women surveyed believe that the national law should punish the woman and only 28% agree with the current legislation (Table ​ (Table17 17 ).

Opinion on the possibility of punishing the woman who interrupts the course of pregnancy or injures the fetus

For the majority of the respondents (40.6%), the penalty provided by the current legislation, the imprisonment between six months and three years or a fine and deprivation of certain rights for the illegal abortion is considered fair, for a percentage of 39.6% the punishment is too small for 9.5% of the respondents is too high. Imprisonment between two and seven years and deprivation of certain rights for an abortion performed without the consent of the pregnant woman is considered too small for 65% of interviewees. Fourteen percent of them think it is fair and only 19% of respondents consider that Romanian legislation is too severe with people who commit such an act considering the punishment as too much. The imprisonment from three to 10 years and deprivation of certain rights for the facts described above, if an injury was caused to the woman, is considered to be too small for more than half of those included in the survey, 64% and almost 22% for nearly a quarter of them. Only 9% of the respondents mentioned that this legislative measure is too severe for such actions (Table ​ (Table18 18 ).

Opinion on the regulation of abortion of the Romanian Criminal Code (Art. 201)

Conclusions

After analyzing the results of the sociological research regarding abortion undertaken at national level, we see that 76% of the Romanian women accept abortion, indicating that the majority accepts only certain circumstances (a certain period after conception, for medical reasons, etc.). A percentage of 64% of the respondents indicated that they accept the idea of abortion after 14 weeks of pregnancy (for solid reasons or regardless the reason). This study shows that over 50% of Romanian women see abortion as a right of women but also a woman’s crime and believe that in the moment of interruption of a pregnancy, a fetus is aborted. Mostly, the association of abortion with crime and with the idea that a child is aborted is frequently found within very religious people. The main motivation for Romanian women in taking the decision not to perform an abortion is that they would want the child, and the main reason to perform an abortion is the child’s medical problems. However, it is noted that, in real situations, in which women have already done at least one abortion, most women resort to abortion because they did not want the child towards the hypothetical situation in which women felt that the main reason of abortion is a medical problem. Regarding the satisfaction with the current national legislation of the abortion, the situation is rather surprising. A significant percentage (61%) of respondents felt as necessary to punish the woman who performs an illegal abortion, although the legislation does not provide a punishment. On the other hand, satisfaction level to the penalties provided by law for various violations of the legal conditions for conducting abortion is low, on average only 25.5% of respondents are being satisfied with these, the majority (average 56.2%) considering the penalties as unsatisfactory. Understood as a social phenomenon, intensified by human vulnerabilities, of which the most obvious is accepting the comfort [ 48 ], abortion today is no longer, in Romanian society, from a legal or religious perspective, a problem. Perceptions on the legislative sanction, moral and religious will perpetual vary depending on beliefs, environment, education, etc. The only and the biggest social problem of Romania is truly represented by the steadily falling birth rate.

Conflict of interests

The authors declare that they have no conflict of interests.

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Good Essay About Medical Ethics Consultation Case Study

Type of paper: Essay

Topic: Children , Patient , Nursing , Child , Medicine , Ethics , The Child , Consent

Published: 03/08/2023

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Introduction

The objective is to analyze critically the application of medical ethics in solving patient-practitioner dilemmas in scenarios where the patient in question is incapacitated to make a decision in the healthcare practice. Three case scenarios that call for an ethical consultation concerning medical intervention forms the focus of the paper. The case is an exemplification of autonomy and consent. The scenario calls into question the extent to which a medical practitioner whether an intern, a resident or a certified physician can be rational in balancing the aspects of patient consent, beneficence, respect and mandate to the role of doing the best for the patient and euthanasia. The resident has to find a way to get informed medical-ethical consultation. The case, as much as there is consent by the patient as presented by the wife, may have stipulated and recommended medical alternatives. One of them is to provide a less expensive, and sophisticated life support program. The patient can be provided with basic home based mechanical ventilation. In my view, a normative approach to assisted suicide with patient or surrogate consent may be a better option; than to allow the patient to continue suffering and financially constraining the immediate keen. Also, scenarios such as the case of no survival chance for a patient is euthanasia is necessary as projected by utilitarian argument. The case deals with an expectant couple with three children whose family is plagued by downs syndrome. The predicament lies on the baby having the downs syndrome, the financial constraints evoked by raising a fourth child who calls for abortion, both parents are against the idea. The husband is even more convinced that child deserves a chance to live. Medically, ethics state everyone has a right to live. The possibilities to salvage the situation is to let the child be born and deal with the syndrome and upbringing later. In my view, children with the syndrome are capable of all affections, feelings and life of a healthy child. Therefore, the baby should be born. The option proves to be better since it gives the child a chance to live. Abortion concerning moral and life argument are wrong, therefore, should be avoided. The case illuminates on limits to medicine. The child at five years has the physical and mental capability of a six months old. The condition evoked by encephalopathy does not change with age. Growing up like that will only pose a bigger predicament of caring for the child. The medical possibility and ethics are that intervention is not necessary. The child can grow up with care from both parents and nurse and later be institutionalized. Limits to what medicine can do include violating autonomy rights of the practitioner and consent rights of a patient to treatment. Though consent by the patient is medically required to impair physical growth, the surrogates, and the physicians in my view may stop the growth of the beneficence of the parents and the life of the child. By allowing the child to grow up in that state, problems associated with maturation such as menstruation and pregnancy will pose a challenge. Therefore, impairing physical growth is necessary than allowing growth.

Bibliography

Lawton, Julia. "Gaining and maintaining consent: ethical concerns raised in a study of dying patients." Qualitative Health Research 11, no. 5 (2001): 693-705. Roberts, Laura Weiss, and Brian Roberts. "Psychiatric research ethics: an overview of evolving guidelines and current ethical dilemmas in the study of mental illness." Biological psychiatry 46, no. 8 (1999): 1025-1038. Stineman, Margaret G., and David W. Musick. "Protection of human subjects with disability: Guidelines for research." Archives of Physical Medicine and Rehabilitation 82 (2001): S9-S14.

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