Every Formal Ethical Scenario in Doing Right

You are a primary care practitioner in the downtown core of a large city. A 32-year-old factory worker, Mr M, attends your clinic as a new patient. You start by asking him the usual accommodating questions. Mr M tells you he has been unwell for 24 hours with a runny nose, aching muscles, a dry cough, and hoarseness. Apart from some tender neck muscles, however, his physical examination is entirely normal; indeed, he barely seems ill. You say by way of conclusion that he has got a simple viral illness. “We can get to the moon, but we can’t cure the common cold. It will get better on its own.” Unconvinced, Mr M requests an antibiotic because he “always got one from the clinic down the road.” He then, rather loudly, voices concern you do not really have the experience or skills to make the proper diagnosis. “I felt so under the weather today I couldn’t go to work! How do you know I don’t have one of those new superbugs I heard about? One of my buddies at work picked something up. He went to see his doctor, who said it was nothing, and the next thing you know he was almost dead in the ICU.” Is there an ethical issue here? Would you do what the patient requests?

A 46-year-old man, Mr H, dying of multiple myeloma, has fought the disease every step of the way with a remarkable determination to live. He has undergone every known treatment—bone marrow transplantation, experimental therapies, naturopathic remedies. Thin and wasted, Mr H is now on dialysis. The disease has, it seems, finally reached its terminal stages. He has but a few weeks to live. Although Mr H recognizes he is dying, he refuses to agree to a “palliative care only” order. To him this would mean giving up. There is still so much he wants to do. He wants any extra moment of life that aggressive interventions might give him. Mr H’s treating team wants to transfer him to a palliative care ward, which, they feel, could better serve his needs. The patient refuses this. “I’m not ready to die!” Mr H states categorically. What would be the next best step to take with Mr H?

A fourth-year medical student, Michael, on a two-week elective in anaesthesia, is observing a patient being intubated in preparation for surgery. Suddenly, the staff anaesthetist, Dr B, removes the patient’s endotracheal tube, asking Michael to demonstrate how he would re-intubate the patient. Not surprisingly, the student, having no prior experience with the procedure, cannot do so. Dr B must eventually and hurriedly do the re-intubation himself. He angrily dresses Michael down in front of others in the OR. Humiliated about his failure, the student does not mention the episode to anyone until much later. What could Michael have done at the time?

You are a healthcare trainee on a multidisciplinary team looking after a previously well 66-year-old married Armenian patient, Mr I, admitted recently due to a two-week history of vomiting and dramatic weight loss. Tests done two days ago revealed he has advanced metastatic gastric cancer. The internist responsible for this patient tells you Mr I is unaware he is dying of cancer. “It was the family’s wish not to tell him and I went along with it. He doesn’t speak much English and the family said in their culture the family is always told first,” she says. “He thinks he has a bad infection in his colon, so don’t say anything.” One evening, when everyone else has left for the day and you are on call, the patient asks to see you. He tells you he has been gradually feeling worse since admission. “Why am I still vomiting? Is there nothing you can do for me?” His English seems perfectly fine to you. He then adds, “Tell me, Doc, it isn’t just an infection, is it?”

Questions for Discussion

1. How should you respond?

2. What if you were not a “doc” but a medical student or another member of the healthcare team?

Dr G works for a medical NGO (Non-Governmental Organization) in rural Ethiopia, an impoverished region of the developing world. There is a wave of diphtheria sweeping through the countryside as the recent vaccine campaign did not reach many of the smaller villages. Several children died of the illness, something quite preventable had there been early diagnosis and prompt treatment. A poor family asks Dr G to come their house in an affected small town. The youngest child in this family, 5-year-old Liya, has developed a fever and refuses to swallow. She defiantly refuses to open her mouth. No amount of arguing, bribing or cajoling by Dr G or her parents will budge her. Dr G decides, with the parents’ consent, to hold Liya down and force her mouth open. She is fierce in her resistance. Dr G is finally able to see a grey web in her posterior pharynx, typical of diphtheria. Exhausted and sweaty from the struggle, she falls back into a chair. Liya stares at her in anger. Dr G thinks to herself, “What did I just do? What kind of person am I?”

Questions for Discussion

1. What makes this scenario so distressing?

2. How could Dr G’s actions be justified?

3. What other options could have been explored?

You are a healthcare trainee doing your rotation in a community health centre. An 80-year-old widow, Ms B, is brought by her son for her annual influenza vaccine. In explaining its risks and benefits, you realize the patient is not following your explanation. An inspection of her chart reveals she has a five-year history of progressive dementia with a decline in many aspects of daily functioning. A brief examination reveals Ms B to be very confused, having difficulty understanding what is being asked of her. She blankly looks at her son and asks, “Who is that person and what does she want?” The son gives you permission to give his mother the injection, saying she always wanted it in the past. However, normally quite docile and quiet, she vociferously refuses. “What do you want my arm for? You have no right to touch me there!” Do you have a right to touch her? What would you do?

Sam E is in the first month of his training to be a healthcare professional. Recently learning about the dangers of suntanning, he has taken to cautioning his friends about melanoma, the most serious form of skin cancer. He’s seen pictures of some nasty-looking lesions in his Dermatology atlas. One hot summer’s day, standing in a crowded bus going to school, he happens to notice a small but ominous-looking lesion on the posterior shoulder of a fellow passenger wearing a halter top. He has never seen her before. Is this an ethical dilemma? What should Sam say, if anything, to the stranger?

A married, 72-year-old retired construction worker, Mr G, has a history of severe coronary artery disease (CAD), Type 2 diabetes, and recurrent depression. Perpetually in a gloomy state of mind, he worries considerably about his health. His family doctor, Dr Y, receives a letter from the local hospital informing her Mr G may have had his prostate biopsy done last year with improperly sterilized equipment. A patient on whom it had been used just prior to Mr G was recently diagnosed with Creutzfeldt-Jakob disease (CJD). Dr Y had read of CJD being transmitted by surgical instruments, but the risk was, she thought, “incredibly low.” She has seen no evidence for this disorder in this patient. She also recalls Mr G reacting almost hysterically when she asked him several years ago about testing for hepatitis C (“What’s this? You want to give me another illness to worry about? I’m sick enough already.”); it took her an hour to calm him down, but eventually Mr G took the test (which was negative). Dr Y decides, on grounds of compassion, not to tell Mr G about his possible exposure to CJD. Was Dr Y’s response the right course of action? What are the arguments you could make for and against warning Mr G?

You are seeing Ms R, a 34-year-old woman, and her partner, Mr P, for the first time. They have been trying unsuccessfully for the last five years to have their first child. As part of the workup for infertility, you need to examine each of them. After spending time talking to the couple, you ask Ms R to disrobe in the next room so you can conduct your physical examination of her. As you enter the room, she appears nervous and hesitant. Finally, she says, “I have to be really honest with you, I had an STD when I was 19 and then again when I was 25. I have never told my partner. Please don’t tell him now.” This information is important in your workup of the couple’s infertility. What is the ethical issue here?

You are the attending physician at a chronic care facility. One of the residents, Mr T, an 84-year-old war veteran with no living relatives, unable to look after himself owing to physical frailty and mild cognitive decline, develops gangrene in his foot due to poor circulation; it does not respond to medical treatment. Advised to have the foot amputated, Mr T refuses, saying, “My foot will get better on its own. I’ve seen lots worse during the war!”

Question for Discussion

1. Should you accept his refusal of treatment?

Ms R is a 46-year-old single woman from the Dominican Republic with a 10-year history of rheumatoid arthritis. It has become very disabling; her small hand and finger joints are barely usable despite numerous corrective surgeries. Pain control has also been a significant issue. Ms R is taking 300 mg of morphine a day and complains bitterly that she is still in pain. Your colleagues are appalled at the dose of opiates you have prescribed for her. Ms R comes to see you today as she needs more painkillers and to talk about methotrexate, the only drug she has found at all helpful in remitting her symptoms. She has been taking the drug much longer than recommended; there are changes in her lab tests suggesting damage to her liver. There are some new biologic agents, but she is skeptical about whether they will help her. In any case, these new drugs are far too expensive for Ms R to afford. You have advised her several times to stop the methotrexate, but Ms R refuses. “It’s the only thing that helps me! Damn the liver, I just want some relief!”

Questions for Discussion

1. As Ms R’s physician, what should you do?

2. What are the pros and cons of following Ms R’s request?

You are the primary care provider for Ms T, a 45-year-old woman admitted with syncope and a possible seizure disorder. This is her second such admission. During a similar hospitalization three months ago, a complete neurological workup, including a brain scan, failed to reveal a cause for these symptoms. The attending physician on this admission orders the same tests to be repeated. Informed of the admission, you come to visit Ms T in the hospital. You are extremely worried. Two days previously, the patient had come to see you and had confided the real cause of her last admission was a beating, one of many she had suffered at the hands of her abusive husband. Ms T had never disclosed this to anyone before and asked you to keep the matter a secret. In their culture, she explained, men are allowed to beat their wives for actions such as going out without the husband’s approval. Ms T does not disagree with this cultural allowance. She does not even regard this as “abuse”—it’s “just how things are.” It’s what she learned growing up. You are pretty sure that the husband’s actions are again the cause for Ms T’s admission. After reviewing the admission notes, you realize this has not been considered by the attending physician. Should you reveal the patient’s secret to her admitting doctor?

Ms E, a 22-year-old woman ill since age 14 with severe anorexia nervosa, was brought into the emergency room in cardiovascular collapse. She was extremely emaciated, weighing less than 60 lbs., and virtually unresponsive. After receiving a bolus of intravenous glucose, she perked up just long enough to pull out her intravenous line. Ms E had been admitted numerous times in her starved state and had spent most of her previous eight years in hospital. She had been considered one of the most “difficult” patients by specialty units of various tertiary care hospitals. All corrective therapy had failed. Drug therapy using antipsychotics and antidepressants was unsuccessful. Different psychotherapeutic approaches over many years—including cognitive-behavioural, family therapy, and even “paradoxical” therapy (admitting to the patient that she is going to die and hoping she will struggle against this pessimistic message)—had also been of no sustained benefit. On previous admissions Ms E had received nutritional rehabilitation, including force-feeding requiring restraints and causing major disruptions on the ward. She had expressed a wish to die but not consistently so. She had recently told her family doctor she wished her suffering would soon end; at that time, she requested no forced feedings in the future. Ms E thought she was, and had always been, overweight, refusing to believe her food refusals endangered her life. Various tertiary care hospitals refused her readmission because of her previous extreme resistance and disruptiveness. The healthcare team involved in Ms E’s care considered the option of providing nutrition through a gastrostomy tube (a tube inserted directly into her stomach through a small incision in the abdominal wall). This would have entailed a minor surgical procedure and, most likely, putting her in physical restraints. What should have been done on this admission? How might Ms E’s situation be distinguished (or not) from that of someone who is terminally ill? How would you assess the status of her request not to be force-fed?

You are the primary care provider for Mr I, a 20-year-old second-year college student with a past history of depression as a teen. For several weeks, he has confined himself to his small garret-like flat, refusing visitors. His best friend was killed two months previously when a car struck his bicycle. According to others in the house, Mr I has not been carrying out his day-to-day tasks, appearing dishevelled when glimpsed. He can be heard crying and shouting day and night. After Mr I misses several appointments, you decide to visit him at his home. Reluctantly, he lets you in. He admits having stopped taking the antidepressant he was prescribed at the university’s health service because one of his housemates told him it was a “psychiatric poison.” He looks ill-kempt and admits to being very sad. Mr I acknowledges that pills and therapy are interventions that might help some people—indeed, his own episodes of depression responded to them in the past. Nonetheless, he refuses them now on the grounds that “I’ve seen Jesus and he can’t help me. I am, as he was, as we all are,” he cries, “under the control of a higher power.”

