Problems for Discussion Groups—
Law and Medicine Day,
University of New Mexico School of Law and Medicine – Fall 2004
Problem 1 -- AN ETHICAL DILEMMA IN PROFESSIONAL RESPONSIBILITY:
CONTROL BY THE PATIENT/CLIENT OR CONTROL BY THE PROFESSION?
Jackie Sanders is a 34-year old mother of three children who is now about 16 weeks pregnant with her fourth child. Her husband is employed as a plumber’s assistant, and she is trained as an elementary school teacher, although she has not worked full time since the birth of her first child seven years ago. She has a close relationship with her husband and her children, and she seems perfectly normal – except for her extraordinary dislike of medicine and medical procedures. In fact, she calls herself a “conscientious objector” to medicine. While her objections to medicine are personal and philosophical rather than religious, they may stem from her Christian Science upbringing even though she has now left that faith.
Ms. Sanders came into her husband’s physician’s office this morning because her husband urged her to come; she had never visited a physician before. She is suffering severe abdominal pain, and several tests indicate that she has acute appendicitis and that she is in need of an immediate appendectomy. The doctors have explained that if she does not have an appendectomy, there is a very high likelihood that she will die. She refuses to consent to the surgery and insists that she has a strength that will allow her to “survive the odds, just as I have all my life.” She refuses to believe that it is unlikely that she will “survive” without surgery. She does not want to die, and her husband is urging the doctors to perform an emergency appendectomy without delay (and without her consent). A delay of more than a few hours will put her life at risk.
Should the appendectomy be performed?
What principles underlie your decisions?
Are there other facts you want to know before you answer these questions?
Problem 2 -- AN ETHICAL DILEMMA IN PROFESSIONAL RESPONSIBILITY:
SHOULD CONFIDENTIALITY BE MAINTAINED OR INFORMATION DISCLOSED TO PROTECT THIRD PARTIES?
Alfred Beans visited a lawyer during the trial of another man for the brutal rape and murder of several women in the Northeast Heights of Albuquerque. Mr. Beans was terrified that the cross-examination of the witnesses at trial would reveal that he had actually committed several (but not all) of the rapes and murders. In fact, Mr. Beans had never gone more than 18 months without committing a serious, sexually motivated crime, although a series of lucky breaks kept him from being discovered. He revealed this information to his lawyer only when the lawyer assured him that their relationship was a confidential one. In fact, Mr. Beans had never covered up any of the deeds, nor did he ever lie about them – the police just never connected him to any of the crimes. Recently Mr. Beans has felt remorse for his acts, and he is very distressed that someone else is being tried for them. Further, in the year between his most recent crime spree and the trial, he sought psychiatric counseling, he found religion, he married, and he had a child. By the time of his visit to the lawyers, Mr. Beans felt that he would never commit another crime of any kind.
The lawyer has just learned that the person on trial has been convicted of at least three rapes and murders committed by Mr. Beans. The defendant was also convicted of one other rape and murder that Mr. Beans claims not to have committed.
Should the lawyer divulge the information provided to him by Mr. Beans? If so, to whom? In
what form?
What principles underlie your decision?
Are there any other facts you want to know to answer these questions?
Problem 3 -- AN ETHICAL DILEMMA IN PROFESSIONAL RESPONSIBILITY: WHAT IS A "MEDICAL" CONDITION? WHO SHOULD DECIDE HOW MEDICAL RESOURCES ARE ALLOCATED?
Bradley Monroe, 36, an unemployed truck driver, and Marjorie Morningstar, 39, an unemployed waitress, seek treatment for their infertility. They have been living together for 12 years, although they are not (and do not intend to be) married. They have wanted children for the last two years. Before that they used various forms of birth control over the period of their relationship. Marjorie has had no pregnancy (that she has known about, anyway) over the last 18 months. She has no children, although she had an abortion twenty years ago.
Neither Bradley, who met Marjorie when he was on parole after serving five years for assault with a deadly weapon, nor Marjorie have any health insurance, and they live off the produce of their vegetable garden and their occasional income as substitute restaurant kitchen staff. They live in a trailer they own on a rented space in the Tijeras Arms Trailer Park in Tijeras. They are not eligible for Medicaid assistance from the state because they are not disabled and they have no dependent children. Ironically, if they had a child all three of them would be eligible for Medicaid assistance.
