Ethics in Health Care
Scenario Analysis
HSA 4431

In Clinical Ethics, three clinical ethicists (a Philosopher Jonsen; a Physician Siegler; and a Lawyer – Winslade) developed a method to work through difficult cases. The process can be thought of as the “Ethics Workup,” similar to the “History and Physical” skills that all medical students use when learning how to “Workup” a patient’s primary complaints. While this method has deep philosophical roots, clinicians who use this method like the way it parallels thinking through tough medical cases.

Medical Indications – All clinical encounters include a diagnosis, prognosis, and treatment options, and include an assessment of goals of care
Patient Preferences – The patients preferences and values are central in determining the best and most respectful course of treatment.
Quality of Life – The objective of all clinical encounters is to improve, or at least address, quality of life for the patient, as experienced by the patient.
Contextual Features – All clinical encounters occur in a wider social context beyond physician and patient, to include family, the law, culture, hospital policy, insurance companies and other financial issues.

Directions: Carefully read each scenario describing an ethical dilemma in health care. Select TWO scenarios for which you will write a thorough response to not exceed ONE complete paragraph for each. One paragraph consists of 5-8 complete sentences. Responses will vary based on an individuals cultural upbringing, ideology, and cognitive development ethical theories and principles. You must be able to support your individual position by applying theory and principle appropriately.

Scenario 1
At your last office staff meeting, the rising cost of rent and overhead was discussed. One of your partners mentioned that he had been approached by a large pharmacy chain with an offer of space adjacent to their new pharmacy that is only one block from your current offices. The cost per square foot is half of what you are currently paying and there was a suggestion that the rent could be lowered if the volume of prescriptions from your office were substantial. 
Although this offer is very tempting, you have reservations about the potential conflict of interest. One of your partners is pushing to explore this option. You are wondering if you could manage the conflict by refusing to engage in any reduction in rent based on prescription volume but still take the space at the reduced lease costs. 
Another partner feels that this arrangement will compromise her autonomy and feels that it will look as if the office is associated with the pharmacy even if it is not. Everyone agrees that the overhead costs need to be reduced. What is the right thing to do?

Scenario 2
You are the training director for a residency program. Recently, several residents have come to you reporting that a physician frequently makes disparaging comments to residents and to patients about the work of other physicians.
The physicians latest comment was to a patient in which he said he would not allow a particular physician to treat his pets. Other comments attributed to this physician involved telling the residents that a surgeon is a butcher and a psychiatrist a mindless twit.
The residents have attempted to speak to him about this practice to which the physician responded by saying he only speaks the truth, adding that patients and residents have a right to know.
The residents report the comments appear to be unwarranted and they seem to be scaring the patients. Is this physician behaving unethically? Should physicians question the work of their colleagues? How should this be done? 

Scenario 3
You are nearing the end of your practice career and many of your patients are older. Several of them have developed mild dementia and youve been discussing their wishes should they continue to lose mental capacity.
The other day, an elderly gentleman arrived for his appointment with his middle-aged son who reported that his father is becoming increasingly forgetful. The son would like to have his father moved to a facility rather than continue to live on his own.
While examining your patient, you note he has multiple bruises on his upper arms that suggest he has been grabbed by someones hand. When you discuss with him the idea of moving to an assisted living facility, he becomes very upset and says his son wants to get his hands on his money and that is why he wants him to move from his own home.
The patients Mini Mental Status examination is within the normal limits and he reports that his multiple bruises are the result of a friend grabbing his arm while they were out walking.
You would like to respect your patients autonomy to make his own decisions but have some concerns that he may be at risk. You are not sure what the ethical principles are and approach your colleague for advice. What advice would you give to this colleague if you were approached?

Scenario 4
You have been treating a 24-year-old man for many years in your family practice. He has an anxiety disorder and had some trouble with substance abuse in his teens but has been doing well and attending university.
After his last visit for a minor injury you noted that a prescription pad was missing. A few weeks later you received a call from a pharmacy asking you to verify a prescription for Lorazepam 1mg bid, 300 tablets and acetaminophen with codeine 300 tabs written for this patient.
You report that this is a forgery and ask the pharmacy not to fill it. Your colleague urges you to report this to the police and states this is allowed under the Health Information Act. You are very angry with the betrayal of trust with your patient, but you have never reported a patient to the police and wonder what you should do.
The CMA code of ethics advises you to keep patients personal health information private and only consent to release to a third party with consent or as provided for by the law, such as when the maintenance of confidentiality would result in a significant risk of substantial harm.
You are wondering if your patient has a substance abuse problem and whether he could be selling this medication. You have called the patient to come in for an appointment, but he has refused. Should you notify the police?
Scenario 5
A patient has rheumatoid arthritis for which she should be taking drugs to control the disease and prevent further joint damage. However, she tells the doctor that she has stopped because she does not like the look of the side effects listed on the leaflet in the packet and would like a treatment she found on the internet. The doctor disagrees with her preferred treatment. What issues does this raise? How should the doctor handle this scenario?

Scenario 6
A newly hired nurse is being given orientation and training in the hospital by a senior member of the nursing staff. Assigned to a medical -surgical unit the nurse receives instructions on procedures. The nurse is instructed to “push Heparin IV” through a tube in the person’s arm. The nurse when being trained in nursing program was instructed not to do such a thing as it could have serious consequences. When the newly hired questioned the procedure that nurse was told by the senior nurse: “Look that is how we do it here, missy. We are understaffed and do not have the time to do it intravenously. If you want to work here that is how you will do it too.” What should the response of the new nurse be to this situation? Why?

Scenario 7
John, a 32-year-old lawyer, had worried for several years about developing Huntington’s chorea, a neurological disorder that appears in a person’s 30s or 40s, resulting in uncontrollable twitching and contractions and progressive, irreversible dementia. It typically leads to death in about 10 years.
John’s mother died from this disease. Huntington’s is autosomal dominant, and children of an affected person have a 50% chance of inheriting the condition. John had indicated to many people that he would prefer to die rather than endure the progression of the illness. He was anxious, drank heavily, and had intermittent depression, for which he saw a psychiatrist. Nevertheless, he was a productive lawyer.
John first noticed facial twitching 3 months ago, and 2 neurologists independently confirmed a diagnosis of Huntington’s. He explained his situation to his psychiatrist and requested help committing suicide. When the psychiatrist refused, John reassured him that he did not plan to attempt suicide any time soon. But when he went home, he ingested all his antidepressant medicine after pinning a note to his shirt to explain his actions and to refuse any medical assistance that might be offered. His wife, who did not yet know about his diagnosis, found him unconscious and rushed him to the emergency room without removing the note.
How much weight should Johns preferences (especially his attempt to end his life) carry in managing his emergency and subsequent clinical care?

Scenario 8

Mrs. Jones has signed a donor card indicating that she is willing to donate her body to science without notifying her husband and son. She gets into an accident and it is determined she is brain dead. The family doctor, who is on call that afternoon, reviews the chart and determines that she would be perfect for medical students to practice the removal of organs for transplantation purposes. The doctor then talks to the family to discuss the procedure and to confirm their consent. They both oppose the procedure and refuse to allow their doctor to move forward. The doctor points out that Mrs. Jones could be helping hundreds of people by educating the medical students and that technically consent has already been provided. The husband understands how beneficial the educational experience is but is too emotional to allow them to continue. The son, a medical student, refuses because he knows the bodies are not treated with dignity. If you were the doctor, how would you proceed? Why?