Questions for Discussion

1. What is the ethical dilemma in this case?

2. What should you do?

You are a nurse practitioner on the Oncology service. Mr O, a 72-year-old male, has been admitted with nausea and ataxia. In hospital he has had several brief seizures and is now on phenytoin, an anticonvulsant. An enhanced MRI reveals a thin coating of tumour wrapped around his brainstem: he has leptomeningeal carcinomatosis. This uncommon condition is virtually untreatable. Time to death after diagnosis is usually weeks to a few months. He is unaware of his diagnosis but his family knows—they had an acquaintance in the MRI suite who tipped them off. The large and supportive family has formed a protective cordon around Mr O. His wife, herself a doctor from another country, pleads with you not to tell Mr O what you know. “I know the prognosis for my husband is terrible. We have all come to accept that. Now we only want to be able to take him home and let him die there in peace,” she says with tears in her eyes. “It would be cruel and do him no good to be told his exact diagnosis. We have told him he has a seizure disorder from a brain abnormality, that it cannot be fixed, and left it at that. We think he should only be told good news; anything else would only make him feel worse. We accept that it is the family’s responsibility to look after the patient. You can’t do anything for him; we will do everything for him.”

Questions for Discussion

1. What are the ethical conflicts here? On which dilemma would you focus if you were the healthcare practitioner in this case?

2. What of families who ask clinicians to do everything for a dying relative?

3. What should be done when deception is in the patient’s best interests?

Ms X, a 60-year-old woman with early-stage breast cancer, accompanied by her 25-year-old daughter, has come to see Dr Y for a second opinion. The breast surgeon explains, as far as surgery goes, fortunately all she needs is breast-conserving surgery (BCS). Ms X does not look relieved. With her daughter translating, she replies, “That’s what the other doctor said, too. But that’s not what I want!” Her daughter explains she wants a modified radical mastectomy, having no confidence in BCS as one of her friends had a recurrence of breast cancer after this. Dr Y is a little confused. She usually finds herself in the opposite position of trying to convince some women to have any surgery at all. Although Dr Y describes the morbidity associated with radical surgery, Ms X remains unconvinced. Her daughter explains this view of BCS is common in their culture. Must Dr Y go along with the request for more radical surgery than is medically indicated?

Mr S had lived on the same street in Parkdale in Toronto for as long as anyone could remember—decades, anyway. He had survived the Nazi occupation of Poland, as had many of his neighbours on the street. But by now he had outlived them all. Mr S was a widower, had no children, and, as far as anyone on the street could tell, had no visitors either. He was fiercely independent, turning down any offers of help from his neighbours, most of whom had moved in during the past several years. That harsh winter, Mr S could be seen now and again shovelling the snow from his walk, his back bent and crooked. Then, his neighbour, Ms T, noticed snow piling up on his walk. Worried about Mr S, she knocked on his front door. Finding it unlocked, she hesitantly stepped into his house, afraid of what she might find. What Ms T found there shocked her. Mr S was lying in a cot off his kitchen, barely able to stand. He looked terrible—pale and dishevelled, wraith-like, a ghost of his usual self. Declining her offer to help him in any way, he insisted he just needed a few days’ rest. He assured Ms T he was fine: “I’m eating raw eggs every day.” This information increased her concern. She offered to take him to the emergency room at a nearby hospital, “just to get you checked out.” Mr S stood firm in his refusal of help: “No hospitals!” Ms T sought help from a general practitioner, Dr P, who had recently moved in across the street. Is there an ethical dilemma here? What could Dr P do?

A 22-year-old unmarried woman, Ms Q, is pregnant for the second time with a Caesarean section already scheduled. Well on in her second trimester, she requests to have her “tubes tied” at the time of the delivery. The obstetrician, Dr R, refuses to do this procedure, citing her young age and unmarried status. “How do I know you won’t change your mind in a few years?” the obstetrician says to her. What is the ethical dilemma here?

“Whatever you do,” the 64-year-old patient, Ms N, warned her anaesthetist, Dr Y, “don’t touch my left arm. You’ll have nothing but trouble there!” Dr Y accepted this cryptic prohibition without seeking further clarification. Soon after Ms N’s elective surgery for a prolapsed bladder began, he lost intravenous access in her right arm. Ignoring the patient’s prior stated request, he started a new IV in her left arm. The operation was completed without incident 27. Unfortunately, the IV in Ms N’s left arm went interstitial post-operatively. A toxic fluid leaked into the surrounding arm tissue, resulting in a significant injury to her arm. At trial, no evidence was presented of any medical reason for her left arm not to have been touched. On the other hand, no evidence was offered supporting the necessity of starting an IV in that arm. Ms N successfully sued Dr Y for battery (non-consensual touching) 28. What is the rationale for this judicial ruling?

An 84-year-old woman, Ms K, has a history of coronary disease. She requests her usual prescription of triazolam, a short-acting benzodiazepine she has taken for years for insomnia. Despite repeated efforts on your part to wean her from this drug, Ms K insists on taking it. Her fervent wish is for a good night’s sleep. And, oh yes, she has tried “everything” already to help her sleep. “Only this little pill works.” Should you prescribe “this little pill” yet again?

Ms W is a 56-year-old woman with a long history of disabling and destructive rheumatoid arthritis, causing her hands and feet to be cruelly contracted. Despite numerous surgeries she is unable to bear weight; even sitting is painful. She is admitted to hospital for yet another attempt at corrective surgery. Unfortunately, she develops C. difficile colitis and, later on, large sacral pressure sores. Now Ms W is refusing to be turned in her bed. The patient has no significant family members to be called upon. After several weeks of intense but fruitless negotiation, the hospital ethicist is asked by the treating team to see her. The team asks the ethicist, “Could Ms W be turned despite her wishes not to be?”

Ms C is a 42-year-old woman diagnosed with breast cancer in 2008. Found to have bony metastases four years later, she undergoes hormonal treatment in conjunction with chemotherapy and radiotherapy. Two years after this she is admitted to hospital with esophageal stricture, dehydration, dysphagia, and poorly controlled pain. A do-not-resuscitate order had previously been entered on her medical record. In the emergency department, Ms C receives small doses of morphine intravenously. Upon transfer to the ward, the patient is inadvertently given hydromorphone instead of morphine. (Hydromorphone is six to seven times as potent as morphine.) Shortly thereafter she is found not breathing.

Questions for Discussion

1. Should Ms C’s previous wish not to be resuscitated be followed? Why? Why not?

2. Does such an order preclude the use of naloxone that may reverse narcotic overdose?

3. Does the fact that an error may have been the cause of her decline make a difference?

Ms K, the 84-year-old patient encountered in Case 4.5, refuses alternative means of sedation. The following year she suffers a myocardial infarction for which she is hospitalized for three weeks. Her illness is complicated by congestive heart failure and arrhythmias. Upon discharge she once again requests triazolam. Examination reveals an elderly woman in no acute distress but with subtle changes in her mental processes; Ms K seems more confused than before her myocardial infarction. You discover she has been using higher daily doses of triazolam to cope with feelings of anxiety and panic over her diminished stamina. Worried that her overuse of this drug might be contributing to her mental state, you decide to involve a community Geriatric Psychiatry team to help her cope better with her losses and end her dependence on the drug. Ms K refuses to see them. She’s seen psychiatrists before and knows they will want to stop her triazolam.

Questions for Discussion

1. What are the ethical issues here?

2. How would this situation be best managed?

A clinical clerk who has been reading about informed consent in preparation for her Surgery rotation asks a disarmingly simple question: “I know we need to get informed consent from patients if we operate on them, but how come we don’t get consent when we examine them in the ER or take their blood or take an X-ray?” Is the student correct? Should consent be obtained from patients for routine matters of healthcare?

Dr N is a newly graduated general surgeon doing a locum at a regional hospital. On his first day on call, he assesses Mrs S, a 57-year-old married woman with two adult children, who has a high-grade bowel obstruction. She has received several doses of IV morphine for pain. After thorough assessment and investigations, Dr N advises emergency surgery to prevent a bowel perforation. He explains to Mrs S and her family in detail the nature of the surgery, risks and benefits, alternatives and possible consequences of not doing surgery. Clearly in distress, Mrs S signs the consent form, pleading, “Please, just fix this problem!” Her family are struck by how awfully young Dr N looks. “How many of these procedures has he done?” they wonder aloud. Maybe they should take Mrs S to somebody more experienced at a larger centre for surgery? What should Dr N tell the family with respect to his experience? Is Dr N legally at risk if something goes wrong with Mrs S at the smaller centre? Given that Mrs S has had several doses of morphine, is her consent legitimate?

You are a first-year resident in your first week of a General Surgery rotation in July, assessing Mr M, a 50-year-old refugee from Sudan with acute cholecystitis. He is a manual labourer, speaks little English, and clearly has a limited understanding of what is going on. After discussing the case with the attending surgeon, you are instructed to admit Mr M and obtain consent from him for laparoscopic cholecystectomy to be done first thing next morning. Despite explaining to the attending surgeon that you are new to Surgery and have not had any experience with obtaining consent for surgery, you are told to nonetheless get consent. “Just tell him he needs his gallbladder out and that the risks of the laparoscopic surgery are 1% risk of bleeding and infection and a 0.1% risk of a common bile duct injury. You can do that, can’t you? I’m caught up in the OR. Reassure him it’s a safe operation and he should be back to work in two to four weeks.” She sounds a little exasperated. What should you do in this situation?

Dr X, a surgeon, diagnoses Mr Y with acute appendicitis and advises an appendectomy. Although he explains the nature of the surgery, he glosses over the risks by saying that it is a very common procedure that should allow him to be home in a day or so and back to work in a week. At the time of surgery, Dr X finds a badly perforated appendix. He removes it and treats the patient appropriately with antibiotics post-operatively. Unfortunately, Mr Y develops an extensive subcutaneous necrotizing infection of his abdominal wall that subsequently requires multiple procedures, debridement, and skin grafts. After six weeks in hospital, he finally goes home, unable to resume work for another six months until he has fully recovered. Mr Y subsequently sues Dr X for failing to adequately inform him of the risks associated with the surgery. Did Dr X adequately obtain informed consent? Should Dr X have explained to Mr Y the remote risk of a developing a necrotizing abdominal wall infection?

A 55-year-old female patient, Ms G, has a five-month history of a sore shoulder. Her physician, Dr H, has prescribed duloxetine, an antidepressant commonly used to treat chronic pain as well. Dr H did not inform Ms G this is a psychotropic medication, nor did he warn her about its possible side effects. Only on discussion with a relative who is a nurse does Ms G realize the dizziness, upset stomach, and racing heartbeat she has experienced for the past week could be due to the drug. The physician later explains it is not his practice to warn people about medications he has frequently used successfully before. Is Dr H’s response acceptable?

Ms W, an elderly Asian woman, has been diagnosed with an early rectal cancer. In the course of preparing her for surgery, Dr R explains the nature of the surgery, the risks, and the possible need for a colostomy. With her oldest son translating, Ms W happily agrees to the surgery. Afterwards, the medical student Dr R is supervising, who also speaks Cantonese, mentions that the son did not inform Ms W of the possible need for a colostomy. When asked about this, the son explains his mother would likely not agree to the surgery if she knew about the risk of colostomy. He adds that it is customary for him to make these sorts of decisions on his mother’s behalf. “Besides,” he says, “it’s not certain she’ll need a colostomy. No need to worry her unnecessarily, if it’s only a possibility.”

Questions for Discussion

1. Is it acceptable for family to make decisions on behalf of elderly non-English-speaking family members?

2. What should Dr R do?

Mr L is an elderly man treated for acute leukemia. He is quite debilitated from his most recent round of chemotherapy which, unfortunately, appears to have failed. Dr B suggests the next best option is a bone marrow transplant. After Dr B explains in great detail what is involved and the risks associated with this procedure, Mr L sighs loudly and asks where he should sign. Concerned about his attitude, Dr B inquires more deeply about Mr L’s real wishes. “In all honesty, Doc,” says Mr L, “I’ve had a long and happy life. If it was up to me, I’d just opt for some pain medication and let nature run its course. I’m not afraid to die. But my family will never let me do that. They want to keep me alive at all costs.”

