Nursing Ethics Term 2 PDF

Page 1 of 17 Nursing Ethics Term 2 (Session 9 – 16) Session 9  The principle of justice means treating everyone fairly and giving them what they deserve. It’s about making sure resources, opportunities, and responsibilities are distributed equally or in...

Page 1 of 17 Nursing Ethics Term 2 (Session 9 – 16) Session 9  The principle of justice means treating everyone fairly and giving them what they deserve. It’s about making sure resources, opportunities, and responsibilities are distributed equally or in a way that’s fair based on needs, rights, or contributions. Contrasting terminologies:  Formal justice is about applying rules and laws consistently to everyone, without bias.  Material justice focuses on the content of fairness, ensuring people get what they need or deserve based on specific circumstances (like need, effort, or merit). Here are common methods for distributing goods and resources: Equality: Everyone gets the same amount. Need: Resources are given based on individual needs. Merit: Distribution depends on effort, achievement, or contribution. Market-based: Resources go to those who can pay for them. Lottery: Distribution is random or by chance. First-come, first-served: Resources go to those who claim them first. Authority-based: A person or group decides how resources are allocated.  Each method is chosen depending on the context and what is considered fair. Fair Opportunity Rule ensures that people have an equal chance to access resources, benefits, or opportunities regardless of factors beyond their control, like race, gender, or socio-economic background. It focuses on leveling the playing field so that personal effort and abilities determine outcomes, not unfair barriers or disadvantages. Contrasting terminologies:  Macro-allocation: Deciding how big resources (like a hospital's budget) are divided across groups or systems.  Micro-allocation: Deciding how limited resources (like a single ICU bed) are given to individual patients.  Two-tier system: A healthcare setup with two levels: basic services for everyone and extra services for those who can pay more.  Lifeboat ethics: A situation where you must decide who gets limited resources (like space on a lifeboat) and who doesn’t.  Triage: Sorting patients based on how urgently they need care, ensuring those who need it most get treated first.  Medical utility: Giving resources to patients who will benefit the most medically from treatment.  Social utility: Prioritizing resources for individuals who are important to society, like essential workers.  First come, first served: Giving resources to whoever arrives or requests them first, without prioritizing need or other factors.  Page 2 of 17  Egalitarian: Focuses on equality; everyone should get the same amount or have equal access to resources and opportunities.  Key idea: Fairness through equality.  Utilitarian: Focuses on the greatest good for the greatest number of people; resources should go where they will create the most overall benefit.  Key idea: Maximize happiness or well-being.  Libertarian: Focuses on individual freedom and personal responsibility; people should get resources based on their choices, efforts, or ownership.  Key idea: Fairness through freedom. 1. Beveridge Model: o Funding: Healthcare is paid for by taxes. o Providers: Hospitals and doctors are often government-owned or run. o Example countries: UK, Spain, New Zealand. o Key idea: Healthcare is a public service, free at the point of use. 2. Bismarck Model: o Funding: Healthcare is funded through insurance, usually shared between employers and employees. o Providers: Hospitals and doctors are mostly private. o Example countries: Germany, Japan, France. o Key idea: Insurance-based system with government regulation. 3. National Health Insurance (NHI) Model: o Funding: Healthcare is funded by taxes, but providers can be private. o Providers: A mix of public and private providers, with a single government-run insurer. o Example countries: Canada, Taiwan. o Key idea: Universal coverage with a single-payer system. 4. Out-of-Pocket Model: o Funding: Individuals pay directly for healthcare services. o Providers: Mostly private, with little to no government involvement. o Example countries: Developing countries or regions without universal healthcare. o Key idea: Pay-as-you-go healthcare. The Patient Protection and Affordable Care Act (ACA), or Obamacare, is a U.S. law that helps more people get health insurance and makes healthcare more affordable.  It stops insurance companies from denying coverage because of pre-existing conditions.  It lets young adults stay on their parents' insurance until age 26.  It offers financial help to make insurance cheaper.  It expands Medicaid for low-income people (in some states).  It requires basic health services to be covered, like doctor visits and prescriptions. The ACA's goal is to make healthcare fairer and more accessible for everyone. Session 10 A Code of Ethics and Professional Conduct is a set of rules that guides how people in a profession should behave.  Ethics: Focuses on doing what is morally right (e.g., honesty, fairness).  Professional Conduct: Covers proper behavior at work (e.g., respect, accountability). It helps professionals make good decisions, treat others well, and maintain trust in their work.  