Informed consent requires not only that a patient receive all of the information necessary to make a reasoned decision, but also that they are able to process and understand the information provided. Language or cultural differences may impede understanding, and a blanket reliance on a doctor’s judgment may subvert the intent of the disclosure. Other barriers to informed consent, such as denial, fear and even family dynamics are often more difficult to spot, but equally if not more detrimental. Relationships between patients, family members and healthcare providers often morph over time into roles and role reversals that present special challenges in healthcare ethics and the doctor-patient relationship. In this activity, you will consider the standards of professional responsibility, medical ethics and the doctor-patient relationship as they apply when the boundaries between the roles become blurred.
Related Reading from Module:
• Module Notes
• Munson text: pp. 46-47 (end at Parents & Children).
• AMA Opinion 10.01 – Fundamental Elements of the Patient-Physician Relationship
• Mitnick, S., Leffler, C., & Hood, V. (2010). Family caregivers, patients and physicians: ethical guidance to optimize relationships. Journal Of General Internal Medicine, 25(3), 255-260.
• Principles of Medical Ethics. (2001).
• Schwartz, P. H. (2011). Questioning the Quantitative Imperative: Decision Aids, Prevention, and the Ethics of Disclosure. The Hastings Center Report, (2), 30. doi:10.2307/41059016
Instructions to Learners:
Please read the case scenario:
Mr. and Mrs. Lovebird were approaching their 65th wedding anniversary when it was discovered that Mr. Lovebird was battling Stage IV lung cancer, with metastasis to his colon. Vowing to “Fight this thing!” the Lovebirds sought out the best specialists and Mr. Lovebird underwent two surgeries, chemotherapy and several rounds of radiation. Mr. Lovebird did quite well for a while, but lately he has experienced severe fatigue and discomfort. He has also lost his appetite, resulting in a 15lb weight loss in just two months. Concerned, the Lovebirds went to see Dr. Friendly, their primary care physician for over 30 years, whom they trust implicitly. Knowing that the Lovebirds are in denial to some extent, but also believing that medicine is an inexact science, Dr. Friendly told them both about an experimental treatment option that might be worth “checking into,” even though the chances were slim that it would provide much benefit.
At a dinner party for a mutual acquaintance, Dr. Friendly is approached by Lancelot, the Lovebird’s only child. Dr. Friendly is aware of the close relationship between Lancelot and the Lovebirds, so he is concerned for their welfare when Lancelot approaches him. Once alone, Lancelot appears upset and tells Dr. Friendly that he is concerned about the experimental treatment option Dr. Friendly mentioned to the Lovebirds, given Mr. Lovebird’s fatigue and weight loss. From Lancelot’s perspective, it is obvious that even if successful, it would only buy Mr. Lovebird a few months and those months may not be very good ones. He is also concerned that Mr. Lovebird is tired of treatments, but goes along to please Mrs. Lovebird. Dr. Friendly smiles and shakes his head “Your mother has always been a force to be reckoned with,” he says “But, in reality, a few months is better than no months!” He also assures Lancelot that if the Oncologist does not think Mr. Lovebird is a good candidate for the procedure, the Oncologist will tell them so.
When Lancelot suggests that Dr. Friendly’s professional judgment may be colored by the Lovebird’s denial, Dr. Friendly becomes defensive, stating that as their doctor all he can do is provide them with information and statistics on the disease prognosis and the benefits and risks of any potential options. He admonishes Lancelot, stating “if your parents want to believe in miracles, I am not going to take that away from them, and you shouldn’t either!”
Visibly upset, Lancelot insists that Dr. Friendly discuss the Hospice option with the Lovebirds, preferably with Mr. Lovebird, first. Although Dr. Friendly is concerned that the idea of Hospice could be more lethal to the Lovebirds than any experimental treatment, he agrees, on the condition that Lancelot raise it with the Lovebirds first. “If your parents seem open to the conversation, give me a call or have them call me, and I will sit down with them to discuss the options.”
The next day, Lancelot goes to see Mr. and Mrs. Lovebird, and shares his conversation with Dr. Friendly, telling them that both he and Dr. Friendly agree that it may be time for Hospice services. Both the Lovebirds become very angry that he was discussing them with Dr. Friendly without them knowing it. They are also devastated that Dr. Friendly would conspire with Lancelot to force a decision on them that is clearly premature. When he leaves, Mrs. Lovebird calls Dr. Friendly and tells him that she is furious with his breach of confidentiality and that he should stick to family practice, as he is not an oncology expert.
