EMJ CASES

Case 1:
A woman enters the emergency room with stomach pain. She undergoes a CT scan
and is diagnosed with an abdominal aortic aneurysm, a weakening in the wall of the
aorta which causes it to stretch and bulge (this is very similar to what led to John
Ritter's death). The physicians inform her that the only way to fix the problem is
surgically, and that the chances of survival are about 50/50. They also inform her
that time is of the essence, and that should the aneurysm burst, she would be dead
in a few short minutes. The woman is an erotic dancer; she worries that the surgery
will leave a scar that will negatively affect her work; therefore, she refuses any
surgical treatment. Even after much pressuring from the physicians, she adamantly
refuses surgery. Feeling that the woman is not in her correct state of mind and
knowing that time is of the essence, the surgeons decide to perform the procedure
without consent. They anesthetize her and surgically repair the aneurysm. She
survives, and sues the hospital for millions of dollars.

Questions for Case 1:

1)Discuss ethical issues

Beneficence: Beneficence is defined as providing the best interest in terms of treatment to the patient
for her or his own benefit. In this case, patient has a 50/50 chance of life and death and abdominal
aortic aneurysm is a surgical emergency and failure to treat as early as possible can lead to mortality.
Hence the medical practitioner insisted to proceed with the surgery as this could save the patients life
despite disregard her wish not to.
Non Maleficence : Do no harm is where a medical practitioner should practice with great care and
equipped with a well background of knowledge to avoid putting a person at risk that could harm the
patient and it is the first step of beneficence. In this case, the practitioner incharge wanted the best
treatment for the patient whereby to save her life and avoiding and disregard the treatment could cause
harm which is death to the patient in this case. Hence, its an ethical thing to proceed with the surgery
as it is a life-saving procedure.
Autonomy: Autonomy is the patients right to make a decision about to proceed with the procedure or
to refused any treatment given. For this case, patients should be well inform regarding the risk of the
procedure and has been explain thoroughly about the consequences of refusing the treatment which is
death. Second, patient should be access for mental incompetency by a psychiatrist. However due to
limitation of time and patient is in a impending life threatening condition, hence the surgery can be
proceed without her consent. Third, we can ask the consent for the next of kin such as her husband or
family members to allow the surgery to be taken place. Fourth, we can try to persuade patient by giving
her alternative treatment available as she was worried of losing her job as a dancer due to the scar
which is a plastic surgery to cover up the scar.

2) Elements to consider.
To explain thoroughly about the procedure in a great manner and get a more experience senior
physicians to consult the patient.
To get consent from the next of kin since patient refuse to do the surgery that could save her life.
To give alternative choice regarding the scar which is the plastic surgery to cover up the scar and avoid
losing her job.
To get a psychiatrist to access the mental competency of the patient rather than blindly assuming that
the patient s mental capability is impaired.
3) would a court order make the physicians ethical?

Yes. In my opinion, it would be ethical to take away the autonomy in this case as currently, autonomy is not the
first priority especially when it comes to a situation whereby the benefit outweighs the risk as well as life
threatening situation and complying to do as patients decision that could lead to death. We also have to
consider other pillars of medical ethics which are beneficence and non-maleficence that also plays a role in
making our decision and choice of the patients best interest. Hence, in my opinion its an ethical thing to do.

4) what would you do if you were one of the health care workers?

If I were the health worker, I would :

Explain thoroughly about the procedure as well as the benefits and risk as well as complication that
can arise from the surgery.
Third, I would try to ask the consent from the next of kin which is the close family member so that
they can try to persuade her in agreeing with the surgery.
Give alternative choice of treatment such as the plastic surgery to cover up the scar so that it wont
affect her job as a dancer in the future.
Try to get an urgent referral to psychiatrist for mental state examination
If patient still refuse then I would refer to a senior surgeon to do a better counselling session to the
patient as they would be more experience in dealing with this kind of patient
Lastly if patient is deteriorating and become haemodynamically unstable, then I would proceed with
the surgery with all the risks and complications in mind without her consent for the best interest of the
patient.

