Sample Midterm
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School
University of Victoria *
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Course
331
Subject
Medicine
Date
Feb 20, 2024
Type
docx
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2
Uploaded by DeaconHeat329
Sample Midterm #1
Instructions
Please identify the ethically relevant issues presented by this case and determine whether they
have been handled in accordance with the concepts that we have studied so far in this course.
Explain your analysis. If they have not been handled appropriately, suggest how they should
have been and handled and indicate why you think so.
1The patient is a 76 year old male suffering from severe schizophrenia. For a while he
lived as a recluse, but was ultimately admitted to Maplewood Lodge with his agreement
and at the request of his family. Soon after his admission fell and fractured his hip, and
was taken to hospital for appropriate treatment, upon the conclusion of which he returned
to the Lodge. He is very stubborn, and resists any change. He spends most of his time in
his room. His wife has asked for a DNR (Do not Resuscitate) order to be placed on his
chart, but his daughter disagrees. The daughter also wants him moved to a facility closer
to her home so that he can have more contact with her and his grandchildren, whom he
adores. However, he likes where he is. The physician in charge of the case has already
indicated that he is willing to do whatever people want regarding DNR orders and
moving him to another facility. The situation is complicated by the fact that a new
experimental treatment for schizophrenia has just been developed and is being used on a
trial (experimental) basis on people like this old man. The physician thinks that it might
benefit the patient and therefore enrolls him in the trial without consulting the family,
since she (the physician) is of the opinion that it is the physician’s job to make health care
decisions for patients.
Points looked for
1. Competence/capacity
The patient is suffering from severe schizophrenia. Schizophrenia is characterized by decreased ability to understand reality, false beliefs, unclear or confused thinking, hearing voices that do not exist, deficits in cognitive function such as working memory, long-term memory, verbal declarative memory, semantic processing, episodic memory, attention, learning (particularly verbal learning) etc. Because his schizophrenia is severe, and because there is no indication that he is medicated, he must be considered incompetent. The fact that he is a recluse does not change this. Consequently he needs a substitute decision maker, and any decision he makes cannot be considered a competent decision.
2. Substitute decision making
The order of substitute decision makers ethically is based on propinquity/closeness to the incompetent person, because this maximizes the likelihood that the substitute/proxy will make decisions that are in keeping with the patient’s previous competently held values, if such exist. The order of substitute decision makers based on this principle is legally stipulated in the Health Care (Consent) and Care Facility (Admission) Act
in in BC, and is reiterated in A.c. v. Manitoba
and similar legal cases. Accordingly—there being no supervenient court order—his spouse/wife is the duly empowered substitute, and what the daughter says is essentially irrelevant unless it can be shown that the wife is using ethically inappropriate values. There is no indication that this is the case. Therefore her decision to request a DNR order stands.
3. Physician/patient relationship
There are two distinct physician/patient relationships that are followed by the physician, both of which are ethically inappropriate. The first is the agency
or engineering
model, which is expressed when the
physician says that he is willing to do whatever the decision makers decide. The second is the paternalistic
model, which is expressed when the physician decides to enroll the patient in the research project motivated
by what he considers to be in the best interest of the patient.
4. Privacy
Every patient has the right of privacy relative to her/his health records. This follows from the Principle of Autonomy, and is captured by applicable legal provisions such as the Personal Information and Protection of Privacy Act
and the Freedom of Information and Protection of Privacy
Act This right may be breached only if the patient or a duly empowered substitute has given permission to this effect. Therefore the patient’s data should not have been shared with the daughter unless there were indications that this was permitted either by the patient when competent, or by the wife. There is no indication that this has occurred. The fact that the daughter is a relative is ethically irrelevant. Consequently there is every indication that there was a breach of privacy relative to the daughter. The fact that the physician had access to the patient’s record does not constitute a breach of privacy because the Principle of Impossibility entails that the physician must have access to the relevant information/data about the patient in order to provide appropriate health care services.
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