I SPECIFICATIONS: 3;.i4 pages (750-1000 words, minimum); writing ,a longer paper n is OK, no penalty. I prefer a typed, double-spaced paper, dark ink, no very light dot-matrix printing. 1 u u .INSTRUCTIONS: Pick only one of the attached cases. Attached are generic II Instruc-t”ions for writing a good phUosophy paper in this course. The most I
~ Important things to keep in mind are these: (1)You must provide a reasoned Ii justification for your position, a series of well-reasoned arguments, derived to’ a large extent from the readings and class discussion and your own reflection on I: those materials; (2)You must articulate at least one strong objection to the view IT you defend, and then respond effectively to that objection; (3)At the beginni.ng of the paper state clearly the moral issues that are the focus of your paper, and your position with regard to those issues; (4)There are usually specific questions attached to a case: be sure you have answered them.
On this first paper there is a large model. of moral debate that has shaped discussion in medical ethics over the past twenty years: this is the conflict between a traditional beneficence-based approach to medical ethics and an autonomy-based approach. It Is simplistic to think that one or the other of these approaches ,WOUld have absolute moral priority over the other. Most often, it is a matter of working out a reasoned balance of these competing moral considerations an’d the demands they make on health care professionals. Hence, I want to see in your papers evidence that you thought about these competing moral perspectives and the bearing they have on the case you choose to address. ” . ‘ ,
Making moral comparisons among cases is a good way to refine your moral judgments. How is the case’ you choose to discuss like or unlike the Dax case? Or some other case that might have been introduced in ,class or in the readings? ‘ If
thc~re
ar~
important facts of a case thatate’ nc>f entirely’clear, then feel free to make them clear “by ttypothesis.” Feel free to alter what you take to be edtical facts of the case that would result in a very different ma’tal jUdgment. That kind of hypothetical case variation is a good tool for moral analysis; you willse’e me do that frequently in class. ,, Don’t waste hundreds of words summarizing the
c~se
itself in your paper. I know the case. refer only to case facts needed to establish, the context for’· your moral analysis.
GENERAL SUGGESTIONS FOR WRITING ESSAYS
GENERAL AIM: Your genera.1 aim Is to develop a morally defensible position that Is best all things considered. This does not mean that youy have to come up with a view that Is correct In the sense that no one would disagree with you. Nor does It mean any old view will do. Your goal Is to show that the weight of evidence Is on your side.
THINGS TO INCLUDE: (1)State your position clearly. (2)Support your position with well-reasoned arguments, mostly from the assigned readings and class discussion. Your objective, In part, Is to show that you have done the assigned readings, and you have done the readings thoughtfully and critically. (3)Antlclpate and respond to objections, strong objections. Your objective here Is to show Intellectual honesty, that you are mindful of what others would argue who disagree with you, but you have good counter-arguments to respond to their criticisms.
STYLE: Your essay should “hang together,’· It should
b~
well-organized, logically coherent. It should not be a set of distinct thoughts that are not logically related to one another, or to the task of making an Informed moral JUdgment with respect to the moral Issues raised by the case you are discussing.
REFERENCES:’ If you use “outside” references, give a standard listing of them at the back of your paper. If you use only material from the course, then In the text. Itself In parentheses give the author’s last name and a page number. NOTE: Always refer to the author of the precise article you are discl:lsslng; never refer to the editors of the text (Arras and Steinbock), unless what you are citing Is the Introductory material they provide at the beginning of each chapter.
HEALTH CARE ETHICS: PAPER #1 (some additional thoughts)
Leonard M. Fleck, Ph.D.