Page 3 of 17 Disparagement of professional colleagues means speaking badly or unfairly about your coworkers or peers in a way that damages their reputation. It's unprofessional because:  It creates conflict and mistrust.  It harms teamwork and respect.  It can hurt someone’s career unfairly. Professionals should focus on constructive feedback instead of negative criticism. Contrasting terminologies: 1. Joint-Venturing: When two or more businesses or individuals work together on a project, sharing resources and profits. 2. Self-Referral: When a healthcare provider refers a patient to their own services or business, potentially leading to a conflict of interest. 3. Sexual Relations: In a professional setting, this refers to any romantic or sexual interactions, which are usually discouraged or prohibited between healthcare providers and patients due to the power imbalance. 4. Role Fidelity: Staying true to the responsibilities and expectations of your professional role, ensuring you perform duties honestly and competently. 5. Nurse-Patient Relationship Models: These are ways nurses can build trust and communicate with patients, ensuring care is compassionate and professional. Models can focus on empathy, clear communication, and maintaining boundaries.  Impaired colleagues refer to professionals who are unable to perform their work duties properly because of physical or mental health issues, substance abuse, or other conditions that affect their ability to function effectively and safely.  In healthcare, this can be particularly serious because it can affect patient safety. It’s important for coworkers to recognize signs of impairment and seek help or report concerns to protect both the affected individual and the patients. Session 11 Healthcare provision in a multicultural society involves delivering care that respects and addresses the diverse cultural, ethnic, and religious backgrounds of individuals. Here’s how it works: 1. Cultural Sensitivity: Healthcare providers must understand and respect different cultural practices, beliefs, and values about health, illness, and treatment. 2. Language Support: Offering translators or language services to ensure patients can communicate effectively and understand medical advice. 3. Inclusive Practices: Ensuring healthcare services are accessible to everyone, regardless of background, and that policies reflect diversity. 4. Avoiding Bias: Professionals should avoid making assumptions about patients based on their culture and instead provide care based on individual needs. 5. Education and Training: Healthcare workers should receive training in cultural competence to better serve people from different backgrounds. WAG KAKALIMUTAN! Overall, healthcare in a multicultural society should focus on equality, respect, and providing tailored care to meet the needs of all individuals.  Page 4 of 17 The ANA (American Nurses Association) Committee on Ethics is a group that helps guide nurses on how to make ethical decisions in their practice. They provide advice on issues like:  How to treat patients with respect and fairness.  How to handle situations where there might be conflicts of interest.  How to follow professional standards while making ethical choices in healthcare. Their goal is to help nurses do the right thing, even when faced with difficult or complex situations. An Institutional Ethics Committee is a group of people in a hospital or healthcare organization who help make decisions about ethical issues in patient care. They guide the staff on situations like:  How to handle tough decisions about patient treatment.  What to do when there are disagreements about what’s best for a patient.  How to respect patient rights and ensure fairness. Their role is to provide advice and ensure that ethical standards are followed in healthcare practices. Session 12 Reproductive issues covered by ethics include a wide range of topics that raise moral and ethical questions. Some of the key issues are: 1. Abortion: The ethical considerations around whether it is morally acceptable to terminate a pregnancy. 2. Contraception: The ethics of birth control methods, including access, choice, and moral views on preventing pregnancy. 3. Fertility Treatments: Ethical concerns surrounding assisted reproductive technologies like IVF (in vitro fertilization) and egg/sperm donation. 4. Surrogacy: The ethics of using a surrogate mother to carry a child, including concerns about exploitation, consent, and compensation. 5. Genetic Testing and Screening: Ethical issues related to testing for genetic conditions before or during pregnancy, and decisions based on genetic results. 6. Reproductive Rights: Issues about access to reproductive healthcare, including laws and policies that affect women’s and men’s choices in family planning. 7. Eugenics: The ethical concerns about genetic manipulation to "improve" the human population, including designer babies. 8. Pregnancy and Maternal Rights: Ethical dilemmas related to the rights of pregnant women versus the rights of the fetus, especially in cases of medical intervention. 9. Sex Selection: Ethical debates about choosing the gender of a child before conception or during pregnancy. 