Learning Activities

SCENARIOS- BIOETHICAL CASE STUDIES

Module

Health Care Ethics
 

Competency

5.  Using an ethical decision making model applied to healthcare situations, describe how ethics influence the care of clients.

Recommended Resources

Background Information: Power Point Competency 3 Ethical Decision Making
PowerPoint for Course: Healthcare Ethics 2014

Developed by:

Elizabeth Duehr: Biology and Health Science Educator
Shakopee High School


Potential Uses

Written Paper

Group Work

Discussion

Online

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TITLE

BIOETHICAL CASE STUDIES
Topics in Bioethics: What Would you do???

 

TO DO

1.  Read the following scenarios and answer the questions.

 

SCENARIO #1 DNR
 

Mr. H is a 24-year-old man who resides in a skilled nursing facility, where he is undergoing rehabilitation from a cervical spine injury. The injury left him quadriplegic. He has normal cognitive function and no problems with respiration. He is admitted to your service for treatment of pneumonia. The resident suggests antibiotics, chest physiotherapy, and hydration. One day while signing out Mr. H to the cross covering intern, the intern says "he should be a DNR, based on medical futility."


QUESTIONS

1.  Do you agree?

2.  Is his case medically futile, and if so, why?

 

SCENARIO #2 HIV

Your 36-year-old patient has just tested positive for HIV. He asks that you not inform his wife of the results and claims he is not ready to tell her yet.
 

                                                                   QUESTIONS
1.  What is your role legally?
2.  What would you say to your patient?

 

SCENARIO #3 LABOR

 

A 29-year-old woman had an obstetrical ultrasound at 33 weeks to follow-up a previous finding of a low-lying placenta. Although the placental location was now acceptable, the amniotic fluid index (AFI) was noted to be 8.9 cm. Subsequent monitoring remained reassuring until 38.5 weeks, when the AFI was 6 cm. The patient declined the recommendation to induce labor, and also refused to present for any further monitoring. She stated that she did not believe in medical interventions. Nevertheless, she continued with her prenatal visits. At 41 weeks, she submitted to a further AFI, which was found to be 1.8 cm. She and her husband continued to decline the recommendation for induced labor.

QUESTIONS

1. Which ethical duty takes precedence, the duty to respect the patient's autonomous decision, or the duty to benefit a viable fetus?
2.  Is induction of labor a harmful intervention, subject to the principle of nonmaleficence?

SCENARIO #4: MEDICATION

Mrs. Jones is a patient of yours who has hypertension that has been difficult to control. You recently tried a new once-daily calcium channel blocker by giving her some free office samples, and had good success in controlling her blood pressure.

Later that week, Mrs. Jones calls your office, upset because the health plan refuses to cover the brand name prescription you wrote for this new medication. A generic equivalent is covered, however. Mrs. Jones adamantly wants the name brand, expressing frustration with being unable to get the medication "that finally works"

QUESTION

1.  What should you do?

 

 

SCENARIO #5 IMMUNIZATIONS


An 18-month-old child presents to the clinic with a runny nose. Since she is otherwise well, the immunizations due at 18 months are administered. After she and her mother leave the clinic, you realize that the patient was in the clinic the week before and had also received immunizations then.

QUESTION

1.  Should you tell the parents about your mistake?

 

SCENARIO #6: ANOREXIA
 

During a visit to her family physician, a 35-year-old woman discloses that she suffers from anorexia nervosa. She complains of fatigue, dizziness, depression, headaches, irregular menses, and environmental allergies. Each day, she uses 15 to 60 laxatives, exercises for several hours, and eats a salad or half a sandwich. At 5'2", she weighs 88 pounds. She demonstrates a good understanding of the diagnosis and the recommended therapy for anorexia. Despite receiving a variety of resource information, the patient refuses any medical intervention. She continues to present to the family physician, offering a variety of somatic complaints.

QUESTIONS:

1.  When a patient's preferences conflict with a physician's goal to restore health, which ethical principle should prevail, patient autonomy or physician beneficence?
2.  Does the patient's depression render her incompetent to refuse treatment for her anorexia?