DUE DATE:
Here are some additional generic questions for the attached cases, as well as some strategic things to keep in mind. Go back to the Dax case. Think of the large questions there: (I)Were the physicians in that case morally obligated to do what they judged to be in Dax’s best interest? Could they have been justifiably criticized if they simply allowed him to die when they knew that they had the capacity to save his life? (2) Was Dax capable of making autonomous choices regarding his own medical care that his physicians would then be morally obligated to respect? How do you know whether or not Dax was “autonomous enough”? To answer that question you would have to apply Miller’s four senses of autonomy and examine carefully the evidence for or against each of those four senses. Pay attention to how Miller uses those four cases at the beginning of the article to frame and orient his discussion and analysis. Remember that in two of those cases Miller says, in effect, that medical paternalism was justified, that the physicians did the right thing in ignoring the vocalizations by patients saying that they wanted to die. So what precisely are the considerations that sometimes warrant medical paternalism? Think about all these general questions as you discuss your case.
Be sure to make case comparisons to show me how your judgment shifts in response to changing circumstances/ case facts. You can use the Miller cases for that purpose. You can use cases in the readings (Case of BB introduced in class or Bouvia). Pay special attention to the Bouvia case because this is the sort of case that is of great concern to advocates for the rights of persons with disabilities. They are concerned that “we” [persons presently without disabilities] are too quick to grant persons with disabilities the right to end their lives, especially when we think that their future quality of life is too compromised. You might also make comparisons with other cases in the assignment itself.
Some Special Notes
Some more specific comments. Each of the attached cases has “a little wrinkle” that makes it a little more difficult to just make a clear, straightforward moral judgment. In withdrawing life-sustaining care, think about the question of how morally important it is that a person is or is not imminently dying. Be careful about ‘ageism.’ It might be a little too easy to embrace “ageism,” a stereotype about old people that suggests they are really worn out and ready to die. And what moral meaning should be attached to the ambiguity that might be communicated by a patient’s family?
In the case of Mr. B the family is quite supportive of his wish to be allowed to die. Are you entirely comfortable with that support? Should that be given moral weight in deciding whether or not it is morally permissible to agree to the expressed wishes of Mr. B?
MORE TOPICS:
INFORMED CONSENT/ TRUTH-TELLING: In class I will have introduced a transplant case from Worcester Massachusetts. The patient needed a heart transplant; he was very near to death. He might have had 2-3 weeks to live. He was not an ideal transplant candidate, so it was very unlikely that he would receive a heart transplant from the usual transplant list. Too many other patients would be seen as being better candidates. So the physician found an organ that was otherwise rejected for transplant purposes because the patient from whom the organ was taken had metastatic cancer. This patient desperately wanted to live. The organ was otherwise a good match. But the physician did not inform the patient that the organ was SUb-par (quality-wise) because it came from someone with an advanced cancer. The physician was afraid the patient would refuse the organ without realizing this was his only realistic chance for a transplant. YOUR TASK: Write a paper in which you argue that the physician did the right thing by withholding this information from the patient. OR write a paper in which you argue that this physician’s behavior was open to justified moral criticism. Was this a case of justified paternalism? Why or why not? You know “the end of the story.” But you must write this paper from the perspective of someone who does not know “the end of the story.”
ETHICS AND MEDICAL EXPERIMENTATION: Go to page 211 of your text, case #3, which is about stopping a clinical trial. Write an essay in which you defend the view that it was morally permissible to stop the trial when they did, OR write an essay in which you argue it was morally obligatory to continue the trial. Be sure to explain carefully your arguments, showing me that you understand what is distinctive about the moral issues that are characteristic of experimental medicine.
ETHICS, CONFIDENTIALITY, and HIV: Imagine that you are a primary care physician caring for an 18-year old high school student whom you have just tested and found to be positive for HIV. He is actually a classmate ofyour daughter. You have heard your daughter talk about how handsome he is and how delighted she would be to have a date with him. Write a paper in which you defend the view that it would be morally permissible for this physician to inform his daughter that this young man is HIV+ OR write a paper in which you argue that it would be morally wrong for this physician to inform his daughter.
