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The following are papers written by students at Mercer University School of Medicine, either as senior papers on ethical issues encountered during their MUSM experiences, or during elective rotations in senior year ethics. More papers could have been posted but space is limited, so only those papers illustrating particular issues in medical ethics are included. Efforts have been made to eliminate information identifying patients, but if we have missed something please let me know at elliott_rl@mercer.edu.
Students have given permission for their papers to be posted on this site. Work in progress - papers to be uploaded soon. If you would like to post questions or to make comments, please use this link: Outstanding Papers Discussion Futility of Care – Whose decision is it, anyway? Narayana Varahabatia  Click Here To Download writes of a 64-year-old woman whose course following a laparascopic cholecystectomy deteriorated to where she was placed on a ventilator and the prognosis was extremely poor. The central ethical issue was whether her previously stated wishes to do everything possible should have been overridden given the futile nature of continued support. When should surrogate decisionmakers make a decision contrary to the expressed wishes of the patient?
Maria Gorokhov Click Here To Download presented the story of a 22-year-old woman with terminal ovarian cancer. As her condition worsened, a decision was reached regarding transfer to an intensive care unit. Family members wanted “everything done” whereas physicians saw transfer as futile. How should this be resolved?
Jane Inhulsen  Click Here To Download points out in her case that futility of care issues are not restricted to adults at the end of life, and that questions regarding future quality of life need to be considered in light of data on outcomes. The outlook may not be as bad as it might seem.Doctor-Doctor and Doctor-Trainee Relationships  Neal Passante Click Here To Download described a situation uncomfortable to most physicians: when should physicians who become aware of a serious error on the part of another physician disclose that error to the patient or family, i.e., when should the “White Wall of Silence” be breached?
Matthew Golden Click Here To Download encountered a situation during his fourth year where a 62-year-old man with a retroperitoneal malignant fibrous histiocytoma. Unfortunately, though the chief resident and other house staff felt strongly that the mass was unresectable, and had serious doubts whether the patient could survive surgery, the attending had instilled hope in the patient that the tumor was resectable. What is the proper role for trainees when such differences of opinion exist?
M. Neil Woodall Click Here To Download asks what a student should do when asked by a resident to perform a rectal exam on a patient must insists on no further tests.
Jehovah’s Witnesses Audra Morabito Click Here To Download wrote of a 16-year-old girl who suffered a fractured femur in a motor vehicle accident. As a result of blood lost as a result of the accident, there was concern that she might need a transfusion during surgery to repair the fracture. The girl expressed a wish for a transfusion, but her mother was adamantly opposed. Decisions involving minors nearing the age of majority are always tricky, never more so than when they pose questions involving both physical as well as spiritual health.
George Hotz Click Here To Download gives an example of an adult Jehovah’s Witness, a 23-year-old woman with sickle cell anemia who was involved in a motor vehicle accident and who had previously expressed a wish not to receive blood. There was no advance directive and she was not conscious at the time a decision needed to be made regarding transfusion. Family was consulted, and they agreed the patient should not receive a transfusion. She died the next day. What would you have done under the circumstances?
HIV, AIDS, and Confidentiality Misty Poole described a 24-year-old man who presented with complications arising from AIDS, about which his family knew nothing. He was specific that the team not tell the family of his AIDS, a request to which the team tried to adhere despite obvious concern expressed by the family and requests for information. The family surmised his condition upon learning of the attending’s specialty (infectious disease). What else could have been done to protect confidentiality? Or preserve trust? Fit to be a mother? Alexa Y. Chai Click Here To Download wrote of a 34-year-old woman, approximately 25 weeks pregnant, with a history of schizophrenia, depression, and occasional homelessness, whose urine drug screen is positive for cocaine and marijuana. The resident in charge of her care states that the patient is unfit to be a mother, and that society will have to pay for her children. He proposes to her that she have a bilateral tubal ligation at the time of delivery. Explanations of the reasons for this, benefits, risks and alternatives are minimal. Is the issue a conflict between autonomy (her right to more complete disclosure about the procedure and alternatives) and social justice (fair distribution and utilization of healthcare resources)?