10. Age and Reproduction: The ethics of delaying pregnancy, especially for women over a certain age, and the risks involved. These issues often involve balancing individual rights, medical risks, societal norms, and moral values. Legal debates: A. Roe v. Wade (January 22, 1973) - established abortion as a constitutional right, fundamentally changing U.S. law and setting a precedent for reproductive rights. The Court ruled in a 7-2 decision that: 1. The Right to Privacy: o The Court found that the Due Process Clause of the Fourteenth Amendment protects a fundamental "right to privacy," which extends to a woman’s decision to have an abortion. o This right, however, is not absolute and must be balanced against the state’s interests in  Page 5 of 17 regulating abortions and protecting potential life. 2. The Trimester Framework: o The decision introduced a framework to balance a woman’s rights against the state’s interests, dividing pregnancy into three trimesters:  First Trimester: The state has minimal interest, and the decision to abort is left to the woman and her physician.  Second Trimester: The state may regulate abortion procedures, but only to protect the woman’s health.  Third Trimester: After viability (around the 28th week), the state has a compelling interest in protecting potential life and may prohibit abortions except when necessary to protect the woman’s life or health. 3. Personhood: o The Court explicitly rejected the argument that a fetus is a "person" under the Fourteenth Amendment. The term "person" was interpreted to apply postnatally, not prenatally. o Roe v. Wade remains one of the most debated and influential Supreme Court decisions in U.S. history. It reshaped public discourse on reproductive rights, privacy, and state power, leaving a lasting impact on law, politics, and society. B. Danforth v. Planned Parenthood of Central Missouri (July 1, 1976) The Supreme Court’s Decision The Court ruled on each provision, finding some unconstitutional while upholding others: 1. Spousal Consent: o The Court struck down this requirement, ruling it unconstitutional. Justice Harry Blackmun, writing for the majority, emphasized that a husband’s interest does not outweigh the woman’s constitutional right to make decisions regarding her own body. o Requiring spousal consent gave husbands veto power, violating the woman’s right to privacy and autonomy as established in Roe v. Wade. 2. Parental Consent: o The requirement for parental or guardian consent for minors was also struck down. The Court ruled that while the state has an interest in protecting minors, parental consent laws must not grant parents absolute veto power over a minor’s decision to have an abortion. o Justice Blackmun highlighted that such laws could place undue burdens on minors seeking an abortion, especially in cases where involving a parent was not safe or feasible. 3. Physician Responsibilities: o The Court upheld some provisions requiring physicians to maintain medical records and obtain informed consent from the woman before performing an abortion. o However, these requirements could not unduly burden the woman’s access to abortion. 4. Prohibition of Saline Amniocentesis: o The ban on saline amniocentesis was struck down. The Court ruled that the state could not prohibit a particular method of abortion unless there was clear evidence that it endangered the woman’s health.  Danforth v. Planned Parenthood remains a cornerstone case that affirmed the principles of Roe v. Wade while addressing specific issues of third-party consent and state regulation.  It established critical boundaries for future abortion-related legislation, particularly regarding minors and spousal involvement. C. The Hyde Amendment The Hyde Amendment is a legislative provision that prohibits the use of federal funds to pay for abortions, except under specific circumstances. First passed in 1976, it is named after Congressman Henry Hyde, a Republican from Illinois and a vocal anti-abortion advocate. The  Page 6 of 17 amendment primarily impacts Medicaid, the federal and state-funded program that provides health coverage for low-income individuals. Key Provisions 1. Initial Scope: o When first passed in 1976, the Hyde Amendment banned federal Medicaid funding for abortions except in cases where the mother’s life was at risk. 2. Exceptions Added Over Time: o In 1977, exceptions for cases of rape and incest were debated but initially rejected. o These exceptions were officially included in 1993 during the Clinton Administration. 3. Current Exceptions: o The Hyde Amendment now permits federal funding for abortions only in cases of:  Life endangerment of the mother.  Pregnancies resulting from rape or incest. The Hyde Amendment represents one of the most enduring and contentious limitations on abortion access in the U.S. It has shaped the abortion debate for decades, serving as a symbol of the broader conflict between pro-life and pro-choice advocates. D. Webster v. Reproductive Health Services (1989) Webster v. Reproductive Health Services was a significant Supreme Court case decided on July 3, 1989. It upheld several provisions of a Missouri law restricting abortion access and marked the beginning of a shift in how the Court interpreted abortion rights established in Roe v. Wade (1973). This case reflected growing conservative momentum to limit abortion rights without directly overturning Roe. The Supreme Court’s Decision The Court ruled in a 5-4 decision to uphold the Missouri law, marking a departure from the strict protections of abortion rights under Roe v. Wade. Key rulings included: 1. Preamble Declaring Life Begins at Conception: o The Court upheld this preamble but clarified that it was not enforceable as law and did not impose restrictions on abortion access. o This allowed Missouri to express its policy preference for protecting fetal life without directly infringing on constitutional rights. 