 

Discussion of Case Studies:

 

SCENARIO #1 DNR

Medical futility means that an intervention, in this case CPR, offers no chance of meaningful benefit to the patient. Interventions can be considered futile if the probability of success (discharged alive from the hospital) is <1%, and/or if the CPR is successful, then the quality of life is below the minimum acceptable to the patient.

In this case, Mr. H would have a somewhat lower than normal chance of survival from CPR, based on his quadriplegia (homebound lifestyle is a poor prognostic factor) and his mild pneumonia (in cases of severe pneumonia and respiratory failure survival is <1%).

Furthermore, his quality of life, while not enviable, is not without value. Since he is fully awake and alert, you could talk with Mr. H about his view of the quality of his life. You could share with him the likely scenarios should he have an arrest and need CPR. After this discussion, Mr. H can tell you if he would like to have CPR in the event of an arrest or not.

One cannot say on the basis of the current situation that CPR is futile. A decision about resuscitation should occur only after talking with the patient about his situation and reaching a joint decision.

                                        SCENARIO #2 HIV

Because the patient's wife is at serious risk for being infected with HIV, you have a duty to esure that she knows of the risk. While public health law requires reporting both your patient and any known sexual partners to local health officers, it is generally advisable to encourage the patient to share this information with his wife on his own, giving him a bit more time if necessary.

 

SCENARIO #3 LABOR

Induction of labor at term is an intervention with demonstrated efficacy and carries low risk to the mother. In this case, it could prevent serious damage to a viable fetus. Informed discussion and persuasive efforts should be continued towards this goal. However, deliberate disregard of maternal refusal for therapy could constitute assault. So long as the fetus is attached to the pregnant woman, her body maintains its life, and bars access to it.

 

SCENARIO #4: MEDICATION

Managed care plans often look to prescription benefits as a way to cut their costs. One common mechanism is formulary restrictions and co-pays on prescription medications. In this case, one initial question is whether the generic equivalent has the same clinical effectiveness as the name brand. When cost can be reduced without sacrificing clinical benefit, the ethical conflict is greatly diminished. If this is the case, Mrs. Jones should be reassured that the generic medication should be just as effective as the name brand.

Another issue is whether the patient should be informed that the pharmacy benefit is restricted because of cost. Many physicians believe that costs should not enter into clinical decision making. In modern health care, however, it is inevitable that costs affect clinical decisions. Patient involvement in clinical decisions is an important ingredient for respecting patient autonomy and fostering trust between provider and patient (see also informed consent). Your discussion should involve an honest disclosure of factors involved in a clinical decision, including costs. Mrs. Jones might be told, "I've looked at the medical literature and consulted colleagues I respect, and found that the generic equivalent is just as good as the brand name. Your health plan wants to save money when it can, which is ok as long as it doesn't result in inferior treatment. I don't believe it will in this instance; if it did, I would appeal."

If on the other hand, your research reveals that the generic is not as effective as the name brand, your duty as a patient advocate would obligate you to take all reasonable steps to appeal the decision. Most health plans have appeal mechanisms that will overturn coverage criteria with fairly minimal physician effort. They maintain this stance to limit their potential liability and to foster good customer relations. While the phone calls and letters this often entails are certainly an inconvenience, the effort is an important part of patient advocacy in a managed care environment.

 

SCENARIO #5 IMMUNIZATIONS

The error is a trivial one. Aside from the discomfort of the unnecessary immunization, no harm has resulted. Nonetheless, an open and honest approach to errors is most appropriate. While the parents may be angry initially about the unnecessary injection, they will appreciate your candor. On the other hand, should they discover the error and believe you have been dishonest, their loss of trust will be significant.

 

 

 

SCENARIO #6: ANOREXIA

Since this patient could rationally discuss her treatment options and her reasons for declining therapy, she could not be considered incompetent. Respect for autonomy is a central principle of bioethics, and it takes precedence in this case. Although the principle of beneficence could be used to argue for coercion towards treatment, compliance may be better improved by providing an ongoing partnership with the patient. Maintaining a therapeutic relationship with ongoing dialogue is more likely to provide this patient with the eventual ability to pursue therapy.