| Bioethics
Home Page | Syllabus | Old Exams | Web Resources LAW AND MEDICINE -- BIOETHICS Spring 1996 1. Please write your Exam/PIN number in the space provided above. You must turn in this exam, with your bluebook, to receive full credit on the exam. 2. This is an open-book exam. You may bring into the exam room the assigned casebook, 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. Suggested times total 3 hours, which is my best guess as to the time actually required to answer all questions fully. The additional half-hour may be allocated as you see fit. I sincerely hope that time constraints are not a factor in determining performance. 4. Unless the question states otherwise, assume that all patients and providers are citizens of Texas and that all treatment decisions arise in Texas jurisdictions. 5. Part I should be answered on the examination itself. Part II is a traditional essay question and should be answered in a bluebook. Please use dark ink, not pencil; write on every other page of the bluebook, and don't skip lines. Part I (Suggested time: 90 minutes) 1. This is the multiple-choice/short-explanation, fill-in-the-blanks, and true-false portion of the exam. These special instructions apply to Part I only. 2. With all types of questions in Part I, please mark your answer on the exam itself. 3. Each correct choice on the multiple-choice questions will earn four points. No points are deducted for wrong answers. In addition, you will have ten lines on which to explain your answer. Explanations can earn up to six points. Thus, the best possible score on these questions is ten points. 4. On the fill-in-the-blanks questions, you will be asked to identify certain key terms we have discussed or read about during the semester. You will receive up to five points for each of your responses. 5. Each correct choice on the true/false questions will earn two points. One point will be deducted for every wrong answer.
BACKGROUND INFORMATION FOR QUESTIONS 1-2: Frank Churchill, a Texas citizen, has been admitted to Dallas Hospital after suffering extensive injuries in a motor vehicle accident. He is unconscious when he is brought into the Emergency Room. The Emergency Room surgeons have determined that Churchill needs immediate surgery to repair extensive external and internal traumatic injuries to the head and abdomen, any of which would be life-threatening if untreated, and all of which are potentially correctable with surgery. His immediate needs, in addition to surgery, include mechanical ventilation and a blood transfusion. The exact extent of his brain injuries, as well as the duration of any impairment that might result, are unknown at this early time. All physicians involved in Frank's care agree that the standard of care, in the absence of a competent refusal to consent, is immediate intubation, transfusion, and surgery. 1. Assume for purposes of Question 1 that Jane Fairfax Churchill, Peter's spouse, was brought into the hospital at the same time. She is conscious, alert, and competent. She is brandishing a Directive to Physicians, executed by Frank in accordance with all of the requirements of the Texas Natural Death Act. The directive is identical in form and content to the document described and set forth in the Texas Natural Death Act. Jane insists (a) that Frank not be intubated or transfused and that (b) major surgery not be performed on the ground that both types of intervention would contravene his "living will." Circle the letter in front of the most correct statement: a. The physicians should proceed with intubation and surgery, because Frank does not have a terminal condition. b. The physicians should follow Frank's advance directive, because failure to do so would violate the principle that physicians should respect their patient's autonomy. c. The physicians should not follow Frank's advance directive, because he is not a qualified patient. d. The physicians should follow the advance directive, because they are obligated to treat the directions of his surrogate as if they were the patient's. e. More than one of the above is true. Explain:
2. Same Background Information as for Question 1. Assume for purposes of Question 4 that Jane Fairfax Churchill, Frank's spouse, was brought into the hospital at the same time. She is conscious, alert, and competent. Prior to the accident, Frank did not execute any advance directives whatsoever. Should the question of foregoing life-sustaining care become relevant, consider the following statements: I. Jane may execute a written directive to physicians on behalf of her spouse, as long as long as neither of them is a minor. II. Jane may issue a nonwritten directive to physicians on behalf of her spouse, as long as neither of them is a minor. III. Jane may execute a durable power of attorney for health care on behalf of her spouse, as long as neither of them is a minor. Circle the letter in front of the most correct answer: a. I is correct. b. I and II are correct. c. III is correct. d. I, II, and III are correct. e. None of the statements is correct. Explain:
