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  • Write a short paper between 1200 to 1500 words long (about 4 or 5 double-spaced pages long) on one of the following topics.
  • Do not rehearse the case in your own words. You can either just assume the reader is familiar with the case or copy and paste my description at the beginning. My description of the case does not count toward your 1200 to 1500 words.
  • The paper is due on Friday, February 25 at 11:59PM. You will submit the paper electronically to the Quercus site associated with your tutorial section.
  • Late papers will be penalized by 1% per day. (This amends what the 2% penalty announced in the Syllabus).
  • The paper is worth 25% of your grade.
  • We are not testing for “the right answers.” What we want to evaluate is how well you understand how the perspectives of some of the different readings bear on particular cases and whether you can offer a plausible argument for your judgment.
  • You will probably find that you can’t discuss every possible relevant consideration. Thus, you will need to make judgment calls about what the most important issues to discuss are.
  • There is a document offering more guidance on writing the papers that can be found on the course Quercus page (just under the Course Requirements).

1. A Pessimistic Patient: Ms. Bathurst is 48 years old, a real estate agent, married, and a mother of two children, ages 12 and 14. Three years ago she was diagnosed with breast cancer and as a result underwent a lumpectomy and chemotherapy. It was a challenging time, but she has been proud ever since to consider herself a survivor. Breast cancer, as it happens, runs in her family. Her maternal aunt died of the disease 10 years ago, and last year Ms. Bathurst’s mother lost a long battle with it at the age of 78. Ms. Bathurst has been open about the fact that she feels somewhat guilty about what happened. Having fought her own cancer into remission, Ms. Bathurst insisted that her mother avail herself of every treatment available. But, now that it is all over, Ms. Bathurst suspects that her mother’s last year alive would have been better had she refused aggressive treatment and entered hospice care sooner. In the last couple of weeks, one of Ms. Bathurst’s routine follow-up examinations revealed something suspicious, and a biopsy has confirmed that her breast cancer has returned. The oncologist, Dr. Keale, still believes Ms. Bathurst has 70% chance of full recovery, though her chances of still being alive in five years are not quite as good as they were the last time around. In any event, as Dr. Keale sees it, Ms. Bathurst’s best bet is to pursue a more aggressive treatment regime than last time: probably a mastectomy (breast removal) and a longer course of chemotherapy. When Dr. Keale revealed the diagnosis to Ms. Bathurst, however, she seemed very discouraged. “I knew it would get me sooner or later,” she said. “I guess it’s my fate to die from this.” To this point, all that Dr. Keale has told Ms. Bathurst is that her cancer has returned and that they “have options.” He has not yet detailed her chances of recovery or the nature of the different kinds of treatment. Ms. Bathurst is scheduled to meet with Dr. Keale again in a couple of days to discuss what to do going forward. Dr. Keale is worried, however, that Ms. Bathurst is considering not treating the cancer, which he thinks would be a mistake.

How should Dr. Keale handle this consultation? What should he tell Ms. Bathurst? How should he present the information? Should he try to frame the choice to influence her decision in any way? Should he try to change Ms. Bathurst’s mind if she still seems pessimistic about another round of treatment? Explain some of the different approaches Dr. Keale might take? What are the ethical issues that need to be taken into consideration? What would you ultimately advise him to do?

In your analyses, draw on at least two of the following three readings: (a) Terrence Ackerman, “Why Doctors Should Intervene,” (b) Dan Brock, “Informed Consent,” (c) Philip Hébert and Wayne Rosen, Doing Right, ch. 4-6

2. A Mature Minor? Just short of her seventeenth birthday, Cassandra C. was diagnosed with non- Hodgkins lymphoma. The disease is almost invariably fatal when left untreated, but it tends to respond well to chemotherapy. However, from the outset, Cassandra and her mother seemed skeptical of the diagnosis and the proposed treatment and proved uncooperative with the doctors. Since the age of medical consent in Connecticut is 18, the legal responsibility for Cassandra’s care lay with her mother. Worried about the risk of delaying treatment, the Department of Children and Families eventually investigated Cassandra’s mother for medical neglect and removed Cassandra from her care. At this point, Cassandra agreed to commence the chemotherapy on the condition that she could return home. But when she was released from state custody, she ran away from home to avoid treatment. Shortly thereafter, however, she returned home, as she feared that her absence would get her mother into further trouble. She then requested that her competence to consent to treatment be evaluated individually and that she be declared a mature minor who could refuse consent for herself. The court agreed to a competence hearing but found that Cassandra had not demonstrated sufficient maturity for competence, citing as evidence such facts as her decision to run away from home, her dependence on her mother, and her misconceptions about her condition and viable treatment options.

Read the legal case of In re Cassandra C (see the optional reading on Quercus.) Outline the thinking of the court on the question as to whether the patient was competent. Then consider whether the court, in your opinion, reasoned in the right way and came to the correct conclusion. In making your case, explain how you think we ought to think about the concept of competence (or “capacity”). You might also consider whether Cassandra would have been considered competent (i) if she had been over 18, or (ii) if the case had unfolded in Ontario, where the law says that everyone is supposed to be presumed competent. In your discussion, draw substantially from at least one of the following readings: (a) Dan Brock, “Informed Consent” and (b) Philip Hébert and Wayne Rosen, Doing Right (chs. 4 and 8).

3. A Dispute Over Death: Mr. N, a 44-year-old man with a large extended family, is admitted to an ICU with raised intracranial pressure from an untreatable cerebral malignancy (a brain tumor). Despite various measures, he has continued to decline and is now on a ventilator. It is obvious to the ICU staff that the patient’s brain is too compressed to respond to any treatment. On no sedatives, he has been in a deep coma for several days, completely unresponsive to any stimulation. His score on the Glasgow Coma Scale (GSC), poor from the outset, has been declining for several days. It is now 3—as low as you can get—and there is complete absence of any brainstem reflect activity on two assessments.

Mr. N is in every neurological sense dead, “brain dead,” as that term is used. As is usual practice, confirmatory clinical testing by way of an apnea test is arranged. This entails temporarily removing the patient’s attachment to the ventilator. In response to raising carbon dioxide levels in the body, a brain-dead patient will fail to initiate respiration as would normally occur. The lack of cortical responsiveness, the absence of brainstem reflexes, the lack of movements or breathing, a flat electroencephalogram, are all consistent with death, whatever the state of the patient’s circulation might be.

Mr. N’s loved ones strongly disagree with the diagnosis of death—they are a religious family and feel everything possible must be done to extend his life, arguing: “If God wanted him to die, He wouldn’t have allowed mankind to invent ventilators. He’s not dead until his heart stops beating.”

As the ICU resident and attending neurologist are about the perform the test on Mr. N, a family member exclaims, “Don’t touch him! If you remove him from the breathing machine, we’ll sue you!” According to the family’s (and the patient’s) religious, where there is a heartbeat, there is life, and one may not disconnect a breathing apparatus. [This case is taken from Hébert and Rosen, p. 333.]

How should the doctors and hospital handle this case? Should they accommodate the family’s religious beliefs? Should they insist that the test be performed, since it is important that hospital resources not be used on someone who is already dead? Explain the considerations on both sides of the question and explain your own perspective. In your discussion, draw substantially on at least two of the following readings: (a) Robert Schwartz, “Autonomy, Futility, and the Limits of Medicine,” (b) Ruth Macklin, “Ethical Relativism in a Multicultural Society,” (c) L. Syd M. Johnson, “The Case of Reasonable Accommodation of Conscientious Objections to Declarations of Brain Death,” (d) Philip Hébert and Wayne Rosen, Doing Right, pp. 289-292, 332-339.

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