3. CASE: Superbugs

Jeannette Cutler is an 83-year old woman admitted to hospital after falling and breaking her arm.  She reports that she fell because she passed out, and so further investigations are being conducted.  She has mild dementia but is otherwise seemingly healthy.  Upon admission, she screens positive for MRSA and is subject to strict isolation procedures as per hospital policy.

Jeannette was a long-time volunteer at the hospital where she is now a patient. Jeannette is having trouble adhering to the isolation protocol, and several times a day she gets up and starts going into other patients’ rooms to “visit”.  The team has had discussions with her regarding the need for her to remain in her room, but they have failed to achieve the desired effect.

Staff is concerned that she is spreading MRSA and are considering various means of confining her to her room.  They aren’t sure how best to express respect for Jeannette while also ensuring that other patients are not unnecessarily exposed to harm.  They have contacted the ethics committee and the legal department asking for help in working through this case.

• What ethics concerns are you thinking about as you respond?
• Who should be involved in making this decision?
• What are some competing values that arise in this case?
• Should the well-being of others take precedence over Jeannette’s freedom of     mobility?
• What potential creative solutions can you think of to resolve this issue?

 Some Values and Ethics Issues to Consider

• Respect for individual liberty
• Patient-centered care
• Distributive justice
• Policy compliance
• Respect for autonomy
• Responsibility for health
• Quality of life
• Respect for dignity
• Capacity
• Beneficence and non-maleficence

2. CASE: Treatment and/or Termination? Tough Choices

Melanie is a 21 year old who was recently involuntarily committed after she started a serious fight at a local shelter, thinking that one of the leaders was trying to steal her favourite T-shirt. Melanie has schizophrenia and is well-known to both the police and mental health care providers. She has been living on and off the streets since she left home when she was 16 years old, and has a rather strained relationship with her parents. They have been trying to support her and often provide money for her medications. When Melanie is taking her medications, she is able to find work and has talked about going back to school. However, Melanie finds the side effects of the medications awful and stops taking them, leading to being kicked out of apartments or friends’ places when she gets too aggressive.

In doing Melanie’s work-up upon admission, it was discovered that she is about 7-8 weeks pregnant. While trying to determine what to do with respect to the pregnancy, she is placed on medications that minimize teratogenic effects for the fetus, and that may have some success in stabilizing Melanie’s condition (although it is recognized that this is not the “gold standard” treatment). Melanie’s mother, Krystine, was named by Melanie as her substitute decision-maker (witnessed by her psychiatrist at the end of her previous admission), despite some of the challenges in their relationship, and she endeavours to do the best for her daughter. The team has been in discussion with Krystine about treating Melanie and about her pregnancy.

Melanie has indicated that she doesn’t know who the father is, as she has had several partners over the last few months. She also alternates between saying that she wants the baby to saying that the baby is cursed and she should be rid of it. Krystine indicates that Melanie has not talked to them about having children, only about trying to get well to go back to school.

Both Krystine and the health care team have some questions and concerns about how to move forward with Melanie’s treatment. The health care team calls for a clinical ethics consultation.

• If the medication regime doesn’t stabilize Melanie, would it be ethical to move to a different treatment plan, knowing that this might cause substantial harm to the fetus?
• Should the possibility of terminating the pregnancy be discussed further?
• Should an attempt be made to find and notify the biological father?
• How do the dynamics if Melanie’s family relationships factor into this case?
• Can or should someone other than Melanie make these decisions?

Some Values and Ethics Issues to Consider

• Capacity
• Respect for patient autonomy
• Living at risk
• Vulnerability
• Patient-family relationships
• Substitute decision-makers
• Beneficence and non-maleficence

1. CASE: Sensitive Information

John is a young man with a traumatic spinal cord injury that has resulted in paraplegia. He is leaving the rehab hospital on a weekend pass and has confided to his chaplain that he intends to kill himself. The chaplain calls the ethics service for assistance.

• Should the hospital issue the pass?
• What are the ethics issues involved?
• What information do you need to find out to move forward?
• Who would you invite to a discussion about this issue?

Some Values and Ethics Issues to Consider 

• Respect for autonomy
• Beneficence
• Non-maleficence
• Duty to provide care
• Living at risk
• Moral distress
• Compliance with policy
• Respect for privacy and confidentiality