Cases

The Road Less Traveled Option 2

You and the other consultants signal to each other that you’re uncomfortable with the manager leading the discussion, but aren’t sure how to break in. The tone that’s been established thus far seems adversarial, and you can see that Daniel is getting frustrated. You try to break in with a question of clarification, but the manager continues to denigrate the treatment approach that Daniel is proposing. The manager says that the team at this point just wants to “wash their hands” of the case and says that Daniel can do what he wants but h shouldn’t expect them to participate in pseudoscientific nonsense. With that, Daniel stands up, says, “fine!” and leaves the room. You suggest that the meeting be adjourned for now, and reconvened is possible at a later point in time....

The Road Less Traveled Option 1

Because you and the rest of the consultant team focused on Daniel’s perspective initially, the team feels that the ethics consultants have sided with Daniel. Many members of the team physically move their chairs away from the table and refuse to participate. You address the response by describing what you see and reiterating that the purpose of the discussion is to get all the perspectives into dialogue with each other. You emphasize that there will be opportunity for the health care team to share their thoughts, but some members of the team remain disengaged for the remainder of the meeting. You eventually hear through various channels that the team felt that the consult was a “waste of time” and that they aren’t planning to engage ethics support again any time soon....

Beneficence/best interests in the case of Mr. Hendricks

Given that Mr. Hendricks seems happy and content in his current life, it would seem that preserving this state of being for him would be the most beneficent course of action. We might get a sense of how Mr. Hendricks understood his best interests if his advance directive or previous conversations described his reasons for wanting to refuse any curative treatments at this stage in his disease progression. Our understandings of what constitutes beneficent action generally as well as of our own best interest shift throughout the life course. For Mr. Hendricks, the course of action that is most aligned with beneficence might be to respect his advance directive if it is anticipated that curative treatments might cause significant reductions to his happiness, function, and overall wellbeing. There are strong arguments for focusing on quality of life as opposed to strictly quantity of life, but there is no consensus across the board that one of these is more strongly aligned with...

Winds of Winter Option 2

The working group reaches a consensus that understands winter storms as a common occurrence, and not the sole reason for staff shortages, and so the strategies for addressing their effect on staffing levels should be addressed in the business plans for each unit. Emphasizing solidarity, the policy working group explores ways that the organization can support units and individuals in meeting the obligation to provide care in conditions where resources are extremely limited, but also looks to identify the barriers and facilitators to reporting for work in a range of conditions. ...

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Autonomy in the case of Mr. Hendricks

A focus on respecting autonomy in this case leads to question of whose autonomous wishes should be respected - the Mr. Hendricks of 20 years ago who wrote the advance directive, or the Mr. Hendricks of today. There is no consensus around this in the bioethics literature. An advance directive is a tool that helps health care providers express their respect for patient autonomy. Even as his dementia progresses, Mr. Hendricks retains some degree of autonomy and is able to express his preferences, whether or not he has capacity sufficient to make decisions that are recognized as legally binding upon others. We often express respect for this sort of autonomy, even if we do not find it sufficient to alter the course established by the wishes set out in the advance directive, by giving an individual the ability to make “small” decisions for themselves, whether or not they fully understand the nature of the decision or the consequences of various choices. Our...

Winds of Winter

The health care organization you work for serves a rural population and most staff members commute to work, some for 45 minutes or more, over roads in varying states of repair. The past winter there were several storms that made it challenging for some people to get to work, and the organization found itself short staffed when this happened. In addition, some managers required employees who couldn’t make it in to take the time as a sick day, while others did not. The lack of consistency in practices raised concerns at a leadership level and has resulted in a degree of antagonism between those who live close to the facility and those who live further away. You are part of a policy working group tasked with developing policy around reporting for work in adverse weather conditions. Committee members have significant concerns about justice. In this case, their concerns about justice focus primarily on fair distribution of risk and fair distribution of workload. In...

The Road Less Traveled

Daniel is a 22 year old with cerebral palsy. He has recently transitioned from care in a pediatric setting, and is reviewing therapies with his new health care team. Daniel tells the team that he wants to pursue homeopathy instead of continuing regular physiotherapy as the primary means of addressing his symptoms. He claims that physio is not making him better, while homeopathy can result in significant improvement. This decision raises concerns for the team about his understanding of his condition and of homeopathy, and the team feels that the homeopathic doctor has not given Daniel an accurate representation of the likely benefits of homeopathy. The team is particularly concerned because Daniel is on a limited income as a university student and the treatment is expensive. The homeopath is requesting a copy of Daniel’s medical records. The team is comfortable with a range of complementary therapies and recognizes that evidence indicates that many of them provide benefit for their patients, but they feel...

Choosing Wisely

Pneumonia season is in full swing in your facility. Recently in the ICU there have been a string of patients who had do not attempt resuscitation (DNAR) orders in place that followed them from the continuing care setting in which they lived but who nonetheless wound up being treated with antibiotics, using noninvasive ventilation, and remaining in ICU for an extended period of time. (more…)...

Money, Money, Money

The ethics committee has received a request to review a donation proposed by a local oil company. The proposed donation is substantial, and your organization would be able to use the money to improve access to primary care providers, which meets a significant need in the community. The organizational values for your organization are respect, stewardship, excellence, person-centered care, and trust. A key strategic direction is responding to primary health needs in communities. The oil company would like its name on a new primary care clinic and is willing to set up an endowment to support hiring health care providers to staff the clinic. In this case, there are concerns about accountability, which center on the motivation behind the donation and what the oil company hopes to gain by making it. Some feel strongly that the organization’s integrity is significantly diminished by accepting the money, and believe that it is too high a price to pay. Others acknowledge concerns about transparency, but focus on how...