Medical Ethics

DISCUSSION TOPICS

There are a number of questions and topics for discussion provided here related to each chapter.  They are intended to be suggestive of a range of questions that might be used in discussions in order to get at the central concepts and issues and principles presented in the chapter.  They are also intended to develop in the learner not only an understanding of some of the concepts but also the ability to analyze and reason and apply principles to situations.

Click on the chapter title to go directly to the topics for that chapter.

Chapter 1 Introduction
Chapter 2 Ethical Traditions
Chapter 3 The Moral Climate of Health Care
Chapter 4 Professionalism, Elitism and Health Care
Chapter 5 Ethics and Nursing
Chapter 6 Rights, Truth and Consent
Chapter 7 Human Experimentation
Chapter 8 Abortion
Chapter 9 Severely Impaired Newborns, Futility and Infanticide
Chapter 10 Care of the Dying
Chapter 11 Deliberate Termination of Life and Physician Assisted Suicide
Chapter 12 Genetics: Intervention, Control and Research
Chapter 13 Reproduction: Assistance and Control issues
Chapter 14 Ethnicity, Race and Gender issues
Chapter 15 HIV and AIDS: Related Issues
Chapter 16 The Allocation of Resources: Scarcity and Triage
Chapter 17 A Claim of a Right to Health Care
CONCLUSION
Chapter 1 Introduction
  1. Why not just go with your "gut feeling" when confronted with a situation that presents a moral dilemma? Why not use feelings as a guide for conduct?
  2. Would you want your physician and your nurse to behave in accordance with some principles for morality rather than just act on their feelings and impulses? Why or why not?
  3. What do you think should be done if what you want your doctor to do disagrees with the doctor's own preference?
  4. Suppose the doctor wants to continue a treatment and you do not? Suppose the doctor wants to amputate a limb and you do not want that done? Suppose the doctor wants to continue to keep you on a respirator and you do not want to continue to live in that manner?
  5. What justification can you provide for your position on this question?
  6. What issues do you want to raise related to this chapter?

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Chapter 2 Ethical Traditions
  1. A surgeon S promises someone P that S will perform an operation on P. The surgeon S has an associate A who needs to learn the new surgical technique used by S. S now is considering whether or not S should tell P that A will acually be doing the surgery. If surgeon S was an ACT Utilitarian how would S go about thinking about the right thing to do? If S were a RULE utilitarian how might S think about it differently?
  2. Physician D is treating someone S who is covered by Medicaid. Physician D thinks that Medicaid does not provide enough financial support for the services being rendered by D to S. Further D wants to do a procedure not covered by Medicaid under its rules which D believes to be antiquated and harmful. D is considering filling out the medical forms in such a manner that would supply financial support for what D wishes to do but in a manner that would not be providing accurate reports of what was actually done. If D is a Kantian and uses the Categorical imperative how would D think about this? What conclusions would be reached?
  3. A child C has a disease. It is life threatening. A bone marrow transplant might help to save the child's life. The child's mother M is having a hard time finding a matching donor for her child. M is getting desperate and is considering getting pregnant again in order to have a child that might be a compatible donor of bone marrow for her daughter C. If M were to ask for moral guidance from a Kantian what would that advice be?  What would a rabbi or priest advise using Natural Law Theory?
  4. Doctors at hospital H are asked to participate in the test of a new drug D that will cause people to expectorate the contents of their stomachs. It is to be used when people accidentally or deliberately ingest something that causes severe illness and threatens life. Now such a drug would most often be used in emergency rooms and with those who attempt suicide. The doctors are wondering whether or not to participate in the tests. If they do so they are expected to administer the drug D to those brought into the ER. People brought into the ER who would need to have the contents of their stomachs emptied quickly are likely to be those who have attempted suicide. Now the doctors are wondering if they can inform people who are to receive the test drug of the experiment and get their permission for participating in the test. If they do stop to inform them and get permission many of those people may not give it as they had wanted to die in the first place. Others may not be conscious and rational at a level that they can understand what is being told to them.   If the doctors were to use the principles of John Rawls how might they go about their deliberations? What conclusion would be based on Rawls principles?
  5. Doctor O performs corrective eye surgery using laser techniques. Doctor O has been doing so for a number of years. Doctor O advertises in a variety of media. Doctor O's practice is quite large and there are several offices throughout the neighboring counties. The doctor charges a premium price for the procedures because of the reputation the doctor has achieved and the large number of successful operations. Doctor O has taken several other physicians into the practice. People who contact the practice are told that there is a difference in the fee charged for each procedure depending on which doctor performs the operation. Those doctors with more completed procedures charge more. The founder of the practice, doctor O, having done the most , charges the most. $750 per eye for the novice physician and $4000 per eye for doctor O.
  6. Doctor O has a very large annual income and a very nice life style and so doctor O wishes to spend less time in the office and surgical room and more time enjoying life. Doctor charges people the full fee for doctor O's services but without informing the person having the operation the doctor often has another physician do most of the work, sometime all of it, if the person consents to being unconscious for the procedure. Doctor O sees nothing morally wrong with this practice. Doctor O enjoys the income, thinks the practice is good for the other physicians, and thinks that recipients of the procedure are happy with the results. Doctor O thus has no problem with what is going on. Morally doctor O thinks it is a "win win" situation and so quite right.   Doctor O is using what type of moral justification for the practice? Do you accept it? Why or why not? What do you think the doctor should be doing if you disagree with what is being done?
  7. What issues do you want to raise related to this chapter?

