PIN No. __________________________

LAW AND MEDICINE -- BIOETHICS

Spring 2001
Prof. Mayo
Final Examination

May 7, 2001

8:30 a.m.

3 hours

Instructions

  1. Please place your PIN (ID) number on this exam and on each blue book you turn in.
  2. This is an open-book exam. You may bring into the exam room the assigned casebook and supplement, all class handouts, your class notes, and your outline, including any outline that may have been prepared jointly with other members of the class.
  3. There are three parts to the exam, with the following suggested times:
    1. Part I (short essays) – 1.5 hours
    2. Part II (essay) – 60 minutes
    3. Part III (True/False) – 30 minutes
  4. Unless the question states otherwise, assume that all patients and providers are citizens of Texas and that all treatment decisions arise in Texas.
  5. In Parts I and II, if you believe that insufficient facts are provided in order to resolve an issue, identify explicitly those additional facts that would be necessary for your analysis.
  6. When time is called, please turn in your bluebook(s) and this exam (inside the bluebook(s)).

* * *

Part I
Suggested time: 1.5 hours

You are counsel to a major, acute-care hospital. The director of nursing has presented you with the following question:

If a patient suffers cardiac arrest and one of the patient's children is present and states that we are not to code the patient, can we withhold resuscitation efforts?

Details:

Patient is married. His spouse is not present or available in the time-frame needed (immediately). Patient has a directive to physicians that contains the standard form language in the Advance Directives Act (i.e., patient does not want life-sustaining treatment (including resuscitation attempts)).

Patient also has a medical power of attorney (identical in form to the standard form in the statute), naming his spouse as agent and naming their adult child as an alternate if the spouse is unable or unwilling to make a decision. (Document does not say anything about what happens in the event the spouse is not present.)

The only physician orders in the patient's chart are orders for antibiotics, pain medications, and diagnostic tests for the next day.

The cardiac arrest is a sudden, unexpected event. Patient is not diagnosed with a terminal or irreversible condition. The spouse/agent is not immediately available; the adult child is present at the time of the arrest and insists that the patient not be resuscitated.

What should the staff do in this instance? Sometimes we face this situation with members of the family literally lying over the patient, blocking resuscitation efforts.

Answer the following ten (10) short-answer questions in the space provided. (Typists: Limit your answers to 100 words per question.) Each answer will be graded on a 14-point scale (14=A+; 13=A; 12=A-; etc.).

 

  1. Has the director of nursing correctly described the patient's directive to physicians?
  2. Disregard the medical power of attorney for purposes of this question (and Question 3). Does the directive to physicians apply to the director of nursing's question? (Answer yes or no and explain why. Do not answer the director of nursing's question.)
  3. Would your answer to Question 2 be different if the patient had previously been diagnosed with a terminal or irreversible condition?
  4. Disregard the directive to physicians for purposes of this question (and Question 5). Does the medical power of attorney apply to the director of nursing's question? (Answer yes or no and explain why. Do not answer the director of nursing's question.)
  5. Would your answer to Question 4 be different if the patient had previously been diagnosed with a terminal or irreversible condition?
  6. The director of nursing does not mention whether the patient has executed an out-of-hospital do-not-resuscitate order. Based on the facts as stated by the director of nursing, if the patient had executed an out-of-hospital do-not-resuscitate order before being admitted to the hospital, would it have been valid?
  7. Assume for purposes of this question that all prerequisites for a valid out-of-hospital do-not-resuscitate order have been satisfied. If the patient had executed a valid out-of-hospital do-not-resuscitate order prior to being admitted to the hospital, would that advance directive apply to the director of nursing's question? (Answer yes or no and explain why. Do not answer the director of nursing's question.)
  8. Is the director of nursing's correct when she says that the medical power of attorney does not say who should be the agent for purposes of making health-care decisions in the event that the primary agent (the spouse) cannot be reached?
  9. Assume for purposes of this question that the patient had not executed any advance directives at all. Under Texas law, would the spouse or the adult child have the authority to consent to a do-not-resuscitate order?
  10. What is the answer to the director of nursing's question?

Note to WWW readers: Each question was allotted 20 double-spaced lines for answers.

 

Part II
Suggested time: 1 hour

You are the legislative counsel for a state senator. The senator hands you the following newspaper article from the May 5 New York Times:

Babies Born in Experiments Have
Genes From 3 People

Some babies born from a new method used to treat a rare form of infertility have genes from three different people in their cells, researchers are reporting.

But the researchers emphasize that the added genes appear to be of no consequence. They are of a type that does not vary much from person to person and appear to have no effect on a child's characteristics, the researchers say. They say that their patients' babies who were born through use of the technique appear to be healthy.

The treatment has been used solely for a rare form of infertility occurring in only a small percentage of patients at fertility clinics. Women with this condition have eggs that can be fertilized, but the resulting embryos simply fall apart, dying before they can implant in the uterus.

