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Bioethics
Summer 2004
Prof. Mayo
Some Suggested Paper Topics
Here are 25+ suggested
paper topics. You are free to rethink the topics, take them off into a
different direction, or come up with your own topic (subject to my
approval):
- Legal status of DNR orders in Texas.
Are they a treatment decision
about withholding or withdrawing life-sustaining treatment for purposes of
the Advance Directive Act? Can they be consented to pursuant to Chapter 313
of the Health and Safety Code? Can a DNR order be written unilaterally?
Even over the objections of the patient or the patient’s family?
- Resolving fetal-maternal conflicts.
Pregnant women sometimes refuse
medical interventions that would benefit themselves, their fetus, or both.
These interventions might be major surgery (a C-section), antibiotic
therapy for a Strep infection (easy to treat, not good if left
untreated), or a fetal monitor (to name just a few). Some of the
interventions are quite invasive, some not so much. Some are inherently
quite risky, others not so much. Sometimes the risk (of either treatment or nontreatment) fall entirely on the fetus; sometimes they fall on the
pregnant woman, too. How should these types of
conflicts be resolved?
- Pregnant women and permanent
vegetative state (PVS) or brain death.
Suppose a pregnant woman is injured in a car
crash and is eventually declared to be in a PVS or to be dead according to
neurological criteria. May her surrogate decision maker choose to support
her organs, and the life of the fetus, until the child can be delivered?
Must the surrogate decision maker continue life-support? Does it matter if
at the time of decision the fetus is not yet viable?
- Children as human research subjects.
The Maryland Court of Appeals last
year handed down two opinions in a case involving the Kennedy Krieger
Institute in Baltimore. The opinions have been widely criticized on the
ground that if the court’s decision is followed elsewhere, it will be the
end of so-called “non-therapeutic” pediatric research. What is the federal
government’s position on such research; where do other states stand; etc.
- Physician-assisted suicide (PAS).
Oregon is the only state to have
legalized the practice. The Supreme Court has ruled that considerations of
neither due process nor equal protection compel states to allow the
practice. Your paper can go in lots of different directions. Should other
states follow Oregon’s lead? Is there an equal-protection argument that
once a state has legalized PAS, it must also legalize active euthanasia?
What are other countries doing and what can we learn from them?
- Is "brain dead" dead?
All 50 states and the District of
Columbia have rules that define death in terms of the irreversible
cessation of all neurological functioning. This notion of “brain death”
has been around since 1968, when the Harvard Medical School Report on
“irreversible coma” (now regarded as something of a misnomer) was issued.
Yet, just as soon as we as a nation seem to have become comfortable with
the idea, it is coming under increasing scrutiny and criticism. Is it
internally inconsistent? Is it a snow job by the transplant community? Are
the NY and NJ variations the way of the future? Is neo-cortical death
preferable to whole-brain criteria for determining when death occurs?
- Out-of-Hospital DNR Orders (OOH-DNR)
and Children. Not many
states authorize OOH-DNR orders. Even fewer authorize them for minors, but
Texas does. Should OOH-DNRs for children be limited to those who are
certified to have a terminal or irreversible condition? What happens when a child with an OOH-DNR order suffers
cardiac or respiratory arrest in school? On a commercial airline flight?
In a restaurant? How the should various rights and obligations of the
various affected parties be balanced? What should a regulation from the
Texas Department of Health, Texas Department of Education, or FAA look
like?
- Organ donation and non-heart-beating
donor (NHBD) protocols.
Usually, cadaveric organs are harvested from donors who have been declared
“brain dead.” Sometimes, however, the donor, the donor’s family, or the
transplant team don’t want to wait that long for the organs. Some
transplant centers have reverted back to the old cardio-pulmonary criteria
for determining death. Of course, they provide a certain amount of medical
assistance along the way, ostensibly to help ensure the viability of the
organs. In so doing, are these centers actually killing patients for their
organs? Taking organs from patients who satisfy none of the criteria for
determining death in this country? What would a good NHBD protocol look
like? Absent the sorts of safeguards contained in such a protocol, should
local DA’s be considering homicide charges of some kind?
- Anencephalic newborns.
Medical texts usually refer to
anencephaly as a condition that is “incompatible with life” or to
anencephalic newborns as “born dying.” Despite this, a few years ago, the
Florida Supreme Court said the organs of a baby born with no neo-cortical
hemispheres could not be donated because the baby was still alive under
Florida law. (The AMA once opined that anencephalics should be regarded as
an exception to the requirement that organ donors be dead and then turned
around at its next session and revoked its own ruling.) A few years later,
the 4th Circuit Court of Appeals said that a Virginia emergency room had
an obligation under federal Medicare law to treat the respiratory distress
of an anencephalic infant who was brought to the ER from a local nursing
home. Do we need to rethink the law’s response to anencephaly? Or are
anencephalic newborns entitled to the same level of protection as any
other member of society
- What are 5 things the next Texas
Legislature needs to fix in the Advance Directives Act?
Maybe it’s just because I helped to write it, but even
after the 1999 overhaul and the 2003 tweaking of the Advance Directives Act,
this law seems
incomplete in some ways and flawed in others. You could study the various
states’ approaches to advance directives law in a reliable treatise such
as The Right to Die by Alan Meisel (3rd ed. (2004), in Underwood
Law Library), talk to ethics committee chairs in the community, compare
provisions to the Texas law, and argue for the changes you think our law
most needs to have.
