Medical Ethics

I am attracted to reviewing medical ethics because the issues are faced by most of us at significant decision points in our life. Also the principles have to be pragmatic and have stood the test of time. There is a long history of development going back to the Classical Greeks with the Hippocratic Oath. The Jewish, Islamic and Christian religions have all substantially contributed to medical ethics.

Our discussion will revolve around several medical ethics cases further below. Before attending prepare your opinions on the questions assigned for each case so you are ready to give your opinion in our discussion.

To inform our discussion I will give a brief introduction to the principles used in medical ethics. The medical ethics principles are:

  1. Autonomy (patient can refuse or choose treatment)
  2. Beneficence: Act for the patient’s benefit (individual interest > community interest)
  3. Non-maleficence: (Do no harm)
  4. Respect for human rights (especially the vulnerable)

The Australian Medical Association's code of ethics that doctors are expected to abide is in the below link. I don't want you to read in detail the long list of individual rules except to note they take a rules-based approach. The Medical Board of Australia's Code of Conduct is similarly rules-based.

https://ama.com.au/position-statement/ama-code-ethics-2004-editorially-revised-2006

http://www.medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx

Cases For Discussion

Case 1:

A woman enters the emergency room with stomach pain. She undergoes a CT scan and is diagnosed with an abdominal aortic aneurysm, a weakening in the wall of the aorta which causes it to stretch and bulge. The doctors inform her that the only way to fix the problem is surgically, and that the chances of survival are about 50/50. They also inform her that time is of the essence, and that should the aneurysm burst, she would be dead in a few short minutes. The woman is an erotic dancer; she worries that the surgery will leave a scar that will negatively affect her work; therefore, she refuses any surgical treatment. Even after much pressuring from the doctors, she adamantly refuses surgery. Feeling that the woman is not in her correct state of mind and knowing that time is of the essence, the surgeons decide to perform the procedure without consent. They anesthetize her and surgically repair the aneurysm. She survives, and sues the hospital for millions of dollars.

Questions for Case 1:

· Vote: What would you do if you were one of the health care workers?

· Do you believe that the doctor's actions can be justified in any way?

· Is there anything else that they could have done?

· Is it ever right to take away someone's autonomy? e.g. would a court order make the doctors' decisions ethical?

Case 2:

You are a general practitioner and a Vietnamese mother comes into your office with her child who is complaining of flu-like symptoms. Upon entering the room, you ask the boy to remove his shirt and you notice a pattern of very distinct bruises on the boy's torso. You ask the mother where the bruises came from, and she tells you that they are from a procedure she performed on him known as "Cao gio," which is also known as "coining." The procedure involves rubbing warm oils or gels on a person's skin with a coin or other flat metal object. The mother explains that Cao gio is used to raise out bad blood, and improve circulation and healing. When you touch the boy's back with your stethoscope, he winces in pain from the bruises. You debate whether or not you should call Child Protection Services and report the mother.

Questions for Case 2:

· Do you think that the doctor should report the mother?

· Should we completely discount this treatment as useless, or could there be something gained from it?

· When should a doctor step in to stop a cultural practice? Remember even simple procedures such as tonsillectomy hurt, so pain is not a good guide.

· Should the doctor be concerned about alienating the mother and other people of her ethnicity from modern medicine?

Case 3

Josh was severely burned by an accidental gas explosion. The burns disabled Josh, and the doctors forced treatment on him. Though he survived the treatment, he still argues that he should have been allowed to refuse it so that he could die.

Questions for Case 3:

· Vote: Do you think that in this case, that the ends justified the means?

· Doctors say that burn patients are incompetent to make decisions when they first enter the hospital because they are in such a great deal of pain. However, patients such as Josh can be in a great deal of pain for a very long time. In such cases, what should be done to determine competence, and when should this be done?

· Do you think the fact that Josh could not see a future for himself should have been taken into account when determining his competency? Could this have clouded his judgment? (He thought that he would end up on the street corner selling pencils)

· Do you think that the fact that Josh was going to recover, and had the possibility of living a happy life, made not treating Josh like suicide… or murder? What if he did not have this possibility?

· After his recovery, Josh attempted suicide. Should the doctors have let him die? Is it ever correct for a doctor to allow a patient to kill himself?

· Do you ever think that it is correct for a doctor to break a competent patient's autonomy? If so, is this one of those cases?

Case 4:

A woman was diagnosed with motor neurone disease (the same disease that Stephen Hawking has) 5 years ago. This is a condition that destroys motor nerves, making control of movement impossible, while the mind is virtually unaffected. People with motor neurone disease normally die within 4 years of diagnosis from suffocation due to the inability of the inspiratory muscles to contract. The woman's condition has steadily declined. She is not expected to live through the month, and is worried about the pain that she will face in her final hours. She asks her doctor to give her diamorphine for pain if she begins to suffocate or choke. This will lessen her pain, but it will also hasten her death. About a week later, she falls very ill, and is having trouble breathing.

