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PHIL 434 Medical Ethics

Midterm Exam

Name:

Date-

1)       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.

Questions for Case 1:

A)            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?

B)            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?

C)            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)?

 

 

 

D)            Weighing everything we have discussed, do you believe the couple acted ethically? By which theory (ies) is this ethical?

 

 

 

 

 

 

2)       You are a general practitioner and a mother comes into your office with her child who is complaining of flu-like symptoms. Upon entering the room, you ask the boy to remove his shirt and you notice a pattern of very distinct bruises on the boy's torso. You ask the mother where the bruises came from, and she tells you that they are from a procedure she performed on him known as "caogio," 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 caogio 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:

A) Should we completely discount this treatment as useless, or could there be something gained from it? Explain.

B) When should a physician step in to stop a cultural practice? (If you answer "when it harms the child" remember that there is some pain in many of our medical procedures, for example, having one’s tonsils removed so your explanation has to have more than just that)

C) Should the physician be concerned about alienating the mother and other people of her ethnicity from modern medicine? Why or why not?

D) Do you think that the physician should report the mother? What ethical theory supports your decision?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3)       Case Three:
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 3:

A)            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? Explain.

B)            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? What would support or not support such a difference ethically?

C)            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? Why or why not?

D)            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? What evidence, if any, exists to support this claim?

E)             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? Which ethical theory would you apply (not opinion or religious stance).

 

 

 

 

 

 

 

 

4)        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 4:       

A)       Do you believe that the physician’s actions can be justified in any way? 

       B)   Is there anything else that they could have done?      

C)       Is it ever right to take away someone's autonomy? (For example, Would a court order make the

physician’s decisions ethical?)      How could we ethically do so? Which theory (ies) support or deny this?

D)       What would you do if you were one of the health care workers? Again stick with ethical theories 

and not just opinions.

 

 

 

 

 

 

 

 

 

 

 

 

 

5)       Twenty-nine year old Janet and her husband Jack were driving home from her ob-gyn appointment when tragedy struck. Another driver, elderly and distracted by an incoming text message, ran a red light and T-boned Janet and Jack’s Mini-Cooper. Both young people sustained severe injuries. Jack died enroute to the hospital. Janet survives, having escaped injury except to her head; but that was unfortunately massive. Her physicians now say, a month after the accident, that the prognosis is grim. The best one could hope for—or perhaps the worst—is continuation for some time in a persistent vegetative state. Just before leaving the doctor’s office, Janet had sent a jubilant text message to her parents. “Guess what?! We’re pregnant!!! ”
 Janet had thought about mortality in advance of this accident. She is, or was, a nurse. She had gone to continuing education workshops about end of life care and advance care planning. Janet then had completed her own advance directives some months ago, naming Jack as her primary agent and durable power of attorney for healthcare decisions. She named her parents as secondary agents.Janet also had completed, with notarized signature, a healthcare treatment directive. Among her directives was a clear, handwritten statement about life prolongation if she were, somehow, “to end up in anything like PVS, from which I am not apt to recover.” Janet had written that, in such a condition, “I do NOT want my life to be extended by means of medically assisted nutrition and hydration, ventilator, or other life support.”
With Jack gone, treatment decisions are left up to Janet’s parents. They both are thoughtful people, healthcare professionals also, who take very seriously their difficult responsibility of acting as surrogates on Janet’s behalf. After consulting her physicians, other family members, and even their priest, a decision is made to stop everything except palliative care. Janet’s parents had received a copy of their daughter’s advance directives, and they have determined that this is what she would have wanted, what in fact she had conveyed with such tragic prescience. Plans are made to transfer Janet to a hospice unit in another part of the hospital. It would take place the following day.
That evening, a resident physician notices in the patient’s chart that Janet is pregnant. Probably about nine weeks, it appears. He wonders if this matters, legally or ethically or religiously, for his patient’s transfer to hospice, especially when Janet is not imminently dying otherwise. The resident does a bit of online research and learns that in the State of Kansas, a woman’s healthcare directives about “withholding or withdrawal of life-sustaining procedures in a terminal condition” may not legally be in effect while pregnant.
 “The declaration of a qualified patient diagnosed as pregnant by the attending physician shall have no effect during the course of the qualified patient’s pregnancy” (KSA 65-28, 103, (4)B).
A note in the patient’s medical record the next morning references this statute, with a question about how it potentially impacts the impending transfer to hospice care. When the attending physician reads the note, she calls Janet’s parents and says hesitatingly, “We have a bit of a problem here. It appears we may need some legal assistance, perhaps an ethics consultation, and must postpone Janet’s transfer of care.” The doctor explains further what her young resident colleague had discovered, and questioned.
 The parents had spent a sleepless night anticipating today. It would be the hardest thing they’ve ever done, and yet the right thing in keeping with their daughter’s wishes. Now they can’t believe what they’re hearing. Postpone? Ineffective advance directives? Continued life support? Did the doctor really say that? That there may even need to be surgery for a feeding tube and a tracheostomy while this legal glitch is being discussed and gets clarified? Almost in unison, Janet’s mother and father protest, “But, Doctor, our daughter didn’t want this!”

 

Answer these questions on case study 5:

a)        What should be done now for Janet and her parents, and on what grounds?


b)        What values underlie the statute making a pregnant woman’s healthcare treatment declarations of “no effect” while pregnant?

c)        Do you agree or disagree with this statute, and on what grounds?

d)        What decision would you be making as Janet’s parental surrogate, and why? Use an ethical theory here for support (not just your opinion or religious stance)

e)        Ought someone to be a surrogate for Janet’s foetus, or not? And why or why not?