84. Case: Who’s Who

 

Pierre is a representative with a company that manufactures devices for use in joint-replacement surgeries.  He is often present in surgeries when his company’s products are being used.  Recently, as a patient was being wheeled into the operating suite the patient asked the surgeon who Pierre was and why he was there.  The nurse explained that Pierre was a with a device manufacturer and was there to provide support if needed.  The patient then asked, “But isn’t that a conflict of interest?”

Is there a conflict of interest?  How should the nurse respond to the patient?  And what should the hospital include in a policy designed to address these types of situations?

 


Resources:

 

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83. Case: Strings Attached

 

A local business owner and philanthropist, whose parent recently died after living with Huntington disease for 15 years, approaches the hospital foundation to offer a significant donation in exchange for creating a new neurological research centre which would be named in memory of the philanthropist’s parent.  The hospital has identified its area of greatest need as improving access to primary care for patients in the remote communities it serves, but the donor is not interested in contributing to that mandate.

Is the hospital in a conflict of interest?  What is the nature of the potential conflict of interest?

 


Resources:

82. Case: Setting Up Shop

 

Arya is an occupational therapist who provides support for children with autism spectrum disorder.  She frequently recommends sensory integration tools to parents, but most of these are only available online through US-based websites and often that is a barrier for parents.  She is considering starting a side business importing and selling these products, but is aware that there will likely be a perceived conflict of interest.  Arya approaches her manager for guidance.

If disclosure is not enough to eliminate the perception of conflict of interest, what could Arya do?  If the perceived conflict of interest cannot be effectively managed, what should Arya do to meet her patients’ needs?

 


Resources:

81. Case: Lending A Helping Hand

 

Alison is a nurse who is working in an endocrine clinic part-time while also working on her Ph.D.  She is studying two different approaches to patient education about diabetes management.  She is putting together her research ethics application.  Alison makes a case for the logistical necessity of her being involved in recruiting patients. Her colleague and friend, Jason, will also help to recruit patients for the study.  Alison proposes that she will disclose that the research is for her Ph.D and that the patient’s decision about participation will not affect care, but Alison and Jason aren’t sure about what Jason should tell patients about their relationship.

Do you think that Jason has a conflict of interest?  If so, how should it be managed?  And does Alison’s disclosure adequately address concerns about her conflict of interest?

 


Resources:

80. Case: Less Talk

 

David is a patient waiting in a treatment room at a walk-in clinic.  He can hear the physician chatting and laughing with someone outside, and from the conversation he guesses that the physician is talking with a pharmaceutical sales representative.  David has been waiting for almost two hours with a high fever.  As the conversation outside continues, David becomes increasingly angry.

Do you think that the physician might have a conflict of interest?  If so, how should it be managed?

 


Resources:

79. Case: It’s the Little Things

 

A patient asks your colleague, Arya, “Where are you from?”  When Arya replies, “Winnipeg,” the patient says, “Oh, but where are you from originally?”  Arya, whose family immigrated to Canada before she was born, is clearly frustrated by this.  You were present during the exchange and were uncomfortable but didn’t know what to say at the time.

Discussion:

  • What are the ethical concerns raised by this case?
  • What might you say to Arya afterward?
  • How might your employer support Arya in addressing these sort of situations?

 

 Resources:

 

 

61. CASE: Ending the Fluoridation of Water – A Public Meeting

The local town council has received a petition signed by more than 500 residents requesting the discontinuation of fluoride in the town’s water supply. Before making a decision on the matter, the council has decided to hold a “town hall” meeting to seek more input and help to educate its members and the audience about the evidence on both sides of the debate.