Questions for Case 4:

· Vote: If you were the doctor, what would you do?

· Does she have a right to make this choice, especially in view of the fact that she will be dead in a short while (say six hours)? Is this choice an extension of her autonomy?

· Is the short amount of time she has to live ethically relevant? Is there an ethical difference between her dying in 6 hours and dying in a week? What about a year, and how do you draw this distinction?

· Is the right for a patient's self-determination powerful enough to create obligations on the part of others to aid her so that she can exercise her rights? She clearly cannot kill herself. She can't move, but should someone be FORCED to help her, or to find someone to help her?

· Should the money used to care for this woman be taken into account when she is being helped? Do you think that legalizing euthanasia could create conflicts of interest for the patient/ or the doctor? Will people feel that they need to end their lives earlier to save money?

Case 5:

Date: June 22, 2015. A 27-year-old man is brought into an emergency room with a 101-degree fever, and what he believes is chickenpox (Varicella). After a brief examination, the 35-year-old doctor is puzzled because the pox does not appear to be typical of the varicella-zoster virus. Worried, he calls in another doctor for her opinion. She takes one look at the patient, determines he has small pox, and immediately orders him to be quarantined. She notifies the Department of Health (DOH) and asks them what should be done.

While doing background on the patient, he tells the doctors that he is a flight attendant and that he has flown multiple flights in the past few weeks while working. Though he is given excellent treatment, and had been in perfect health a few days earlier, the patient dies 7 hours after admittance to the hospital.

The DOH decides that mandatory small pox vaccines will be administered to all workers in the hospital, and to all patients who were in the ER. His co-workers are all given mandatory vaccines as well, as are all people living in his apartment complex. They also ship stored quantities of the vaccine to all of the cities where the man had flown to for work. The vaccines are offered to citizens of these cities. Finally, all people, along with their families who had been on the man's flights in the weeks preceding the appearance of the disease are forced to receive the vaccine.

Questions:

Note: The flight attendant was most likely given small pox by a bio terrorist who flew on his plane sometime during the past week/week and a half. The terrorist would have been contagious but would not have shown symptoms. Virtually every person the man came into contact with would have gotten the virus.

Questions for Case 5

· Vote: Is it ethical for the DOH to force people to get the vaccine?

· A woman on the flight is religiously opposed to vaccines. Under state law she can normally refuse vaccines on religious or personal grounds. However, the government says she must receive the vaccine or face mandatory quarantine. What do you think of this?

· Do you think that for more common diseases, for example measles, that it is ethical for the state to allow people to refuse vaccines (even for religious grounds)? What if their refusal can harm others who cannot have the vaccine, such as people who are immunocompromised like AIDS patients?

· Is it ethical for someone to refuse the vaccine?

· You had driven down to one of the cities visited by the patient 5 days ago to visit a friend for the weekend. While in town, you visited many tourist attractions. You are worried and you try to get the vaccine, but are denied it because of limited resources. What do you think of this?

· Citizens begin calling for the mandatory quarantining of people directly exposed to the victim, i.e those living in his apartment complex, those working in the ER, those who flew on the plane in the prior week. What do you think of this?

· The smallpox vaccine, like many other vaccines (example: oral polio vaccine) can actually transmit the virus to others. In light of this, is it ethical for people to get the vaccine? (Note: they are vaccinating those who may not want to be vaccinated)

  • Today, should health care workers be allowed/forced to get the smallpox vaccine? What about non-health care worker citizens?

Case 6:

You are trying to get a new medical device approved for sale. You are aware of a recent problem in Australia for women who used a trans-vaginal mesh medical device when they have a pelvic floor prolapse. http://www.smh.com.au/federal-politics/political-news/weve-lost-so-much-senate-urged-to-act-on-failures-over-mesh-device-implants-20160413-go5obe.html

Questions for case 6:

  • You have a significant shareholding in the company. How do you ensure your incentive to maximise the value of the company is balanced against the needs of patients? Note surgeons make the purchase decision, not patients.
  • What should you do to ensure if there are any adverse patient events that you have a clear conscience? Would that change knowing you have product liability insurance? The TGA requires a minimum of 30 patients’ data to prove safety. Each patient costs an extra $1,500. Should you enrol more or just the 30?
  • You recognise there is some risk with a first in human clinical trial. Should you be able pay patients to enrol in your trial? How much?
  • Should you prioritise rich countries where profit margins are fat or less developed countries where margins are thin but the patient need and volumes are much greater? Would this differ if as a Director you are legally responsible for maximising shareholder value under the Corporations Act?