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Chapter 3 The Moral Climate of Health Care
  1. How is it that health care providers can often treat the recipients of care with less than respect and genuine concern? How does it happen that such indifference can arise?
  2. What harm can come from calling people "PATIENTS"? How does it happen?
  3. How is it that medical malpractice can occur as often as it does?
  4. What issues do you want to raise related to this chapter?

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Chapter 4 Professionalism, Elitism and Health Care

1. Do you agree that whether or not a physician or a nurse is operating out of a code or covenant model it makes a difference?  For example consider a physician or nurse observing a colleague make a mistake that leads to the injury of someone.

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2. A student preparing for a career as a nurse was working part time in the office of a proctologist. She told this tale to her class in Medical Ethics.

She was instructed by the office manager to clean the instruments used between services being performed by the physician. She was told to place them in a device and to set it on "RINSE". When she asked why not set the device to "STERILIZE" she was told that it takes too long and the doctor has need of the instruments again. In the beginning whenever she place the instruments into he device she set it to "STERILIZE". Her supervisor observed her doing so and then instructed her once again to set it on "RINSE". She asked: "Won't that put patients at risk of infection?" The answer was : "Yes it will . But , by the time they learn of the infection several days would have gone by and they probably won't relate it to their visit to this office."

The student went on working for that office and she attempted to set the device to "STERILIZE" whenever she could. She told the class this story and when asked by the instructor in front of the entire class for the name of the doctor so that the instructor could avoid that office if such services were ever needed by the instructor, the answer was : "Well I'll tell you after class but I do not want to day in front of everyone here."

How would you feel if you were a member of that class?

What is prompting her to continue to work at that office and accept the setting of the device on "RINSE" and subjecting people to possible harm of infection?

What model of the relationship of physician to recipient of care do you think the doctor holds? What is the model of their relationship to those whom they serve being used by the office assistants in this situation ?

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3. How should a doctor, nurse, EMT, or medical technician behave when they are not working and they encounter an accident scene with people who are injured?

Why?

What model of their relation to the injured parties do you favor?

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4. What issues do you want to raise related to this chapter?

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Chapter 5 Ethics and Nursing

1.  What do you think of the conflicts that arise in the myriad of relationships that nurses have to doctors, fellow nurses, administrators, recipients of care and the families of the recipients of their care? How are nurses to handle the conflicts?

2. A simple case: A family wants to know the condition of a 55 year old women who has been undergoing a procedure in the hospital. They crowd into her room and in the doorway and as the nurse enters and leaves family members ask many questions. The nurse is aware that the doctor accurately reported the diagnosis and prognosis to the care recipient but has misinformed the family.  What is the nurse to do and why?

How would someone respond to this situation and questions using the ethical principles of:

  • an Egoist
  • a Rule Utilitarian
  • a Kantian
  • a Natural Law Theorist
  • a Rawlsian?

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3. Consider: A newly hired nurse is assigned to the recovery room of a hospital that specializes in heart surgery. She is working there for a week when one evening a man in the recovery room is being closely monitored after surgery. The signs are not good. He recovers consciousness. The doctors inform him of the situation. They leave the recovery room.