Bradley and Marjorie have been referred to the New Mexico Fertility Clinic, where you work as medical director, by their family practitioner because your clinic is the only infertility specialist in the community which is capable of providing in vitro fertilization services. The clinic has done a battery of tests on both Bradley and Marjorie, and it has concluded that the only hope of creating a pregnancy is through in vitro fertilization. Their treating physician has come to tell you that she plans to tell Bradley and Marjorie that she cannot provide them with in vitro fertilization services because, in her words, "I do not provide these services to single people; I do not provide these services to people who cannot support themselves, and thus cannot support a child; finally, I never do anything for people who can't pay for it up front." She would like you to support her position, although she will do whatever you request.
Should you support her, or should you ask her to provide the service in this case? Would your answer be any different if the costs of the procedure were covered by Medicaid? If the procedure were covered by a national health insurance scheme? If the procedure were covered by private insurance if the physician were to certify that it was "necessary medical treatment"?
If Marjorie needed a hip replacement instead of infertility treatment -- if she were in continuing moderate pain that could be treated only with continuing high doses of codeine or the hip replacement -- would she be entitled to the hip replacement? Why is that any different from the fertility treatment?
Problem 4 – AN ETHICAL DILEMMA IN PROFESSIONAL RESPONSIBILITY: OBLIGATIONS TO FRIENDS AND OBLIGATIONS TO PATIENTS/CLIENTS
You are a good friend of PS, who has been in your study group from the first year. In fact, you knew PS as an undergraduate, too, and you often discuss both personal and professional issues. You know that over the last year PS has faced a number of personal crises, including the death of a parent and the end of a long-term relationship. About ten months ago PS began drinking heavily over the weekends, and you have become concerned as PS’s drinking has become heavier and heavier. Because of PS’s intelligence and extraordinary abilities, PS has been able to cover for this condition, and only a few good friends know about it. Although you have encouraged PS to seek help, PS has refused to do so – in large part because it just doesn’t seem necessary.
Later today PS, as a part of her clinical experience, will be going to court for the first time, representing a defendant in a DWI trial that may result in a year of incarceration for the client. You know that PS is nervous about it, and there was a heavy smell of alcohol on her breath at lunch. You are terribly worried about whether her alcohol use will impair her ability to represent the client in court. When you talk to her about it, she admits that she has been drinking, but assures you that it will not affect how she does that afternoon. You threaten to tell the supervisor, but she begs you not to do so before the trial because it could put her law school career at risk.
Later today PS, as a part of a clinical experience, will be placing an arterial catheter in a patient for the first time. You know that PS is nervous about it, and there is a heavy smell of alcohol on his breath at lunch. You are terribly worried about whether his alcohol use will impair his ability to perform this medical task. When you talk to him about it, he admits that he has been drinking, but assures you that it will not affect how he does that afternoon. You threaten to tell the supervisor, but he begs you not to do so because it could put his medical school career at risk.
Problem 5 – PAIN – TO TREAT OR NOT TO TREAT?
DB, a 46 year-old male, presents to the ER on a busy Saturday night. He is complaining of severe lower back pain and is requesting pain medication. He has had back surgery several years ago for a ruptured disk. Your physical exam does not reveal any muscle weakness or neurological deficits, but DB states his pain is “10/10” and he wants “something strong” right now and a prescription for Vicodin (a narcotic) to go home. He says that he is unable to contact his doctor until Monday.
Looking up his record in Powerchart, the electronic database, you discover that he has been seen in the ER for the same complaint at least 6 times in the last three months. Each of those visits was on a weekend, and he was given a prescription for narcotic pain medication at each visit. In an office visit note two months ago, his private doctor mentions that he and the patient have negotiated a “pain contract” for refilling his prescriptions.
What should the doctor do? Why?
Is society’s concern with addiction and the distribution of narcotics relevant to the doctor’s decision? What effect would it have? Why?