Exam 1

Question 1

What are three functions of a health care ethics committee?

Answer 1

1) Help patients, families and professionals with especially difficult decisions
2) Educate the professional staff
3) Recommend policies regarding ethical standards for patient care

Question 2

What are examples of professionals who work on a health care ethics committee?

Answer 2

Physicians, nurses, clergy, social workers, ethicists, administrators, and community members

Question 3

When should a bioethics consultation be requested?

Answer 3

A bioethics consultation is designed to support, not replace, normal lines of communication about ethically troubling situations. Requests for help from the bioethics consultation service are encouraged when:

1) A patient, family member or health care professional wants help to “talk through” options in patient care
2) Efforts by the patient, family, the attending physicians and other professional staff to resolve disagreements have been inconclusive
3) Conflict exists among the concerned parties about the “best” course of action

Question 4

Who can request help from a bioethics committee?

Answer 4

A bioethics consultation about a specific patient or problem may be requested by the patient, family member or health care surrogate or by any nurse, physician or other professional caregiver

Question 5

What is a tracheostomy?

Answer 5

1) A tracheostomy is a surgically created opening in the neck leading directly to the trachea (the breathing tube)
2) It is maintained open with a hollow tube called a tracheostomy tube

Question 6

Why is a tracheostomy performed?

Answer 6

1) to bypass an obstructed upper airway (an object obstructing the upper airway will prevent oxygen from the mouth to reach the lungs)
2) to clean and remove secretions from the airway
3) prolonged mechanical ventilation (breathing machine)
4) to more easily, and usually more safely, deliver oxygen to the lungs

Question 7

What are some possible risks and complications of a tracheostomy?

Answer 7

1) Airway obstruction and aspiration of secretions (rare)
2) Bleeding. In very rare situations, the need for blood products or a blood transfusion
3) Damage to the larynx (voice box) or airway with resultant permanent change in voice (rare)
4) Need for further and more aggressive surgery
5) Infection
6) Air trapping in the surrounding tissues or chest. In rare situations, a chest tube may be required
7) Scarring of the airway or erosion of the tube into the surrounding structures (rare)
8) Need for a permanent tracheostomy. This is most likely the result of the disease process which made the a tracheostomy necessary, and not from the actual procedure itself
9) Impaired swallowing and vocal function
10) Scarring of the neck

Question 8

Where is a tracheostomy usually done?

Answer 8

1) Intensive care unit

2) Operating room

Question 9

What is a percutaneous endoscopic gastrostomy (PEG)?

Answer 9

1) Percutaneous endoscopic gastrostomy (PEG) is a surgical procedure for placing a tube for feeding without having to perform an open operation on the abdomen (laparotomy)
2) It is used in patients who will be unable to take in food by mouth for a prolonged period of time
3) A gastrostomy, or surgical opening into the stomach, is made through the skin using a flexible, lighted instrument (endoscope) passed orally into the stomach to assist with the placement of the tube and secure it in place

Question 10

What is the purpose of percutaneous endoscopic gastronomy?

Answer 10

1) The purpose of a percutaneous endoscopic gastronomy is to feed those patients who cannot swallow food
2) Irrespective of the age of the patient or their medical condition, the purpose of percutaneous endoscopic gastronomy is to provide fluids and nutrition directly into the stomach

Question 11

Who does percutaneous endoscopic gastronomy?

Answer 11

Percutaneous endoscopic gastronomy is done by a physician. The physician may be a general surgeon, an otolaryngologist (ENT specialist), radiologist, or a gastroenterologist (gastrointestinal specialist)

Question 12

Where is percutaneous endoscopic gastronomy done?

Answer 12

1) Hospital
2) Outpatient Surgical facility
3) Not necessary to perform a PEG in an operating room

Question 13

How is percutaneous endoscopic gastronomy done?

Answer 13

1) Local anesthesia (usually lidocaine or another spray) is used to anesthetize the throat
2) An endoscope (a flexible tube with a camera and a light on the end) is passed through the mouth, throat and esophagus into the stomach
3) The physician then makes a small incision (cut) in the skin of the abdomen over the stomach and pushes a needle through the skin and into the stomach
4) The tube for feeding then is pushed through the needle and into the stomach
5) The tube then is sutured (tied) in place to the skin

Question 14

When can the percutaneous endoscopic gastronomy patient go home?

Answer 14

The patient usually can go home the same day or the next morning

Question 15

What are the possible complications with percutaneous endoscopic gastronomy?

