The following are papers written by students at Mercer University School of Medicine, either as senior papers on ethical issues encountered during their MUSM experiences, or during elective rotations in senior year ethics. More papers could have been posted but space is limited, so only those papers illustrating particular issues in medical ethics are included. Efforts have been made to eliminate information identifying patients, but if we have missed something please let me know at email@example.com.
Students have given permission for their papers to be posted on this site.
Futility of Care – Whose decision is it, anyway?
Narayana Varahabatia writes of a 64-year-old woman whose course following a laparascopic cholecystectomy deteriorated to where she was placed on a ventilator and the prognosis was extremely poor. The central ethical issue was whether her previously stated wishes to do everything possible should have been overridden given the futile nature of continued support. When should surrogate decisionmakers make a decision contrary to the expressed wishes of the patient?
Maria Gorokhov presented the story of a 22-year-old woman with terminal ovarian cancer. As her condition worsened, a decision was reached regarding transfer to an intensive care unit. Family members wanted "everything done" whereas physicians saw transfer as futile. How should this be resolved?
Jane Inhulsen points out in her case that futility of care issues are not restricted to adults at the end of life, and that questions regarding future quality of life need to be considered in light of data on outcomes. The outlook may not be as bad as it might seem.
Doctor-Doctor and Doctor-Trainee Relationships
Neal Passantedescribed a situation uncomfortable to most physicians: when should physicians who become aware of a serious error on the part of another physician disclose that error to the patient or family, i.e., when should the "White Wall of Silence" be breached?
Matthew Golden encountered a situation during his fourth year where a 62-year-old man with a retroperitoneal malignant fibrous histiocytoma. Unfortunately, though the chief resident and other house staff felt strongly that the mass was unresectable, and had serious doubts whether the patient could survive surgery, the attending had instilled hope in the patient that the tumor was resectable. What is the proper role for trainees when such differences of opinion exist?
M. Neil Woodall asks what a student should do when asked by a resident to perform a rectal exam on a patient must insists on no further tests.
Audra Morabito wrote of a 16-year-old girl who suffered a fractured femur in a motor vehicle accident. As a result of blood lost as a result of the accident, there was concern that she might need a transfusion during surgery to repair the fracture. The girl expressed a wish for a transfusion, but her mother was adamantly opposed. Decisions involving minors nearing the age of majority are always tricky, never more so than when they pose questions involving both physical as well as spiritual health.
George Hotz gives an example of an adult Jehovah's Witness, a 23-year-old woman with sickle cell anemia who was involved in a motor vehicle accident and who had previously expressed a wish not to receive blood. There was no advance directive and she was not conscious at the time a decision needed to be made regarding transfusion. Family was consulted, and they agreed the patient should not receive a transfusion. She died the next day. What would you have done under the circumstances?
HIV, AIDS, and Confidentiality
Misty Poole described a 24-year-old man who presented with complications arising from AIDS, about which his family knew nothing. He was specific that the team not tell the family of his AIDS, a request to which the team tried to adhere despite obvious concern expressed by the family and requests for information. The family surmised his condition upon learning of the attending's specialty (infectious disease). What else could have been done to protect confidentiality? Or preserve trust?
Fit to be a mother?
Alexa Y. Chai wrote of a 34-year-old woman, approximately 25 weeks pregnant, with a history of schizophrenia, depression, and occasional homelessness, whose urine drug screen is positive for cocaine and marijuana. The resident in charge of her care states that the patient is unfit to be a mother, and that society will have to pay for her children. He proposes to her that she have a bilateral tubal ligation at the time of delivery. Explanations of the reasons for this, benefits, risks and alternatives are minimal. Is the issue a conflict between autonomy (her right to more complete disclosure about the procedure and alternatives) and social justice (fair distribution and utilization of healthcare resources)?
Geri Justice asks when patient autonomy should no longer be the deciding factor in the case of a 22-year-old young woman requesting a primary elective Cesarean delivery. This case is especially timely in the face of the mother in California who chose to be implanted with six embryos despite having six other children already.
Robert Lott wrote of another schedule Cesarean delivery, but, in this case, the issue was whether it was proper to remove a skin growth on the patients abdomen without her prior consent. Does the physician's obvious desire to act out of beneficence outweight the patient's desire for autonomous decisionmaking?
Jared Shell described a case of a young man with carpal tunnel syndrome, for whom the surgeon recommended endoscopic surgical release. The issue in the case is whether physicians allow subtle biases, e.g., for surgical over non-surgical options, to influence the manner in which we present information to patients. How can we be more alert to this?
Shaefer Spires also questioned how far physicians should go in influencing patients or surrogate decisionmakers in the case of a 40-year-old woman who was incapacitated from multiple medical decisions, and whose husband was faced with deciding whether to proceed with bowel surgery having a 5% chance of survival.
Kala Cartwright asks how far we should go in accepting the decision of an incompetent patient to refuse medically life-saving treatment, ultimately including food. Should the family's willingness to accept the patient's refusal, despite his obvious lack of competence, be sufficient to override a decision to force basic supportive care?
Nicole Briley gives a nice summary of Georgia law around surrogate decisionmaking as it applied to the case of a young man with AIDS and possible PML whose mother was faced with a difficult decision regarding possible brain biopsy.