Case 2 :

A woman was diagnosed with motor neurone disease 5 years ago. This is a
condition that destroys motor nerves, making control of movement impossible, while
the mind is virtually unaffected. People with motor neurone disease normally die
within 4 years of diagnosis from suffocation due to the inability of the inspiratory
muscles to contract. The woman's condition has steadily declined. She is not
expected to live through the month, and is worried about the pain that she will face in
her final hours. She asks her doctor to give her diamorphine for pain if she begins to
suffocate or choke. This will lessen her pain, but it will also hasten her death. About
a week later, she falls very ill, and is having trouble breathing.
Questions for Case 2 :
Does she have a right to make this choice, especially in view of the fact that
she will be dead in a short while (say six hours)? Is this choice an extension of
her autonomy?
Every competent adult who able to understand his/her illness has a right to determine which
treatment that he/she does or does not wish to received.
As for this patient she clearly understood her conditions as being explained by the doctor.
Due to her mental competency, she has the right to determine which treatment is the best
for her and the doctor should respect for the patients wishes.
 She stated her decision to get diamorphine to relieve her pain. The doctor should first
explain to the patient that by giving this medication it will hasten her death and if the
patient able to understand the consequence and still want to receive the treatment, then
the doctor should respect for the patients decision as patients autonomy should be
respected. The doctor should document the patients wishes in her medical record.
There is also no reason for the doctor to refuse to give the medication, as the doctors duty
is to reduce the pain of the patient eventhough it will shorten the patients life. The only
reason the doctor can reject the patients wishes is when the patient clearly stated that by
giving the medication will shorten her life and there is clearly intention to die/suicide. As for
this case, there is no clear intention of dying and the patient only want this medication as
she cannot bear with the pain, so the doctor must follow her decisions.

Case 3 :
A married couple wishes to have a child; however, the 32 year old mother knows that
she is a carrier for Huntington's disease (HD). HD is a genetic disorder that begins
showing signs at anywhere from 35-45 years of age. Its symptoms begin with slow
loss of muscle control and end in loss of speech, large muscle spasms,
disorientation and emotional outbursts. After 15-20 years of symptoms HD ends in
death. HD is a dominant disorder which means that her child will have a 50% chance
of contracting the disorder. Feeling that risking their baby's health would be
irresponsible, the couple decides to use in vitro fertilization to fertilize several of the
wife's eggs. Several eggs are harvested, and using special technology, only eggs
that do not have the defective gene are kept to be fertilized. The physician then
fertilizes a single egg, and transfers the embryo to the mother. Approximately 9
months later, the couple gives birth to a boy who does not carry the gene for the
disorder.
1) Does this consider eugenic? Discuss

"Eugenics" is defined as "the hereditary improvement of the human race

controlled by selective breeding" The purported goals have variously been to

create healthier, more intelligent people, save society's resources, and lessen

human suffering.

The report (report of the presidents council on bioethics, washington) further

claims that if PGD is used for eugenic purposes, there is fear that it will in

future further stigmatise the disabled and discriminate their lives as not worth

living.

Thus, this would be considere a eugenics case.

 2) Would it be acceptable/ethical for the parents to select for sex as well, or
should they only select an embryo that does not have HD? How would this be
different?

It would not be acceptable to select for sex. The selection should be used

based on the presence or absence of the genetic trait that would cause harm.

PGD should be offered for 3 major groups of disease :

- Sex linked disorder

- Single gene defect
- Chromosomal disorder

Sex selection may contribute to a societys gender stereotyping and overall

gender discrimination

Gender should not be a reason to value one person over another.

It is sometimes argued that in selecting the sex of child, parents are using

their child to fulfil their own desire and that this fails to respect the child as a

person.

Case 4 :

Sandra is 15 yrs old. She is pregnant but she has not told her parents and has disguised her pregnancy
by wearing baggy clothes. She visits her GP, Dr Turner, for antenatal checks and has told him that
under no circumstances should her parents be informed. When she is twenty five weeks pregnant an
antenatal test shows that the foetus is suffering from a serious genetic condition.

