Have an ethical question? I'll try and break it down for you!

Discussion in 'Interviews' started by MSP, Aug 9, 2018.

  1. MSP

    MSP Banned

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    The question: You are a doctor and your patient, a 25yo male who is a Jehovah’s witness, has declined to have a blood transfusion which he requires in order to survive. What do you do?


    Background: The mass use of this ethical predicament has been deconstructed by mainstream media for years due to it’s unique situation. Generally a Jehovah’s witness will refuse blood transfusion and site religious reasons for doing so.


    Pre-Understanding:

    Medical ethics work off the four pillars of medicine; autonomy, justice, non-maleficence and beneficence. It is crucial to understand each of these concepts before engaging and answering medico-ethical questions. Along with these concepts there must also be an understanding of a doctors requirements under law (both state and national) in Australia refer to section 39 (Good medical practice) and then relevant state legislation which may be relevant. If the scenario is changed and the patient is a minor, or pregnant – there may also be other relevant authorities, laws and ethics which should be considered.


    Structuring your response:


    1) Before considering patient AUTONOMY we must first assess whether the patient has the ability to make a decision. This is important in all cases – we assess their CAPACITY; their ability to understand a procedure, weigh up options and then make an informed decision.
    In this specific case we may question the patient’s ability to have capacity because they may have been losing blood (hence requiring the transfusion) or they may be in shock etc. So the first thing we do is assess their capacity and we may need to bring in a psych team or a third party to help in doing so. Also the patient may have a congenital/genetic syndrome/disease which may make it difficult to ascertain whether they have the proper capacity to make a decision like this. E.g. Patients with intellectual disabilities or heart/respiratory issues that affect oxygen/blood perfusion to their brain.

    2) Autonomy – it is now time to consider patient Autonomy since we have assessed capacity. This may be words from the patient, or it could be from a legal parent/guardian if there are appropriate forms giving medical authority to them. If we can not find someone who has authority, and the patient does not have CAPACITY we might involve lawyers at the hospital and even the Guardianship Tribunal in order to seek permission to act in the patient’s best interest.

    3) Beneficence & non-maleficence – here we assess the pro’s and con’s of giving treatment. What are the adverse effects of receiving blood; in Australia we have fantastic screening for infectious diseases and there should be ample time to type the blood and ensure the patient does not experience adverse effects to receiving the treatment. By not giving the patient blood we also make an argument that we are not ‘doing good’ and are possibly ‘doing bad’ by the patient.

    4) Justice – this doesn’t play much of a role in this scenario but you could explore the fact that by choosing one treatment to give or withholding treatment we set a precedence for other people to do so and cite other religious or cultural beliefs.

    5) Other considerations – Is there another treatment available that makes the doctors happy and the patient happy? Can we put the patient on a ventilator and dialysis machine and wait for him to naturally produce more red blood cells and give them IV fluids in the meantime to stabilise them?

    6) Ideal response – It would be ideal to note that if the patient had capacity then we would respect their decision to decline medical treatment. It is also worth adding that you would be required to explain the outcome (possibly death) and they would need to understand and accept that. All other treatment options should be explored, sometimes there is something that could be done (if there is minimal blood loss perhaps IV fluids and close monitoring will give the patient enough time to recover by growing their own red blood cells).


    Thanks for reading! If you would like to suggest a type of question to be deconstructed in the future post here!
     
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  2. sixtythree

    sixtythree New Member

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    I have one:

    Anna and Bianca are born as conjoined twins, connected at the pelvis. The twins share an artery through which blood and other nutrients can be exchanged. Apart from her conjoined nature, Anna is otherwise a completely normal baby with healthy organs and body systems. On the other hand, Bianca's heart, lung, and kidneys are extremely weak. She is completely dependent upon Anna to execute her vital bodily functions.

    Six months after they are born, Anna's organs are showing signs of distress. The immense strain of having to sustain Bianca has weakened them to the verge of failure. The twins will both die within three months if no action is taken.

    The only viable treatment is to separate the twins. As Anna is an otherwise healthy baby, she would grow and develop normally after the separation. Unfortunately Bianca, who is reliant on Anna to sustain her, will die. Apart from Bianca's guaranteed death, the procedure is expected to be relatively safe.

    Do you go through with the separation?
     
