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

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 physician’s 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 you’ve 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 someone’s 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 patient’s 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 patient’s 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 so 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 John’s 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?