The man calls the nurse over and asks for a pen and some paper. Thinking that he might die and do so soon he informs her that he needs to write a brief letter to someone. She finds pen and paper and gives it to him. He writes his note and writes the address and asks the nurse to send it out for him. She agrees. As she is taking the pen and papers back from him the recovery room supervisor enters and observes her. The supervisor calls her over and inquires as to what she was doing. When the newly hired nurse reported that she had assisted the man in writing a letter and took it to mail it for him , the supervisor responded that :

"It is not your responsibility to do such things."

The new nurse responded that she was simply trying to help the man and had agreed to mail the letter. The supervisor replied with: "This is not a post office!"

The new nurse repeated that she was only attempting to help the man. That he might die shortly. The supervisor wrote up the new nurse for subordination. The new nurse was dismissed form the hospital as she was in her probationary period.

What was the new nurse to do and why?  What ethical principles are you using in arriving at yur decision of what the morally correct action would be?

How would someone respond to this situation and questions using the ethical principles of:

  • an Egoist
  • a Rule Utilitarian
  • a Kantian
  • a Natural Law Theorist
  • a Rawlsian?

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4.  A newly hired nurse is being given orientation and training in the hospital by a senior member of the nursing staff. Assigned to a medical -surgical unit the nurse receives instructions on procedures. The nurse is instructed to "push Heparin IV" through a tube in the person's arm. The nurse when being trained in nursing program was instructed not to do so such a thing as it could have serious consequences. When the newly hired questioned the procedure that nurse was told by the senior nurse: "Look that is how we do it here, missy. We are understaffed and do not have the time to do it intravenously. If you want to work here that is how you will do it too."

What should the response of the new nurse be to this situation? Why? What ethical principles are you using in arriving at your decision of what the morally correct action would be?

How would someone respond to this situation and questions using the ethical principles of:

  • an Egoist
  • a Rule Utilitarian
  • a Kantian
  • a Natural Law Theorist
  • a Rawlsian?

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5.  What issues do you want to raise related to this chapter?

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Chapter 6 Rights, Truth and Consent

1.  From:  Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000  ., Page 451, Decision Scenario #1 

“I don’t want to be treated,” Alice Nuvo said.  “According to the statistics you gave me, even with the best treatment I’ve got no more than a five percent chance of surviving for another year.”

                “Pancreatic cancer is a bad customer,” Dr. Cervando Lupe said.  “I wish the numbers were better.”

                “So why should I suffer the pain and nausea of chemotherapy and then radiation if I’m going to die anyway?”  Alice snorted in contempt.  “It’s absurd.  I’d rather spend the remaining time with my husband and two daughters, then die in peace, instead of puking up my guts in some hospital.”

                “We can use drugs to control the nausea from the chemotherapy,” Dr. Lupe said.  “Wand we don’t know that the statistics apply to you.  They apply to a whole group of people, and I never tell a patient that she has a five percent chance.”

                “Just give me something to control the pain and let me go home,” Alice said. “I don’t want to talk about it anymore.”

Should Dr. Lupe continue to urge Alice to have the treatments? Should Alice be forced to undergo the treatments?

How would someone respond to this situation and questions using the ethical principles of:

  • an Egoist
  • a Rule Utilitarian
  • a Kantian
  • a Natural Law Theorist
  • a Rawlsian?

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2. From:  Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000  ., Page 454, Decision Scenario #6

“You realize that I talked to him for only fifteen or twenty minutes,” said Dr. Susan Beck.

                “Yeah, but you psychiatrists are supposed to be able to size up a guy just by listening to how she says hello,” Dr. Mark Brunetti said.

                “Tell me more about him,” Beck said.

                “His name is T.D. Chang.  He’s fifty-two years old, a professor of Asian history at Southwestern University.  He’s married, has two children in college, and has a solid scholarly reputation.”

                “What was his complaint?”  asked Beck.

                “About a month ago he began to experience difficult and painful urination.  His doc examined him, found he had an enlarged, knobby prostate and a wildly elevated PSA.  His doc sent him here, and we’re doing a biopsy in the morning.”

                “And you want me to tell you how he’ll take it if you tell him you suspect cancer?”

                “Right,” said Brunetti. 

“I think he would take it all right.  He shows no tendency toward hysteria, and his background reveals him to be a person who functions well under normal conditions of stress.”

                “Good, then if I have to tell him, I won’t worry about it.”

“Mark, do you mean you’re not going tot ell him?”

“Not until I know for sure.  It’s a kindness to him. What he doesn’t know won’t hurt him, and there’s no reason to cause him unnecessary anxiety. ”

                “I don’t think I agree with that decision,” Beck said.  “I think a man like Br. Chang has a right to know as much about his condition as you do.”

