ISSUES IN HEALTHCARE (HSM604)

OCTOBER 2021 - FEBRUARY 2022

GROUP ASSIGNMENT: CASE STUDY

GROUP: 
BA235 5A 

DATE OF SUBMISSION: 
30 DECEMBER 2021

PREPARED FOR: 
DR. NAFFISAH BINTI MOHD HASSAN

PREPARED BY:

NO. NAME STUDENT ID

1. MUHAMMAD HAFIZ BIN ZAINI 2019468818

2. NOR SYAFIQA BINTI MUHAMMAD 2019853666

3. NURAMALIN SYAHIRA BINTI SUFFIAN 2020980559

4. NURUL ASHIQIN BINTI MOHAMED RODZI 2020985779

5. NURUL IRDINA AINAA BINTI ABDULL 2020977439

HARIS

BACHELOR OF HEALTH ADMINISTRATION (HONS.)

 FACULTY OF BUSINESS MANAGEMENT

Case study One: Our Pregnant Daughter Didn't Want This

By Tarris Rosell, PhD, DMin

1. What should be done now for Janet and her parents, and on what grounds?
Janet should indeed be kept alive on life support until the end of her pregnancy and
the birth of the baby. For Janet's parents, they should be urged to take legal action or consult
with the health proxy who is aware of the underlying difficulties. This is because the case has
proceeded to a new tier, which demands a new interpretation. A regulation which somehow
prevents Janet from obtaining hospice care because she is pregnant which means it is
exceptional and needs proper interpretation. When the law is redone, proper preventative
measures will be realised (Torke, Sachs, Helft, Montz, Hui, Slaven & Callahan, 2014). The
interpretation of the law will decide whether Janet is kept on life support long enough to give
birth to a healthy new-born baby.
However, this decision should be based on two grounds which is first, the law, as the
resident doctor pointed out that a pregnant woman is not allowed to carry Do Not
Resuscitated (DNR) and may not legally be in effect while pregnant. Second, the facts of this
case, which are Janet's requests, should be followed as stated in DNR but with the advance of
the medical technology, it will keep the foetus alive and it would not have to die along with
her mother. According to a 2010 study, there are only thirty reported cases where such after
death gestation has occurred using life-support technology thus far, with twelve viable
foetuses successfully brought to term and only one of those foetuses experiencing deformities
at birth. Therefore, regarding the interpretation of the law, Janet's parents have an important
role in making decisions for her.

2. What values underlie the statute making a pregnant woman's healthcare treatment
declarations of "no effect" while pregnant?
When one is pregnant, the underlying values are connected with health care concerns.
The values indicate that pregnancy should be prioritised, rendering other contingent services
to have “no effect” (DeMartino, Dudzinski, Doyle, Sperry, Gregory, Siegler & Kramer,
2017). “No effect” means the law prohibits your healthcare directive from taking risks while
you are pregnant. The healthcare practitioners are normally expected to follow your desires as
expressed in your healthcare contracts, but pregnancy is an exception. On the other hand,
some jurisdictions' laws prohibit doctors from withdrawing or withholding life support from a
pregnant woman or from withholding such care if the foetus may be carried to term. Hence,
the unborn foetus’s life, which is yet unable to make any decision on its own, is more
important and precious. 
Besides, if a pregnant woman in a persistent vegetative state does not specify in her
advance directives what her end-of-life desires are in the case of pregnancy, but does declare
that she intends to discontinue life-sustaining care, state law should not automatically void
the advance directives. Instead, the law should presume that the woman wishes to forego
medical care even throughout her present pregnancy. This assumption of refusing medical
care despite the woman's pregnancy may therefore be overcome by showing proof that the
woman would have changed her mind if she had known she would be pregnant at the time a
decision about life support suspension was required.
3. Do you agree or disagree with this statute, and on what grounds?

This statute does not sit well with me. According to Flanagan (2020), there is a clear
conflict between state pregnancy exclusion laws and bioethical principles that suggest
physicians could perhaps respect advance health care directives, or at the very least permit
health care agents or close relatives to make major decisions based on prior knowledge of the
patient's wishes. Janet clearly stated in the case study that she does not want her life to be
prolonged through medically assisted nourishment and hydration, a ventilator, or other forms
of life support. Janet's parents, acting as secondary agents and surrogates on Janet's behalf,
have also decided to put an end to everything, believing that this is what Janet would have
wanted.