Sandra wishes to have a termination and asks Dr Turner whether she can get an abortion at such a late
stage in her pregnancy.

Q : Identify and discuss the legal issues arising from all of the above facts.

- The legal issues include confidentiality, autonomy, consent to medical treatment by children
and abortion.
- Regarding confidentiality, the dr should make the care of the patient the first concern,
respect the patients dignity and privacy, and support and encourage the patient to be
involved, as far as they want, in decisions about disclosure of their personal information.
- The dr should ask the patient why she did not want her information to be disclosed to her
parents. The dr should also try to persuade her to tell her parents herself or to allow her
parents to be involved in the consultation. If they refuse, and the dr is convinced that it is
essential in their best interests, the dr may disclose relevant information to a legal authority
but with patients knowledge. The dr shall document in the patients record the discussions
and the reasons for deciding to disclose the information.
 - However, that does not mean the authority have a general right of access to the patients
records or to have irrelevant information about the pt (example past healthcare)
- The practitioner shall also share relevant personal information with anyone who is
authorised to make decisions on behalf of, or who is appointed to support and represent the
patient.
- The patients initial refusal might be due to fear and denial. Thus the dr should offer help
and support to Sandra by acting as an intermediary in whatever capacity he can.
- Meanwhile, in regards to abortion, the dr should refer the patient to a psychiatrist to assess
the mental competency. As a general rule, abortion is illegal in Malaysia. Exception to this
is when a registered doctor formed in good faith, that the continuance of the pregnancy would
involve risk to the life of the pregnant woman, or injury to the mental or physical health of the
pregnant woman, greater than if the pregnancy were terminated and a pregnancy with
foetus that is unlikely to survive. In this case, if the fetus is unlikely to survive and
can bring harm to the mother, the abortion should be done.

Case 5 :

Karen had a bad fall several years ago and has suffered intractable back pain ever
since. She has tried complimentary medicine which has not helped. Finally she sees
Mr Hutchins, a consultant at Freeside NHS TrustHospital. He advises her that she
needs an operation. She agrees to the operation but, unfortunately, she becomes
paralyses as a result of complications. The risk of such complications inherently
arising in the course of such procedure is 5%. Dr Hutchins did not warn Karen of this
risk. He considered that as she was desperate for treatment, information of such a risk
would have put her off the operation, which he regarded as being in her best interests.
1. Identify & discuss the legal issues arising from above.
Autonomy
Autonomy is defined as pts right to determine her own health care decision
which there is no form of a treatment can be pursued wo her agreement,
even if the proposed of therapy is for her own good.
The doctor must give adequate information & suggest the best treatment to
the patient.
In this case, it is the pts decision to go for the surgery. But, the dr has the
responsibility to tell her all the possible risk and complication that might be
arise from the surgery which she might go into paralyse after the surgery.
In order to proceed with the procedure, a doctor must ask for pts consent.
A valid consent is needed for the surgery which are the pt had already been
informed about the relevant information relating to the nature, the
purposed & the risk of the procedure. The pt also need to be competent &
understand what had been proposed. The last one is she is free to decide
whatever decision. So, the consent for this procedure is not valid as pt didnt
know the possible risk.
According to the case, dr hutchins did not warn the risk of the surgery as the
percentage of getting into paralysis is just 5%. But dr hutchins should never
assume as the risk is still there.
 Non-malefecience
By definition is the doctor shouldnt do harm to the pt.
In this case, the doctor do harm to the pt as he did not tell the pt the risk &
complication of the surgery which is she might go into paralysis.

Beneficience
By definition is to be proactive in promotion of good & prevention of harm.
Eventho the dr think that the pt was desperate for treatment, the dr should
prevent the harm such as by telling the pt the risk of surgery eventho the
benefit of surgery outweight the risk.