Jennifer Heer Ford reminds us of how painful, but necessary, it is to deliver "bad news" that may be part of informed consent. Can this duty be relegated to others? Tricia Lee presented another case where the presentation of bad news to a patient, over the wishes of the family, was the central issue. In some cultures the family is the "patient" – should more consideration be given to family's wishes? How do we balance this with respect for patient autonomy?
Jason Tully tells the story of 46-year-old woman whose care was compromised by her insistence on smoking. How far should physicians go to get cooperation with other parts of a treatment plan?
Brooke Newman described the case of an 83-year-old woman with Alzheimer's disease with a small bowel obstruction who was presented with the choice of proceeding with bowel surgery having a poor prognosis. Under circumstances where the proposed procedure high risks and a low probability of success, should marginally competent patients be allowed to refuse?
William McRae gave an example where a conflict between the treatment team and the patient over proposed surgery for a gangrenous foot was resolved through patience and the involvement of family, leading to a good clinical outcome for all.
Meg Gossett has given us a very nice review of ethical issues in the use of preimplantation genetic diagnosis. This will doubtless become an ever more visible topic for clinicians and ethicists.
Minor's and Informed Consent
Carrie Sidwell tells us about Ryan, a 16-year-old boy with cystic fibrosis who is facing the prospect of a double lung transplant. He objects, but his mother wants to go ahead. How should the team proceed?
Shae Evans wrote of a 16-year-old with an ectopic pregnancy facing surgery who did not want her mother to be told. How would you handle this?
Empathy and Impartiality in Healthcare
Heather Friedman writes of two patients – both victims of gun shots, but one has been shot by police while the other is the victim of the first patient. How can we overcome our natural response to provide better care for one over the other?
Brad Hobbs wrote about a 33-year-old man who had overdosed on Darvocet and who was refusing potentially life-saving treatment with Mucomyst. Should a lucid patient be able to refuse such treatment, or should involuntary treatment with Mucomyst be started? Matthew R. Barton described another situation where our capacity for empathy would surely be challenged – a 69-year-old man who killed his wife before shooting himself. His injuries would require what staff called a "million dollar workup, just so he can go to prison." Should such considerations play a role in our care, especially when the injury was self-inflicted?
It is stressful to deliver bad news, particularly regarding a terminal illness. Can this be left to residents or other health care staff? Jennifer Heer Ford discusses this Ford case analysis.
Essay on Medical Ethics
Medical practitioners are people who help us cure our sicknesses. They studied for many years just to acquire all the knowledge they have. They have different specialties designated for different types of diseases. Medical practitioners are the most reliable health care personnel to assess and treat disabilities and diseases that are either caused by both internal and external. Some of us may think that their profession is perfect because they can do anything and everything they want worth their patients, but the people in the medical field also have to follow proper ethical procedure.
Medical or health care ethics has different versions. During the Byzantine era, there was a manuscript where Hippocratic Oath Medical or health care ethics is considered as moral principles that apply values in the practice of clinical medicine and scientific research. The medical or health care ethics applied to the concepts of health care setting. The application and significance of ethics are based on the set of values that the professionals can refer to when they experience either a conflict or confusion. The values that are included in the medical or health care ethics are respect for the concepts of beneficence, autonomy, justice, and non-maleficence. Medical or health care ethics was first understood and applied in 1803 by academic researchers. Thomas Percival was a medical practitioner who published a book that describes the expectations and requirements and professional expectations in the medical field. Code of Ethics began to be understood and then started to spread worldwide. The concept has been amended; however, many academic professionals kept the essence of Percival’s written document on medical or health care ethics.
The medical or health care ethics has at least four basic principles. These are justice, beneficence, autonomy, and non-maleficence. These four principles are essential to evaluate the difficulties and merits to health care procedure and expenses. Autonomy requires that the patient should provide their full consent when making decisions about their health care condition. The medical practitioner should always ask for the patient’s consent before addressing a procedure. The decision of the patient must not be affected by the medical practitioner’s persuasion and it must always be his or her personal decision. The patient is informed about the expected consequences and risks after the procedure. The next principle is justice. This states that all the new medical information is always available to the public. The medical practitioner should not partake in discrimination and share the information whether the patient is either poor or rich. Justice applied to considering a fair distribution of scarce resources, competing needs, rights and obligations, and potential conflicts with established legislation. All the technologies should be available for all in order to diminish medical dilemmas. Beneficence requires that all medical procedure provided for the patients should all be beneficial. The health care providers should also update their knowledge, skills, and training in order to fit in the demand of the evolving world. In all circumstances, the medical practitioner should strive for the benefits of his or her patients in order to give them quality service. The last one principle is non-maleficence; this requires the health care provider to do his or her best to not do any harm to the patient or anyone who is involved. If harm cannot be fully diminished, it is their duty to, at least, minimize it by pursuing the greater good. Some assistive reproductive technologies have limited success rate, so it is sometimes difficult for the medical practitioner to apply the “no harm principle.”
Principles of medical ethics always serve as a guide for the medical practitioners to fulfill their duty. Ethical standards provide a basis to prevent committing errors in their career. Medical ethics is very important because it helps medical practitioners save their patients in the most critical operations. The code is a written and used as a living testament that is always available to be edited by medical practitioners and researchers.