Answer 15

Possible complications include infection of the puncture site (as in any kind of surgery), dislodgement of the tube with leakage of the liquid diet that is fed through the tube into the abdomen, and clogging of the tube

Question 16

What are the advantages of percutaneous endoscopic gastronomy?

Answer 16

1) Percutaneous endoscopic gastronomy takes less time, carries less risk and costs less than a surgical gastrostomy which requires opening the abdomen
2) Percutaneous endoscopic gastronomy is commonly- performed so there are many physicians with experience in performing the procedure
3) When feasible, percutaneous endoscopic gastronomy is preferable to a surgical gastrostomy

Question 17

What is the study of ethics?

Answer 17

1) The analysis, study or consideration of morality
2) Morality tells what the right or good action is, while
ethics considers why this action is right
3) Ethics assumes some reflective and critical judgments
about acts and beliefs; it means both to understand and
to critique

Question 18

Define Humanism (as defined by the Healthcare Foundation Center for Humanism and Medicine, NJMS)

Answer 18

1) Empathy: Compassion, healer, active listener
2) Enthusiasm: motivation, passion
3) Respect for life: openness, diversity, quality
4) Advocacy and service
5) Leader by example: collaboration, role-model
6) Awareness leading to self-development
7) Honesty: integrity, code of conduct
8) Academic integrity: creativity, research

Question 19

Define Profession

Answer 19

1) An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills
2) It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others
3) Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and to the promotion of the public good within their domain
4) These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation
5) Professions and their members are accountable to those served and to society

Question 20

What counts as an ethical question?

Answer 20

1) Any question that is or can be framed as a “should” question is an ethics question
2) The need to “do” ethics arises when your path is not clear but you have to choose and you have to justify that choice

Question 21

Why use ethics?

Answer 21

1) Ethics is our attempt to build a solid ground to stand on when we have to take a stand
2) When we are caught on the horns of a dilemma, Ethics does the heavy-lifting of justifying our choice of one option over another

Question 22

What are the two most common types of ethical theory?

Answer 22

1) Deontological: belief that actions are good/evil in and of themselves; focus is on action itself, not results
2) Consequentialist: justify actions by claiming the greatest good for the greatest number

Question 23

Describe characteristics of deontological ethical theory

Answer 23

1) After Greek word “deontos” meaning duty
2) Person looks for absolute “truth”
3) Seeks a universal rule to guide actions
4) Kant describes it as “categorical imperative” (no exceptions)
5) Examples in form of “ethical commandment” e.g. Thou shalt not kill
6) Persons are ends in themselves, never a means to an end
7) The ethical person must obey the demands of the principle regardless of consequences (Truth-telling, Promise-keeping, Sanctity of life)

Question 24

What are four ethical principles?

Answer 24

1) Autonomy
2) Beneficence
3) Nonmaleficence
4) Justice

Question 25

What is autonomy?

Answer 25

1) One aspect of a larger principle: respect for persons
2) Autonomy acknowledges the moral right of every individual to choose and follow his/her own plan of life and actions
3) Patients have the right to freely accept or reject MD’s recommendations
4) All states have laws requiring informed consent for medical treatment except in certain emergency situations
5) Bodily intrusion without consent constitutes illegal battery
6) Every human being of adult years and of sound mind has a right to determine what shall be done with his body - Schloendorff v Society of NY Hospital (NY 1914)

Question 26

What is beneficience?

Answer 26

1) One ought to prevent harm
2) One ought to remove harm
3) One ought to promote good
4) Each of these forms of beneficence require taking action

Question 27

What is nonmaleficience?

Answer 27

1) One ought not to inflict harm
2) Supports some moral rules:
a) Do not kill
b) Do not cause pain or suffering
c) Do not incapacitate
3) Nonmaleficence requires intentionally refraining from actions that cause harm

Question 28

What is justice?

Answer 28

1) Equals must be treated equally
2) Justice has 2 major theoretical forms:
a) retributive justice: returning good for good (compensation for service; rewards for achievement) bad for bad (punishment for crimes)
b) distributive justice: social equity in how we should order the distribution of goods in a community

Question 29

What are common ethical problems in medical practice?

Answer 29

1) Informed consent
2) Confidentiality
3) Determine person’s capacity for decision-making
4) Disclosure of upsetting information
5) Reproductive rights
6) Withdrawal of life support
7) Pain management

Question 30

What are three types of advance directives?