Questions for Discussion

1. Is Mr L’s consent valid under these circumstances?

2. If not, what should Dr B do to ensure genuine consent on Mr L’s behalf?

A 20-year-old female student has recently become a patient in your primary care practice. She has been well, other than undergoing surgery as a young teen for what she was told were “diseased reproductive organs.” She knows little else about that surgery. When her medical records are received, there is a letter from her pediatricians stating that “she” is, in fact, genetically a male with Androgen Insensitivity Syndrome. (In this disorder of gonadal dysgenesis, patients usually have an XY karyotype with inguinal testes and a female phenotype. Due to lack of responsiveness to testosterone in utero, male genitalia do not form. Children are often not diagnosed until puberty, when they fail to menstruate. The testes are removed during adolescence because of an increased risk of testicular cancer.) The patient’s family and her physicians had decided not to tell the patient of her “true sex,” feeling it would possibly cause great psychological trauma. The letter urges future healthcare providers not to tell her. What, if anything, should you say to this patient?

Mr K is an 80-year-old widower, originally from Peru, now living in a supportive housing facility. After an incidental finding of a left-sided kidney mass, he is referred to a urologic surgeon for removal of the kidney. Dr U explains the rationale for the procedure and outlines the main risks including pain, bleeding, infection, and the risk of renal insufficiency post-op that might necessitate dialysis. Mr K consents and surgery is booked. The procedure is uncomplicated and the pathology confirms an early kidney cancer, which appears to have been adequately resected. Unfortunately, in the weeks after the procedure, Mr K’s remaining kidney function deteriorates, forcing him to go on dialysis. This necessitates placement of a dialysis catheter, with trips to and from the dialysis unit three times a week for 4 to 6 hours at a time. His diet and fluid intake is restricted and his entire life now seems organized around dialysis. Mr K complains bitterly that if he’d understood what dialysis involved, he would never have proceeded with the surgery. Was Dr U’s disclosure of risks adequate? Did Dr U have an obligation to ensure that Mr K understood what dialysis entailed?

Mr P is a 55-year-old divorced bank employee living on his own, who comes to the emergency room late one evening on the advice of his chiropractor because of abdominal pain. Workup demonstrates a large amount of free air on X-ray. After confirming peritonitis on exam, Dr D, the general surgeon on call, advises immediate surgery. She explains all the relevant aspects of the surgery, including the risks, benefits, and prognosis with and without surgery. Mr P thanks Dr D for her time and consideration, but declines the surgery. He explains he has had similar pain on many occasions; the pain generally resolves with a glass of warm soy milk. Besides, he has lots of yard work to do the next day. Dr D then restates the seriousness of the condition and the risks of not having surgery—including the very real chance of dying. Although their discussion is very cordial, Mr P still declines the surgery. Besides, he emphasizes, he does not want to miss the finale of his favourite TV show. What should Dr D do? Would it be a sign of Dr D’s abiding respect for autonomy to accept Mr P’s refusal?

After investigations for recurrent episodes of dizziness and vision changes, Mr Z, a 65-year-old widower, is found to have suffered multiple small strokes due to atrial fibrillation. A cardiologist, Dr M, advises that he start a blood thinner, warfarin. Mr Z is reluctant, explaining that because he has a very active lifestyle (skiing, squash, and karate), he is concerned about the risks of bleeding. He prefers to use ASA to prevent further strokes. In order to impress upon Mr Z the seriousness of the situation, Dr M ratchets up his rhetoric. ASA won’t do, he says. He warns him there is a real chance he’ll suffer a massive stroke and end up in a long-term care facility, unable to control his bodily functions, drooling and being spoon-fed Pablum by his children. Is scaring a patient reasonable in some circumstances? How do we draw the line between persuasion and coercion?

Mr N is a 38-year-old male with a history of a few episodes of biliary colic. He is seeing Dr J and in the process of arranging an elective laparoscopic cholecystectomy. As Dr J begins explaining the nature and risks of the procedure, the patient says, “No need to go into details, Doc. I trust you completely. If you told me everything that could go wrong, I’d probably run like heck.” Although the surgeon makes a few more attempts to explain the procedure, Mr N interrupts each time and asks, “Where do I sign?” Is it acceptable to proceed with consent in this way? Is there anything else Dr J should do?

A 58-year-old woman, Ms T, agrees to undergo a colonoscopy by Dr E. During the procedure, despite moderate sedation, she suddenly experiences pain and cries out, “Stop! I can’t take this anymore!” Should the physician continue the examination?

A patient is brought to the ER in shock; he has suffered a serious abdominal wound in a drive-by shooting and needs urgent surgery. The team knows his chances of recovery are slim. But he is still alert and able to talk. On the way into the OR, he turns to the nurse anaesthetist and says, “I’m going to make it, right?”

Mr V, an active 80-year-old man with a history of stable coronary artery disease, is admitted to the ICU with a large and serious, but quite survivable, presumed self-inflicted gunshot wound to the side of his face. He had become despondent as the primary caregiver for his spouse with advanced dementia but had never been treated for a psychiatric disorder. Neither a suicide note nor advance directive had been found. At the time of his admission Mr V is neurologically intact but heavily sedated and intubated to protect his airway. He is unable to take part in decision-making. A plastic surgeon, Dr A, seeks consent for the repair of Mr V’s facial injury from the appropriate substitute decision-makers, his two grown children. Mr V’s children refuse consent. They say their father has “suffered enough” and must have had good reasons for doing what he did. Moreover, they add, at his age, further intensive treatment would not work. They request all treatment be withdrawn and their father be allowed to die. Dr A subsequently declines to operate because of Mr V’s children’s refusal of consent. “They’re the substitute decision-makers,” he says. “If Mr V were my father, I wouldn’t want him to live either.”

Questions for Discussion

1. What should the response be to the children’s refusal of consent?

2. How might one respond to Dr A?

A 76-year-old reclusive single female, Ms D, is admitted to a large tertiary hospital with a fractured hip. When told surgery is required, she refuses to consent. She explains she does not believe she is in a “real hospital,” as people had been rude to her and she had noticed dust on the X-ray machine. Ms D says she doubts she has a hip fracture, as she is not in that much pain. “Just send me home with a wheelchair,” she exclaims. “I want to discuss this with an old ladies’ organization.” Dr S, the resident, finds her line of reasoning unusual and deems her incapable. He wants her prepped for surgery first thing tomorrow morning. In contrast, the anaesthetist in his pre-operative assessment writes in her chart that he found her “entirely competent” to refuse surgery, specifically highlighting the patient’s score of 30/30 on the MMSE (Mini-Mental State Examination) that had been part of his evaluation. The surgeon, Dr W, is eager to proceed with the surgery. “What’s the big hold-up?” he asks Dr S.

Questions for Discussion

1. Is there an ethical problem here?

2. What should Dr S do?

Mr X, a 44-year-old civil servant, is admitted to the hospital under Dr Y for an examination under anaesthesia of his rectum. It turns out he has a large foreign object lodged in his rectum: the distal part of a poorly made sex toy. It will require removal in the OR. Excruciatingly embarrassed, Mr X can hardly make eye contact with nurses and other staff. He asks: “Do you have to put this in my chart? Everyone in the whole hospital will know what I did. I just want to die.” Will everyone in the hospital know what Mr X did? What will you say to him?

Late one night, the surgeon on call, Dr S, is asked to see Kaylee, a 16-year-old girl with right lower quadrant abdominal pain. Her mother is present during the encounter. Kaylee’s history and exam are very typical for appendicitis. She reports her menstrual periods are regular, and she adamantly denies being sexually active. Quite self-possessed, she signs the consent form herself. In the operating room at midnight, the appendix is found to be normal, but there is bleeding mass in her right fallopian tube, almost certainly an ectopic pregnancy. A gynecologist is called in and carries out a right salpingectomy (removal of the fallopian tube). After the procedure, Dr S goes out to talk with Kaylee’s mother in the waiting room. What should Dr S tell Kaylee’s mother?

You are the attending physician on an internal medicine service when John, a first-year resident, asks a favour of you. He knows he is not supposed to access his own records through the hospital medical information system. So he asks if you would, with his consent of course, access his recent shoulder MRI report and provide him with a copy. What would you do?

Mr A is being investigated for fatigue and malaise. Because he frequently travels for work, he requests you notify him by email of the test results. Is this acceptable practice?

Ms K, a 60-year-old patient, is in your office to discuss results from a recent CAT scan of her abdomen. It reveals she has a pancreatic mass with metastases to her liver. As you begin explaining the findings, Ms K halts the conversation to ask if she can record it on her smartphone. Her family are going to have lots of questions, she says, and she is fearful she will not remember everything. Should you permit her to record the conversation? How would you approach this?

You are working a shift in the ER one night when 24-year-old Mr J comes in under his own power complaining he has a bullet in his buttocks. He relates a somewhat unlikely story about throwing some bullets into a campfire, causing one to ignite and hit him. Sure enough, when you examine him, there is a small entrance wound in his right buttock. An X-ray shows fragments of a bullet in the pelvic tissues. A police officer loitering around the front desk approaches you to ask if you are treating a patient with a gunshot wound sustained in a crime that evening. What should you tell the officer?

You are a family physician working in an inner-city drug rehabilitation clinic one day a week. One of your patients, Mr H, admits to you that he has committed numerous robberies over the years to support his drug use. He even confesses that the police have mistakenly convicted another man for one of his robberies.

Questions for Discussion

1. Does this situation justify breaching patient confidentiality?

2. What would you do?

You are a second-year dermatology resident attending this week’s Grand Rounds presented by one of your fellow residents. The patient, identified as Ms J, is described as a 23-year-old drug addict who has had multiple sex partners. A photograph of the lesion on her back is presented on the screen. To your great surprise, you recognize the tattoo and realize Ms J is one of your younger sister’s best friends.

Questions for Discussion

1. As Ms J’s name has been anonymized, is there a breach of confidentiality in this case?

2. Using ethical principles, discuss why or why not consent needs to be obtained to use patient information for teaching purposes.

Ms Q, an 87-year-old woman from Russia with advanced Parkinson’s disease living in a nursing home, is suffering from visual hallucinations. Her cognitive function is otherwise normal. She is assessed by Dr P, a geriatric psychiatrist, who advises a trial of a new antipsychotic medication to help control her distressing symptoms. Dr P explains there is a chance the medication could worsen her Parkinson’s symptoms, but Ms Q is keen to try something. After discussing the recommendation with her attending physician, Dr P orders the medication. As is common in many nursing homes, relatives are routinely asked about any medication changes. When Ms Q’s daughter is contacted, however, she refuses to allow this new drug, expressing concerns about over-medication of her mother. When the psychiatrist returns the next month, he discovers the new antipsychotic has never been given. Should Ms Q’s daughter be making medical decisions for her?

Mr G is a 44-year-old man with a long history of less than optimally treated schizophrenia. He presents to the emergency room with a comminuted fracture of his left arm. His injury and the surgery proposed to correct it are explained to him by the orthopaedic resident on duty. Willing to have surgery, Mr G provides consent to the resident, but is evasive in explaining how the injury happened. The surgery resident wonders if the patient’s mental disorder obstructs him from giving valid consent. He pages the resident on call for Psychiatry to see the patient. Should the on-call psychiatry resident see Mr G before his surgery?

Mrs F, a 78-year-old widow, had been living an active and full life before sustaining a subarachnoid hemorrhage as a result of a motor vehicle accident and lapsing into a coma. She is now intubated and ventilated in the ICU. She has an advance directive specifying her son, an evangelical minister, as her substitute decision-maker. Despite her son’s religious affiliation, or perhaps because of it, she has instructed not to be kept alive “artificially if she will be unable to tend to her garden or enjoy walks in the forest.” After six days in the ICU without improvement, her CAT brain scan and EEG are repeated, indicating severe brain injury with little chance of functional recovery. When her physicians broach the topic of discontinuing life-sustaining measures, Mrs F’s son adamantly refuses to consider any such actions. In fact, he insists that they implement tube feedings. Even when confronted with her express wishes in her advance directive, he rebuffs the ICU physicians, insisting, “She made me her substitute decision-maker, so I’ll make the decisions as I see fit!” What should the ICU physicians do?

