Essay Instructions: Please reflect and respond in 2 pages per question. I am a liberal female christian.
Required Text: Critically Thinking about Medical Ethics, ed Robert F. Card, Pearson-Prentice Hall .
Unit Two:
Topics: Virtue Ethics, Care Ethics, Narrative Ethics
Readings:
“Images of Relationship” by Carol Gilligan.
“On Virtue Ethics” by Rosalind Hursthouse.
Excerpts on Narrative Ethics from Ethics: Systematic Theology Vol. 1 by James McClendon, Jr.
Assignments:
(1) Answer second Forum questions, with at least one response to posts made by each of your classmates.
(2) Continue your Journal reflections in your Personal Forum area, respond to the Journal posts made by your classmates in their Personal Forums, and respond to classmates’ comments on your journal
Unit Three:
Topics: Absolutism vs. Relativism; Emotive theory; Naturalistic Fallacy; Divine Command Theory; Situational Ethics
Readings:
Excerpts form Ethics, Theory and Practice by Jacques Thiroux and Keith Krasemann
Other resources including powerpoint on St. Thomas Aquinas and Natural law
Assignments:
Unit Four:
Topics: The Relationship between Medical Professionals and Patients; Informed Consent; Competence; Conflict of Rights; research on Human Subjects; Risk Management
Readings: Critically Thinking about Medical Ethics, Chapters Eight and Nine
“Risk Management: Extreme Honesty May be the Best policy” in Critically Thinking about Medical Ethics, p.490-496.
Assignments:
Unit Five:
Topics: The Pastor or Chaplain’s Role in Medical Ethics
Readings: “The Christian Pastor’s Role in Medical Ethics” by Joseph J. Kotva Jr.
Guidelines for Disclosure and Discussion…” in Critically Thinking about Medical Ethics, p.487-489
Assignments:
(1) Answer fifth Forum questions, with at least one response to posts made by each of your classmates
(2) Continue your Journal reflections in your Personal Forum area, respond to the Journal posts made by your classmates in their Personal Forums, and respond to classmates’ comments on your journal
Unit Six:
Topics: Assisted Reproductive Technologies; Abortion
Readings: Critically Thinking about Medical Ethics, Chapter Four
“Reproductive Autonomy in Light of Responsible Parenthood” by Hille Haker, Harvard Divinity School Bulletin Vol 34, No.1 (2006)
Other resources placed on Moodle.
Assignments:
Unit Seven
Topics: Stem Cell Research, Genetics and Morality
Readings: Critically Thinking about Medical Ethics, Chapter Six
Other resources placed on Moodle.
Unit Eight:
Topics: Allocation of Resources and Issues with Organ Transplantation
Readings:
“The Prostitute, the Playboy and the Poet: Rationing Schemes for Organ Tranplantation” in Critically Thinking about Medical Ethics, p.455-459.
“Alcoholics and Liver Transplantation” in Critically Thinking about Medical Ethics, p.460-464.
“Aging and the Ends of Medicine” in Critically Thinking about Medical Ethics, p.464-471.
Assignments:
(1) Answer Eighth Forum questions, with at least one response to posts made by each of your classmates.
(2) Continue your Journal reflections in your Personal Forum area, respond to the Journal posts made by your classmates in their Personal Forums, and respond to classmates’ comments on your journal.
Unit Nine:
Topics: Ethical Issues at the End of Life
Readings: Critically Thinking about Medical Ethics, Chapter Five
“Buddhist Views of Suicide and Euthanasia” by Carl. Becker (1990)
“Gender, Feminism and Death: Physician-Assisted Suicide and Euthanasia” by Susan M. Wolf
2. When she was only sixteen, Anissa Ayala, the daughter of Abe and Mary Ayala, was diagnosed with chronic myelogenous leukemia and was given only three to five years to live. Only a bone marrow transplant could save her. Unfortunately, neither Abe nor Mary, nor their son, Aaron, had compatible bone marrow. A search conducted by the National Marrow Donor Program did not reveal a suitable candidate, and neither did several other bone marrow drives. So Abe and Mary decided to conceive another child in the hope that it would have compatible bone marrow that could be used to save Anissa.