2. What kareen need to do to prove that the dr liable for negligence.

Kareen should prove that the dr meet the criteria for medical neglicence which
consist of :
The doctor owed a duty of care to the relevant individual
In this case, kareen was under dr Hutchins supervision and dr H is the one
who perform the surgery
The dr was breach the duty of standard care to the pt
Dr H did not tell kareen the risk & complication of the surgert thus make the
consent is invalid
That the breach of duty of care cause harm to the pt
The pt was suffering from the complication of surgery which is getting into
paralysis.

Case 6 :

Jenna Peterson, a 20-year-old college student, made an appointment to be seen by Dr Susan

Grant. Jenna had been seeing Dr. Grant for a few years. Dr. Grant was also the long-time
family practitioner for Jennas mom and older sister. On this visit, Jenna said she would like
to get a prescription for birth control pills. After reviewing Jennas medical history and
performing a brief physical examination, Dr. Grant gave Jenna a six-month along with
educational materials on oral contraceptives.
She told her to schedule a six-month follow-up appointment over summer break. When Jenna
checked out with the front office, she told the billing office that she did NOT want this visit
submitted to her mothers insurance. Instead, she would pay for the visit herself because she
didnt want her mother to know the reason for the visit.
The billing clerk said that she would send Jenna a bill because the practices billing system
was undergoing a software upgrade. Jenna asked that the bill be sent to her college address.
About two weeks later, Mrs. Peterson had a routine appointment with Dr. Grant. When she
checked in, she stopped by the billing office and asked the insurance clerk to check a notice
of claim statement she recently received from her insurance carrier about a visit by Jenna.
Mrs. Peterson said, I know Jenna hasnt been here because shes away at school. The clerk
said shed check on the claim and should have information for Mrs. Peterson by the time she
was done seeing Dr. Grant.
Mrs. Peterson was then taken back to an exam room for her appointment. While seeing Mrs.
Peterson, Dr. Grant inquired about the Peterson family and mentioned that Jenna has really
blossomed into a beautiful, intelligent young woman. Mrs. Peterson thanked Dr. Grant and
asked, When did you see Jenna? Dr. Grant unthinkingly said, Oh, a couple weeks ago
when she was in for her appointment. When Mrs. Peterson questioned why Jenna had been
seen, Dr. Grant realized she had said too much. Mrs Peterson force the doctor to tell her about
the reason why Jenna came for visit to the clinic.
Q1 : What should the doctor do?

Additional Syahmis questions for Q1 :

1. Answer question 1:
Ethical issue:
Patients autonomy: every competent adult who understand his/her illness
has the right to determine which treatment that he/she does or does not
want to received. In this case, the patient clearly understood her illness as
the doctor already explained to the patient regarding her illness, treatment
available for her and also complication that might occur if she refused to
undergo the surgery. The doctor should first ask the patient the reason why
she rejected the surgery and what are the options available for her. Then,
doctor should try to persuade the patient to undergo the operation to save
her life. Also the doctor should ask the decision maker for the patient so
that the doctor can discuss with that person to persuade the patient to
 undergo the surgery. However, if the patient still does not want to proceed
with the surgery so the doctor should respect the patients decision. The
doctor should also document the refusal of the patient to undergo surgery
in her medical report.
Beneficial: by undergo the operation, the risk for the patient to die due to
hypovolemic shock can be avoided and patient will be able to prolonged
herlife by getting early intervention done to her.
Non-maleficence: eventhough the patient refused to go for the operation,
however, the benefits of undergoing the surgery outweigh the risk. The
patient would be able to avoid from dying due to the hypovolemic shock.
Elements need to be considered:
First we need to assess the patients mental competency. This can be done
by referring the patient to the psychiatrist to check for the mental
competency.
Next of kin: ask the patient for the decision maker in her-life so that the
doctor would be able to discuss with the person to persuade the patient to
undergo the surgery.
The doctor should also tell what are the treatments available for her
especially if she is worrying about the scar that might be seen after the
surgery, then the doctor should suggest that she can go for the cosmetic
surgery to reduce the appearance of the scars.
The doctor should document the patients refusal in her medical report.