Answer 30

1) Proxy directive – designates a person to make health care decisions
2) Living Will – outlines the circumstances for treatment
3) Combined Directive – designates a proxy AND outlines circumstances for treatment

Question 31

How do you complete an advance directive in New Jersey?

Answer 31

1) 2 witnesses – 18+ and competent OR a notary
2) CANNOT be witnessed by the appointed proxy or attending physician
3) Attending physician cannot serve as proxy

Question 32

When does an advance directive take effect?

Answer 32

1) Transmitted to physician or institution
AND
2) It is determined that an individual lacks capacity to make health care decisions

Question 33

If there is a valid advance directive when can treatment

be withdrawn?

Answer 33

1) Patient is permanently unconscious
2) Patient is terminal
3) Treatment is experimental or is likely to be ineffective or futile
4) Patient has serious irreversible condition AND the burdens of treatment outweighs the benefits

Question 34

What does NJ law require in respect to advance directives?

Answer 34

1) Any health professional who honors an advance directive has absolute immunity under NJ law
2) Any health professional who is unwilling to honor a pt’s advance directive MUST withdraw from the case and find another physician to care for the patient

Question 35

What does “capacity to make a decision” mean?

Answer 35

1) Person must understand the consequences of decision including:
a) diagnosis and prognosis
b) risks and benefits of
decision
2) Must have the ability to reason and make judgments about information

Question 36

How are law and ethics similar?

Answer 36

1) Language
2) Both attempt to regulate individual decisions and
activity
3) Both present a standard of behavior from which we learn what is socially sanctioned and what is frowned upon
4) Education: both are taught using case studies

Question 37

How are law and ethics different?

Answer 37

1) Laws are accompanied by public sanctions
2) Ethic sanctions are usually private
3) Laws define the floor of acceptable behavior
4) Ethics defines goals to which we aspire (or tries to identify the best action)

Question 38

What are examples in which law follows ethics?

Answer 38

1) Justice, slavery civil rights
2) Evolution of tort law
3) Practice guidelines

Question 39

What are examples in which ethics follows law?

Answer 39

1) Informed consent
2) Standards of care
3) Medical confidentiality (Tarasoff decision)

Question 40

What are three legal issues from case law that are important to medical ethics?

Answer 40

1) Quinlan: New Jersey
2) Cruzan: US Supreme Court
3) Vacco vs. Quill US Supreme Court

Question 41

In the case of Ms. Terri Schiavo, who was Ms. Schiavo’s guardian?

Answer 41

Her husband, Mr. Michael Schiavo was appointed as Ms. Terri Schiavo’s legal guardian

Question 42

Why were malpractice lawsuits carried out against physicians in the case of Ms. Terri Schiavo? What did this result in?

Answer 42

1) Malpractice lawsuits were won against physicians who misdiagnosed Ms. Schiavo
2) Mr. Schiavo places award of about $750,000 in a trust fund specifically for Ms. Schiavo’s medical care

Question 43

In the case of Ms. Terri Schiavo, what occured over 8 years after the initial event?

Answer 43

1) Mr. Schiavo petitions the court to authorize the removal
of the PEG tube; the parents oppose, saying that she
would want to remain alive (May 1998)
2) By order of trial court Judge Greer, and upon issuance of an appeals court mandate, the PEG tube is removed (Apr 2001)

Question 44

How many times was a PEG tube removed from Ms. Terri Schiavo?

Answer 44

1) By order of trial court Judge Greer, and upon issuance of an appeals court mandate, the PEG tube is removed (Apr 2001) - Reinserted in 2003
2) PEG tube is removed a 2nd time (Oct 2003)
3) PEG tube is removed for the 3rd time (Mar 2005)

Question 45

What are elements of legally valid consent by a patient or surrogate?

Answer 45

1) Disclosure (what the doc says)
2) Decision process (dialogue)
3) Assessment of capacity & voluntariness

Question 46

What is disclosure?

Answer 46

1) Description of patient’s condition
2) Description of proposed intervention
3) The potential risks and benefits, including the probabilities of each
4) Alternatives, including no treatment, and the risks and benefits of each
5) An offer to answer any questions
6) Assurance that the patient may withdraw consent at any time

Question 47

How much disclosure is enough?

Answer 47

1) Ordinary Medical Practice: What would a reasonable practitioner, in a similar situation, disclose?
2) Reasonable Person Standard: What would a reasonable person need to know before making this decision?
3) Plus: Whatever this particular person says he or she wants to know

Question 48

What is the decision process (dialogue)?