Their chance of success, however, was small. Abe was 40 years old and had had a vasectomy that needed to be reversed, leaving him with only a 50% chance of fathering a child. Mary's chances of getting pregnant were low because she was already forty-two. In addition, there was only a 25% chance that their offspring would have compatible bone marrow. This reduced the odds of having a child that could save Anissa's life to 6.4%.
Nonetheless, Mary Ayala became pregnant and gave birth to a girl in April 1990. She was named Marissa-Eve and she turned out to be a suitable donor for Anissa. When Marissa-Eve was just fourteen months old, her bone marrow was used in a transplant to save Anissa's life. The transplant was successful and both sisters are alive and healthy today. The sisters reportedly share a close bond even today and Anissa Ayala is now the assistant director of donor recruitment for the National Marrow Donor Program in Southern California.
Some questions for discussion:
Because Abe had a vasectomy, we know that he and Mary had decided that they did not want another child. Apparently, it was Anissa's getting ill that changed their minds. It appears that Marissa-Eve was conceived solely to save her sister. Could this harm Marissa-Eve's future personal relationships with her family? If so, how?
Kant says that we should never treat any person simply as a means to an end; persons must always be treated as ends in themselves. Was Marissa-Eve treated as a mere means to an end? Why or why not?
Clearly, Marissa-Eve had no input into whether her bone marrow should be used to save her sister's life. Athough a bone marrow transplant poses little health risk to the donor, it also offers no benefit to the donor and can be painful. In view of these circumstances, do you think that her parents had a right to decide to use her bone marrow? why?
If it is permissible for parents to create and use one child to save another, what else could be permissible? Where should the line be drawn? Would it be right for parents to decide to use one child's kidney to save another?
3. This is from the text, p.39.
"A middle aged man is diagnosed by his family physician with a case of pneumonia and is given a course of antibiotics. This man's condition does not improve and he is admitted to a local hospital. After a full workup, icluding blood tests and chest X-rays, it is discovered that this man has a rare form of pneumonia, called pneumocystis carinii, which is associated with immunodeficiency, and particularly with HiV infection. The man's medical history does not reveal any risk factors for HIV. THe medical team approaches the man to ask him further questions about his medical history, and this man reveals with some discomfort that he has had several homosexual experiences in his past. Blood tests reveal that the man is HIV-positive. The man is adamant that his wife and four children not find out that this is the likely cause of his illness. This man, whose condition is now life-threatening, secures a "death bed promise" from his attending physician to ensure that his family will not find out these elements from his past.
How would a virtue ethicist evaluate this death bed promise? Would a virtue ethicist think that the physician should not tell the patient's family?
Questions not in the text, but which I hope you will also discuss:
If the same death bed promise were requested of you as a chaplain or priest/pastor would the answer be any different than the answer the doctor should give? Why or why not?
Also- how does the virtue ethics approach to this problem differ from other ethical theories we have studied (utilitarian, deontological, divine command)?
4. The following cases illustrate dilemmas
related to communication with individual patients and their families, an issue
that is known to be a frequent source of ethical dilemmas in Cancer
Medicine.
CASE REPORTSPatient #1:A 65-year
old woman with advanced non-small cell carcinoma of the lung was referred to a
palliative care program. She had
been diagnosed 8 months before, after endoscopic biopsy and had received
radiation therapy plus 2 courses of chemotherapy for locally advanced disease. She had developed progressive local
disease plus lung and bony metastases.
Upon referral she had chest pain due to pleural and chest wall
involvement by the tumor, profound anorexia and cachexia, and mild continuous
dyspnea. She was a widow and came
accompanied by her son and daughter.
She was living her daughter’s home. The patient was originally from Egypt and spoke no English.
The
patient was admitted to a palliative care unit for appropriate symptom
control. During the first two days
of admission the palliative care physicians and nurses felt that the family was
only partially translating information.