Dr. Jacques Cohen, an infertility researcher at the Institute for Reproductive Medicine and Science at St. Barnabas Medical Center in Livingston, N.J., reasoned that the problem might be in the cytoplasm, the material that surrounds the nucleus of the egg and that directs its development after fertilization. So, in experiments that began a few years ago, Dr. Cohen and his colleagues began injecting cytoplasm from the eggs of fertile women into the eggs of these infertile women.

The group has treated 30 women, Dr. Cohen said, and they have given birth to 15 babies. About 30 babies have been born worldwide as a result of this technique, he added.

But the cytoplasm of an egg contains more than just proteins to help an embryo grow. It also contains mitochondria, which are self-contained tiny structures that use oxygen and nutrients to create energy for the cells. And mitochondria have their own genetic material.

That gave rise to a question. If the investigators injected cytoplasm containing mitochondria into an infertile woman's egg and then fertilized the egg and created a successful pregnancy, would the baby have genes from three people: the infertile woman, the man whose sperm fertilized the egg, and the woman whose egg was the source of the additional cytoplasm?

The answer, Dr. Cohen and his colleagues reported, was yes. In the March issue of a British journal, Human Reproduction, they described a genetic fingerprinting method they used to detect mitochondrial genes from the donor cytoplasm in blood cells of two 1-year-old babies born with this technique.

They tracked the one region of the mitochondrial genetic material that normally varies from person to person, a region, Dr. Cohen said, in which genes are inactive. "There are differences, but they are not meaningful," he said.

But in an editorial published in the journal Science on April 20, two ethicists, Erik Parens of the Hastings Center in Garrison, N.Y., and Eric Juengst of Case Western Reserve University in Cleveland, suggested that such treatments, because they result in permanent genetic alterations that in turn will be passed on to the babies' children, might not have been approved by a federal committee that oversees experiments that involve gene transfer. But, they explained, since the work was privately funded, the researchers had no obligation to ask the committee's permission to go ahead. The federal government does not pay for research related to human fertilization and early embryo development.

Dr. Cohen said: "We didn't come to them because they didn't give us federal funds. I would be happy to talk to them if they gave us funds."

Your senator wants to know:

(A) whether the creation of babies with the DNA of three people has the potential for legal or ethical problems;

(B) whether current legal rules deal with the problems sufficiently, or whether a statute might that might be needed to clarify the legal and ethical issues; and

(C) whether this form of assisted reproduction should be prohibited or regulated by a new state law on the subject.

Please write your answer in a blue book and label the parts of your answer A., B., and C.

 

Part III
Suggested time: 0.5 hours

Circle the appropriate letter (T/F) preceding each of the following statements to indicate whether they are true or false.

T F 1. Demetris Rogers was stabbed by Robert Courchesne when she was 8-1/2 months pregnant. Her child, Antonia, was delivered by emergency Caesarean section following which Demetris died. Antonia was placed on life support, and after six weeks, she died. In most states, Courchesne could not be charged with murder in the death of Antonia because she was not a “person” at the time she was injured.

T F 2. On the same facts as Question 1, Antonia's estate would be able to maintain a tort action against Courchesne even if she had been stillborn.

T F 3. In medical research involving human subjects, the requirement of “equipoise” applies only when the research subjects are minors, incompetent, or prisoners or are from some other vulnerable population.

T F 4. Under the Common Rule, nonviable ex utero fetuses may be research subjects.

T F 5. Anthony has primary liver cancer that has spread to other organs, his lymphatic system, and his spine. He is in enormous pain and his physician, Dr. Brown, believes Anthony has less than six months to live. Anthony has asked Dr. Brown to leave a lethal dose of morphine on the table next to his bed so that he “can end it all now” or, alternatively, to inject a lethal dose of morphine into Anthony's IV line. If Dr. Brown complies with either of Anthony's requests, he would be acting in accordance with the doctrine of double effect.

T F 6. On the same facts as Question 5, if Dr. Brown complies with either of Anthony's requests, he would be acting lawfully in Oregon, alone among all U.S. jurisdictions.

T F 7. With appropriate safeguards, human organs may be harvested from a non-heart-beating donor who does not satisfy the requirements for “brain death.”

T F 8. In a majority of U.S. jurisdictions, an anencephalic newborn is born dead for purposes of the Uniform Anatomical Gift Act.

T F 9. Under the Texas Advance Directives Act, artificial nutrition and hydration may be withheld or withdrawn from an incompetent patient with a terminal or irreversible condition, even if the patient has not executed any advance directive.

T F 10. The principle of respect for autonomy is consistent with Kant's individualistic deontology but is not consistent with either act- or rule-utilitarianism.

 

EXAMINATION ENDS HERE