Ethical Issues

Essex County College

PTA 101

Ethical Issues

Case Example 1

A dental assistant is working with a dentist in the examination of a new patient. The patient has a severely abscessed tooth and will require extensive root canal work. As the assistant prepares for the invasive procedure, the patient mentions that his lover has recently died of AIDS and that he, too, has AIDS. The assistant freezes. He is afraid of getting infected with the AIDS virus. Can he refuse to assist in this procedure?

Case Example 2

A nurses aide in a hospital is making rounds to pick up lunch trays. An elderly patient has not eaten her foodagain. The aide asks if the patient wants her lunch to be heated. The patient shakes her head no. Please just tell them I ate everything. I dont want any more food. I just want to die. The aide leaves the room with the tray but is upset. Without food, the patient will starve to death. If she lies to the nurse at the patients request, is she helping the patient commit suicide? Can a competent adult refuse to eat? Is the patient competent?Case Example 3

A nurses aide has been employed by a family to take care of a 7-year-old girl severely brain damaged in a near-drowning accident when she was 3. During the 3 months the aide has been employed, he has gotten to know his young patient well. Although the girl cannot talk, he has learned what foods she likes and does not like, that she sleeps better if she is placed on her right side, that she cries whenever she hears loud noises, and that she likes to listen to music. One day, the aide accompanies the patient and her mother to a doctors officethe patient needs minor surgery on her hand to remove a small cyst, and that will be done in the doctors office. The doctor asks the aide to stay with the child to help hold her hand in place while the minor surgery is done. The aide notices that the doctor is not preparing to give the child a numbing shot on her arm where the surgery is to be done. The aide asks about this, and the doctor states, She doesnt need anything. Shes just a vegetable. How should the nurses aide begin to solve this moral dilemma? Where should any healthcare professional begin when faced with a bioethical problem?Case Example 4

A medical assistant is employed in an oncologists office. He greets a patient he knows well, a 62-year-old woman with leukemia. Her bloodwork shows that her white blood cell (WBC) count is down. The assistant gives this result to the doctor, who orders an infusion of fresh frozen plasma (FFP). The assistant reminds the doctor that the patient is a Jehovahs Witness, a religious group that refuses all blood products, including FFP, in treatment. The doctor becomes angry. Just tell her its medicine that I ordered. Dont tell her its a blood product. Its not red, so shell never guess. Its the only thing I have that can help her right now. Should the medical assistant lie to the patient at the request of the doctor? Either he must obey the doctor and lie or refuse to reveal to the patient that the doctor has ordered a blood product for her, or he must disobey the doctor and inform the patient that her treatment is a blood product. His only other option is to leave the officewhich will cost him his job and will still not assist the patient. The medical assistant must make a choice.

Case Example 5

A high school student studying in a health professions course at school spends a day following a nurse in her practice in an obstetrics-gynecology clinic. While at the clinic, a classmate patient comes in to be treated and is recognized by the student. The patient is pregnant and is upset and unsure about what to do about her pregnancy. The nurse, with the student watching and listening, spends a lot of time counseling the patient. Later, the health professions student is stopped by a friend in her class. Hey, I saw you with Didi in the clinic, the friend observes. What was she in for? Is she pregnant? Should the health professions student reveal the patients diagnosis?

Case Example 6

An elderly woman is transported to an Emergency Department with severe respiratory distress. She has severe, end-stage lung disease and has clearly expressed to her family, friends and physicians that she does not want her life artificially prolonged. However, her loving husband and family cannot bear the thought of her death, and beg that everything be done to preserve her life. They state that she is mentally depressed by her condition and her family is best able to decide her medical treatment. Her attachment to a respirator will allow her to survive. If this is done, she may or may not recover sufficiently to come off the respirator. What should be done?

Case Example 7

A 14 year old female is brought against her will to the ER by her parents. The teenager has been missing from home for three days and when she returned home was found to have bruises on her neck she could not explain. Her parents want her to be evaluated for possible sexual abuse. Dr. Green obtains a history from the parents and discovers that the parents have recently separated. Their daughter provides a vague story of her three day adventure, including sleeping over at her girlfriends boyfriends house, going to sleep and waking up with marks on her neck. What should be done?