Please respond to the following questions (approx. 350-500 words) using the template format provided for the assignment:
Given Dr. Friendly’s longstanding relationship with the Lovebirds, his insight into their processing and coping mechanisms, and the close family relationship he has witnessed between the Lovebirds and their son, did Dr. Friendly’s breach his professional responsibility to Mr. and Mrs. Lovebird by suggesting that Lancelot discuss the Hospice option with the Lovebirds first?
Use the following template for your assignment:
1. Use Microsoft Word to create a document.
2. Copy/paste the title of the question.
3. Describe the most relevant ethical dilemma(s) presented (no more than two).
4. Briefly describe the primary issue or issues that are relevant in the scenario with respect to the dilemma.
5. Identify the most relevant stakeholder(s) (no more than 3) and briefly describe the situation from their perspective.
6. Analyze the dilemma, using scholarly discussion, from the perspective of the primary stakeholder (typically the patient). Include a discussion of at least two ethical theories or bioethics principles studied in the course that relate to the dilemma and issues you identified. Include any relevant legal concerns or requirements outlined in the readings.
7. Present your assessment, resolution or potential solutions for resolving the issue. Remember that there are no right answers, per se, so reflective questions can be as appropriate as a firm conclusion.
8. Title page + APA formatted reference(s).
Final Case Analysis: Morally Wrong or Ethically Challenging?
Introduction to the Activity:
Many states have considered enacting PAS legislation since Oregon first legalized the practice in 1994, but as of yet, only Oregon and Washington have laws allowing for Physician Assisted Suicide (PAS) 127.800; RCW 70.245). In Montana, although there is no current legislation regarding PAS, the Montana Supreme Court provided protection for doctor’s providing lethal medication to terminally ill patient’s upon request (Baxter v. Montana, 2009 MT 449). Currently, forty-three states have specific laws (either statutory or common law (case law) prohibiting assisted suicides, but four states (Hawaii, Nevada, Utah, Wyoming) and the District of Columbia have no law regarding the subject. Just recently, Massachusetts voters defeated a ballet initiative based upon the Oregon statute by a marginal 51% majority.
Related Reading from Module:
• Module notes and assigned textbook pages
• Arras, J. (1997). Physician-assisted suicide: a tragic view. The Journal Of Contemporary Health Law And Policy, 13(2), 361-389. (28)
• *The New York State Task Force on Life and the Law, (1997). When death is sought assisted suicide and euthanasia in the medical context supplement to report. Retrieved from website: https://wings.buffalo.edu/bioethics/suppl.html.
*Scroll down and read until the end of the passage “IV The Distinction Between Administering High Doses of Opioids to Relieve Pain and “Physician-assisted Death.”
• Public Health, (1997). Oregon revised statute: Death with dignity act (Chapter 127). Retrieved from Oregon Health Authority website: https://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/ors.
o rules: 127.800 s.1.01. Definitions – 127.875 s.3.13. Insurance or annuity policies.
• Dep’t of Public Health, Annual Report on Oregon’s Death with Dignity Act (2012)
https://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year15.pdf
*Scan through the report to get an idea on how the statistics are compiled and trends recorded
Instructions to Learners:
Please read the case scenario:
You are a physician-ethicist at Hope hospital in Nirvana, USA. Your state is voting this month whether to allow PAS, under the exact guidelines and safeguards instituted in Oregon. The local news station has asked you to join a televised multi-disciplinary panel and discuss the following questions:
Reviewing the safeguards included in the Oregon Statute, which one(s ) potentially raise the most concerns in terms of their ability to protect patients in Nirvana, USA? In developing your response, consider whether the concerns are morally founded or policy oriented. Also keep in mind the rules of professional responsibility, patient rights and the principles of bioethics we have studied throughout the course.
NOTE: Please use the modified template below when considering your response with respect to completing the template, remember that a stakeholder can be described as many entities, such as but not limited to an individual, a professional society, the public at large or a subset of the population.
Modified Template:
1. Use Microsoft Word to create a document
2. Copy/paste the title of the question
3. State the safeguards that you find most concerning.
4. Identify the most relevant stakeholder(s) (no more than 3) potentially affected by the safeguards you listed.
5. Analyze the concerns, using scholarly discussion from the perspective of the primary stakeholder. Include a discussion of at least two ethical theories or bioethics principles studied in the course that relate to the dilemma and issues you identified. Include any relevant legal concerns or requirements outlined in the readings.
6. Present your assessment, resolution or potential solutions for resolving the concern. Remember that there are no right answers, per se, so reflective questions can be as appropriate as a firm conclusion.
