Developing World

An African country is experiencing high rates of a fatal disease. The only means of reducing infections is to kill all of the sheep in the country that carry the disease. The country’s health department asks an American doctor to do research to identify the number of people afflicted with the disease. The country wants to decide if enough people are afflicted to kill the sheep, as it would severely reduce the food supply.

The doctor needs to take blood samples from 1,000 villagers. He tries to explain the reason for his study to the villagers, but they do not believe that diseases are caused by viruses; but instead by bad spirits. A government representative says that the villagers will gladly give their blood if told that it is part of a religious ceremony that will scare the bad spirits away. Should the doctor agree to the deception?

Smoking Study

You are a famous researcher at Norwich University who has been approached by a cigarette company about doing research aimed at determining if smokers with certain genetic profiles are at greater risk of developing lung cancer. There is some evidence to suggest a genetic connection to lung cancer in smokers. However, you suspect that the cigarette company will use the information to claim that smoking is safe for those who do not have the genetic propensity to lung cancer. Is it unethical for you to participate in the study? Can you ethically participate under certain conditions?

Conflict of Interest

Pharmaceutical companies routinely hire doctors at research universities to carry out clinical trials for approval of experimental drugs. These doctors are paid well for their work, but some wonder if the payments raise a conflict of interest. Do you see a conflict of interest in these payments, and if so, is there a way to resolve the conflict while allowing doctors to get paid for drug research?

Anorexia

A 21 year old woman with anorexia is recruited by a local hospital for a research trial that will examine certain chemical levels in the blood and spinal fluid of those with anorexia. The trial involves removing blood and spinal fluid every day for three weeks. The woman is told that the study is not likely to be of benefit to her; it is only for general knowledge of the condition. She readily agrees to enter the trial. However, a nurse working with her worries that people with anorexia are often motivated by masochistic tendencies. Should she be allowed to enter the trial?

Cheating the Research?

A 48 year old man has a form of cancer with no known cure. The only treatment just slows the growth of the tumor. He tells his doctor that he only wants treatment if it has a chance of saving his life. His doctor learns of a research trial for a drug that has shrunk tumors in 20 percent of the cases. The only way to get the drug is through the trial. The study involves giving half of the patients the drug, and the other half a placebo, with the groups chosen at random. As his doctor, she will know if he is in the control group. The man says that he will enter the trial only on condition that the doctor notifies him if he is in the control group so that he can leave the trial. Should the doctor agree?

Treatment on a Child

An 8 year old girl develops a rare degenerative disease that will kill her in a few years if not treated. The only known treatment has only a five percent success rate, but minor risks. Her father agrees to put her into an experimental protocol involving a treatment that has a twenty percent success rate, but a higher risk. The treatment causes severely elevated cholesterol levels that normally taper off over time. The individual must complete the six weeks of treatment if it is to be successful.

After two weeks the girl’s cholesterol level is alarmingly high and the care team wants to end the treatment. The father insists on continuing until the end of the six weeks. What should the care team do?

Ulysses

A 24 year old man has schizophrenia that can only be controlled with Prolixon. He develops a form of cancer that is treated with chemotherapy; however, one of the drugs used in the chemotherapy interacts poorly with Prolixon, and so he must go off of the drug for the six weeks of treatment. The situation is fully explained to him and he agrees to the chemotherapy. After two weeks he is in a psychotic state so severe that he is curled up in his bed smearing feces on himself. He is also sick from the chemotherapy and refuses any further treatment. Must his care team end the treatment?

A Father’s Decision

A pre-teen girl is admitted to the hospital with multiple congenital anomalies, including incontinent bladder and a uterus with no outlet for menstrual flow. The uterus problem led to extreme pain when she started menstruating, and a temporary drain was placed. Surgical correction of uterus and bladder are extensive operations, and the latter would require multiple steps. The family's religious beliefs do not permit them to carry health insurance nor to accept governmental assistance (in the form of Medicaid). The patriarch of the family has therefore suggested the possibility of a less expensive hysterectomy to resolve the menstrual issues. Is that ethical?

Surrogate vs. Care Team

A middle aged patient was rescued from a fire. He now has profound respiratory failure of multiple causes. In addition he has sustained significant anoxic brain trauma and is unresponsive. His care team does not see much chance of return to normal human functioning, and suggests a switch to comfort care to allow him to die. He has not spoken to any family members for years after a disagreement about an inheritance. His brother reluctantly shows up at the hospital and says that he wants full treatment for the man. Must the care team honor the brother’s request?

Would your response be different if the brother wanted to end treatment and the care team wanted treatment continued?

Suicide

A patient with a long history of mental illness is admitted to the ER with chest pains. The care team wants to keep him under observations for a few days. There is a DRN order in his record signed by his primary care physician five years ago, but there is also a record of recent suicide attempts. Should the care team honor the DNR order?

Who should be the Surrogate?

A middle aged patient is intubated for respiratory distress. The patient has been estranged from the majority of her family for many years. The patient's brother has been acting as surrogate decision-maker. The daughter shows up at the bedside claiming she should be the surrogate since she is next-of-kin. What criteria should be used to determine a surrogate decision-maker?