Ms M, a 56-year-old single woman who lives alone, presents to the emergency room complaining of a foul odour she cannot seem to escape. Complaining it follows her everywhere, she is convinced there is something wrong with her nose. When the ER physician, Dr S, enters the cubicle, the smell is overwhelming. She sees an obvious visible deformity beneath Ms M’s clothing on her right chest. Examination reveals a 10 by 15 cm ulcerated mass in her right breast, the obvious source of the problem. When asked about the breast mass, Ms M downplays it, reporting that it appeared a few weeks before, but denying it bothers her. It’s the odour she can’t stand. It is obvious she is in profound denial about a large, infected breast cancer. When her condition is explained to her, she expresses disbelief, declaring it’s just a bruise and will get better on its own. She thanks Dr S, telling her she would like to go home. How should the case of Ms M be managed?

Ms C is a 58-year-old woman with an unremarkable medical history who was apparently well until she stopped eating approximately three weeks ago. She had worked as an accountant until the birth of her children, now 21 and 25 years old. Both parents are deceased, her father having died in a farming accident when she was a child and her mother in her late 50s due to a rapidly progressive dementia. Ms C has repeatedly said she does not want to die as her mother did, in a nursing home, incontinent, lacking in dignity. “Better to die with your boots on,” she has told her family. Ms C is now quite ill. She is dehydrated and her electrolytes are out of whack. She seems unconcerned but looks pale and seems withdrawn. She explains she would like to eat but cannot, due to an upset digestive system. She plays with her food and says she’ll maybe eat tomorrow if her stomach feels better. “I need to cleanse out my intestines and liver,” she says to the nurse looking after her. She says she’s done this before and does not believe she will die. She refuses any artificial hydration and nutrition, specifically, an IV and nasogastric tube. She wants to go home. Her husband is not much help. “She’s stubborn, all right. She’ll do whatever she needs to do,” he asserts, and shrugs in an offhand way. “I think we’d best go home,” he adds.

Questions for Discussion

1. Why might Ms C be refusing nutrition?

2. Do you think she is an autonomous person?

3. If you feel Ms C is not competent, would you go along with her husband’s decision to take her home?

Mr M, a 26-year-old male living with his parents in a small agricultural town, was diagnosed with paranoid schizophrenia a number of years ago. He is often aggressive, and does not trust his parents or doctor. He says the prescribed medicines make him “mad.” Mr M stopped taking them two months ago and resists all attempts by his parents to take him to see his psychiatrist. While on medication he was able to work, but now he has spent the last six weeks wandering around the town and returning home to sleep when he feels tired. His mother is worried he will be assaulted or jailed if he becomes aggressive. She confides her fears to her son’s doctor, and is advised to give him an antipsychotic mixed in his coffee. She takes this advice, with the result her son quiets down and starts working again. Every time Mr M’s parents bring up the subject of his treatment he shouts he will run away from them if he is forced to take pills again. His mother continues her deception, concealing his medicines in his coffee or other food.

Questions for Discussion

1. Is Mr M’s refusal of pills a capable one?

2. Was his doctor’s advice appropriate?

3. Can you foresee any problems with the mother’s actions?

4. Does this kind of situation occur elsewhere?

You are a surgeon with an 81-year-old female patient, Ms R, who has just been diagnosed with pancreatic cancer, a malignancy usually leading to death within a year of diagnosis. Surgery is the only option that might prolong her life, but involves a risk of significant adverse effects (post-operative sepsis, delirium) and a risk of death from the surgery itself (intraoperative cardiac arrest, hemorrhage). Informed of the diagnosis and treatment options, Ms R explains she has always been terrified of surgery and adds that she feels she has lived a full life. She declines the surgery. Should you accept Ms R’s refusal of surgery? What if Ms R was 35 years old with two young children, not yet school-aged?

It is the last month of Dr F’s residency training program. On one of his last half-days, he is happy to see on his list two of his favourite patients, Mr and Ms D, a lovely Eastern European couple, both in their mid-80s. They appreciate his diligence. On this day, he is surprised to hear bruits over both of Ms D’s carotid arteries (the main blood vessels to the brain). Dr F sends her for neck Dopplers (an ultrasound) to check on her circulation. These reveal a 90 per cent carotid artery blockage bilaterally. Ms D is then referred to a surgeon who recommends an endarterectomy but cautions her that, with or without surgery, she is at high risk of having a major stroke. “Well, I certainly don’t want that, Doctor!” Later, she questions Dr F, expressing her ambivalence about the proposed intervention. The resident tells her that of course she doesn’t have to go ahead with the procedure, but points out there aren’t many options for her. Ms D agrees to the surgery, which is successful: blood now flows through her carotid arteries. She is sent home from hospital two days later. On her third day at home, Ms D suddenly collapses and cannot be revived. A post-mortem reveals she died of a massive cerebral hemorrhage. Did Dr F do anything wrong? Did the surgeon?

You are on a long-awaited vacation, flying to Mexico, celebrating with several friends your successful completion of medical school. Now others can call you “Doctor.” A half hour into the flight, just as you are settling into your seat to read your favourite author, an announcement comes over the loudspeaker, “Is there a doctor on board the plane?” How would, and should, you respond? Must you respond?

Ms E is an 84-year-old patient who is as fiercely independent as she can be—she’s outlasted several husbands and considers most men incompetent fools. An inveterate smoker, she likes nothing better than lying in bed in silken pyjamas, imbibing her single malt scotch, reading magazines, and smoking cigarette after cigarette. To make a house call on this patient is like taking a trip back in time to some smoky 1950s lounge bar. The patient also hates most aspects of aging—she cannot stand the way it has gradually stripped away her dignity, her smooth complexion, her muscle strength, her stamina, her joie de vivre, and now her memory. Most frustratingly, Ms E is finding it hard to cope with the requirements of living on her own. Bills are accumulating, papers and magazines are in piles everywhere, the bathrooms are filthy, food is rotting in the fridge, stale air hangs like a thick haze about her house, and cigarette burns have punctured her bedroom carpet, her sheets, and even her usually immaculate pyjamas. Will she accept any help or consider moving? No way! Ms E is, in her own view, “perfectly fine.” What should her primary care provider do?

In 2008 Ms W, a 26-year-old former charity shop worker, called an ambulance after taking a lethal dose of antifreeze. Although she said she wanted to die, she did not want to do so alone or in pain. According to newspaper reports, she had an “untreatable personality disorder” and had attempted suicide by swallowing antifreeze on nine previous occasions in less than a year. Each time, she had accepted dialysis treatment to flush the toxic solution from her system. This time, however, she produced a suicide note declining dialysis. The consultant, Dr H, who would have treated her antifreeze ingestion, sought legal advice from hospital counsel. The counsel’s opinion was that treating Ms W was illegal, as it would contravene her express wishes not to be rescued. As a result of this legal opinion, Dr H concluded that he could not intervene. Ms W died the following day. Questioned about his decision to withhold dialysis, he explained, “I would have been breaking the law, and I wasn’t worried about her suing me, but I think she would have asked, ‘What do I have to do to tell you what my wishes are?’ 20” Did Dr H do the right thing in following the dictates of Ms W’s suicide note?

A six-year-old girl, Annie L, has a severe and untreatable neurological disorder that has left her profoundly impaired, with the mental life and physical abilities of a three-month-old child. She is looked after by her parents at home. They inquire as to the possibility of ceasing Annie’s physical maturation—specifically, they would like her bone growth halted and her sexual maturation prevented by surgery to avoid menstruation and pregnancy. They argue she will never benefit from or understand her sexual development and that a smaller size will make her easier to care for—she will be a “pillow angel.” As such, Annie will be less likely to develop pressure sores and feeding problems or to require institutionalization. Keeping her small would make looking after her easier and more comfortable for all 49. Is the parents’ request for such treatment of Annie a legitimate one? Which do you think is better—to stunt Annie’s growth or not?

Mr A visits his family doctor, Dr L, for a persistent cough and weight loss. His last visit to the clinic was 15 years ago. He is now 71 years old and somewhat of a recluse, living alone in a small apartment, venturing out only to buy a few food items. Dr L thinks he looks unwell and orders blood tests and a chest X-ray. “You don’t think it’s anything serious, do you, Doc?” he asks. His family doctor responds there could well be a problem and encourages him to get the tests done. Instead, Mr A goes straight home. He phones Dr L the next week, however, saying he feels no better. He agrees to do the tests and make a follow-up appointment but then doesn’t come back. Concerned, Dr L decides to make a house call. He knocks on Mr A’s apartment door, but there is no answer. He knocks again but is met with silence. When he calls out, “Mr A, is that you?”, he hears a shuffling sound on the other side of the door. “Mr A, how are you? It’s Dr L—from the clinic. May I come in?” “Not now!” Mr A replies through the closed door. “I’ll come to your office when I’m feeling better.”

Questions for Discussion

1. What factors should Dr L consider in deciding whether or not to agree to Mr A’s request to be left alone?

2. Would it be permissible to breach his confidentiality by speaking to his neighbours or his superintendent about him?

Ms R is a 70-year-old widow, hospitalized with cognitive impairment and advanced Parkinson’s disease. No longer able to swallow without aspirating her food, a gastrostomy feeding tube has been placed with consent from her 40-year-old son, her only relative. On several occasions, however, he is found secretly feeding his mother by mouth. Moreover, after a weekend visit to her home, she returns to hospital with bruises sustained in falls when he went out and left her alone unsupervised.

Questions for Discussion

1. What is the ethical problem here?

2. Is this necessarily elder abuse?

Melinda R is a 19-year-old woman admitted to an urban hospital for routine gallbladder surgery. Her discharge is delayed as her bowels are sluggish and her incision hurts more than she expected. On Friday, three days after surgery, although still in some discomfort, Melinda begs to be discharged home, a two-hour drive away. She does not want to spend the weekend in hospital. Her surgeon, Dr T, authorizes the discharge despite not having seen her or her parents that day. Busy in the OR, she reasons the nurses would have alerted her to any concerns. Melinda is advised by the discharge nurse to go to her local hospital if she develops any troubles. Dr T arranges to see her in follow-up in her clinic in a week’s time. On the drive home with her parents, Melinda suddenly feels short of breath. Once home, she is overcome by fatigue. Feeling quite ill, she retires to her bed. Several hours later, she collapses on the way to the toilet. Her parents call 911. Although the paramedics arrive within minutes, she cannot be revived. Distraught and overwhelmed with grief, her parents call Dr T. “If our daughter was so sick,” they angrily exclaim, “how could you have let her go home?” How should the surgeon respond?

Dr N’s life at the hospital seems a little crazier than usual. In addition to her outpatient clinics getting busier than ever, she has agreed to head up the department’s interprofessional Grand Rounds schedule. Flattered when asked by the department head, who praised her work habits and youthful energy, she is now finding this a thankless task. Dr N has to pester her physician colleagues to present—most eventually do, if sometimes reluctantly. “Now, if only they would listen at Rounds,” she mutters to herself. These take place over lunchtime and she can’t help but notice that some of her colleagues seem more interested in the food than listening to their colleagues. They spend most of the rounds talking and being preoccupied by their cell phones. What, if anything, is wrong with this picture? What, if anything, should Dr N do?

An 84-year-old single female, Ms P, in the early stages of a dementing illness, attends her dentist of many years, Dr F. In the course of the visit he mentions that he has fallen on hard times financially and might have to close his clinic. Ms P, who is quite well-off, asks, “Is there anything I can do to help?” Quite fond of the dentist, she generously offers him $50,000—as a loan or a gift, Ms P doesn’t really care. She lives alone and her nearest relatives, living some distance away, visit infrequently. Should Dr F accept Ms P’s offer?

You have a particular interest in hypertension and are willing to try new drugs for your patients with resistant hypertension. One such drug, “Syperia,” is released following a large international drug trial showing it to be at least as safe and as effective as the leading drugs for this condition. A pharmaceutical representative asks you to take part in a phase IV research trial (undertaken after a drug has been approved for use). All you have to do is switch patients to Syperia and assess their response to treatment every three months. For every patient you enrol, you will receive $100 per year; you will also receive an extra $100 at the study’s completion for your efforts. Should you agree to participate in this research? What are your concerns, if any?

