1.”could adequately provide this care, namely, thepatient’stwenty-two-year-old sister Consuela, whoin fact was willing toaccept this burden. Theirmother had died almost ten years ago, andCon-suela had been a mother to Carlos and theiryounger sister sincethen. Carlos had no objection toConsuela’s providing this care, buthe insistedabsolutely that she was not to know his HIV status.Hehad always been on good terms with Consuela,but she did not know hewas actively homosexual.His greatest fear, though, was that hisfather wouldlearn of his homosexual orientation, which isgener-ally looked upon with great disdain by Hispanics.WouldCarlos’s physician be morally justified inbreaching patientconfidentiality on the groundsthat he had a “duty to warn”?Thepatient, Carlos R., was a twenty-one-year-old His-panic male whohad suffered gunshot wounds to theabdomen in gang violence. He wasuninsured. Hisstay in the hospital was somewhat shorter thanmighthave been expected, but otherwise unremarkable. Itwas feltthat he could safely complete his recovery athome. Carlos admittedto his attending physician thathe was HIV-positive, which wasconfirmed.At discharge the attending physician recom-mended a dailyhome nursing visit for wound care.However, Medicaid would not fundthis nursingvisit because a caregiver lived in the home who” casestudy
Conflicting Professional Roles and Responsibilities
Case Study #1
Please Don’t Tell!
1. What is the issue in this case?
2. What is the argument against disclosure?
3. What is the argument for disclosure?
2.”Best in a 1989 survey of non-doctoral genetic coun-selors,and their results were even more uniform.Pencarinha et al.surveyed545 counselors. Of the 199respondents, 98.5% said that they wouldnot disclosemisattributed paternity to the male partner in order“topreserve patient confidentiality.”2Because oftheir similarity ofviews, I will refer to both groupswhen I use the term“counselor.”This practice of the counselors contradictstherecommendations of the President’s Commissionfor the Study ofEthical Problems in Biomedical andBehavioral Research (1983) whichstudied the ques-tion of misattributed paternity. ThePresident’sCommission recommended that misattributedpaternity bedisclosed to both partners.3In 1994,however, the Committee onAssessing GeneticRisks of the Institute of Medicine (IOM)recom-mended that only the woman be informed and thatmisattributedpaternity should not be disclosed toher partner.4The IOM’s majorjustification was sim-ilar to the rationale given by the geneticcounselors:“Genetic testing should not be used in ways thatdisruptfamilies.”INTRODUCTIONGenetic counseling is the process by whichindividu-als are informed about the risks to themselves and/ortheir offspring of genetic diseases and susceptibil-ities. Thecounseling provides information aboutgenetic conditions, theirinheritance, short- and long-term implications, and, when relevant,procreativeoptions. To promote “client autonomy,” geneticistsandgenetic counselors emphasize information giv-ing and truth telling.Yet there are situations inwhich genetic counselors do not disclosepertinentinformation to all involved parties. The focus ofthispaper is on one such situation: the case of “non-paternity” ormisattributed paternity. In 1990,Dorothy Wertz, John C. Fletcher,and John Mulvihillreported on an international study conductedin1985–6 in which 1,053 M.D. and Ph.D. geneticists in18 nationsanalyzed frequent ethical dilemmas inmedical genetics. One casedepicted a child with anautosomal recessive disorder for whichcarrier test-ing was possible and accurate. Genetic workuprevealedthat [the mother’s] husband was not thebiological father. Of the677 respondents, 96%believed that “protection of the mother’sconfiden-tiality overrode disclosure of true paternity.”1Ofthese,81% said they would tell the woman alone;13% would tell the couplethat they were both genet-ically responsible, and 2% would ascribethe child’sdisorder to a new mutation which was unrepeatable.Thesame question was asked by Deborah Pencar-inha, Nora K. Bell,Janice G. Edwards, and Robert G.110Part One / Foundations of theHealth Professional–Patient RelationshipCASE STUDYDISCLOSINGMISATTRIBUTED PATERNITY”
Case Study #2
Disclosing Misattributed Paternity
What is the issue in this case?
