Bioethics Home Page | Syllabus | Old Exams | Web ResourcesLAW AND MEDICINE -- BIOETHICS Final Examination
* * * Part I Special instructions: Part I consists of 5 questions that are based upon a single fact pattern. Within each question, you are asked one or more subquestions, each of which is separately lettered (e.g., (a), (b), (c), etc.).
Facts for Questions 1-5 You are general counsel to a county hospital and have been consulted about treatment decisions in connection with a patient, Lloyd Lubber. Lloyd, 51 years old, of Abilene, Texas, was brought into your hospital suffering from a gunshot wound to the head. The bullet had entered through the roof of the mouth and exited through the top rear portion of his head. At the time of admission, Lloyd was comatose. Because of massive bleeding, swelling, and clotting inside his mouth, his airway was largely obstructed, so the emergency room physicians immediately performed a tracheostomy. This is an operation that cuts away the skin over the trachea and allows a surgical wound to be created in order to provide the patient with an unobstructed airway. Once the airway was opened, a respirator tube was placed through the opening in Lloyd's trachea, and he was ventilated mechanically. An hour after Lloyd was admitted to the hospital, his wife, Lurleen, and his three adult daughters arrived at the hospital. They had all been at home when they heard the sound of a single gunshot in the garage, where they found Lloyd with his .45 caliber handgun still in his hand. Although Lloyd had some respiratory drive, it was insufficient to sustain life (hence the need for the ventilatory support), and his respiratory drive appeared to be steadily decreasing. In addition, his pupils were fixed and dilated, indicating significant brain stem damage. His electroencephalogram (EEG) was abnormal but not completely flat; the tracing was consistent with an absence of neocortical function, which was confirmed by CT scan. The most significant threat to Lloyd's survival, however, was his inability to maintain blood pressure (another autonomic function), which was being sustained largely by drugs through an intravenous catheter. The attending physician in the emergency room explained to Lurleen and her daughters that Lloyd's condition was extremely grave and that he did not expect Lloyd to survive beyond the next 2-4 hours. Lurleen then told the attending physician that her husband had been depressed for the past 10 years, that Lloyd had tried to commit suicide on two prior occasions, and that she believed this time he had succeeded. She then produced a directive to physicians, and a durable power of attorney for health care (naming Lurleen as Lloyd's agent). Both documents were executed and witnessed in accordance with Texas law.
Question 1 When Lloyd arrived at the hospital's emergency room, it was quickly determined that he qualified for inclusion in a randomized clinical trial (RCT) to test the safety and efficacy of an experimental (i.e., unapproved) drug designed to prevent seizures in patients with severe head trauma. Pursuant to the research protocol, which had been approved only one day before by the hospital's IRB, a patient like Lloyd could be randomized to one of three arms of the study. Patients randomly assigned to the first arm receive a drug that has been approved by the FDA for this purpose and that represents the standard of care for head-trauma patients. Patients assigned to the second arm receive the experimental drug. Patients assigned to the third arm receive a placebo.
Question 2
Question 3 Assume that the surgeons refused to harvest Lloyd's organs at this time. Against all odds, Lloyd began to sustain his blood pressure on his own during the first 8 hours of his admission to the hospital. His pulse was normal, but his respiratory drive continued to be weak and he therefore required continued ventilation. His surgeons believe that he is now ready for surgery to clean up the wound area in his brain and scalp and that his chances for long-term survival are "reasonable," although he will never regain consciousness and will probably require ventilator support and artificial nutrition and hydration for the rest of his life. Lurleen has invoked her authority under the durable power of attorney for health care and has instructed the attending physicians and surgeons to remove the respirator tube from Lloyd's tracheostomy wound and to close up the tracheostomy wound by stitching a thick gauze pad over the wound: "Let him die. That's what he's been trying to do for the last 10 years anyway."
Question 4 In the course of discussing Lurleen's requests, it becomes apparent to the physicians that all three daughters -- Doreen, Clorine, and Murine -- oppose Lurleen and believe that their father was simply crying out for help, not trying to end his life. In their opinion, he would want everything done to preserve his life. They believe their mother's decision reflects her own unhappiness over her life with Lloyd and her fear that Lloyd will be a medical and financial burden on her for the rest of her life. Lurleen believes that the sisters, none of whom are employed, simply want to continue to collect Lloyd's disability checks from Social Security and fear that when he dies, the checks will stop coming.
Question 5 Apart from the on-going discussions concerning organ donation, extubation, and undoing his tracheostomy, the attending physicians in the Intensive Care Unit (ICU) want to write a do-not-resuscitate (DNR) order for Lloyd. Lurleen objects to the DNR order because (i) she objects to the fact that Lloyd is in the ICU in the first place, (ii) she objects to the fact that he is receiving life-sustaining care over her objections, and (iii) she feels that consenting to the DNR order will be equivalent to acquiescing to his treatment in the ICU.
Part II The first section of this Part consists of 6 true/false questions. Write the question number and your answer ("T" or "F") in your blue book. Do not write your answers in the examination itself. Each question is worth 2 points.
* * * Questions 6 and 7 are multiple-choice questions. For each question, indicate in your bluebook the answer (i.e., the letter of the option) you believe is correct, or the most correct, and briefly explain your choice. You will receive 2 points for the correct option and up to 5 points for your explanation. Be sure to explain not only why your preferred option is correct but also what is wrong with the options you rejected. Questions 7-8 Fred and Martha's third child has been diagnosed with anencephaly. The diagnosis was made during the 26th week of gestation. In the medical opinion of Martha's obstetrician, (i) the fetus is probably viable, and (ii) childbirth at full-term would not pose a medical risk to Martha's life. Under state law, a fetus may be aborted only if continuing the pregnancy would constitute a threat to the life of the mother or if the pregnancy is the result of rape or incest.
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