You decide to join the Phase IV Syperia trial, confident you are immune to any untoward influence of the study on your practice. There are many alternatives for refractory hypertension, but the new drug’s apparent lack of side effects and once-daily dosing may make it a valuable alternative for your patients. You see the rep from the pharmaceutical company before your clinic, accept drug samples for use with your patients, decline the $100 offer, but agree to attend an educational dinner at a pleasant restaurant with a speaker on resistant hypertension, sponsored by the same company. Are you doing anything unprofessional in accepting this invitation?

You are a primary care clinician seeing a new patient, Ms G, for the first time. In taking her history, you ask about her most recent medical care. She tells you she has been without a primary care practitioner for some time. Reluctantly, she states she did not feel comfortable seeing her former doctor, Dr E, as he had made, on more than one occasion, sexually explicit remarks to her, even asking her out on a “date.” Ms G has told no one else about this. Dr E’s interactions with her left her feeling soiled and guilty—as if she had somehow encouraged him. What should you do?

A 33-year-old physician, Dr T, was in a Newfoundland jail awaiting extradition for the murder of her ex-boyfriend in Pennsylvania. Apparently estranged from her family, she had no one to put up the $60,000 for her bail set by the Newfoundland and Labrador court. In desperation, she called her psychiatrist, pleading with him to help her. Concerned about her mood, he cancelled a half-day of patients to attend her bail hearing and provided the surety for the bail 52, allowing Dr T to be released from jail. Tragically, she subsequently drowned her infant son and died by suicide. Was the psychiatrist’s action a breach of professionalism?

Dr S is a relatively new general internist with a growing practice in a mid-sized city. One day, a colleague alerts her to some negative reviews found on a physician-rating site. When she checks it out, she finds most of the reviews are very positive. However, the two most recent reviews are extremely negative. Both contributors rate her bedside manner as exceedingly unprofessional. One reviewer disparages her by saying she couldn’t diagnose a common cold if her life depended on it. While she has some suspicions as to who may have rated her, she is not certain. She can see no validity in their complaints. How should Dr S respond to these comments?

Dr R, an orthopaedic surgeon at a community hospital, attempts to refer his 55-year-old patient, Ms F, who had undergone a total shoulder arthroplasty, to his privately owned physiotherapy facility. She responds she would prefer a referral to a competitor’s clinic where she had a previous good experience with the physiotherapists 72. Dr R tells Ms F she will receive better care at his facility, as he will be present to follow up with her on a more consistent basis. Furthermore, he suggests that his “team,” the physiotherapists working at the clinic, are more capable of following his instructions and requirements. The physician, however, is not familiar with the other clinic and so has no basis for suggesting this, nor does he provide Ms F with alternative options to his own facility for receiving therapeutic care.

Questions for Discussion

1. Has Dr R fulfilled his legal and moral duties by referring Ms F to his clinic?

2. What must he disclose to Ms F about his physiotherapy arrangements?

3. If you were a trainee in physiotherapy or physical medicine, would you have any responsibilities to discuss the arrangements and the alternatives with the patient?

A general internist, Dr Max Y (“Dr Max” to his patients), has been in practice for more years than he cares to remember. The “senior statesman” in his group practice, he is well liked by his patients, many of whom he has seen for years and gotten to know quite well. From time to time patients ask for reassurance he will not be retiring. He jokingly tells them he will be “working to the max. Don’t worry! I’ll be here until they have to carry me out!” But worry they do—especially the nurses in the clinic where he works. Now in his mid-70s, he just doesn’t seem as sharp as he used to be. Two weeks ago he ordered the wrong dose of epinephrine for a young patient. As a result, the patient developed palpitations and had to go to the ER. And just this week he gave meperidine (Demerol) IM, an old drug he had always used with good effect for acute pain, to Ms M, a 55-year-old patient who had pleaded with Dr Max “to do something” for her bad migraine. Unfortunately, he had forgotten her psychiatrist had recently prescribed Nardil, an equally old MAOI antidepressant. This drug should never be taken with Demerol due to the risk of a hypertensive crisis. Indeed, after the Demerol injection, Ms M complained she had a splitting headache and had “never felt so bad.”

Questions for Discussion

1. Why might Dr Max be making these mistakes?

2. How should Dr Max respond to these events?

3. Given the context of these events, which one of the following statements is the next most appropriate step? a. Dr Max should be encouraged to resign from the clinic. b. Dr Max must be reported to the appropriate authorities. c. Dr Max must take extra caution in carrying out his duties. d. Dr Max should see his own family doctor.

Dr B is a young physician recently out of residency who has set up practice in a large city. Within a couple of months, he starts to receive messages on his personal Facebook page, asking whether he wishes to “friend” certain people, many of whom are his patients and with whom he has no social connection. These are not actual friend requests, but rather “friend suggestions.” He does receive a friend request from a patient, Mr C, with whom he shares a passion for various sports. Why do you think Dr B is getting these “friend suggestions” from patients? Should he accept the friend request from Mr C?

Dr P is a middle-aged urologist in a large metropolitan city. One day he receives a private message from Mr K, an acquaintance from his mosque who is also a Facebook friend. The message reads, “Hello Dr P, I really hate to bug you, but my family doctor retired last year and I’ve not found a new one. I’m having increasing problems with frequent urinating, especially at night. Any chance you could prescribe something? Perhaps I could see you in your office about my problem?” Is it acceptable for Dr P to engage with Mr K online about his medical problem? Is it appropriate to give him advice? To write a prescription? To take Mr K on as a patient?

During a post-graduate session on professionalism, a surgical resident comments that he was reprimanded by his program director for some “dodgy” Facebook posts he made while on holiday in Mexico with some buddies. “What I post on my personal social media is my business,” he asserts, and then asks, “Why should I be held to a higher standard than other professionals?” Is the resident right? Are medical professionals held to a higher standard? Is he right from an ethical perspective?

Ms V, a nurse with the transplant team, is aiding in the process of preparing Mr C for a liver transplant. The patient has progressive end-stage liver disease, secondary to longstanding alcohol abuse. He has been compliant with the workup so far and appears very motivated to have a transplant. He has assured Ms V and the transplant team that he is in recovery, sober for the past eight months, and attending 12-step meetings. Mr C, who is very gregarious, is involved in the local art and theatre scene. Somewhat curious about his work, Ms V Googles him and lands on his personal Facebook page. His privacy settings permit general viewing. While perusing some of his entries, Ms V sees several recent photos of Mr C celebrating with family and friends. In many of these photos, he is holding what look like alcoholic beverages. Although she cannot be sure, it certainly appears as if he is “lit up” in several of the photos. Checking the dates of the photos, she finds they have been posted in the past month. Was it wrong for Ms V to Google Mr C? To check out his personal Facebook page? What should Ms V do, given she suspects Mr C is still drinking?

You are a family medicine resident on rotation in the ER. You are seeing a homeless and self-neglecting man with a huge infected wound on his right thigh crawling with maggots. The attending physician tells him she would like to show it to the surgeon on call. She snaps a photo of the lesion with her phone and sends it to the surgeon for advice. She also copies you on the message. The next week, while reading some medical blogs online, you see a picture of the same wound on a blog called “Nightdoc in the ER.” It is, in fact, the very same picture you received from the physician in the hospital. And the author is clearly the physician with whom you worked the week before. Is there anything wrong in taking a photo in this circumstance? Sharing the photo on a blog? Blogging about the case?

Dr Kevin Patterson, a Canadian surgeon-novelist who had recently finished a tour of duty, wrote a story in 2007 about the death of a Canadian soldier he had treated. The article, describing in explicit and gruesome detail the soldier’s final hours, was published within weeks of his death on the website of a widely circulated US magazine 52. The identity of the deceased soldier was not concealed. The Department of National Defence viewed this as a breach of confidentiality for which Dr Patterson faced court martial 53. Was Patterson wrong to write about the soldier’s death?

Dr D has recently completed his medical training and is ready to go into independent practice. He and several colleagues are unhappy with being a “doc in a box” with the usual ten-minutes-per-patient-visit routine. They decide to set up a “virtual clinic” that will combine the power of modern computing with the ability to interact online with sick patients at home. Patients will be able to book appointments online and have access to advice by email. Fees will be charged for online advice or assessments and be paid through PayPal. Access to the patient’s hospital files, research participation, and genetic testing will be incorporated into the patient’s electronic medical record.

Question for Discussion

1. What are the pros and cons for patients and for healthcare professionals of such a virtual clinical arrangement?

You enjoy trawling the Internet and come upon a site that links persons in the community with health professionals. One part of this site is devoted to graduate-level trainees and newly minted health practitioners acting as mentors by providing hints and insights into medical culture to younger, would-be medical students. As you scroll through the site, you recognize a physician assistant who has posted a number of pictures of himself establishing a central venous line in a patient. In one photo he holds a syringe at a man’s neck with the caption, “When you can’t start a line in a junkie’s arm, go for the neck.”

Question for Discussion

1. What, if anything, should you do?

You are a busy family practitioner in independent practice. You are seeing Ms L, a 45-year-old corporate lawyer with two children, who complains of fatigue of several months’ duration. She reports working very long hours preparing for a case and has been additionally stressed as her assistant is on maternity leave. She admits she is not eating properly nor getting enough sleep. She often works late into the night. You both agree she should strive for more balance in her life. Just to rule out other causes of fatigue, you send her that day for some basic blood tests, telling her your assistant will call her only if the results are abnormal. Otherwise, Ms L should come back to see you in three months. When she returns for her three-month follow-up visit, you look over her chart just before entering the examining room. To your horror, you see that her bloodwork at that time indicated a significant reduction in her platelet, red, and white blood cell counts, most compatible with aplastic anemia. You have absolutely no recollection of ever having looked at the report. “Doctor, I’m still feeling really exhausted even though I’m getting more sleep and worrying less about work,” Ms L says as you sit down. What should you say or do?

Dr V, a hospital-based obstetrician-gynecologist, did a Pap smear on Ms B in May 1992. The patient was not informed that pre-cancerous cells were found. Eleven months later, she was diagnosed with an advanced form of cervical cancer. Only then did she receive treatment. Despite this treatment, Ms B died of the disease a year and a half later. Her estate sued Dr V for negligence. Evidence was presented at trial that Dr V had left the country for an extended period shortly after doing the Pap smear. The hospital closed the clinic in which he worked without making any arrangements to handle his reports. As a result, Ms B’s Pap smear report remained unseen by a clinician until almost a year later. What is the central issue at stake here?

Inquiry In 2005 in Newfoundland, a patient with advanced metastatic breast cancer not responsive to conventional treatment, whose hormone receptor test was initially negative, was re-tested and found to be positive. This represented an important finding, as the results of receptor hormone assays determine further treatment of breast cancer. It was subsequently demonstrated that the lab procedures were deeply flawed, and up to one-third of women tested had received incorrect diagnoses about their hormone status. An external audit of the lab noted poor quality control, deficient procedures, and frequent turnover of staff 37. The errors in the lab had a significant impact. A review confirmed that 108 patients who died had not received adequate treatment. Another 383 of 1013 women had not received the recommended treatment 38. What and when should the women have been told?

You are a physician caring for Mr S, a 45-year-old diabetic man, who is being investigated in hospital for dizziness. You write an order to give him 10 units of short-acting insulin. Shortly after receiving the insulin, he becomes lethargic and confused and has a cardiac arrest. He is resuscitated and taken to the ICU. It appears the order you wrote was not clear and that Mr S received 100 units of insulin, instead of 10, leading to hypoglycemic shock. Mr S spends 22 days in the ICU, complicated by pneumonia and sepsis, but eventually recovers.