  3. MSP

    MSP Banned

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    Cheers! Will have some time on the weekend to have a read through and break it down for you :)
     
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  4. pi

    pi Junior doctor Administrar

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    I have one that was apparently asked about 10 years ago; to paraphrase:

    You are a medical applicant and have been offered an interview at your first preference university. Your childhood best friend is also an applicant to the same program, but was not offered an interview, despite scoring higher on all the criteria and being from the same socio-economic background. This puzzles your friend, so they make an inquiry with what the interview cut-off scores were. In their reply, the uni provides a set of scores that confirm that your friend should have got an interview, but that you should not have. Your (best) friend asks if they can use your scores in a reply email to justify them getting an interview as well, as they feel this would add more to their argument. You feel that if mentioned, that might jepordise your interview and place at your first preference medical school. What do you do?
     
  5. Mana

    Mana Resident Medical Officer Administrar

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    You hope that your father is the Vice Chancellor of the university and lets you in anyway ahead of several hundred applicants with higher scores including your friend.
     
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  6. A1

    A1 Admissions Speculator Moderator

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    Interviewers are funny people :p
    My friend does not need to quote my scores. Their scores being higher than the ones provided by the uni is more than adequate to justify.

    (But I hope they don't persist with the next question whether I should voluntarily relinquish my interview spot haha)
     
  7. rustyedges

    rustyedges Otago MB ChB Moderator

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    You're the lone doctor in ED one night when an unconscious patient is wheeled in. You're about to commence CPR when you notice the patient has a tattoo across his chest that reads: "Do not resuscitate." He is not able to be identified and has no contact information. What do you do?!
     
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  8. pi

    pi Junior doctor Administrar

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    Well luckily we have all read this beforehand ;) NEJM - Error
     
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  9. Sherlock

    Sherlock Breaker of order

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    [​IMG]

    do you pull the lever?
     
  10. pi

    pi Junior doctor Administrar

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    Well if you pull the lever so that the ?tram moves towards the one person, it will almost certainly derail given how tight that angle is. So yes, you pull it to derail the tram.
     
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  11. A1

    A1 Admissions Speculator Moderator

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    And maim the tram driver + passengers instead?
     
  12. Sherlock

    Sherlock Breaker of order

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    [​IMG]

    Throwing the fat man off the bridge will save 5 people, but the fat man will die. What do you do?
     
  13. rustyedges

    rustyedges Otago MB ChB Moderator

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    Throw the fat man off. The end justifies the means.
     
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  14. Sherlock

    Sherlock Breaker of order

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    There are 5 ill patients in a hospital. They all need urgent organ transplantation to survive otherwise they will die. 2 people need a kidney each, 2 need one side of lungs each, and one needs a heart. There's another healthy patient who's at the hospital for a routine check up. His organs are a match for all those 5 patients. If you take out the organs from the healthy patient, 5 ill patients survive. Should you kill 1 healthy patient to save 5 others? The end justifies the means.
     
  15. rustyedges

    rustyedges Otago MB ChB Moderator

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    The end does justify the means. In this case, all five of the patients will be need to go on immunosuppression post-transplant, and given that they are already predisposed to major organ failures, their cumulative quality of life will be less than the single man's. Therefore, it's best to not use his organs.
     
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  16. Sherlock

    Sherlock Breaker of order

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    All patients survive and they live fine with no problems. Does the end still justify the means?
     
  17. rustyedges

    rustyedges Otago MB ChB Moderator

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    In this situation? Sure. What do you think?
     
  18. Sherlock

    Sherlock Breaker of order

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    I don't think it's right to let a healthy person die to save diseased people. I'd also argue that the fat man shouldn't be pushed off the bridge.

    Whilst the outcome is same, the playing field isn't in the latter two scenarios compared to the one in the first case.

    To give it a little twist: What would you do if the fat man was your close loved one?
     
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  19. rustyedges

    rustyedges Otago MB ChB Moderator

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    Do you think it's right to kill a healthy person to save a million people?

    Why is the playing field different for the second two situations?
     
  20. A1

    A1 Admissions Speculator Moderator

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    I wouldn't do it if the fat man runs an orphanage with his own money and the 5 people have just massacred a whole class of school kids.
    I would do if it's the other way around.

    So... more information please :p
     

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