Answer 48

1) Clarify pt’s goals & values
2) Elicit concerns/fears/hesitations
3) Check pt’s understanding
4) Elicit questions

Question 49

What is assessment of capacity and voluntariness?

Answer 49

1) NOT mere acquiescence
2) NOT a document
3) NOT only for invasive procedures
4) NOT an ancient duty

Question 50

What are exceptions of assessment of capacity and voluntariness?

Answer 50

1) Emergencies
2) Patient waiver
3) Regulatory waiver
4) “Therapeutic Privelege”

Question 51

Is there such a thing as “administrative consent”?

Answer 51

No

Question 52

What are common distortions of assessment of capacity and voluntariness?

Answer 52

1) Neutral enumeration of burdens and benefits, rather than helping patients to assess and discern
2) Poor differentiation between what is properly a patient’s choice and what properly belongs to medical judgment
3) “All or nothing”/”now or never” consent, rather than appreciation of the conditional and dynamic nature of much decision making
4) Failure to appreciate the inequality of power and its implications for a physician’s obligation to further empower patients/surrogate
5) System factors: lack of training in communication skills, wide variation in “informal curriculum” and physician behavior, insufficient oversight of consent quality

Question 53

What is competence or capacity or choose?

Answer 53

The ability to:

1) understand the relevant information
2) communicate about the decision
3) reason about the alternatives, e.g., to appreciate and evaluate consequences

Question 54

What are three comparisons of competency vs. capacity?

Answer 54

1) Legal vs. clinical
2) Global vs. specific
3) Rare vs. routine

Question 55

What is the test of capacity?

Answer 55

1) Not a categorical test (too old, depressed, intoxicated, etc)
2) Not an outcomes test (“that’s irrational”, “to do that is suicidal”, “that’s crazy”, etc)
3) It is a functional test

Question 56

How do you test for capacity?

Answer 56

To test, do the consent process:

1) Can the patient appreciate: condition? intervention? burdens and benefits? alternatives? voluntariness?
2) Can the patient process all of this and arrive at a decision?

Question 57

The capacity test is specific to what three things?

Answer 57

1) Person specific
2) Decision specific
3) Time specific
Can this person make this decision at this time?

Question 58

When is a psych evaluation needed to see if a patient is capable of making their own decisions?

Answer 58

When our clinical judgment about capacity is in question because of the presence of psychiatric history or symptoms

Question 59

What are marginal patients?

Answer 59

1) Patients with “psych problems”
2) Anyone facing new, scary or painful situation
3) Frail elderly

Question 60

What is assent (agreement) required for?

Answer 60

1) Required for research consents in older children
2) Since 1980s, increasingly common practice for therapeutic consents
3) In addition to parental consent

Question 61

What obligations must a physician make to a surrogate?

Answer 61

1) Same obligations as to patient
2) Same elements of consent
3) Same functional test for capacity
4) Same right to refuse …EXCEPT:
a) Holds right to choose as a trust
b) Should act on behalf of the patient, not on behalf of own or some other interest
c) “fiduciary” relationship (involving trust, especially with regard to the relationship between a trustee and a beneficiary)

Question 62

What standard should a proxy use?

Answer 62

1) Choose what this particular patient actually chose
2) Choose what this particular patient would choose were he/she able to choose now
3) Do what a reasonable, typical patient would choose
4) Do what is in this patient’s best interest

Question 63

What are the realities of obtaining consent?

Answer 63

1) The consent requirement is an ideal
2) Providers have power to manipulate information
3) Some patients/surrogates are ignorant, dependent, irresponsible, indecisive
4) Time pressures are real

Question 64

What is the most often forgotten information item in a prognosis discussion between physicians and patients?

Answer 64

1) The most forgotten item is alternatives
2) This may be because the physician thinks that what he has in mind is the best option, when really the patient might prefer a different option due to several reasons (including family, culture, religion, etc.)

Question 65

What was the verdict in the Quinlan case?

Answer 65

1) In Re Quinlan, 70 N.J. 10, 355 A.2d 647 (1976), was the first major judicial decision to hold that life-sustaining medical treatments may be discontinued in appropriate circumstances, even if the patient is unable or incompetent to make the decision
2) In addition to establishing a patient’s right to refuse life-sustaining medical treatments, the Quinlan decision also made clear that a decision to remove or withhold life support systems from an incompetent patient would not constitute Homicide or Medical Malpractice