Questions for Discussion

1. How should you explain to the family, and eventually the patient, what happened?

2. Because a nurse gave the wrong dose, does this mean it is a nursing error and they should deal with it?

3. Should patients be notified of minor errors (such as receiving 12 units of insulin instead of 10) with no sequelae?

4. Can you think of general guidelines for dealing with patients and family when addressing situations of “medical error”?

You know Mr P, your next patient, well—he has been your family practice patient for years. A retired bus driver of 75, he has a nice sense of humour. He tells you he is tired today. He didn’t sleep that well due to an annoying cough that has been attributed to his new blood pressure medication. As well he had been in the local ER with another bout of blood in his urine. When Mr P had the same problem a year ago, an ultrasound found kidney stones. He had lithotripsy done at another hospital and was fine until this current episode of hematuria. When you saw him for hypertension a few months ago, he reported no more renal pain or blood in the urine. He wonders if you can tell him about the CAT scan they did last night in the ER. He tells you he’s not sure why it was done and says, “So, Doc, when will I get my next stone-pulverizing appointment?” Able to electronically access his hospital chart, you are shocked to read the report: “The mass in the right kidney seen on ultrasound one year ago is now much larger, filling in the whole renal pelvis.” There was also evidence of tumour involving the lower lobes of his lungs. The news could not be much worse. Terror grips your heart; you search for last year’s report. Last year’s ultrasound indeed indicated Mr P had multiple kidney stones at that time. As well, however, an “incidental note” was made of a small mass in the right kidney for which “follow-up is recommended.” You are shocked. You wonder to yourself what you did wrong. You honestly don’t recall ever seeing that report... Mr P is waiting in the examining room for you. His urologist is away.

Questions for Discussion

1. Why do you think the report from last year was not acted on?

2. What would you say to Mr P?

3. What are your responsibilities as his family physician?

You are the primary care provider for Ms E, a 92-year-old widow who visits you monthly in the clinic. Her main complaints are fatigue and sadness connected with her experience of aging. Although she has the usual depredations of old age—arthritic joints, fatigue—she is not acutely ill in any particular way. Your main reason for seeing her is simply to listen to her concerns and be supportive. But after a number of visits, you wonder whether the time spent with this patient is justified, given your many other patients who also need your time. Just yesterday you delayed seeing a patient with a seemingly more urgent physical problem rather than disheartening Ms E by postponing her appointment. Should you de-prioritize seeing Ms E?

You are a practitioner who has recently joined a community health centre in a poor neighbourhood. One of the patients assigned to your multidisciplinary professional team is Ms D, a proud woman of Ukrainian descent in her late 50s. She has had a difficult life, singlehandedly raising her own three children and now caring for her two young grandchildren since her daughter was murdered a year ago. Ms D lives on a small disability pension from the university where she had worked as a cleaner for 20 years. She has been unable to work for some time due to her multiple morbidities—disabling osteoarthritis, emphysema, adult-onset insulin-dependent diabetes, obesity, and congestive heart failure. In discussing her functional status, she reveals she is now confined to the front of her small house because of her inability to manage steps. Because she cannot get to her pharmacy easily, she sometimes goes without insulin for days. Anyway, the money it costs for diabetes care is not money she can readily afford. Even with a walker, she can negotiate only short distances. She stopped taking the publicly funded “Wheel-Trans” bus service when she found the drivers downright rude at times. Now dependent on her two surviving children for transportation, Ms D is reluctant to bother them. She avoided her last medical appointment, as she knew her numbers would be bad and she didn’t want to feel like a failure again. “Life,” she sighs, “hasn’t turned out the way I thought it would”

3. What are the responsibilities of her primary care providers?

Dr Q, a physician, originally from a war-torn country whose name he does not care to remember, is doing a six-month medical locum in northern Manitoba. As the only health professional around for hundreds of miles, he finds his medical practice has its challenges. A typical day can involve reading ultrasounds, casting broken limbs, and even deftly removing a fish hook embedded in a patient’s cheek. The locals have appreciated his dedication and interest. Mr V is a 55-year-old lumberjack of Métis heritage whom Dr Q has been treating for hypertension. Today, there is a new problem: he has had a severe headache for two days unresponsive to the usual medications. On examination, Dr Q finds a concerning sign in his left eye: what looks like early papilloedema (a swollen retina that almost always means the pressure in the patient’s skull is very high). If he’s right, this is an ominous finding requiring prompt intervention. However, having not done many fundoscopic examinations, Dr Q is unsure of his findings. He considers sending Mr V to the city, but because it is midwinter, the only way out is via a special rescue by plane: the runway is the frozen lake. Dr Q also recalls a missive from the Ministry of Health reminding doctors to “use society’s resources wisely.” In his home country, doctors would not dare to ignore such governmental edicts. What should Dr Q do? Should he call for an (expensive) air evacuation for Mr V? Or should he send his patient home and wait and see how he is tomorrow?

Mr and Ms K, a wealthy and “demanding” (in this case, “having a sense of entitlement”) older couple, come to see you, their general practitioner. They have just been to the Mr K’s new internist (his old one has retired) and tell you they are disappointed because she has not ordered an EKG, a urinalysis, or a blood test for the prostate. On questioning, you discover the 75-year-old husband has no new cardiac or prostate complaints. All the same, the couple has come to expect these tests to be done yearly and asks you to order them. Should you order the tests Mr and Ms K have come to expect as the standard of care?

You are a nephrologist with an interest in end-stage renal disease. One of your patients is a 45-year-old well-connected businessman, Mr C. He has insulin-dependent diabetes and has been on the waiting list for a kidney transplant for three years. He has survived on home peritoneal dialysis, but has been finding it increasingly burdensome and uncomfortable. He has no idea when, if ever, a kidney will become available for him. Mr C decides to look into buying a kidney from another country. He has been your patient for many years and asks for your opinion. How would you respond?

You are a healthcare practitioner working in a poor and medically underserviced area. You work long hours and have large bills to pay—alimony, children in private school, overhead on the office, mortgage on the house... it all adds up. But you worry more about the population you serve. Among your patients is a large group of destitute and frequently homeless men and women. With poor nutrition, minimal protection from the elements, and poor hygiene, they are sitting ducks for TB and protein and vitamin deficiency syndromes. You feel a great deal of empathy for les misérables, the unwanted and uncared for, of society. “Talk about the social determinants of disease,” you think to yourself as you walk through your crowded waiting room. “Surely, one important way I can help is to improve their nutrition.” You decide to use a regional food aid program to prescribe socially funded “special diets” for your destitute and weary patients. After all, you reason, you will be helping the poor; you alone are their social advocate. Your receptionist greets you as you enter your office. “You’re booked to see between 50 and 60 patients today, Doctor. Remember, it’s important to fully bill for each and every patient.”

Questions for Discussion

1. Is your program ethically (as opposed to legally) defensible? Discuss using ethical theories of justice.

2. How is this program any different from ones that advocate prescribing money for impoverished patients?

You work as a primary care physician with a large cohort of older patients. Many are snowbirds who spend months in Florida, returning periodically to ensure their medicare coverage is continued and they get their free drugs. One of these is Mr V, an aging but active retiree. Your patient for some years, he has developed wet age-related macular degeneration (AMD), a common cause of blindness in the elderly. In the United States he was started on Avastin, a recognized, but off-label, treatment for AMD. This drug is given by intraocular injections every month or two at a cost of $100 USD per injection. Mr V’s AMD has not progressed since he started Avastin. But Mr V is unhappy: he wants to be referred to an ophthalmologist in Canada to get Lucentis, a newer treatment for AMD. He has heard about this drug due to direct-to-consumer (DTC) advertising of prescription drugs allowed in the United States and learned that it is considered by some doctors to be superior to Avastin. Both drugs are biologic agents that counter the over-growth of new blood vessels characteristic of AMD and are considered “biosimilars,” not bioequivalents. The problem is expense: Lucentis, given in the same way as Avastin, costs twenty times as much, or about $2000 USD per injection. You know the evidence for Lucentis having increased effectiveness in treating AMD is equivocal. “It must be a better drug,” Mr V says, “It costs so much more. Anyway, it’s free, so why not?” You work in BC, a province that pays for both drugs.

Questions for Discussion

1. Would you send Mr V to an ophthalmologist for a consultation?

2. What are the pros and cons of doing so?

A 23-year-old woman, Ms J, who seems happily pregnant, is screened at 16 weeks for fetal anomalies. When the ultrasound reveals her fetus has a cleft palate, she requests a pregnancy termination. Considering this a trivial reason for a therapeutic abortion, her clinician, Dr I, shares this view with her. Is it acceptable for the clinician to voice her opinion in this way? Should the clinician simply keep quiet and fill out the referral form for the abortion? How else might she respond?

You are a primary care practitioner looking after a professional couple in their early thirties with two young girls at home. The woman is in the first trimester of her third pregnancy. At low risk for congenital anomalies and accurate for time of conception, she nevertheless requests an “ultrasound or amniocentesis.” Her spouse admits they are primarily seeking to know the sex of the fetus. If it is a girl, they will seek termination and try to get pregnant again. You know it is the standard of care to offer an ultrasound between 11 and 14 weeks of pregnancy (late first trimester) when it is too early to determine sex 3. Amniocentesis, which would give this answer, is not done until the second trimester, by which time it might be too late to easily obtain pregnancy termination. There are alternatives to consider, however. All women, regardless of whether they are high or low risk, are offered prenatal genetic screening for “aneuploidy syndromes” (chromosomal irregularities, such as Down syndrome)—testing covered by provincial and territorial medicare. Less well known is NIPT (non-invasive prenatal testing)—a maternal blood test that can be done as early as 10 weeks and can, if the patient so chooses, report fetal sex with a very high degree of accuracy. However, it is not a covered entity under all provincial medicare programs. You personally believe abortion on account of sex to be wrong. Must you tell the couple about the limits of ultrasound and the availability of other ways (such as NIPT) of determining the sex of the fetus?

A childless lesbian couple, Ms K and Ms M, arrange for the creation of an in vitro embryo from Ms K’s egg and sperm donated anonymously. Neither Ms K nor Ms M is physically able to bear a child. The embryo is successfully implanted into a surrogate mother, Ms L, contracted by the couple to give birth to the child, Baby B, whom the couple intend to raise. The pregnancy is successfully carried to term; however, Ms K and Ms M split up acrimoniously shortly before the child’s birth. The gamete provider, Ms K, now says she wants her former partner, Ms M, to have nothing to do with raising Baby B. Ms M objects and seeks legal remedy. Who should be considered the parents of this child? What if Ms L decides to simultaneously apply to be legally considered Baby B’s mother? Does the source of the gametes make a difference?

Although currently in remission, a three-year-old girl, Becky L, has been gravely ill with leukemia. Curative treatment is possible but requires bone marrow stem cell donation from a suitable donor. Without it, the child will almost certainly die when the disease recurs, as it almost certainly will. No suitable match is found. The parents decide to conceive a new child in the hope this will result in a suitable donor, but they need ART because Becky’s mother, now 38, experienced premature ovarian insufficiency at age 36. The mother’s twin sister is prepared to donate her eggs. Is this an acceptable use of ART? Is doing prenatal genetic testing (PGT) to find HLA compatibility acceptable?

You are a nurse practitioner in a clinic in the Lower East Side of downtown Vancouver. One of your patients, Ms S, is a 29-year-old woman in her second pregnancy. Her first child suffers from fetal alcohol syndrome (FAS) and is in foster care. Ms S continues to drink heavily during this second pregnancy. Alerted to this by her common-law spouse, you are concerned for the well-being of the fetus as well as of the mother. Someone suggests you get tough with Ms S by making an urgent application for court-ordered protection for the fetus and seeking involuntary hospitalization away from skid row for the woman to ensure compliance (with a plan to treat her alcohol problem and control her alcohol intake).