2. What is the argument for disclosure to only the mother?
3. What is the argument for disclosure to neither parent?
4. What is the argument for disclosure to bothparents?
3.”workers and may not be perfect. However, theirproven efficacyin reducing the risk for transmissionmade it easier to holdphysicians to their obligationto care for patients despite personalrisk.Malaria, HIV infection, tuberculosis, and a hostof otherdeadly infections are more devastating thanSARS. However, while itsnovelty focused dispro-portionate attention on SARS, the attentionhas beenof incalculable value. These lessons—the importanceof thepublic health infrastructure throughout theworld, the importance ofimproving health and liv-ing conditions in developing countries,the reaffir-mation of the moral center of the medicalprofession,and the urgent need to implement measures thatminimizerisks to health care workers—are valuablefar beyond SARS. Indeed,they may help to focusworldwide attention on the global threat ofbothlong-standing and emerging infections.REFERENCES1. Viets J.Surgeon urges AIDS tests for her colleagues.San FranciscoChronicle. 16 February 1989:1.2. Emanuel EJ. Do physicians have anobligation to treatpatients with AIDS? N Engl J Med. 1988;318:1686–90.[PMID: 3374540]3. Freedman B. Health professions,codes, and the right torefuse HIV-infectious patients. HastingsCent Rep.1988; 18:S20–5. [PMID: 11650067]with caution is differentfrom refusing to care forpatients, different from declaring thathealth careworkers are not obliged to risk their lives forpatientswith SARS, and different from threatening to quitpracticingrather than care for such patients. Thus, indealing with SARS, thehealth professions have reaf-firmed Dr. Urbani’s model ofphysicians’ dedicationto caring for the sick. They have rejected a“me first”philosophy.Affirming health care workers’ ethical dutytocare for the sick imposes a correlative duty onhealth careadministrators and senior physicians toquickly develop and deployprocedures to maxi-mize the safety of frontline physicians andnurses.The gloves, eye shields, and other paraphernaliathat are nowroutine did not exist 20 years ago.While it took many years todevelop and implementthese measures in response to HIV and AIDS,theresponse to SARS took just a handful of weeks.Canadian healthand hospital administrators in par-ticular seem to have done anextraordinary jobdeploying maximal protective measures,includingN95 respirators, negative air pressure examiningrooms,long-sleeved gowns, redesigned traffic flowpatterns to ensureminimal contact with suspectedcase-patients, and adequatequarantines of healthcare workers with suspected SARS. Thesemeasuresdoubtless stressed hospital facilities and health care”
Case Study #3
THE LIMITS OF CONSCIENTIOUS OBJECTION…
What is the issue in this case?
What are the arguments in favor of a Pharmacist’s right toobject?
What are the arguments against a Pharmacist’s right toobject?
4.”134Part One / Foundations of the Health Professional–PatientRelationshipDNA evidence and the quality of legal representationareresolved. Arguably more important are the resultsof a recent surveyof American physicians findingthat, despite the norms adopted bythe AMA andother professional societies, the majority ofphysiciansapprove of physician participation inexecutions.1Further, the media, seizing this opportunity,hasflooded the public with articles and television showsquestioningthe accuracy, fairness, and morality ofcapital punishment inAmerica. The nation appearsto be reassessing the institution ofcapital punish-ment, and central to that evaluation is theappropri-ate role for the scientific community, and particularlythemedical profession, in the accurate and ethicalimplementation ofthat punishment.Unique circumstances and compelling argumentsexistboth for and against continued physician par-ticipation inexecutions, making any choice aboutparticipation a difficult one.This article criticallyexamines the relevant ethical, legal, andpolicy argu-ments that bear on this decision. By doing so, itcomesto the conclusion that, taken as a whole, all perspec-tivesspeak in favor of an active role for physicians inthe lethalinjection process, conditioned, in every case,on the wishes of thecondemned. However, currentlegal tensions between state deathpenalty statutesand medical practice acts stand in the way,creatingan unnecessary and unwarranted ethical bind forphysicians.Although most death penalty statutesprovide for or even requirephysician participation inexecutions, many current medical practiceacts allowphysicians to be subjected to professional disciplineforsuch actions. Although the negative effect of thisthreat ofsanction and delicensure is difficult to quan-tify, it increases asour system of capital punishmentbecomes more and moremedicalized….INTRODUCTIONPhysician participation in theimplementation ofthe death penalty is a highly contentiousissue,spawning voluminous professional and academicdebate. Societyhas long provided a role for physi-cians in the execution process,but as the deathpenalty has become more and more medicalized,theappropriate contours of such participation havecome underincreasing scrutiny. Should physiciansbe present at executions?Should they oversee theexecution process? Should they deliverlethal injec-tions or pronounce death? Social consensus onthesepressing issues is imperative in order to guidelegislation andremove current roadblocks to appro-priate physicianinvolvement.Resolution is particularly crucial at a time whendebateconcerning the institution of capital punish-ment is experiencingrenewed intensity. Recently,politicians, physicians, and the mediahave pulledthe death penalty back into the nationalspotlight.Governor Ryan’s moratorium on executions inIllinois (theresult of numerous DNA-confirmedwrongful convictions), the start ofGeorge W. Bush’spresidential administration, and the recentfederalexecutions of Timothy McVeigh and Juan RaulGarza after athirty-eight-year hiatus on federal exe-cutions have focused thepublic’s attention on manyaspects of our capital punishmentsystem.At both its 2000 and 2001 annual meetings, theAmericanMedical Association (AMA) considered, butultimately rejected, aresolution calling upon the entiremedical profession to support amoratorium on allexecutions until questions regarding theavailability o”
Case Study #4
“TO COMFORT ALWAYS”: PHYSICIAN PARTICIPATION IN EXECUTIONS
What is the issue in this case?
What are the arguments against physician participation?
What are the arguments for physician participation?
What are the policy arguments against physicianparticipation?