As the Public Health officer for the area, you have been invited to be a member of the panel in charge of this meeting. Other panel members include the mayor, a local dentist, a family doctor, and the two residents who initiated the petition. On the night of the meeting, the local fire hall is at capacity; the mayor who is chairing the panel asks the two residents to begin the discussion by presenting their concerns with regard to water fluoridation. They make the following remarks:

Resident 1: “Everyone says fluoride in the water prevents cavities. What about looking at what causes the cavities in the first place- junk food, pop, sugary snacks and juices are all stuff that parents should be limiting. Why should we all be forced to ingest fluoride in our water because some parents aren’t doing their job? Like everything else, we are what we eat. Good health starts with what we put on the end of our forks- that is how I raised my children. In addition, a routine oral program and thorough brushing is key to any successful prevention.For those that want to provide their kids with fluoride, there are many readily available treatments and over the counter products.I am a victim of too much fluoride because I chose to eat healthy and drink lots of water. Fluoride severely damaged my thyroid and I am now forced to take pharmaceutical drugs for the remainder of my life.

Fluoride is not only in our water (which is also absorbed through the skin), it is used as a pesticide on our food crops, and even organic food crops could be contaminated if watered with fluoridated city tap water. All beverages produced with water, reconstituted juices, contain fluoride, and for those that still receive fluoride treatments at the dentist, brush three times per day with fluoridated toothpaste and maybe even use fluoridated mouthwash, well, that is FAR MORE than any health organization (CDC, EPA or Health Canada) recommends.

I cannot remove fluoride from my water and am therefore forced to purchase distilled water to use for drinking and cooking. I am one of the lucky ones, as I am able to afford to do this. I was never asked if I wanted this industrial waste dumped into my water supply- it was a decision made for me without my consent or even any input. It was a decision made a long time ago and now it needs to undone.”

Resident 2: “I am for choice. So I would rather choose whether or not I drink a toxic chemical. I think that by giving me no choice, the city is not doing me any favours. I have done my own research, and there is very little credibility on the side that says “fluoridate the water.” Instead many experts say fluoride works best as a topical treatment. Bang on. Use it topically then, by choice, don’t force me to ingest it. I use a fluoride rinse and it has absolutely 100% made a difference in my dental health. I have not changed my diet or oral hygiene habits except for the addition of this rinse, but 4 years strong now with no new cavities. Cavities used to plague me with at least a couple new ones a year. I feel that this should be a personal choice, and if people are concerned about costs for poor communities/people then perhaps a subsidy for toothpaste or fluoride tablets is the answer (but only if those people want to purchase the items).One should also keep in mind the effect of excess fluoride on growing teeth. What if your child really likes water and ingests a lot of fluoridated water? Even dentists admit it’s only useful in the right doses. Fluoride is carcinogenic, so I would like to see statistics on cancer rates vs. fluoridation in the region. Plus, fluoride has been linked to lots of other serious conditions, but we are not told about all that – just that it prevents cavities. The jury is out on whether that is actually true. There are countries who do not add fluoride to their drinking water but their rate of cavities is as good or better than ours. So what is that about?! The town could be saving a ton of money each year by not putting fluoride in the water. It’s a smart move in my opinion.”

  • Identify the conflicting values that are relevant to this discussion and select the ones that will guide your response. What is the basis of your choice(s)?
  • As the public health officer, how will you respond to these statements?

Some Values and Ethics Issues to Consider

  • Respect for autonomy
  • Community/ public health ethics
  • Compliance with policy
  • Patient safety
  • Community relationships
  • Consent
  • Risk
  • Social justice

57. CASE: Caregiver Stress

Dr. Morrison has been the only physician in his small community of 1,500 people for about 15 years and is known as the “Town Doc.” When he first moved to town, he quickly became friends with many people and involved in the community. However, the longer he practiced, the more awkward his social life became.

He helped coach the baseball team for several years. But then he treated one of the boys on the team for chlamydia and the boy stopped coming to practice. Dr. Morrison didn’t sign up to coach the following year. He began to turn down social invitations, as more friends became patients. Eventually he began to feel burdened and overworked but unable to decrease his workload. He attended to numerous horrific farm and motor vehicle accidents, often as the only provider for multiple patients, resulting in increasing mental trauma and distress.