Case Example 8

A 47 year old woman is brought by a paramedic ambulance to the hospital because of severe injuries sustained in a MVA. She demonstrates signs of shock including significantly low blood pressure, and appears to be in need of a blood transfusion to prevent death. The emergency physician, Dr. White, explains the seriousness of her injuries, the need for immediate blood resuscitation and the high risks, including possible death if the transfusion is not administered. In spite of her injuries, she is conscious and appears to comprehend the seriousness of her medical condition. She refuses the transfusion and clearly explains her religious objections since she is a Jehovahs Witness. Dr. White faces the ethical decision as to whether save the patients life and live her a blood transfusion against her will or honor her religious beliefs and allow her to die. What should be done?

Case Example 9

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:

Do you believe that the physician's actions can be justified in any way?

Is there anything else that they could have done?

Is it ever right to take away someone's autonomy? (Would a court order make the physicians' decisions ethical?)

What would you do if you were one of the health care workers?

Case Example 10

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:

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?

In the United States it is illegal to pay a person for non-replenishable organs. The fear is that money will influence the poor to harm their bodies for the benefit of the rich. Do you see a parallel between this case and this law? Can allowing surrogate mothers to be paid for their troubles allow poorer women to be oppressed?

Does paying the surrogate harm her and/or the child's dignity?

Is it selfish/conceited for this couple to want children of their own genetic make-up? If yes, does this change if you can "easily" have a child? (Note: Over 100,000 children in the U.S. are waiting to be adopted. However, most are older, have several siblings, or have special needs.)

On their website, the AMA says "that surrogacy contracts [when the surrogate uses her own egg], while permissible, should grant the birth mother the right to void the contract within a reasonable period of time after the birth of the child. If the contract is voided, custody of the child should be determined according to the child's best interests." Do you see any problems with this? (What's a reasonable time? In a way can you steal the surrogate's child?)

One of the main arguments against the use of surrogate mothers is that carrying and giving birth to a child is such an emotional event that it is impossible to determine if the surrogate will be able to give up the child. Though adults enter into the contract, the child could ultimately suffer if a long custody battle ensues (as it could in states where surrogacy contracts hold no legal value, such as Virginia). With the possibility of such battles, do you think it is acceptable for parents to use a surrogate mother?

Do you think that if the surrogate is awarded the baby, this could cause emotional harm to the child?

Who do you think should receive the child, and why?Case Example 11

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?

Case Example 12

A mother brings her son into the emergency room during an asthma attack. Though both of his parents work, they cannot afford medical insurance for themselves or him. They also earn too much money to qualify for state or federal aid. He is treated for his asthma attack at the hospital and he and his mother leave. Two weeks later, they return to the hospital in a virtually identical scenario.

Questions:

Do you think that this boy is receiving adequate care?Shouldn't he be able to see a primary care physician before his condition gets so acute that he must visit the ER?

Should everyone be entitled to a basic "minimum of health care" or to the exact same health care?

Do you think that health care is a right? If so, are we forced to honor this right?

If you answer right to this question, is this right relative or universal? Does this right exist because of the wealth of the United States, or is it applicable everywhere? Is health care a luxury?

Does having money entitle a person to better health care? (they may have worked harder for their greater wealth)Case Example 13

An upper middle class, middle aged, Canadian man is playing racket ball when he suddenly feels a pop in his knee. In pain, he makes an appointment with his general practitioner and is seen the next day. He is given pain medication, and is referred to an orthopedic surgeon (he has no choice of who he will see). After a week wait, he is seen by the orthopedic surgeon and is told he will need surgery. Two weeks later surgery is performed on the man's knee. The physician, who is not very good, does a poor job on the knee, and the man walks with a slight limp for the rest of his life. The surgery costs the man no money directly, however, he pays for it with higher taxes.

Questions:

What do you think of this man's experience in comparison to case 1? Which situation seems worse, and why?

Does it seem like it took too long for him to receive care? (The physicians will perform surgery on the more urgent patients first and then on the less serious.)

What do you think about not being able to choose your own physician? (Note: In the United States, many insurance companies limit which physicians you choose.)

One suggested solution for our current health care woes is that care for the elderly be decreased/eliminated. For example, people over the age of 80 will no longer be placed on life support, which costs approximately $10,000 per day to operate. What do you think of this?

What do you think could be a good middle ground solution to this problem?

Case Example 14

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?

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