                “That’s silly,” Brunetti said.  “He can’t possibly know as much as I do, and he wouldn’t  know what to make of the information even if I gave it to him.  He would probably figure he’s going to die in the next hour.”

                “So you aren’t going to tell him what you suspect or why you’re doing the biopsy?”

                “I’m not that cruel.”

Should Mr. Chang be informed of his condition, the possibilities and the reason for further tests?

How would someone respond to this situation and questions using the ethical principles of:

  • an Egoist
  • a Rule Utilitarian
  • a Kantian
  • a Natural Law Theorist
  • a Rawlsian?

 

3.  From:  Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000  ., Page 457, Decision Scenario #12 

“Sometimes I think that what I really want to do is to kill people and drink their blood.”

                Dr. Allen Wolfe looked at the young man in the chair across from him.  The face was round and soft and innocent looking, like that of a large baby.  But the body had the powerful shoulders of a college wrestler.  There was no doubt that Hall Crane had the strength to carry out his fantasies.

                “Any people in particular?”  Dr. Wolfe asked.

                “Women.  Girls about my age.  Maybe their early twenties.”

                “But no one you’re personally acquainted with.”

                “That’s right. Just girls I see walking down the street or getting off a bus.  I have a tremendous urge to stick a knife into their stomachs and feel the blood come out on my hands.”

                “But you’ve never done anything like that?”

Crane shook his head. “No, but I am afraid I might.”

                Dr. Wolfe considered Crane a paranoid schizophrenic with compulsive tendencies, someone who might possibly act out his fantasies.  He was a potentially dangerous person. 

                “Would you be willing to take my advice and put yourself in a hospital under my care for a while?”

                “I don’t want to do that,” Crane said.  “I don’t want to be locked up like some animal.”

                “But you don’t really want to hurt other people, do you?”

                “I guess not,” Crane said.  “I haven’t done anything yet.”

                “But you might,” Dr. Wolfe said.  “I’m afraid you might let yourself go and kill someone.”

                Crane smiled.  “That’s just the chance the world will have to take, isn’t it?”

 

Should Dr. Wolfe have him committed? Should Dr. Wolfe inform the authorities?

How would someone respond to this situation and questions using the ethical principles of:

  • an Egoist
  • a Rule Utilitarian
  • a Kantian
  • a Natural Law Theorist
  • a Rawlsian?

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4.  What issues do you want to raise related to this chapter?

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Chapter 7 Human Experimentation

 

What issues do you want to raise related to this chapter?

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Chapter 8 Abortion

 

What issues do you want to raise related to this chapter?

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Chapter 9 Severely Impaired Newborns, Futility and Infanticide

 

What issues do you want to raise related to this chapter?

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Chapter 10 Care of the Dying

 

What issues do you want to raise related to this chapter?

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Chapter 11 Deliberate Termination of Life and Physician Assisted Suicide

 

What issues do you want to raise related to this chapter?

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Chapter 12 Genetics: Intervention, Control and Research

 

What issues do you want to raise related to this chapter?

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Chapter 13 Reproduction: Assistance and Control issues

 

What issues do you want to raise related to this chapter?

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Chapter 14 Ethnicity, Race and Gender issues

 

What issues do you want to raise related to this chapter?

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Chapter 15 HIV and AIDS: Related Issues

 

What issues do you want to raise related to this chapter?

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Chapter 16 The Allocation of Resources: Scarcity and Triage

 

What issues do you want to raise related to this chapter?

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Chapter 17 A Claim of a Right to Health Care

 

What issues do you want to raise related to this chapter?

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CONCLUSION

1. OK, here we are at the end of the semester.  What does Medical Ethics now mean to you and why?  Is it any good at all for anyone?  What has it meant to others through time? 

2. What can we do to make this course better and why do you think so?

What seems to work well, the best, the least?  Try not to rate things by the amount of work involved.  Please attempt an evaluation based on its effectiveness in assisting you to achieve the learning objectives or intended outcomes.  We know that the course required a great deal of time, effort and labor on your part.  Here is where we can express whether the labor was worth it in terms of contributing to the goals for the course. Those goals were set by both the instructor and the students.  For those of you who wanted to take a course like this because you wanted to learn about how others thought about things,  etc...  Did you get to learn about such things?   For those of you who were looking to find answers to questions are you now in a better position to go about that task?  

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© Copyright Philip A. Pecorino 2002. All Rights reserved.

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