Furthermore, the American College of Obstetricians and Gynecologists' Committee

on Ethics has mentioned that health professionals should support a pregnant woman's
personal freedom and choices whenever legally possible, and that the health care facility
should not attempt to override her wishes, whether she expresses them directly or through a
surrogate decision maker (Flanagan, 2020). The professional organisations assert more,
respecting the rights of the pregnant mother who is the primary patient must take priority
over the delivery of the foetus in ethical deliberations. Finally, it is argued here that if the
pregnant woman provides explicit instructions regarding discontinuing life support in the
event of loss of competency, physicians should obey her instructions, particularly if the
foetus is during the first and second trimester (Wall, 2021).

4. What decision would you be making as Janet's parental surrogate, and why?

         Janet's decision to halt medical treatment, as expressed in her healthcare treatment
directive, would be respected by me as Janet's parental surrogate. This is because acting
against Janet's requests would be a violation of her human rights, especially in circumstances
where a woman has explicitly conveyed her end-of-life wishes during pregnancy. According
to Flanagan (2020), state law should not automatically invalidate advance directives even
though if a pregnant woman in a persistent vegetative state does not specify in her advance
directives what her final wishes would have been in the case of pregnancy, but it does state
that she intends to remove life-sustaining care. Therefore, the law should consider that the
woman wishes to avoid medical care even if she is now pregnant.

Furthermore, when a physician disregards a pregnant patient's advance directives, not

only does this inhibit the woman from dying a natural death, but the forcible use of
technology to keep the foetus alive may also cause the woman's body to deteriorate, causing
additional pain and grief to her surviving family and friends (Flanagan, 2020). Besides,
maintaining Janet on life support until she is delivered, assuming a successful pregnancy, is a
purposeful act of planned orphanhood (Wall, 2021). One can wonder if it is in a child's best
interests to live in and serve as a memorial to her deceased and artificially preserved mother.
In the case of post-mortem reproduction, it is believed that substantial psychological
counselling should be provided and that the future child's psychological well-being must be
considered (Wall, 2021). As a result, it is in Janet's surrogates' best interests to protect Janet's
preferences to avoid negative consequences for both the primary patients and the future child.

5. Ought someone to be a surrogate for Janet's foetus, or not? And why or why not?

When someone is ought to be a surrogate for Janet’s foetus can be called surrogacy, a
process in which a woman agrees to bear a baby for someone else and then transfers care and
guardianship to the original parent when the baby is delivered (Patel et al., 2018). It is
feasible to find a surrogate mother for Janet's foetus. This procedure, however, might be
controversial. Surrogacy, according to Patel et al. (2018), has sparked numerous ethical
arguments in the past. When women are paid to be pregnant and deliver infants, the main
ethical concerns highlighted in the surrogacy process are about exploitation,
commercialization, and coercion, notably when there are huge economic and power
disparities between original parents and surrogates.

Surrogacy also introduces a new level of psychological complexity, necessitating a

multidisciplinary approach (Patel et al., 2018). This is because both the surrogate mother and
the original parents must contend with negative sentiments toward the surrogacy process
(Ruiz-Robledillo & Moya-Albiol, 2016). Surrogacy was considered the least appropriate way
to have children in one of the early research (Dunn, Ryan, & O'Brien, 1988), that could
influence the psychological of the surrogate mother, original parents, and offspring
(Krishnan, 1994; Weiss, 1992), and most survey respondents disagreed of the process
(Krishnan, 1994; Weiss, 1992). On the other side, a woman's right to enter into a contract and
make choices about her own body is a counter-argument. Therefore, it is possible to find
someone to be a surrogate for Janet’s foetus if there is consent from the surrogate’s mother
and the original mother, Janet.

Case Study Three: The Wanted, Unwanted Doctor

By David Emmott, MD, and Helen Emmott, Rn

Bioethics forum 16 (3)

Case by David Emmott, MD, and Helen Emmott, Rn.
Discussion questions compiled by Robert Potter, MD, PhD.
 