Should vent be stopped?

A 51 year old man has a progressive degenerative muscle disease that has caused him to lose use of his legs and much of his upper body. He entered the hospital with pneumonia and wanted full treatment. During treatment he suffered respiratory failure and now needs a vent. He is unable to respond to others, possibly due to the pneumonia, the meds, or a combination of the two. He has left no advance directive or durable power of attorney. His wife wants the care team to remove the vent, but his brothers and sisters want full treatment and accuse the wife of wanting her husband dead. What should the care team do?

To whom should we listen?

A 42 year old man with insulin-dependent diabetes is brought to the hospital by his wife for fever, anorexia, vomiting, and stupor. He has been unable to eat for two days and has not taken his insulin. He is unconscious. The examination indicated pneumonia and diabetic shock. On his wife’s consent, the care team inserts an IV to begin antibiotics, insulin, and electrolytes. Just after insertion, the man wakes up and states “Leave me alone, no hospital, no needles; I’m OK.” The wife asks that the care team ignore the man, restraining him if they must to insert the IV. What should they do?

Where is the AD?

A 77 year old woman comes to the hospital after suffering a stroke. She is paralyzed on the left side of her body and cannot speak, though she can squeeze a hand and follow an object. It is not clear yet how much movement and speech, if any, can be recovered with therapy. Over the last couple of years the woman was suffering progressively worsening memory loss, confusion, pain, and vision loss. Her family says that the woman signed an advance directive stipulating that she would want only comfort care in this situation, but they cannot find it. What should the care team do?

AD vs. Proxy

A 76 year old woman comes to the hospital after suffering a stroke. She is conscious but can’t respond. She needs a breathing tube and has a poor chance of recovery. She will need a PEG in her stomach if treatment is continued. Here advance directive says that she would only want comfort care if there is no reasonable chance of returning to normal functioning. Her family wants to continue full treatment. What should the care team do?

Head injury

A 51 year old man comes to the hospital with a severe head injury from a motorcycle accident. He was unconscious upon admittance and had a softball size piece of his scull removed and frozen to relieve pressure on his brain from swelling. The doctor who removed his scull noted significant brain damage, but what this means cannot be determined until he begins rehab. He has regained consciousness after a few days but is not competent. The man needs a PEG for rehab. He has left no advance directive and his only known family member, his mother, refuses to allow the PEG. However, the mother has never visited the man, claiming that she does not have transportation to the hospital. What should the care team do?

Mother wants daughter home

A 49 year old woman has been mentally retarded from birth—she has the mental age of a 3 year old—and is morbidly obese (370 pounds). The woman has been cared for by her mother all her life. She comes to the hospital after having fallen at home. She can’t walk by herself or get out of bed. Her care team recommends that she go to a nursing home. Her mother is herself in a wheelchair and has inoperable cancer. The mother insists on bringing the woman home and says that neighbors are always around to help get the woman out of bed. What should the care team do?

Suicide and Diabetes

This week's case involves a patient voluntarily admitted to the locked inpatient psych unit for suicidal ideation. The patient has a long history of diabetes, but reports that she feels better when her blood sugars are in the 500+ range, and she believes that treating her diabetes makes her depression worse. Is it ethically permissible to treat her diabetes over her objections?

Refusing treatment

Our case this week involves a patient who was noted to have altered mental status, which is thought to be due to barbiturate withdrawal. The patient is now refusing low-dose barbiturates to moderate the withdrawal. Is it okay to treat her over her objections?

Does the patient understand the situation?

This week's case involves a young woman who is at almost 24 weeks gestation with a chronic placental abruption, and whose fetus is somewhat small-for-age and has some potentially concerning findings on ultrasound. Maximizing the fetus's probability of a good outcome would likely require a classical C-section, which entails risk and carries significance for the mother's future reproductive options. The team is concerned that the patient may not appreciate the significance of this decision, as well as resuscitative options for the baby. What should we do if a patient in this situation lacks the capacity to make these complex decisions?

Coerced to Live?

A woman in her sixties with multiple medical problems says she just wants to "go" (i.e., be allowed to die), but her husband is pressuring her to continue treatment, even to the point of threatening to end his own life should she "give up." What should the care team do?

Changes his mind

An elderly patient is admitted to the hospital with chest pains. His care team believes that he needs a pacemaker to control his heart rhythms. The man agrees but then changes his mind and refuses as they prep him for surgery, believing that the surgery will kill him. After discussion with his family and care team, he again agrees to the surgery, but then again refuses at the last minute during prep. What should the care team do?

Helping a Patient become Autonomous

An elderly man is resuscitated following a witnessed arrest in the community. He is now confused and at times agitated and thus cannot make an informed decision. The standard of care would be to perform a cardiac catheter, however, the patient has stated that he doubts if he would be reliable in taking routine medications if a heart stint is placed. He is described as a "loner" and none of his family is responding to phone messages. His case team would like to release him from the hospital after inserting a cath. What can they do to make sure that he is taken care of?