Question for Discussion

1. Would you go along with this suggestion?

A 23-year-old healthy female, Ms N, has decided to donate several of her oocytes to an upper middle-class couple seeking reproductive assistance. She will also act as a gestational mother for the couple. Currently unemployed, she will find the money from the oocyte harvesting ($5,000 per oocyte) paid to her by a private fertility clinic quite helpful. She’s unattached at the time of the donation and has never been pregnant. Her oocytes are successfully conjoined in vitro with male gametes and two are implanted in case one fails. Both are successful in achieving viability and she will deliver twins. The intended parents are delighted. Ms N receives a handsome monthly retainer fee (under the table, of course) to offset the cost and inconvenience of pregnancy 78. During her pregnancy, she reads a magazine article arguing against surrogacy. It posits that surrogacy, such as she has undertaken, exploits poor women and treats offspring as chattel to be bought and sold, like calves at an auction. As her pregnancy progresses, she develops an increasing attachment to her embryonic duo and begins to consider keeping the babies. She then meets a partner who is willing to help her raise the children but is not able to support her financially. Ms N feels some twinges of guilt towards the contracting couple. She and her partner decide to offer one of the children to them at birth and to keep the other.

Questions for Discussion

1. This scenario raises a number of legal and unethical issues. What are they?

2. Is dividing the twins between the two couples a fair compromise?

3. Should the law prevent such arrangements? Why or why not?

Nancy B, a 25-year-old woman from Quebec, was hospitalized in 1988 with an unusual and extremely severe form of Guillain-Barré syndrome (an autoimmune condition affecting the peripheral nervous system that can result in severe muscle weakness or paralysis, but which usually resolves spontaneously within a few weeks). In Ms B’s case, the condition did not resolve, leaving her permanently paralyzed, bedridden, on tube feeds, and dependent on a ventilator. She was considered incurable, but not “terminal” (she could potentially be kept alive in that state for many years). Although significantly physically incapacitated, her mind remained intact and she could talk.

Mr X, a 58-year-old homeless man with no known relatives, is admitted in respiratory distress with resistant tuberculosis. Emaciated and dishevelled, he looks 20 years older than his stated age. Uncooperative and resistant to care, he yells at staff, complains about the food, and repeatedly pulls out his tubes. Nonetheless, he undergoes various procedures including bronchoscopy and urinary catheterization. A few days into his hospitalization, Mr X is approached about the issue of cardiopulmonary resuscitation (CPR). If his heart stops, he is asked, would he want them to try to restart it? “What kind of crap is this?” he responds. “I don’t want any more treatment!” The staff takes this to mean he does not want CPR. They enter a “No CPR” order into his chart and do not return to discuss this with him. A week later, Mr X suffers a cardiac arrest and dies. CPR was not performed. Why might there be cause for concern in Mr X’s care?

Ms H, a 56-year-old otherwise completely healthy woman, is admitted to hospital with acute cholecystitis. Just as she is being wheeled into the OR for gallbladder surgery, she informs the surgeon, anaesthetist, and nurse: “Oh, I forgot to mention to you before, but I have an advance directive. If something should happen to me in the OR, I don’t want to be resuscitated.” How should the team respond? Should her comments guide her care in the OR?

Ms L, a 70-year-old widowed mother of six children, has been treated for multiple myeloma for the past three years. Over the past month, there has been a dramatic deterioration in her health. Her body is shutting down. Along with kidney and liver failure, Ms L has developed respiratory failure from pneumonia, requiring ventilation in the ICU. She has been unconscious for several days after suffering a major stroke. The circulation to her lower limbs has been very compromised and now both legs are showing signs of impending gangrene. Ms L does not have an advance directive. Her oldest daughter, Anita, has been designated her guardian and substitute decision-maker. The ICU team meets with the family to explain that further aggressive treatment offers no hope of recovery and will only serve to prolong her suffering. They advise discontinuing the ventilator and reassure the family Ms L will receive supportive treatment to keep her comfortable until she dies. Anita and the rest of the family, however, will not agree to this treatment plan. Not only do they dispute that Ms L is dying, they also question the diagnosis of multiple myeloma in the first place. They also make it clear they harbour deep suspicions about the hospital system and what they see as the trend to save money by not caring for people like their mother. They request a transfer to a centre where doctors will try to save their mother, not kill her. How should the ICU physicians and team respond?

Mr Z, a 75-year-old widowed and retired lawyer, has planned meticulously for his care at the end of life. He has recently undergone open-heart surgery to repair his mitral valve. He has been in the Cardiovascular ICU for one week, on mechanical ventilation, making a very slow, but steady recovery. His advance directive specifies his oldest son as his substitute decision-maker. Of the many wishes he specifies in this document is one indicating he would not want to continue aggressive care if dependent on a ventilator for more than a week. His son asks the physicians, given Mr Z’s advance directive, to discontinue mechanical ventilation and see how he does. He says his father would not want to continue living like this.

Questions for Discussion

1. What should his doctors do?

2. Should they honour the explicit request in his advance directive?

Ms W, a tiny but feisty 91-year-old, comes to hospital with a history of severe back pain and difficulty breathing of a week’s duration. Initially the team thinks she may have pneumonia, but it turns out to be right-sided heart failure. Treatment options are limited— she needs a longer course of hospitalization than initially expected. She has a large family and many friends who come to visit. Bright as a pin, her social interactions are “well-preserved.” On admission to the ward, Ms W agrees to a level of care that would not include CPR or aggressive resuscitative interventions, but has otherwise not completed an advance directive. Her back pain was a red herring—it had nothing to do with her heart failure. Ms W has very severe degenerative spinal arthritis for which she is prescribed a low dose narcotic. Two days after admission, Ms W is accidentally given a much larger dose of the prescribed narcotic. She lapses into a comatose state with very shallow breathing and is in danger of acute respiratory failure and cardiac arrest.

Questions for Discussion

1. Should CPR be performed on this patient despite the No CPR order? Should any resuscitative efforts be attempted?

2. Should age be a factor in deciding to perform CPR?

Born and bred in Newfoundland and possessing a wry sense of humour, Ms C is the picture of health when she is diagnosed at age 65 with widely metastatic gallbladder cancer. This uncommon cancer rarely responds to chemotherapy and is often fatal within six to 12 months. After some ineffective chemo that makes her miserable, Ms C accepts her fate with grace. Told of her prognosis, she quips, “Well, I want to enjoy what time I have left on this earth. But when I have to go, make it quick! No point in hanging on.” What Ms C does not anticipate, however, is how this cancer takes control of her life. A few months after the surgery and chemo, she develops numerous openings in her abdominal wall, which start draining feces. No matter how much the nurses attempt to control the drainage, they cannot contain the leaking stool, nor the foul odour of rotting flesh. Ms C’s life becomes intolerable. Increasingly despondent, she finally begs her palliative care physician, Dr E, “Surely to God, you can do something about this, Doc. Enough is enough. I mean, come on, what are we waiting for?” How should Dr E respond to Ms C? What options are available to Dr E—and to Ms C?

William was 12 years old when he was first diagnosed with osteosarcoma of his right thigh. He underwent state-of-the-art chemotherapy and surgery with good effect. Unfortunately, a year after he completed his treatment, the cancer recurred in his lungs, brain, and spine. Despite experimental chemotherapy, the cancer progressed and led to partial paralysis below his waist. Having exhausted all curative treatments, his oncology team suggested he pursue a palliative approach at that point. Now, after three tumultuous years, William and his parents have come to accept he is going to die from the cancer. Although his symptoms are reasonably well-controlled at present, he tells his physicians and his parents that when he is no longer able to tolerate the pain, he would like to be put out of his misery. William is a thoughtful, self-possessed, and articulate 15-year-old. He not only meets the criteria to be designated a mature minor, but shows more wisdom, insight, and maturity than many adults. Although grateful for everything that has been done for him, he would like assurance he can have some control over the timing of his death. Should William have access to MAID?

Dr D is a physically healthy 65-year-old retired spinal surgeon who lives with his spouse in Toronto. In the past few years, both he and his wife have noted issues with his memory. He not infrequently forgets people they have met recently, discussions they have had, and movies they have seen together. After seeing some specialists in cognitive assessment, he is diagnosed with early dementia of the Alzheimer’s type. Although he still functions very well, enjoys life, and continues to manage his own finances and healthcare issues, Dr D has strong recollections of how his mother with advanced dementia lived her final years. He can picture her still, just sitting around all day in the nursing home, incontinent, blankly watching television, and unable to recognize even her family. This is not how Dr D wants to spend the last years of his life. After much thought and consideration, he and his wife draft a meticulously worded advance directive expressing his wish to have a medically assisted death, if his dementia reaches the point where he no longer recognizes his children. Can his request be honoured?

Mr S is a 45-year-old man, living alone, who has suffered from severe depression since the age of 15. He subsists on a disability pension, having been unable to work for more than a decade due to his unrelenting depression. He has several times attempted suicide but has always somehow survived. While he is not afraid of dying, he is afraid of the pain and violence involved in jumping out of a building or shooting himself. Despite consulting the best psychiatrists in the field and trying all forms of therapy, including innumerable types of antidepressant medications, psychotherapy, group therapy, ECT, and even experimental treatments, nothing has helped. His depression has become “treatment-resistant.” Mr S finds it impossible to interact with people, even his family. He cannot concentrate, read, or carry on discussions. He stays in bed most days and gets up only to eat. He feels hopeless and insignificant. His life is a constant torment. His sense of overwhelming hopelessness is so deep that the only thing providing any relief is the thought of being dead. His feelings in this regard have not changed for over five years. He desperately wants to die. In response to Bill C-14, he writes his psychiatrist, requesting help through a medically assisted death. Should his psychiatrist arrange a consultation with a MAID team?

Dr G is a palliative care physician who manages patients in a hospice. While she is not religious, she has found the recent developments with regard to assisted dying very disconcerting. She has made it clear this is not something she would be willing to perform or facilitate. She does occasionally administer palliative sedation to patients, but sees that as fundamentally different from MAID, given that her goal with palliative sedation is to relieve symptoms, not accelerate death. Many of the nurses at the hospice share her reservations about MAID, although a few do support it. One day, Mr Z, a patient with pancreatic cancer who has been under her care at the hospice for almost two months, tells her he is ready to “go.” Although he has a partial bowel obstruction, suffers from unrelenting pain, and has become increasingly weak and tired, his death is not imminent. He might live for another three or four weeks. He tells Dr G he’d like to explore the option of MAID. Given her opposition to MAID, what should Dr G do?

A few months after the birth of their third child, Robert and Helen, a young Jewish couple, are informed the baby has Tay-Sachs Disease and will likely not survive past age four or five. Over the next few years, as he is cared for by his parents, Noah becomes deaf and blind, develops extensive skeletal spasticity, requires a feeding tube, and experiences regular seizures, despite high doses of anti-epileptic medications. At age four, he is unable to engage with his parents at all, but continues to live, mostly because of tube feeding and compassionate care. His parents approach the palliative care team to ask for help. They do not want to prolong Noah’s misery, but are reluctant to discontinue the feedings, concerned he will suffer as a result of being starved and dehydrated to death. They request their son be put to death compassionately to end his suffering.

Questions for Discussion

1. Should Noah’s parents’ request to end his life be allowed?

2. What are the ethical issues in this case? The legal issues?

For five years you have been the physician caring for Ms Y, a 94-year-old woman, who lives alone with occasional assistance from social agencies. Although she has multiple medical problems causing great suffering (such as severe arthritis, fecal and urinary incontinence, and poor eyesight and hearing), she has no obvious condition which will lead to her foreseeable death. She continues to deteriorate slowly. During each of your visits to her home, she reiterates the same thing. “I wish I were dead,” she states. “Can’t you just prescribe me something to help me get a good night’s sleep? I hear barbiturates are good for that,” she says, winking at you.

Questions for Discussion

1. Would it be wrong to prescribe Ms Y some barbiturates?

2. What if she intentionally starved herself, until her death was foreseeable? Would she then be eligible for MAID?

Daniel and Laura L have an eight-month-old son, Ryan, who has seemed a little floppy since birth. His doctor, having noted this as well but unable to determine the cause, refers the child to a local university-affiliated children’s hospital. There, Ryan is diagnosed with Canavan disease, a rare disorder causing irreversible neurological decline due to a single mutation in a gene that codes for an essential brain enzyme. Absence of this enzyme leads to breakdown in the myelin sheath protecting nerve cells and subsequent irreversible brain atrophy. There is no treatment for the disease. Ryan’s parents are devastated by this news. Faced with the terrible prognosis, they search for alternatives for Ryan. They read on the Internet about a clinical trial of CRISPR, a revolutionary new way of treating genetic illness through genetic manipulation. Ryan’s parents are eager but wonder about the safety of a gene trial. Are they right to be concerned?