 
Discussion Questions:
 
1. What makes this a difficult patient-physician relationship? What beliefs and
preferences are in conflict between Dr. Clarke and Mary Jo Hoffman?

     One of the reasons this has made a difficult patient-physician relationship is

because of  failures of communication between patient and physician Dr Clarke and
Mary Jo Hoffman. Dr Clarke failed to recognize the needs and expectations of
patients, and failure of physicians to recognize the symbolic or phenomenological
aspects of their patients' illnesses. Dr Clarke should send written notice to Mary Jo
Hoffman by certified mail and return receipt requested. He also should continue to
treat the patient until she has a reasonable time to find an alternative source of care. In
addition, Dr Clarke cannot ethically or legally turn away a patient who is in an
emergency situation as reported that Mary Jo Hoffman would have less than a 25
percent chance of living two years. If the physician is unable to adequately treat the
patient, then Dr Clarke should call for emergency assistance from paramedics or other
hospitals.
      The amount of time necessary may depend upon such factors as the acuteness of
the patient’s medical condition, the availability and accessibility of alternative care,
and the patient’s ability to afford such care.
 While physicians do have discretion as to whether to provide services to any
particular person, they should be aware that there are legal and ethical constraints on
the scope of that discretion such as contractual obligations and non-discrimination
laws.
    Some doctors label patients difficult if they appear uninterested in the doctor's
diagnostic opinion. In that context, patients look up their symptoms and diagnoses on
the internet because they want to anticipate the tests and treatments that are likely to
be recommended.

 
2. Was Mary Jo Hoffman being "difficult" by not agreeing with the doctor's
recommended therapy?

   Yes, Mary Jo Hoffman being "difficult" by not agreeing with the doctor's
recommended therapy. It is shown that Mary Jo Hoffman and her husband are more
trusting of research on the Internet and had made up their minds to seek alternative
and holistic care. She also claimed she felt better after going to a health spa in the
Caribbean where a special diet, acupuncture, meditation, and yoga were used to
cleanse the spirit, mind, and body. From the perspective of Dr Clarke, she is a patient
who is noncompliant. A patient who is noncompliant happens when a Mary Jo
Hoffman patient poses a unique problem because  she may not be able to understand
the need for treatment. 

3. What authority does the Internet exert on the belief system of Baby Boomers?
Does the fact that the bladder tumor is completely invisible and produces few
symptoms, while the Internet is totally visible and convincing, have any influence
on the patient's preference to follow the Internet?

    There is such an authority related to the Internet on the belief system of Baby
Boomers. The Baby Boomers are using Google and other internet stuff for their
medical advice instead of asking their respective doctor. They believe by doing so,
they can save their  money and wealth for other stuff since baby boomers came from
generations of the economic hardships and uncertainties of the Great Depression and
World War II. In addition, the baby boomers also tend to believe medical advice from
least accurate websites such as blogs where it can be found to be only accurate 30% of
the time. 

 
4. Did Dr. Clarke do all that he ethically could to persuade Mary Jo Hoffman to
agree with his recommendation?

       No, Dr Clark did not understand Mrry Jo Hoffman's belief and was being harsh to
her.  As an adult patient, Mary Jo Hoffman has a moral and legal right to make
decisions about her own health care, including the right to refuse treatment that may
be life-saving. As a physician, Dr Clark has to explain politely and clearly to his
patient  the possible and probable outcomes of refusing the proposed treatment. He
should attempt to understand the basis for the patient's refusal and address those
concerns and any misperceptions the patient may have. 
5. Would it have been more persuasive to show the patient pictures of the bladder
disease, consult with both the patient and her husband together, insist on
referral to another urologist, or refer to other specialists?

     Yes, for this case Dr. Clarke needs to be more persuasive to patients and her
husband by showing them the picture of the bladder disease. It is to ensure that the
patient and her husband put their trust on the treatment that will be given to treat the
pain because a better doctor-patient relationship is link to the behaviour and their
health status (Auerbach et al., 2002) and also physicians’ empathy is related to their
patient’s health conditions. (Wodskou et al., 2014). He also needs to refer and consult
with another urologist or refer to other specialists by making sure that the big
mistakes do not happen. The decision made by the doctor and another specialist must
be agreed upon to convince them because there is a study from Parchman et al.
(2010), participatory decision-making encouraged patient activation, which led to
greater medication adherence and improved health status. 