5.2 Competent Adult Patients Who Wish Not to Be Treated
CASE NO J. Hl’m old and tired. so let me alone”: The significance of a wish to be allowed to die
FACTS Mrs. A Is an 84-year-old woman who was widowed in her early thirties. She was left with three small children whom she raised on her own. Raising these
children was very difficult because of her lack of education and vocational experI ence, but she did It, never asking for any help, either from family and friends or
from social agencies. In general, Mrs; A was a very independent lady wh,9.always
did thin s on her own. Her heallh had always been gOOd. She had no significant
history of illness an a Mt . n osplta I prevIOusly. She was admitted to the
hospital after sustaining a compound fracture of the tibia In an automobile accident,
because people weren’t quite sure that a woman of her age in a cast could handle her
4ily needs. Since entering the hospital, she has clearly been depressed. She doesn’t
like the nurses caring for her because she resents the dependent role in which she Is
placed, and she has become progressively withdrawn. Her family reports that she is
listless and nonresponsive and spends most of her time lying in bed and staring out
the window. From the beginning she ate very little and has therefore become
progressively weaker. Recently she stopped eating. While she speaks very rarely,
Mrs. A”has said on more than one occasion something like the ()Jlowing: “I am old
and tired. I am ready to die. If you will just let me alone, I will stop eating and die. I
am ready to go to God.” Psychiatry was called for a consultation concerning her
mental status. They report that she is clearly oriented, has good short-term recaJl,
understands what she is doing, and has made a decision to die. They therefore
evaluate her as competent, although they recognize that she is also showing signifi
cant symptorns of a reactive depression, presumably caused by her hospitalization
and dependency. The medical and nursing staff like this woman, although she is
Making life hard for them, and they are very ambiguous in their feelings about
“whether they shoJld respect her wish and let her die or whether they should restrain bet and force-feed her. Her three daughters have equally ambiguous feelings.. It is clear that they love and respect their mother and arc reluctant to go against her wishes. At the same time, they don;t want her to die, and they think that if she eats and gets stronger, she will be able to go home to live on her own. [i !i ;::: QUI!S110NS A great many questions
~ raised by this case. The major reason for
~ DOt force-feeding this lady must be her own expressed wish that she be allowed to
~ “.. die. She Is suffering from no significant illness and is not experiencing a great deal Ii r
~: . of pain. So she Is not like those patients Who are allowed to die because their death
<‘ is imminent anyway and we want to avoid prolonging their painful suffering. Ifshe ~ ;:: ·eats and gets stronger, she can go home and live as she did before her hospitaliza. I’t: tion. The quality of her life befote her hospitalization was certainly quite satisfacto I::) ry both to her and ~o outside observers. So she is not like those patients who are ‘, allowed to die because they can only continue to live with a very low quality of life. I: ‘” In her case, it is a matter of her having decided that she is tired and ready to die. It ‘;:” therefore becomes crucial for us to ascertain whether she is competent to make such ~;. decision. Her history and the psychiatric evaluation indicate both the basis for a . ieactive depression and sympt()matology of such a depression. But is that enough to :~ say that she is incompetent? This is not the only question. Suppose that she is ‘;’ competent. Suppose.I.. WSl~.(Q~ that. her wishes t() be left alone and al!lll’l~ 10 starVe ~ hene ewishes ()f a competent adult. DOes that mean that the.X should .. … ommitri’ng-suicldeTThe cause ·i: of her death, after all, would ncitbo any underlying Il1ness but s mp15′-fier decision to die at this time. Ate we prepared to acquiesce In that decision and allow her to commit suicide? We have laws againslaiding and abetting a suicide. Doesn’t this express a social decision thaI suicide ought t() be prevented?StiIJ further questions “are raised. .what is the r()le Qfthe family in this case? Can they play any tole at all if we assume that the patient Is competent? And if We assume that the patie.nt is not competent, ought the decisIon to be theirs?1n any case, What can their role be in light of their own ambiguities and vacilJati-ons?’FinaJly, the’following compromise strategy has been suggested by several members of the tcaIn: Why don’t we enslJl”t that she eats, either by force-feeding her or by taUcing ‘her into eating, and see that $h~ goes .home? If she still”watlts to die, she can always stop eating and die at home. MIght thiS not he the best way to reconcile respecting her wishes with protecting her Iifl>?