Informed Consent Geri Justice Robert Lott Click Here To Download wrote of another schedule Cesarean delivery, but, in this case, the issue was whether it was proper to remove a skin growth on the patients abdomen without her prior consent. Does the physician’s obvious desire to act out of beneficence outweight the patient’s desire for autonomous decisionmaking?
Jared Shell Click Here To Download described a case of a young man with carpal tunnel syndrome, for whom the surgeon recommended endoscopic surgical release. The issue in the case is whether physicians allow subtle biases, e.g., for surgical over non-surgical options, to influence the manner in which we present information to patients. How can we be more alert to this?
Shaefer Spires Click Here To Download also questioned how far physicians should go in influencing patients or surrogate decisionmakers in the case of a 40-year-old woman who was incapacitated from multiple medical decisions, and whose husband was faced with deciding whether to proceed with bowel surgery having a 5% chance of survival.
Kala Cartwright Click Here To Download asks how far we should go in accepting the decision of an incompetent patient to refuse medically life-saving treatment, ultimately including food. Should the family’s willingness to accept the patient’s refusal, despite his obvious lack of competence, be sufficient to override a decision to force basic supportive care?
Nicole Briley gives a nice summary of Georgia law around surrogate decisionmaking as it applied to the case of a young man with AIDS and possible PML whose mother was faced with a difficult decision regarding possible brain biopsy. Jennifer Heer Ford Click Here To Download reminds us of how painful, but necessary, it is to deliver “bad news” that may be part of informed consent. Can this duty be relegated to others?
Tricia Lee presented another case where the presentation of bad news to a patient, over the wishes of the family, was the central issue. In some cultures the family is the “patient” – should more consideration be given to family’s wishes? How do we balance this with respect for patient autonomy? Jason Tully Click Here To Download tells the story of 46-year-old woman whose care was compromised by her insistence on smoking. How far should physicians go to get cooperation with other parts of a treatment plan?
Brooke Newman Click Here To Download described the case of an 83-year-old woman with Alzheimer’s disease with a small bowel obstruction who was presented with the choice of proceeding with bowel surgery having a poor prognosis. Under circumstances where the proposed procedure high risks and a low probability of success, should marginally competent patients be allowed to refuse?
William McRae Click Here To Download gave an example where a conflict between the treatment team and the patient over proposed surgery for a gangrenous foot was resolved through patience and the involvement of family, leading to a good clinical outcome for all.
Genetic Diagnosis Meg Gossett Click Here To Download has given us a very nice review of ethical issues in the use of preimplantation genetic diagnosis. This will doubtless become an ever more visible topic for clinicians and ethicists.
Minor’s and Informed Consent Carrie Sidwell Click Here To Download tells us about Ryan, a 16-year-old boy with cystic fibrosis who is facing the prospect of a double lung transplant. He objects, but his mother wants to go ahead. How should the team proceed?
Shae Evans Click Here To Download wrote of a 16-year-old with an ectopic pregnancy facing surgery who did not want her mother to be told. How would you handle this?
Empathy and Impartiality in Healthcare Heather Friedman Click Here To Download writes of two patients – both victims of gun shots, but one has been shot by police while the other is the victim of the first patient. How can we overcome our natural response to provide better care for one over the other?
Brad Hobbs Click Here To Download wrote about a 33-year-old man who had overdosed on Darvocet and who was refusing potentially life-saving treatment with Mucomyst. Should a lucid patient be able to refuse such treatment, or should involuntary treatment with Mucomyst be started?
Matthew R. Barton described another situation where our capacity for empathy would surely be challenged – a 69-year-old man who killed his wife before shooting himself. His injuries would require what staff called a “million dollar workup, just so he can go to prison.” Should such considerations play a role in our care, especially when the injury was self-inflicted? Professionalism It is stressful to deliver bad news, particularly regarding a terminal illness. Can this be left to residents or other health care staff? Jennifer Heer Ford discusses this. Ford case analysis |
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© 2004 Mercer University School of Medicine. All Rights Reserved. Contact Us Today.
For comments or suggestions about this site contact our webmaster
GA Hotline: 1-800-342-0841, National Hotline: 1-800-637-2378