After discussion with the son and daughter it was clear that the family
did not want the patient to know her diagnosis and prognosis. The whole family had immigrated to
North America less than 3 years before and was very concerned about a
disclosure of diagnosis and prognosis having devastating effects on the
patient’s mood and hope.
The team
was able to identify an independent volunteer translator. The private meeting between the
physician and social worker, translator and patient was arranged. The family was initially very angry
about this meeting taking place but agreed to allow the patient to communicate
independently with the health care professionals. During the meeting it became clear that the patient was
cognitively intact and had no major mood problems. The patient stated firmly that she expected her children to
discuss all issues regarding her treatment with the health care professionals
and did not have any interest in learning about her diagnosis and prognosis.
The team
proceeded to change her opioid therapy, to add megestrol acetate for the
management of anorexia and cachexia, and to start oxygen and intermittent
morphine for the management of dyspnea.
After stable symptom control was achieved, the patient was discharged
home. No further discussions
regarding diagnosis or prognosis took place with the patient. The patient died
2 months later at home in good symptom control.
Patient #2: A 58-year old man from South America was admitted to
a palliative care unit. He had
been diagnosed with non-small cell carcinoma of the lung six months prior. He had undergone surgical resection of
his cancer. Four months after
initial treatment he was found to have multiple bone metastases. Upon admission he had bone pain in
multiple areas, anorexia, profound fatigue, and depressive symptoms. He lived with his wife in his
daughter’s home. Both wife and
daughter did not want the patient to know his diagnosis or prognosis. They were mostly afraid that he would
become more depressed and give up all hope of living. The patient had recently completed one course of
chemotherapy that was discontinued due to severe toxicity and progressive
disease.
The
physicians and nurses organized a meeting with the patient privately. The
patient expressed concerns about his illness. He felt he could not discuss his worries with his family
because they always said, “he would get better soon”. He did not want to cause his family more distress by
expressing his feelings that he was very ill and probably going to die. When asked if he wanted to know his
diagnosis and prognosis, the patient said that he would find this very
useful. The physicians and nurses
proceeded to disclose this information to the patient. After the disclosure the patient became
tearful and received supportive counseling from the health care workers.
The
family was initially very angry about the diagnosis and prognosis being
disclosed to the patient without their consent. Over the following three to four days counseling sessions
continued with the physicians and nurses in the unit. The patient progressively became less distressed and was
able to talk openly to his family about his illness and impending death. During these conversations he expressed
the fact that he had been aware for some time that his illness was incurable
and that he was going to die and that the open discussion was helpful to him. After symptom control was stable, the
patient was discharged to home where he died 4 weeks later.
In both
of the above-described cases the main ethical dilemma is the same and can be
made explicit as follows: Is the family’s
requests to withhold the truth about diagnosis and prognosis to a patient
ethically acceptable? There are further questions that are contained and/or
related to the previous one, such as: Should a physician respect a family’s
request not to disclosure a patient the truth about his or her diagnosis and
prognosis? Does a family have a right to make such kind of requests? Do
patients have a right not to know their diagnosis and/or prognosis? In the above referred cases truth telling is regarded by relatives as being
harmful for the patient, while medical professionals consider it to be part of
their duty of beneficence.
Seemingly, what is beneficent for some appears to be maleficent for
others. This contrast in moral perspectives is precisely what underlies the
ethical dilemma in these cases. Thus, one question at stake is What ought to be
done if two or more of the prima facie principles
conflict with each other? Can we simply say that the problem here is one of
cultural and ethnic differences with regard to truth telling?
--------------------------------------------------------------------------------
[1]Prima facie isthe Latin for “at a first
look”. In this context, the expression refers to moral obligations that are
self-evident and need no further foundation or explanation in order to be
accepted as truth.