CASE NO 2. ”’I’ve been in the hospital too many times”:
The significance ofpathetic wishes oftragic patients , t’ I
PACTS Mr. B was born 32 years ago with spina bifida. It was a little too early for the more effective procedures for treating such patients that have developed in recent years. He suffered all the traditional problems of the midlevel spina bifida patient, including paraplegia and loss of bowel and bladder.control. As a result, he has been hospitalized many times for surgical and medical treatments. and his life has been limited in many ways. One of his major problems has been recurrent pyelonephritis and renal insu.ffjciency. Six years ago, his left kidney was removed.
~enal function continued to decline, and this led to his current hospitalization. It is now clear that he can continue to live only ifhe is regularly dialyzed. When that Was . explained to him and his family, his initial reaction was extremely negative. He said that he was tired of being in the hospital all the time, that his life was no joy even before the current crisis, and that he wanted to go home to die rather than spend even more time receivIng health care. His family is strongly supportive of his wishes, claiming that he has been unhappy for 50 long because of his unending set of medical problems. Their support may, however I a result e fact that they too are tired of the ni u ens fCSU tlO fro . fOf him. Several people have suggested that Mr. B try dialysis for a period of time. They point out that he would have the option of not showing up (or trcItment later on. He has refused. He ( wouldn’t even go up to the dialysis unit to see what’s involved and to talk to other
pa~ents. Psychiatric evaluation of this patient has revealed that he is oriented
~d
that there is no problem with his short-tenn memory. He is clearly very anxious
about having to come to the hospital regularly for dialysis. There is a150 the sug
gestion of some denial of the prognosis that he will die shortly without dialysis,
since be regularly talks about his faith in God and his belief that God will save him.
Unfortunately, it is hard to find out whether this means that he believes that God
will miraculously intervene and keep him alive without the dialysis or simply that he has faith in OOO’s eternal salvation.
QUESTIONS This case. like case 1. presents a question of competency. There is evidence of !UlXiety and perhaps of denial, although there are none of the clinical sigt1s of depression which were present in case I. Furthermore, the family is strongly supportive of the patient’s wishes. In case I, we might be persuaded to keep the patient alive in light oflhe family’s vacillation about tespecting the pat,ient’s WiS,hes. In this C,.ase’.hOW , e,,ver, th,e family is very supportive of the patient’s Idesires. However, to complicate matters, there is some question about the motives of the family. Arc they really thinking of the best interest of the patient, or are they more concerned with their own ex.haustion from dealing with his many medical problems? There is a further complication. In case I, the patient was already very old, and accepting the patient’s Wishes might not have that much of an impact on how long she lived. In any case, the patient had alrea.dy had a long and good life. In this case,. however, the patient is much younger. He could live for many years on renal dialysis, and he has not lived a long life. Many membetli of the’ health-care team
~ swayed by that factor and therefore believe in dialyzing him. Still more complications a,bound. Mr. B’s quality of life has always been considerably lower than the nonn because of his recurrent medical problems dating baCK to his initial spina blfida. Those who argue for respecting the patient’s wishes make this point and urge that we respect the patient’s wishes in light of the pOor quality of his life. Other arguments ate appeaJed to by those who would respect the patient’s wishes. Even if we forcibly dialy7.ed the patient now, we couldn’t keep him in the hospital pennanently. The patient will go borne and may not show up for the ne}l appoint ment. This is differeni from the case of Mrs. A, whom we ejn force feed for a time,
b~lp to regain her strength, and send home without her current medical problems. Mr. B’s medical problems would be recurrent, and the patient can’t be kept in the hospital forever. What’s the point of forcibly diaiytirig the patient? Not, everyone is swayed by this argument. Some respond by saying that if we can just get the patient ove.. the current crisis and get him used to being on dialysis. he may see
tha~ it isn’t
too bad and may continue on treatment for an indefinite time.