7. Title page + APA formatted reference(s)
Final Case Analysis: The Emily Dilemma – Abortion
Introduction to the Activity:
Recall, that an ethical dilemma can be defined as two morally acceptable choices, both of which will result in morally disturbing and unwelcome consequences. Often when we considering our position regarding an ethical dilemma, it is helpful to consider not only the issue presented, but whether we can justify our position based on an extreme, yet realistic set of conditions. Abortion is perhaps one of the most disturbing and confounding of issues for engaging in such an exercise, as it is sometimes difficult to justify the inconsistencies in our moral intuitions when confronted with situations that define an ethical dilemma.
Related Reading from Module:
• Module notes and assigned textbook pages
• Videos:
o Ankele, J. (Producer), &Macsoud, A. (Producer) (2010). Beyond the politics of life and choice: A new conversation about abortion (link available in Mod 7)
o Tsiaras, A. (Director) (2011, November 14). Alexander Tsiaras: Conception to birth — visualized TedTalks. [Video podcast]. Retrieved from https://www.youtube.com/watch?v=fKyljukBE70 (apprx. 10min)
o Iadarola , J. (Performer) (2012, November 25). Study: What happens to women denied abortions? The Young Turks. [Audio podcast]. Retrieved from https://www.youtube.com/watch?v=dWBjQ7P9SSs (apprx. 5 min)
Instructions to Learners:
Please read the case scenario:
Twenty year old Emily who suffers from Bi-polar disorder and Schizophrenia lives at home with her parents, but is fairly independent. Last year, Emily had a breakdown while living away at school and required hospitalization. Due to a complex mix of anti-psychotics, antidepressants and other medications to control her condition, Emily is now working part-time at a local bookstore and taking two classes at the community college. Emily loves children and hopes eventually to become a kindergarten teacher. Although Emily is on birth control pills, she had missed some days over the past few months during a brief ‘lapse’ in her mood, but insisted throughout that time that her boyfriend wear a condom. The condom failed at some point and Emily is now eight weeks’ pregnant.
Emily’s doctors insist that the baby is at an exceptionally high risk for severe physical and mental impairments, including incomplete limb and/or brain development. At best, there is no solid data detailing teratogenicity risk for all of her medications, but the combinations and inability to incorporate less harmful substitutes raise significant concern. Because she is within the first trimester, there are no legal concerns based on the Roe v. Wade decision so the doctors, her parents and her boyfriend are insisting that Emily have an abortion to spare the burden on the child. Emily, a devote Catholic, insists on carrying the baby and raising it once it is born. She has also personalized the arguments, finding that by devaluing the life of her baby, her family and others devalue her as well.
Emily’s parents have threatened to file for guardianship over her so that they can force the abortion, under their belief that she lacks decision-making capacity and the abortion is in her best interests. Although the doctors have no standing to join the suit, they have agreed to serve as expert witnesses for the parents. Emily’s boyfriend is considering petitioning the court–after the baby is born–for the right to be released from any parental responsibilities, given his lack of a position in the decision to abort.
Emily’s Psychiatrist, Dr. Heady is very troubled by the case both for Emily and for the developing fetus. Knowing that you are a famous ethicist, he contacts you informally and presents the case as a hypothetical, maintaining Emily’s confidentiality. Dr. Heady is unsure whether the parents can legally force the abortion, but he is troubled on a much more fundamental level, which is why he is seeking your counsel.
Please respond to the following questions (approx. 350-500 words) using the template format provided for the assignment:
Presuming that Emily has decision-making capacity, Dr. Heady would like to hear your thoughts on the following:
• Ethically, should Emily be able to reject the abortion in the first trimester, knowing that it is highly probable that continuing to take her necessary medications will severely and permanently impair the baby?
• In reflecting upon the question, recall the court’s arguments in Roe v. Wade, and any counter arguments provided in your materials. Also, consider the question of the fetus (encompassing all stages from conception through prebirth development) and the concept of moral standing.
Use the following template for your assignment:
1. Use Microsoft Word to create a document.
2. Copy/paste the title of the question.
3. Describe the most relevant ethical dilemma(s) presented (no more than two).
4. Briefly describe the primary issue or issues that are relevant in the scenario with respect to the dilemma.
5. Identify the most relevant stakeholder(s) (no more than 3) and briefly describe the situation from their perspective.
6. Analyze the dilemma, using scholarly discussion, from the perspective of the primary stakeholder (typically the patient). Include a discussion of at least two ethical theories or bioethics principles studied in the course that relate to the dilemma and issues you identified. Include any relevant legal concerns or requirements outlined in the readings.
7. Present your assessment, resolution or potential solutions for resolving the issue. Remember that there are no right answers, per se, so reflective questions can be as appropriate as a firm conclusion.
8. Title page + APA formatted reference(s).