He felt indebted to the community but also began to feel resentful. Where he once took pride in the fact that people looked to him for support, he began to feel overwhelmed and useless. He recognized that he was depressed but had no idea where to turn for help. His patients began to notice that he seemed tired and irritable. At the nearby critical access hospital, where Dr. Morrison is affiliated, the administrators were increasingly concerned about his ability to practice and feared he might even resign.

[From Rural Health Ethics: A Manual for Trainers. William Nelson & Karen Schifferdecker. https://geiselmed.dartmouth.edu/cfm/resources/ethics/%5D

  • What, if anything, should the administrators say or do?
  • What steps can rural health care providers take to avoid isolation and burnout?
  • What steps can rural health administrators and community leaders take to avoid isolation and burnout among their health care providers?
  • What resources could Dr. Morrison access to assist in this situation?


Some Values and Ethics Issues to Consider

  • Community and family relationships
  • Respect for privacy and confidentiality
  • Resource allocation
  • Patient-provider relationships
  • Professional boundaries
  • Honesty, trust and truth-telling
  • Duty to provide care
  • Moral distress among health care providers
  • Overlapping roles and responsibilities

56. CASE: Family Friends/ Family Doc

Dr. Jones has been a close friend of the Smith family since coming to town 18 years ago. The Smith’s oldest child, Sally (15 years), has come to the office to have a physical to be on her school’s track team. Her mother has brought her to the office, but as usual, Dr. Jones sees Sally alone.

After taking the history and doing an exam, it is evident that Sally wants to talk about something. In response to a question about whether she has started dating, she explains that she has been dating JJ for the last six months. She says that she really likes him a lot, and although they “haven’t done it yet, they have been thinking about it a lot.” She is wondering if she could start taking birth control pills.

Sally also explains that her parents do not know anything about it. She said that when she has tried to talk with her mother, her mom just, “got weird—talking about babies having babies, and nobody having morals any more.” She says her mother would be very upset if she knew Sally was talking about it, and asks that this information not get back to her parents.

[From Rural Health Ethics: A Manual for Trainers. William Nelson & Karen Schifferdecker. http://geiselmed.dartmouth.edu/cfm/resources/manual/manual.pdf%5D

  • Is it ethical to prescribe birth control without parental permission to a patient who is below the legal age of consent for sexual activity?
  • Should Dr. Jones try to separate her role as Sally’s physician with her role as a friend of her parents?
  • What is the main ethics question in this case? What are the conflicting values?
  • How should Dr. Jones proceed and why?


Some Values and Ethics Issues to Consider

  • Community and family relationships
  • Respect for privacy and confidentiality
  • Patient-provider relationships
  • Professional boundaries
  • Honesty, trust and truth-telling
  • Duty to provide care
  • Overlapping roles and responsibilities

55. CASE: What is My Obligation?

A family physician in a small, remote community assesses a patient, who is a local schoolteacher, as developing a post-partum psychosis. He feels he lacks adequate training or experience to manage her care.

He recommends she seek treatment at a distant large mental health centre but she refuses to travel to the centre because of the distance involved. He feels uncertain about caring for the patient when the treatment is outside his area of competency.

  • How should the physician proceed with the patient’s care? Should he treat the patient when he feels it is is outside his area of competency?
  • If the patient is unwilling to disclose her health issues to her employer, as a healthcare professional and/or a member of the community, should the physician report them to school authorities?
  • What ethics issues are at play here?
  • What resources could the physician seek to assist with this situation?

Some Values and Ethics Issues to Consider

  • Community and family relationships
  • Respect for privacy and confidentiality
  • Patient-provider relationships
  • Professional boundaries
  • Honesty, trust and truth-telling
  • Patient safety
  • Equality of access
  • Resource allocation
  • Duty to provide care
  • Intellectual honesty
  • Respect for professional integrity
  • Professional competence
  • Overlapping roles and responsibilities