Man wants full treatment

A patient with end-stage Lung Cancer and developmental delay has been hospitalized repeatedly for aspiration pneumonia, requiring mechanical ventilation. He lacks decision-making capacity, and there is nobody close to him that can serve as a surrogate decision-maker. Full-treatment of the cancer can extend his life a little, but he will die from his disease. Treatment also causes him pain, which can’t be controlled without threatening his life. The man insists on full treatment, but is also very agitated by the pain. The care team wonders if they should cease treatment of the cancer in order to provide better palliative care. What should they do?

Non-voluntary sedation

An elderly patient with end-stage dementia is taken to the hospital from a nursing home because he can no longer live at home or in a nursing home due to combative behavior. The care team wishes to treat him with intramuscular neuroleptics (antipsychotic medication) and return him to the nursing home. The treatment will also have the side effect of heavily sedating the patient, and because of this the patient refuses the treatment. What is the care team to do?

Piano Man

A concert pianist has his left hand crushed in a car accident. Despite efforts to return circulation to his hand, gangrene has set in. Amputation is the only way to save his life. While not terribly religious, he insists that he would rather pray for a miracle than end his career, though he admits that he would rather live without a hand than die. What should the care team do?

Feeding Tube

An 84 year old man has had Parkinson’s Disease for 6 years. Medication doesn’t help much to control the symptoms. He has been in a nursing home for the past two years. He is incontinent, and cannot feed himself (he is spoon fed by others). He also has dementia, resulting in delusions and on and off recognition of his family members. He has just started having trouble swallowing, and because of this often has trouble breathing during feedings. The nursing home wants to either insert a feeding tube into his mouth, or a PEG that would provide nutrition through a tube from his side directly into his stomach. But they are uncertain about whether they can order it without his consent. What should they do?

Heart Disease

A 55 year old man, who lives by himself, is admitted to the hospital after his neighbors notice that he is having trouble breathing. It is discovered that he is suffering from heart disease, and had a mild attack. Once stabilized, he is told that he must take heart medication every day to prevent another attack. The man refuses to believe that he has any heart problems at all, insisting instead that he was just working too hard, and if he “takes it easy” he will be fine without any medication. Should the care team release him?

Accident

A man enters a cab one evening. He instructs the driver to take him home, about a 20 minute drive, when a few minutes later the cab is struck by a car running a red light. The man in the back seat of the cab is severely hurt and loosing massive amounts of blood through a severed artery. The cab driver is uninjured but slightly dazed. Without hesitation the driver gets out and begins to help the man in the backseat. He applies pressure to the wound with his bare hands but the pressure causes the blood to squirt in all directions. He then takes off his shirt and uses it to control the bleeding until the paramedics arrive and relieve him.

Upon admittance to the hospital the cab driver is checked out and told he is fine for release, however the man in the back seat is in the ICU. The doctor finds through the passenger’s medical file that he has been diagnosed with HIV. Should the doctor tell the driver this information?

Sexual Assault

A woman admits to a hospital stating that she has just been sexually assaulted. She would like a physical exam and a morning-after pill, but she insists that the hospital not report the incident to the police. Should the hospital honor the request? What if she says that she will leave without any treatment unless the hospital promises not to report the case?

Corporate Doctor

IBM once provided employees with corporate physicians that they could see free of charge. Martha Nugent was an IBM physician who informed the company about an employee with paranoia that affected his job. The company held that the information was legitimate business communication. Do you think that the doctor acted wrongly?

Couple

A couple comes into an emergency room, her complaining about vaginal discharge, him of a urethral discharge. The tests on the husband prove positive for gonorrhea. He insists that you do not tell his wife until he has time to break the news to her himself. Her tests will not be available for two days. Do you honor the request?

Older Driver

An 88 year old man has a stroke leaving him blind in one eye. He also has a very slow reaction time. His physician learns that he is still driving, and he refuses to stop because he says it is necessary for his freedom. Should the doctor report the patient to the DMV?

Two Patients

You are the primary care physician of a patient with the HIV virus, but no AIDS symptoms. One day you greet him in the waiting room and see another female patient of yours. You are surprised to see her because she does not have an appointment with you that day, but she explains that your male patient is her boyfriend and she drove him to his appointment. You ask him in the examining room if he has notified his girlfriend about the HIV, and he says “no.” Do you notify her?

College Doctor 2

You are a doctor at a small liberal arts college. A student comes in complaining about irritation around a 7 inch mark on his chest. You learn it is a burn caused by a branding ceremony used to initiate freshmen into a fraternity. The irritation is caused by an infection, which is easily treated, but if untreated could become dangerous. The college has a strict policy against hazing. What do you do?

College Doctor

You are a doctor at a small liberal arts college. During treatment of a student you discover that he is infected with HIV. You ask him if he has sex partners, and he replies that he does; however, he does not tell his partners that he has the HIV virus. He says that he practices “safe sex.” Should you warn someone at the college about the man? If so, who should you warn and how? Would your answer change if he did not say that he practices safe sex?