BACKGROUND INFORMATION FOR QUESTIONS 3-4: Betty Caprice is a 48-year-old woman who lives at home with her parents. When she was admitted to the county (public) hospital for treatment of a bladder infection, she weighed 85 pounds and appeared emaciated. She also had large decubitus ulcers (bedsores) on the backs of her legs, indicating that she has not been moved in her bed for quite a long time. Upon admission, the admitting physician discovered that Betty has breast cancer that has spread to her lungs, lymphatic system, and skeletal system. She is in obvious pain. Her mother filled out the admission papers for Betty, listing herself as her daughter's surrogate decision maker. Both she and Betty have been informed of the diagnosis of cancer. When she is alone (away from her mother), Betty says she is in terrible pain and pleads for pain medication. When pain medication is brought to the room, however, Betty's mother inevitably appears and tells her daughter, "You're not in pain. You don't need pain medication, do you?" Betty inevitably replies that she does not want the pain medication. This scenario repeats itself two or three times a day. Even if pain medications are started, they are always stopped when Betty, in the presence of her mother, asks for them to be discontinued. Betty and her parents claim that their religion requires them to attempt to heal naturally and that pain medications would interfere with the natural healing process. The attending physician, Susan Brown, has questioned the mother privately: Dr. Brown: Do you know that your daughter is in pain? Dr. Brown has called for a psychiatric consult on Betty. The consulting psychiatrist has found that Betty is lucid, oriented as to time and place, understands that she has untreatable cancer, and can discuss her diagnosis, prognosis, and alternatives for care. Dr. Brown has asked you, as the hospital's in-house counsel, whether
she may ethically or legally disregard the mother's wishes and follow the daughter's
(intermittent) request for pain medication. 3. If you tell Dr. Brown that she may administer pain medications, which of the following ethical principles most clearly supports your advice (circle the letter in front of your answer): a. respect for patient autonomy. b. nonmaleficence. c. beneficence. d. justice. Explain: 4. If you tell Dr. Brown that she should not administer the pain medications, which of the following considerations best supports your conclusion (circle your answer): a. The mother, as next of kin, is the lawful decision maker. b. The mother is listed on the hospital's own admission form as her daughter's surrogate decision maker. c. Pain medication is not a fundamental right and may be denied like any other treatment modality. d. Betty's wishes should be respected as long as she is competent, and her choice is ultimately to refuse pain medications. Explain:
Five terms are listed below, followed by a limited amount of
space in which you are to discuss each term. You may define the term, compare and
contrast it with other related terms, describe it, or all of the above. Nonlegal
terms should be defined and their legal significations discussed. 5. Futility: 6. Wrongful life:
7. Anencephaly:
8. Rule utilitarianism:
Following are thirteen statements that are either true or false. Circle T for
true (or mostly true) or F for false (or mostly false). All general statements are
subject to qualification and are, therefore, somewhat incorrect. Still, the
following statements are, I believe, generally and fairly recognized as either
"true" or "false." Indicate any critical assumptions upon which
you base your answer on the reverse side of the page. T F 10. The rule announced by the O'Connor/Kennedy/Souter plurality opinion in Planned Parenthood of Southeastern Pennsylvania v. Casey does not permit states to prohibit all post-viability abortions. T F 11. John Rawls' ethical theory may be classified as "teleological." T F 12. The Uniform Determination of Death Act permits families to "opt out" the whole-brain criterion of death and to insist upon a declaration of death only on the basis of cardio-pulmonary criteria if "brain death" is inconsistent with their religious beliefs. T F 13. After the U.S. Supreme Court's decision in Cruzan, a state could deny a competent person's right to refuse unwanted medical treatment only if the surrogate can demonstrate the patient's actual preferences by clear and convincing evidence. T F 14. Commercial surrogacy has not been held to violate the statutory prohibition against baby-selling in most states. T F 15. Although not required by law to do so, most institutions subject all human research to IRB review that conforms to federal requirements, regardless of whether or not the research is supported by federal funds or is going to be submitted to the FDA in connection with a new drug or medical device approval. T F 16. If a state's Medicare program covers the medical expenses associated with live births, it must also (under equal protection principles) cover IVF. T F 17. Infant Care Review Committees, though never required by federal law, were nonetheless promoted by the Department of Health and Human Services. T F 18. After Roe v. Wade, which held that a fetus is not a person, states may not permit a wrongful death recovery for a stillbirth. T F 19. The federal Patient Self-Determination Act requires hospitals that receive Medicare or Medicaid