You are a primary care provider looking after a 24-year-old man, Mr M, who develops ataxia and paranoid ideation. Noticing unusual copper-tinged rings in his pupils, you make a diagnosis of Wilson’s disease, a disease affecting copper metabolism with protean manifestations that has genetic markers and is amenable to treatment 20. After the diagnosis is confirmed through further biochemical and genetic testing, the patient is started on standard treatment. Mr M has two siblings also in your practice. You advise him to disclose his diagnosis to his siblings, recognizing they each have a one-in-four risk of also having the disease. Mr M refuses to do this, saying he has never gotten along with his siblings and they can “rot in hell” as far as he’s concerned. Does the duty to prevent harm to others outweigh the duty to protect the confidences of Mr M?

Dr R, a primary care physician early in his training and working in a family medicine setting in downtown Halifax, is carrying out a complete physical examination on an anxious young man. Mr W is a 24-year-old patient who recently immigrated to Canada from rural Nigeria and as yet lacks health benefits. Dr R has only done a complete examination on a few patients as a medical student and never on someone from Africa. He wonders what issues he should raise with Mr W. In particular, he cannot help but notice deep scars on his face and back: Are they perhaps ceremonial ritual scars or has he been tortured? He wonders if he should ask about these scars or not. Should he ask about Mr W’s background? Dr R feels uncertain about what he should do and wishes he had someone else present for the examination. Does Dr R need someone to supervise this encounter? What other steps might he take to become more culturally sensitive to this patient?

Mr. N, a 44-year-old man with a large extended family, is admitted to an ICU with raised intracranial pressure from an untreatable cerebral malignancy. Despite various measures, he has continued to decline and is now on a ventilator. It is obvious to the ICU staff that the patient’s brain is too compressed to respond to any treatment. On no sedatives, he has been in a deep coma for several days, completely unresponsive to any stimulation. His score on the Glasgow Coma Scale (GCS), poor from the outset, has been declining for several days. It is now 3—as low as you can get—and there is complete absence of any brainstem reflex activity on two assessments. Mr N is in every neurological sense dead, “brain dead,” as that term is used. As is usual practice, confirmatory clinical testing by way of an apnea test is arranged. This entails temporarily removing the patient’s attachment to the ventilator. In response to rising carbon dioxide levels in the body, a brain-dead patient will fail to initiate respiration as would normally occur 49. The lack of cortical responsiveness, the absence of brainstem reflexes, the lack of movements or breathing, a flat electroencephalogram, are all consistent with death, whatever the state of the patient’s circulation might be 50. Mr N’s loved ones disagree strongly with the diagnosis of death—they are a religious family and feel everything possible must be done to extend his life, arguing: “If God wanted him to die, He wouldn’t have allowed mankind to invent ventilators. He’s not dead until his heart stops beating.” As the ICU resident and attending neurologist are about to perform the test on Mr N, a family member exclaims, “Don’t touch him! If you remove him from the breathing machine, we’ll sue you!” According to the family’s (and the patient’s) religion, where there is a heartbeat, there is life, and one may not disconnect a breathing apparatus. What should the response of the ICU staff be?

A 14-year-old boy, Neseem R, has recently arrived in Canada as a refugee from a war-torn Middle Eastern country where both his parents were killed. His father’s brother and his wife, landed immigrants in Canada for the past year, have adopted him and his only known surviving sibling, a younger sister. Neseem speaks surprisingly good English and seems mature. He has been unwell for some time as medical services were unavailable in his home country. Prompt attention in Canada has resulted in a diagnosis of a large, almost certainly incurable, glioblastoma multiforme, an aggressive form of brain cancer. His uncle is devastated by the news. “It’s like a wound upon wound in our family!” he cries out to the pediatricians who delivers the devastating news. “This is too terrible to bear!” He asks that Neseem not be told about the diagnosis, explaining that in their culture, children, when seriously ill, are looked after by their family. “I will make the decisions about my nephew’s care,” he states assertively. “Talk to me first!” How should the pediatricians respond?

You work as a healthcare professional in a clinic evaluating individuals and couples as to their suitability for IVF services. A young heterosexual couple, Mr and Ms J, with a history of infertility, linked to male and female factors, come for assessment. Both are deaf due to congenital hearing loss. Neither have a cochlear implant and converse in sign language. They request help with getting pregnant and assistance as well with ensuring that their child will be, like them, congenitally deaf by using PGD (Preimplantation Genetic Diagnosis). If pregnancy is successful, they intend to raise the child within the Deaf community, expressing their intention not to allow their child to receive a cochlear implant.

Questions for Discussion

1. Should PGD or other forms of antenatal testing be used to screen for conditions that satisfy parental wishes as regards future offspring?

2. What if both parents were high-functioning adults with Down syndrome who wanted help with reproduction?

While working as a family physician in a large city, you are seeing increasing numbers of Hungarian Roma. One of your patients, Mercianna T, a 15-year-old Roma girl in the process of claiming refugee status, informs you she is recently pregnant by her 19-year-old boyfriend. She has dropped out of school and plans to raise the baby with the help of Ms W, her 48-year-old grandmother. Her mother died of TB when Ms T was quite young. Her grandmother, her main support, is not terribly happy about the pregnancy, but admits that she had her first child at 15 as well. In Roma culture, you are told by a colleague working in this area, girls frequently marry by age 16 and have children at very young ages 64. They frequently smoke and tend to shun medical care. And indeed, during the pregnancy Mercianna smokes, misses appointments, and is generally noncompliant with prenatal care and advice. When you talk to her about the risks to the fetus and the importance of prenatal care, she reacts dismissively. “Everything will be fine!” You are not so sanguine and wonder whether or not to involve the child protection agency, both for Mercianna and her baby-to-be.

Questions for Discussion

1. What is the ethical dilemma here? Is there more than one?

2. What should you do in this situation?

3. How would you deal with your worries and concerns about this pregnancy and Mercianna’s welfare?

4. Are there limits to how far cultural acceptance should go?

5. What does cultural sensitivity involve in this case?

Dr S is an internist with a particular interest in disorders of consciousness. One of her patients is Mr Z, a 35-year-old father of two, in a minimally responsive state for over a year following a burst cerebral aneurysm. Initially in a persistent vegetative state, he brightened a little several months after the bleed. Since then there has been no further change in his level of awareness. Mr Z’s mother and his wife have been very attentive and hope each day will bring an improvement. Dr S has heard of a new study using a type of transcranial stimulation on the brains of patients in various comatose states. She mentions this to Mr Z’s spouse. “Oh, yes! We want him in the study right away! We know it will help him!” she replies. Is this an ethically acceptable study? Ought Mr Z to be enrolled in the trial? What reservations might Dr S have about doing so?

It is hypothesized that a new drug, “Tarquinia,” is superior to lithium, the standard of care for maintenance therapy of bipolar disorder. A study is proposed whereby 100 participants with bipolar disorder who are stable on lithium will be enrolled in a randomized controlled trial (RCT), the gold standard for most research in medicine 14. Participants will be randomly assigned to one of three groups: one to receive lithium, another to receive Tarquinia, and a third to receive a placebo. Would-be participants are told about the randomization, but neither they nor the researcher will know to which group they are assigned. Would you have any ethical concerns about this trial?

A 27-year-old woman, Ms T, has responded to treatment for T-cell lymphoma and has now been disease free for three years. As part of the treatment for her condition, she participated in a clinical trial of a new anti-lymphoma agent, which she tolerated well. Ms T also donated samples of her blood that were anonymized (to protect her privacy) and used solely for future research for “purposes connected with her condition.” Since that trial, new genome-wide studies have unexpectedly revealed an increased risk for hormonally dependent breast cancer in the first-degree relatives of patients, like Ms T, who responded well to the anti-lymphoma drug. The researchers involved in a proposed new trial now want to contact Ms T’s relatives in order to study their health and genomes. They can do so only if they de-anonymize her results. Should the institutional ethics board charged with overseeing the trial allow the researchers to “break the code” and contact members of at-risk families?

A medical researcher, Dr D, is running a study looking at the possible benefits of a new type of medication for diabetes. In order to spend more time with his family, he arranges to work on his research at home. The plan is to enjoy family dinners and work on his research after the kids have been tucked in. He puts all the information from the study onto his laptop, including patient names, their dates of birth, diagnoses, and test results. The research is going well and so is his family life. Then, one day Dr D stops off at the grocery store on his way home to buy some bread and milk. When he returns to the car, he discovers his laptop is no longer on the back seat where he’d left it. Only after he searches the car to make sure the computer didn’t fall and slide under the front seat does it hit him: his laptop has been stolen. What should Dr D do?

Radha, a three-year-old girl in rural India, is playing at home when she suddenly suffers a seizure. She is stabilized after her parents rush her to the hospital in the nearest town. The doctor explains she most likely has a seizure disorder, but that further testing, including a CAT scan of her brain, is needed to rule out other causes. When her parents tell him they cannot afford the tests, he asks if they would consent to enrolling Radha in a pharmaceutical company-sponsored study comparing two types of anti-seizure drugs. If so, the study sponsors will pay for her hospitalization, the investigations, and drugs as well, should she need them. She will be required to come to the hospital every month, but the pharmaceutical company will pay for transport. Radha’s parents readily agree. Tests reveal she has an epileptogenic focus. She does well in the trial. When the study ends 18 months later, her parents are informed that they will no longer receive free medicine and the local clinic does not carry either of the test medications. Lacking effective medication, her seizures will almost certainly recur, with negative impact on her long-term neuropsychological development. Indeed, one week later, Radha suffers another seizure. What is wrong with this trial? What ethical concerns about medical research does it raise?

A research study proposes to use a new drug, “Superbia,” for the maintenance of positive symptom regression in schizophrenia. Preliminary research suggests that Superbia may have a better patient tolerability profile and possibly be safer as there appears to be a lower risk of agranulocytosis, a serious side effect of one of the currently accepted antipsychotic drugs. In this 48-week study, one-third of the 200 patients to be enrolled at 30 sites will be randomized to continue their current regimen, one-third randomized to Superbia, and the remainder to placebo. All participants will be seen every two weeks initially, then every four to six weeks, with some visits conducted by telephone. Regular blood tests will be done throughout the study to look for evidence of reduced white cells, liver inflammation, and kidney damage. Other side effects noted with Superbia, as with other maintenance drugs, include high blood pressure, dizziness, headaches, fatigue, dry mouth, nausea, rashes, numbness in the body, a fuzzy feeling in the head, and diarrhea. Additional side effects—previously unidentified, it is noted—may also occur. Doses 15 times as high as those used in this study resulted in weight loss, inflammation of the gastrointestinal tract, and red, swollen gums in rats and dogs. No deaths have been reported to date with Superbia. Patients who deteriorate during this study will be withdrawn from the study and offered “rescue” antipsychotics.

Questions for Discussion

1. What concerns might you have about this trial?

2. Discuss what improvements could be made in the trial to make it more appropriate.

Dr U has had a longstanding interest in chronic kidney disease, hypertension, and non-insulin-dependent diabetes. All three conditions, he knows, are prevalent in the Indigenous communities in the North. He has acted as a long-distance consultant to various northern communities and has been frustrated by his poor success rate in preventing renal failure in this population. Dr U is unsure how much of the burden of the disease is due to nature and how much due to the environment. He proposes a study that will compare the genomes of Indigenous patients in various communities and Indigenous people in the city. All he needs, he speculates, are buccal swabs from individuals and data that would link these to an individual’s family and medical history. He hopes then to piggyback on to this a promising new anti-hypertensive drug.

Questions for Discussion

1. What concerns ought Dr U have about his proposed study?

2. What authorization should he seek?