6. Would Dr. Clarke have been more ethical if he had not reported the second
biopsy over the phone, but rather talked to the patient in person? Why did he
not call on the patient's primary doctor as an ally?

      No, Dr Clarke needs to be more ethical by reporting it to the second biopsy for
further action and should encourage the patient to do the treatment. He should enlist
the help of the patient's primary care physician and ask the second biopsy about Mary
Jo Hoffman’s history related to the cancer. Dr Clarke has to persuade the patient to
come to the hospital to explain details about it because better communication between
physicians and patient can change their decision. According to Cals et al, (2009)
showed that better communication skill will give results in less prescription of
antibiotics among their patients while Moffat et al., (2006) stated that poor
communication between physician and patient could lead to illness severity because
the patient does not take their health status.

7. Did the doctor's reluctance to tell the patient the truth about his beliefs
compound the difficulties in this relationship?

       Yes, the doctor should tell the patient the truth because if she believes in
alternative and holistic care, it could give an impact on having a serious illness. Her
husband should support the decision that was made by the physician to help her wife,
Mary Jo Hoffman. Being honest as a doctor is associated with respecting their patient
because has capable of making decisions to determine the action and managing the
patient. Giving patients the right information is a way to enable them to make the
right decisions about their health conditions because, without this knowledge, patients
can make the right decisions themselves. The patient must be suffering from must be
treated immediately because needs to be given immediate treatment as it is very
dangerous to her life.  

8. Did the doctor make an adequate effort to understand the patient's point of
view?

      No, Dr Clark did not make an effort to understand Mary Jo’s belief.  In order to
administer the highest quality of care, health care delivery needs to integrate the
needs, beliefs, characteristics, and experiences of the patient. As a result, patients will
 be more on board to adhere to the treatment plan if they believe their physicians
understand their perspective and experience. In this situation. Dr Clark should at least
do some research about the treatment that Mary Jo will undergo. Dr Clark can then
negotiate an agreement that respects Mary Jo’s cultural framework while still
providing for her the kind of plan she needs. 
Was anger an appropriate emotion for the doctor to feel or express? Did the
patient feel any anger toward the doctor?
       As someone who regularly deals with the public, Dr Clark should professionally
manage his short temper as he needs to gain patient’s trust. Furthermore, to build
good patient-physician relationships Dr Clark needs to greet his patient and approach
them in a way that is natural and fits the individual situation. 

10. Was Dr. Clarke being manipulative when he announced that he could no longer
be Mary Jo's doctor? Was it reasonable of the patient to assume that Dr. Clarke
would continue to be her doctor if she would not take his advice? Does the
rejection of the doctor's recommendation also mean rejection of the patient-
physician relationship?

      Yes, based on our reading, Dr Clark is being manipulative to Mary Jo because he

wants to change his patient’s behaviour. For Mary Jo, yes it is reasonable for her to
not be aware in this situation as Dr Clark did not give appropriate notice for his
refusal. Moreover, according to the American Medical Association (AMA) (2008)
Code of Medical Ethics, patient-physician relationship is considered established when
a physician starts to provide medical care for a patient, by mutual consent, implied
consent (emergency care) or, rarely, without consent (a court order). For  reasons such
as  failure to keep appointments, refusal to undergo recommended testing or
behaviour that is offensive or dangerous, physicians are allowed to terminate or reject
to treat the patient. However, they must offer the patient a valid reason through  a
written notice for their termination. (CMA’s California Physician Legal Handbook,
2006) In the case discussed above, Dr. Clark and his patient, Marry Jo, have clearly
established a patient-physician relationship, and it is permissible for Dr Clark to reject
as Mary Jo refuses to do suggested treatment. Anyhow,  Dr Clark should provide an
advance notice of the specific reasons for his termination so that Mary Jo will
understand her actions can cause termination of the patient-physician relationship. 
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