funding to maintain an Institutional Ethics Committee that meets certain minimum federal standards. T F 20. States may constitutionally prohibit the sale of contraceptives to minors but may not prohibit abortions for minors. T F 21. Active euthanasia is deemed by the American Medical Association to be unethical and is unlawful in all 50 states. T F 22. Although Emmylou and James are not married and have no intention of getting married, they do want to start a family. James, however, is sterile, and so they decide that Emmylou should be impregnated through artificial insemination with donor sperm from their friend, Randy. James consents in writing to the AID. The parties' rights are determined under the Uniform Parentage Act, which provides that James will be regarded as the natural father, and Randy will have no parental rights. Part II (Suggested time: 90 minutes) William Welch is a 37-year-old male patient, married for 18 years to Wendy Welch (who became divorced from Welch in 1994), and the father of one daughter, Liz (16 years of age). Welch (a Texas citizen) is in a Dallas, Texas, hospital with encephalitis. Encephalitis is, in simple terms, an inflammation of the brain, of which there are quite a number of distinct varieties. Welch's variety has permanently killed most of the his brain cells and left him with little cortical or brain-stem function. He does not respond to ordinary stimuli but does respond to profound pain. His neurological state most nearly resembles that of PVS. He apparently retains a few of his brain-stem functions. Welch receives artificial nutrition and hydration and is maintained on a mechanical ventilator. His attending physician, a neurologist, has recently raised the question whether Welch ought to be maintained indefinitely on the ventilator and feeding tube. Welch has no advance directive of any kind. The attending physician, Regina Morgan, M.D., has talked with Wendy, Liz, and the patient's mother, Mary Welch, about discontinuing all aggressive (life-sustaining) therapies (ventilator and tube-feeding) and placing a DNR order in his chart. Liz is distraught, but appears to understand the issues raised by Dr. Morgan and states that she believes her father would not want to be kept alive his present condition. Wendy Welch, who has joined her daughter in the hospital, agrees. She bases her opinion on the 18 years she has known her husband and on a conversation she once had with him, before he became ill, in which he said he would not want to be kept alive by artificial means if there were no prospect for his recovery. There were no witnesses to this conversation (other than William and Wendy). Wendy is named as William's agent in his durable power of attorney for health care, which was executed and witnessed with all requisite formalities in 1990. Welch's mother, Mary Welch, vigorously opposes
the withdrawal of any life-sustaining care. She bases her opinion on her 37 years'
experience with her son. "He would never, ever, want anyone to give up on
him. Miracles happen that doctors cannot explain. He would want every
opportunity for a miracle to happen in his case. If God is ready to take him, God
will take him. This is not a decision for us to make. If we turn off the
ventilator and take away food and water, we will not be letting him die. We will be
killing him, and Willy would never agree to the taking of a human life -- especially not
his own -- under any circumstances." In support of her claim, Mary Welch can
point to William's membership in the local anti-abortion organization and his consistent,
public opposition to the death penalty in Texas. She also has indicated that she has
contacted her lawyer. A. (Recommended time: 30 min.) Dr. Morgan has asked for a meeting with you, the hospital's in-house counsel, to find out: 1. who, if anyone, has the authority to act as a surrogate decision maker for William Welch; and 2. whether she (Dr. Morgan) would be within her rights if she declared Welch to be brain-dead and to discontinue all further medical interventions. B. (Recommended time: 60 min.) Dr. Morgan is also concerned that on balance, the benefits of William Welch's continued existence are far outweighed by the burdens. She asserts that it is a matter of time before the imbalance is obvious to all. She also states that she is unwilling to stand by and "do nothing" about this situation and that she wants to "do something" to relieve the patient of this burdensome existence. When pressed for details, she tells you that she might be willing to "just go in there turn off the ventilator myself" or to inject him with a lethal dose of morphine. She wants advice concerning her options. Assume for this part of the question that you are in a jurisdiction that follows the Courts of Appeals' decisions in both Compassion in Dying and Quill. State law otherwise resembles the laws (statutory and common-law) of Texas. Prepare an analysis of the ethical and
legal issues raised by these facts. Think strategically, as the legal officer of the
hospital. Consider the ethical and legal implications of various strategies that you
might pursue, as well as your chances of prevailing in any litigation that might be
commenced by Wendy and Liz, Mary, or the hospital. |