CASE NO 3. “‘r’s so Iwrd ro breathe”:
What to do when we don’t really know what the palielll wallis
PACTS Mr. C is a 64-year-old palient with a long history of smoking two packs of cigarrelles a day. For the last ten years, he has suffered from emphysema. He bad to stop working about four years ago because of shortness of bn:ath. In the last six months, it became increasingly difficult for him even to walk across a room. Two nights ago, because of extreme shortness of breath, he was brought to the emergen cy room, where he underwent emergency intubation, and was admilled to the leU. It is clear that he can be gOllen through this current crisis, but his physicians estimate that he has at best six months to a year to live. His wife wants him to be In:aled. She is a very dependent person who will have great difficulty in handling his death. She recognizes that he doesn’t have long to live, but she is trying to put off the inevitable. She is supported in her wishes by all of his children. So everyone Is perfectly ready for Mr. C to be treated aggressively except Mr. C. He has pulled out his endotracheal tube twice, the second time even after he was restrained. His physicians have explained to him that it’s too soon for extubation and that he will almost certainly die without respirator support. They have explained, moreover, that his family wishes him to be treated. It’s very hard to assess the roots of Mr. C’s actions, because he has to write his responses 10 questions and is reluctant to do that. The health-care team is not sure whether he w.mts to be e.xtubated now simply because he· hates being intubated or because he feels that bn:athing is so much trouble that he would prefer to be dead. Psychiatry is reluctant to do a serious assessment of his competency because of the difficulties of communicating with him. But even his family admits that he was reasonably competent before admis sion, and it’s hard to see why.he should now be judged to be incompetent.
QUES110NS There are new complications introduced by this case. Here, as in the
last two cases, is a patient who wishes not to be treated even though be probably
understands that this means he wiD die. Of all three patients, however, this is the
ftrSt who is suffering from a teoninal illness that wiJI result in his death no matter
what we do. But he will not die in the very near future. He can be pulled through the
current crisis, and the best estimate is that he can go on to live for six months to a
year. There is no doubt, however, that the qualitY of that life will be lessened by the
severe restrictions on his physical activities. Still, without a clear expression of his
Wishes to be extubated, everyone would have treated him. This is not a case in
which people would have stopped treating the patient because his death js immedi
ately Inevitable or because of a miserable qualitY of life. Are Mr. C’s actions really
an expression of a wish to die, or is he simply expressing the fact that he fmds being
Intubated extremely painful? Can we respect his wishes to die. if that is what he
Wishes, in light of the fact that we can’t do a full-scale evaluation of his competen
cy? What strength should be given to the family’s strongly expressed desire that he
not be extubated. that he be treated as fully as possible, and that he
~ pulled
through this crisis? Shall we accept the argUll1cnt·of some of
thos~
involved that it would be inappropriate to continue to treat him against his wishes whatever their roots, In light of his short life expectaiicy and the poor qUality of bis life? Another themc bas cmerged In the thinking of some members of the Ilealth-care team. This is a man whose illness is self-induced. Against all sound medical advice. he has smoked for many years. Why, they argue, should we invest so much energy and resources, against the wishes of the patient, to pull him through an acute crisis j induced by a self inflicted illness? As one team member put it. “He assumed responsibilitY for his smoking. Now let him assume responsibilitY for his dyin$.” Is that a legitimate exe.,ression, or docS it represent an
jl18lU?!:~eriate
~djme~t? Finally. at least sorne members of the team would have had no trouble WIth the ,dea of not intubating Mr. C when he arrived in the emergency room if they had known then about his wishes. However, they cannot accept the Idea of extiJbating him at this point. They feel that would be killing him, not just allowing him to die, and they are not prepared to do that. Other members of the team don’t see any difference between not intubating him before and extubating him now.
..
1. _._Understands the nature and complexity ofthe issue(s) raised by the case under discussion.
2. __States clearly the position that is taken, without ambiguity, vagueness, or self-contradiction.
3. __Gives plausible reasons to support tlie position.
4. __Anticipates at least one plausible objection to the position, and responds to it fairly and persuasively.
.~
5. __Makes good use ofassigned readings, especially to think ofpossible objections to the .favored position; and shows good comprehension of the readings that are cited. . 6. __Organizes the essay coherently and employs a clear style.
7. __OVERALL GRADE (need not be a numerical average ofthe above)
Comments (continue on opposite side):