Cases taken from "ETHICAL
DECISION MAKING REGARDING TRUTH DISCLOSURE IN PALLIATIVE
CANCER CARE: A PERSONALIST APPROACH" by Taboada P, M.D. MA. Phil.§, Bruera E, M.D.¨
5. This assignment is based on the "Sherry" case which has been posted as an MSWord Document. Instructions: Read the case study, which considers informed consent issues. Then write up an analysis. The analysis must present a complete “situational awareness” (list the facts in the case and list the good and bad features of the case), “prudential reasoning” from the perspective of each participant in the case (patient, proxy (if relevant), and physician), and a “final resolution” to the dilemma.
SITUATIONAL AWARENESS
Facts: make a short list of the significant facts of the "Sherry" case. (Separate the facts from opinions people give about the case; deal with the case/problem to be decided, not so much with past events; look for diagnoses, prognoses, and treatment options.). In general, these sorts of facts are significant here: who the patient is, what the diagnosis/prognosis is, the treatment plan, the treatment alternatives, the patient's wishes, whether the patient is decisionally-capable, surrogates identified, family wishes, clinical opinions. These are not necessarily available in each case. Good and bad features: identify the good and bad features present in the case. There are three aspects of this identification to look for:
1. What features in the case are good? [We will want to enhance these if we can reasonably do so.] Examples of good features: being alive (in any form); preserving life; ordinary (proportionate treatment); intending to stop disease, cure people, and/or keep them comfortable; knowing what you want done.
2. What features are bad? [We will want to eliminate these whenever possible.] Examples of bad features: pain and suffering, family or physician distress, risks of death, low expectations for continued life (impending death), financial hardship, burden of caring for someone; inappropriate (disproportionate) treatment
3. Are there any bad features that could result from possible courses of action in the case? [We can only deliberately choose these courses of action if we sufficiently overriding reasons to compensate for these bad features.] Examples: we expect that removing the respirator will cause death??"if someone was to chose this, are there reasons that would sufficiently override this bad effect? Other examples: performing CPR causes trauma and damage to the patient; a DNR order will lead to death in the case of an arrest; surgery without informed consent would be forced, and that is bad.
Be careful not to make ethical judgments yet.
PRUDENTIAL REASONING
Present the prudential reasoning for each agent in the case??"at least the patient and the provider, but the nurse and the family as well. Prudential reasoning determines what is truly good for the moral agents in the situation. The key difference between this section and the situational awareness is that in the situational awareness you are identifying the good and bad features “present” in the situation (“he is alive,” “she is in pain,” “they are confused”) while in prudential reasoning you are trying to determine what is reasonable for someone to do. In other words, you are making ethical judgments here (“it is reasonable/ethical for A to forgo treatment,” “it is reasonable to B to honor D’s request here”)
You need to justify your answers here, because prudential reasoning is not guessing or simply saying what a person believes they want or should do (= “apparent good” while prudence determines the true good). If in the case the agent has given some desires or wishes, you should consider those in light of what you consider would be the appropriate results of prudential reasoning. If in the case the agent has not expressed any wishes or desires, then you should determine, as best you can, what that agent should/could ask for, and justify that.
This is the section where moral principles and guidelines, double effect reasoning, ordinary/extraordinary treat determinations, would happen.
FINAL ETHICAL REFLECTION
What finally is to be done (that is, should have been done)? Resolve any conflicts that may have arisen in the prudential reasoning you gave for each agent above.
6. Here’s a scenario that chaplains often describe:
The condition of a terminally ill hospital patient or nursing home resident is deteriorating. The patient has a surrogate ??" typically, an adult child ??" who has been involved in the patient’s care to some extent. The patient may or may not have a DNR order or other documented end-of-life preferences, but is still receiving some form of life-sustaining treatment or could potentially receive such treatment. For example, a hospitalized patient dying of cancer is still receiving chemotherapy or radiation, or a nursing home resident with multiple co-morbid conditions is still being transferred to the local hospital whenever breathing difficulties arise. The patient is not enrolled in hospice.
