Important Ethical Cases

PA630: Medical Ethics and Professionalism

Spring, 2017

Wednesday 12:00-1:50pm HEC 103

 
 Review: Case Based Analysis
• Casuistry, or Case based reasoning, focusing
on practical decision-making in particular
cases based on precedent.
1. particular features of a case are identified
2. a comparison is made with other similar
cases and prior experiences, attempting to
determine not only the similarities but also
the differences.
 Universalizability
 whatever is right (or wrong) in one situation is
right (or wrong) in any relevantly similar
situation
 a basic logical feature of all moral discourse.  
 Review - Major Moral Theories
Used in Medical Ethics:
Utilitarianism (Consequentialism)

 Deontological (Non-consequentialism)
• Kantian ethics

 Virtue Ethics
 Utilitarianism
• morality should be guided by "the greatest
good for the greatest number”
• Utility or happiness for all should be
maximized.

• Also called Consequentialism:

– the rightness or wrongness of actions and
institutions is a function of the goodness or
badness of their consequences.
 Kantian Ethics
(deontological, rule based)
1. Persons as ends-in-themselves
2. Social contract theory
3. Universalizability
 The Categorical Imperative
• Moral rules should comply with the categorical
imperative:
• should be universalisable (i.e. applied to all
rational, moral members of the community
rather than to just some)
• All persons should be treated never simply as
means but also always as ends in themselves
• Members of the moral community should take
a hand in making the laws as well as living by
them
 Virtue ethics
The key ethical concept is neither utility, rights,
nor principles, but virtue, or good character
traits, which is what moral education should
focus on developing.
 Respect for Autonomy:
respecting the decision-making
capacities of autonomous persons;
enabling individuals to make reasoned
informed choices
 Beneficence:
balancing benefits of treatment
against the risks and costs;
the healthcare professional should act
in a way that benefits the patient.
 Nonmaleficence:
avoiding causing harm;
the healthcare professional should not
harm the patient.
Most treatment involves some harm,
even if minimal, but the harm should
not be disproportionate to the
benefits of the treatment.
 Justice:

 Distribution of a fair share of

benefits.
 Legal justice - doing what the law
says.
 Rights based justice,
 Human rights,
 Legal rights.
 Casuistry
• Case based reasoning, focusing on practical
decision-making in particular cases based on
precedent.
1. particular features of a case are identified
2. a comparison is made with other similar
cases and prior experiences, attempting to
determine not only the similarities but also
the differences.
 Case Based Approach 1

Bases on four "topics” that are intrinsic

to every clinical encounter:
1. Medical Indications 
2. Patient Preferences
3. Quality of Life 
4. Contextual Features
1
Adapted from Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical
Medicine, 8th Edition by Albert R. Jonsen, Mark Siegler, and William J. Winslade
(2015), University of Washington School of Medicine  
 Questions to ask:
 What is at issue?
 Where is the conflict?
 What is this a case of?
 Does it sound like other cases you may have
encountered?
 What do we know about other cases like this
one? Is there clear precedent? 
 How is the present case similar to the
paradigm case? How is it different? Is it similar
(or different) in ethically significant ways? 
Famous Biomedical Ethics Cases…
1946-1947 – Nuremberg War Crimes Trials
23 German doctors were charged with crimes
against humanity for “performing medical
experiments upon concentration camp inmates
and other living human subjects, without their
consent, in the course of which experiments the
defendants committed the murders, brutalities,
cruelties, tortures, atrocities, and other inhuman
acts…”
 The Nuremberg Code (1947)
1932 to 1972 - Tuskegee Syphilis Study

American medical research project conducted

by the U.S. Public Health Service, examined the
natural course of untreated syphilis in black
American men.
The subjects, all impoverished sharecroppers
from Macon county, Alabama, were unknowing
participants in the study; they were not told that
they had syphilis, nor were they offered effective
treatment
 1951 - Henrietta Lacks
An African-American woman who was the
unwitting source of cells from her cancerous
tumor which were cultured by George Otto Gey
to create the first known human immortal cell
line for medical research.
The HeLa cell line was “immortal” and used
extensively around the world for research and
biomedical industries.
Neither she nor her family were informed of the
widespread use of the
 1973 - Dax Cowart
Suffered severe burns and challenged efforts to
sustain his life against his wishes, following an
accident in which he suffered severe and
disabling burns over most of his body.
 1976 - Karen Ann Quinlan
Landmark “right to die” case

21-year-old woman in a persistent vegetative state,

whose parents filed suit to remove her from life
support after health providers refused the request.

Courts endorsed concept of “judicious neglect”

and concept that human life ended when the brain
stopped functioning.
 1994 - Jack Kevorkian
“Dr. Death,” an American pathologist known for
publicly championing a terminal patient's right to
die via physician-assisted suicide;

Claimed to have assisted at least 130 patients to

that end.

Helped set the platform for reform. "Dying is not

a crime."
 2005 - Terri Schiavo
Florida woman in a persistent vegetative state,
whose husband fought to remove her from life
support, while her parents fought to keep her on
life support from 1990-2005.

Prolonged series of legal challenges presented by

her parents, which ultimately involved state and
federal politicians, caused a seven-year delay
before the feeding tube was ultimately removed.
 
 2013 - Marlise Munoz
A woman declared brain-dead by her physician.
Her husband and family wish to remove life
support.
The hospital persists in keeping her on life support
because it claims it cannot legally withdraw life
support from a pregnant patient.
 
 2013 - Jahi McMath
California teenaged woman declared brain-dead
and her family fought to maintain her body on
mechanical ventilation perpetually.
 
 2015 - Brittany Maynard
29-year-old San Francisco Bay Area resident who
became the public face of the "death with
dignity" movement after she was diagnosed
with brain cancer in 2013.
After discovering her diagnosis was terminal,
Moved to Oregon, where it was legal for doctors
to help patients end their own lives.
Died Nov. 1, 2014.
“End of Life” Act signed by Governor Brown on
October 05, 2015.
 Example - Clinical Case: “The Slip”
Jenny is a student on her internal medicine rotation
at the Veterans Administration Hospital. The
rotation has been a great learning experience; her
patients are generally friendly and grateful for the
care they are receiving.
One of Jenny’s favorite patients is Mr Hackman, a
53-year-old veteran who has been diagnosed with
alcoholic cirrhosis and is currently on the transplant
waiting list.
Every afternoon Jenny talks with Mr Hackman, and
he often shares stories with her about the past.
Jenny takes a genuine interest in the stories about
his family and supports his attempts at sobriety.
During one of their sessions, Mr Hackman revealed
that he had taken a drink at a friend’s house 2
months prior. He swore that this was “the only
drink I’ve had in the last 2 years.”
He pleaded with Jenny not to tell anyone about his
transgression because he knew that alcohol abuse
could affect his status on the transplant list.
 What Should Jenny Do?
1. What are the issues?

2. What is at conflict?

3. Who is involved?

4. Which moral and ethical principles are at

issue?