- Should DNR orders be respected during
surgery and in recovery?
Patients with DNR orders sometimes get surgery, and that surgery may
involve general anesthesia. Customarily, DNR orders are suspended during
surgery and patients who need it are given CPR and full life support.
Although they have taken somewhat different positions on this, surgeons’
and anesthesiologists’ groups have come out in favor of a more nuanced
approach to DNR orders during and immediately after surgery. What would a
hospital policy look like? Is it a good idea?
- Demands for futile treatment.
Surrogate decision makers often
ask that “everything be done” for a patient. Sometimes they are more
specific. Occasionally this request is for treatment deemed by the medical
team to be “futile.” Should physicians be able to withhold or withdraw
nonbeneficial interventions? If so, under what circumstances? What process
values should be respected?
- Should the U.S. Senate vote with the
House (H.R. 543, passed Feb. 27, 2003) and ban all human cloning (reproductive and “therapeutic” cloning)?
This is a subject that may be
superseded by events this summer, since many think
there will be a vote on the Senate bills before Labor Day. The distinction
between types of cloning activity is driven by the desire of many to
create new sources of embryonic stem cells by creating new embryos. What
are the arguments for and against both types of cloning? Which do you find
persuasive and why? Note: the
President's Commission on Bioethics has weighed in on this topic with
its
first report.
- Federal funding for stem cell
research. President Bush’s policy,
announced August 2001 and fleshed out by the NIH since that time,
superseded an earlier funding policy put out by Pres. Clinton’s NIH chief,
Dr. Harold Varmus. There are a couple of ways (at least) to proceed on
this topic, e.g.: Which funding policy got it right (if either did)? On
the merits, how did Bush do? Is this a funding policy that is doomed?
Internally inconsistent? Based upon unsustainable premises or
distinctions? Or a principled compromise that will stand the test of time?
- Ethics of third-world drug research.
Drug companies have been accused
of running drug-testing protocols in third-world countries that would be
unethical and impossible to run in the U.S. Other times, they have been
criticized for testing drugs that will eventually be marketed at a price
the third-world countries couldn’t afford. What should the rules be for
such research?
- The federal "Baby Doe" rule.
Two Dallas
Morning News articles in 2002 highlighted some problems with the Baby Doe rule. The
Texas Supreme Court has a case before it now that raises some of these
issues (even though the Court of Appeals refused to discuss Baby Doe).
Should the Baby Doe rule be abandoned? Modified? Or kept just the way it
is?
- Living related organ donors and
paternity information. When
an adult child decides to donate an organ to a parent on the donor waiting
list, blood samples are analyzed to determine whether the offspring is a
match. This information provides information that is also conclusive (or
nearly so) on the question whether the recipient is the donor’s biological
parent. Are potential donors entitled to genetic parentage information?
How do genetic counselors handle the analogous situation (if an analogous
situation exists)? Should the transplant surgeon provide this information?
What are the implications of your answer for the informed consent process?
- Medical decision making for minors.
What should the standards be for reviewing and overruling parental medical
choices? You might focus on one set of such decisions (end-of-life
decisions, decisions by Christian Scientists, etc.) for your analysis.
- Health law and ethics. Various regulations and statutory
prohibitions have their roots, and their continued justification, in
ethics. Illegal remuneration, fee-splitting, self-referral,
corporate practice of medicine doctrine, patient abandonment . . . these
and many more represent not only legal norms, but ethical norms as well.
Is the ethical thinking about these doctrines outmoded or still valid?
Are there newer and better ways to deal with the harms these doctrines try
to address?
- Sex selection (and other genetic manipulations). What
limits, if any, should be placed on the ability of prospective parents to
guide or alter the genetic makeup of their offspring?
- Bioethics and literature. The
President's Commission on Bioethics
has posted five
sets of readings on various bioethics themes. Pick one or more
themes and evaluate the readings. Are they biased or balanced?
Are essential points of view missing? What do you make of the
readings that are listed? Do they speak to policy issues in any
useful or unique way?
- Medicine and criminal law. Should physicians be allowed
to medicate prisoners to make them competent for trial? For execution?
The AMA has opinions on this; are they correct?
- Conjoined twins. What should the rules be for the
separation of conjoined twins? What if separation is necessary to
save one twin but will inevitably lead to the death of the other?
- Physical restraints in emergency medicine. What are the limits?
Should they be changed?
- "Boutique medicine." Now there's a national society for
doctors who want to charge upfront fees to patients who want preferential
treatment. What should the law say, if anything, about "concierge"
or "boutique" medicine? Is this a development hospitals might want
to emulate?
- Veterinary ethics. This is an overlooked area, except
perhaps with respect to the use of animals in research for human products,
but practicing veterinarians have ethical issues, too. For example,
do veterinarians have an obligation to provide charity care? Can
they refuse to return a pet to its owner until the owner pays the bill for
services rendered? What are the limits on an owner's right to insist
that an animal be euthanized (i.e., is it ethical to euthanize a
cat that sprays? a treatable horse for the insurance proceeds? a
sick animal without the owner's permission?)? Should veterinarians
be required to report animal abuse? What should be the limits on a
veterinarian's ability to sell nonprofessional goods and services?
Note: Many, many useful web
sites exist to help get you started with your research. My own
Bioethics Web Resources
page is a good place to start.
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