The physician responsible for the patient’s medical care right now believes that the patient is no longer able to benefit from further life-sustaining interventions ??" that these now constitute “doing to,” not “doing for.” The other members of the patient’s medical team agree with this conclusion. The patient’s surrogate is asked to meet with the patient’s physician and with other members of the team, to discuss the patient’s deteriorating condition, to recommend stopping life-sustaining interventions, and to describe the palliative care that the patient will receive to ensure comfort now and through the end of the patient’s life.
Then, at least one of the following things happens:
• The surrogate refuses to meet with the team.
• The surrogate doesn’t show up for the meeting.
• The surrogate meets with the team and rejects their recommendation, perhaps citing a non-specific religious objection (“I still have faith that she’ll beat this ??" miracles happen”) to forgoing interventions.
• The surrogate meets with the team, rejects their recommendation, and also seeks to rescind an existing treatment directive made while the patient had decision-making capacity.
Somewhere along the way, the chaplain is paged. Perhaps the chaplain has been in the mix all along, as a team member. Perhaps the responsible professional called for a clinical ethics consultation, and the chaplain is on the consultation team. Perhaps the surrogate’s mention of religion triggered the chaplain’s involvement. Perhaps the chaplain is perceived as someone who is good in a crisis, or adept at conflict resolution.
Or perhaps team members are experiencing moral distress ??" the sense that they are harming their patient and that they are powerless to change this situation ??" and need someone to listen to their concerns.
What does the chaplain do? How does the chaplain collaborate with others to act in this patient’s best interests? What courses of action would be unacceptable, from the perspective of ethical practice? What would constitute a good outcome?
7. Judith Jarvis Thompson asks us to consider if having an abortion is a meaningful parallel to unplugging the violinist. Both circumstances catch the woman by surprise. Both the violinist and the unborn child are attached to her body, which both need in order to survive. Both will eventually release her.
Thompson's view is that disconnecting the violinist is morally justified even though he'll die, and there seems to be merit to this appeal. To stay connected would be heroic??""a great kindness," in her words??"but, like all acts of heroism, it is voluntary and not morally required. If that's the case, then it's moral to abort a child, even if he or she is a fully human person, just like the violinist. If the first is morally acceptable (unplugging the violinist), and if the second (having an abortion) is similar to the first in a relevant way, then the second should be acceptable also.
The key question is whether the two situations are truly similar in a morally relevant way. If not, then the illustration is guilty of a logical slippery slope fallacy. The analogy fails and the argument falls apart.
Are there important differences between pregnancy and the scenario Thompson describes? Are you convinced by her argument? What would Hauerwas' response to Thompson be? Remember-- this is not a journal entry where you simply tell me what your views on abortion are. What you are being asked to do is read and respond to Thomson and Hauerwas.
Nonetheless, Mary Ayala became pregnant and gave birth to a girl in April 1990. She was named Marissa-Eve and she turned out to be a suitable donor for Anissa. When Marissa-Eve was just fourteen months old, her bone marrow was used in a transplant to save Anissa's life. The transplant was successful and both sisters are alive and healthy today. The sisters reportedly share a close bond even today and Anissa Ayala is now the assistant director of donor recruitment for the National Marrow Donor Program in Southern California.
Some questions for discussion:
Because Abe had a vasectomy, we know that he and Mary had decided that they did not want another child. Apparently, it was Anissa's getting ill that changed their minds. It appears that Marissa-Eve was conceived solely to save her sister. Could this harm Marissa-Eve's future personal relationships with her family? If so, how?
Kant says that we should never treat any person simply as a means to an end; persons must always be treated as ends in themselves. Was Marissa-Eve treated as a mere means to an end? Why or why not?
Clearly, Marissa-Eve had no input into whether her bone marrow should be used to save her sister's life. Athough a bone marrow transplant poses little health risk to the donor, it also offers no benefit to the donor and can be painful. In view of these circumstances, do you think that her parents had a right to decide to use her bone marrow? why?
If it is permissible for parents to create and use one child to save another, what else could be permissible? Where should the line be drawn? Would it be right for parents to decide to use one child's kidney to save another?