2. Restrictions on Public Resources: o The Court upheld Missouri’s prohibition on the use of public funds, facilities, and employees for performing or assisting in abortions, except when necessary to save the mother’s life. o It ruled that the state was not obligated to provide resources for abortion services, reinforcing the principle established in Harris v. McRae (1980). 3. Viability Testing: o The Court upheld the requirement for viability tests at 20 weeks or later, reasoning that this did not impose an undue burden on a woman’s right to choose abortion. Conclusion Webster v. Reproductive Health Services was a pivotal case in the history of abortion rights in the United States. It marked a shift toward allowing states greater flexibility in regulating abortion, reflecting the influence of a more conservative judiciary. While it did not overturn Roe v. Wade, it significantly weakened its framework and laid the groundwork for future restrictions on abortion access.  Page 7 of 17 Moral issue: 1. Personhood: This is about when a human being is considered a "person" with rights, especially in issues like abortion or euthanasia. It asks, "When does a human life deserve legal and moral protection?" 2. Sanctity of Life: This is the belief that all human life is precious and should be protected, often tied to religious or moral views about the value of life from conception to death.  Page 8 of 17 3. Quality of Life: This focuses on whether life is worth living based on factors like health, happiness, and the ability to function. It asks if it’s better to end suffering, even if it means ending a life. 4. Autonomy: This is the right of individuals to make their own choices, especially about their bodies and lives, without being forced by others. It’s about respecting personal freedom and decisions. 5. Mercy: This is showing kindness and compassion, especially in situations where someone is suffering, and might involve making difficult decisions like helping someone end their life to stop pain (euthanasia). 6. Freedom: The right to make choices and live without excessive restrictions, as long as those choices don’t harm others. It’s about personal liberty in making decisions. 7. Social Stability: This is about maintaining a peaceful and orderly society, where rules and morals help prevent chaos and ensure well-being for all. It sometimes means making sacrifices for the greater good of society. Pro-life and Pro-choice are two opposing views on abortion: 1. Pro-life: o Believes that life begins at conception, and therefore, abortion is morally wrong. o Advocates for protecting the unborn child’s right to life, arguing that it is a human being with rights from the moment of conception. o Opposes abortion in most or all cases. 2. Pro-choice: o Believes that women should have the right to choose whether or not to have an abortion. o Supports the idea that individuals should make their own decisions about their bodies, including pregnancy and reproductive health. o Emphasizes a woman’s autonomy and the right to make decisions about her own life and health. In short, Pro-life focuses on the rights of the unborn child, while Pro-choice focuses on the rights of the woman to decide what happens to her body.  The sanctity of life argument is the belief that all human life is precious and valuable, and therefore should be protected. It suggests that life, from conception to death, is sacred and should not be harmed or taken, often based on religious or moral beliefs.  This argument is commonly used in debates about issues like abortion and euthanasia, where supporters believe that ending a life, regardless of the circumstances, is morally wrong because life itself holds inherent worth. Here are the basic facts of fetal development in simple terms: 1. Conception: When a sperm fertilizes an egg, a single cell called a zygote is formed. 2. Week 1-2: The zygote starts dividing into more cells and travels to the uterus. 3. Week 3-4: The cells form into an embryo, and the heart begins to form. 4. Week 5-6: The embryo develops a basic structure, and the heart starts beating. 5. Week 7-8: The baby’s arms, legs, and facial features begin to appear. 6. Week 9-12: The baby is now called a fetus, and organs start to work, like the kidneys and liver. 7. Week 13-16: The baby’s muscles and bones are developing. It can move and might be able to hear. 8. Week 17-20: The baby’s movements are noticeable, and skin and hair start to form.  Page 9 of 17 9. Week 21-24: The baby’s lungs begin to develop, and it can start to hear sounds. 10. Week 25-28: The baby gains more weight, and the brain is developing quickly. 11. Week 29-32: The baby’s eyes can open, and it begins to develop more fat. 12. Week 33-36: The baby is growing stronger and getting ready for birth. 13. Week 37-40: Full-term; the baby is ready to be born. These stages show how a baby grows and develops inside the womb, from a single cell to a fully formed infant. Killing in self-defense refers to the act of using force, including lethal force, to protect oneself from an immediate threat of death or serious harm. Here's a simple explanation:  When is it justified? It's generally considered justified if someone is in immediate danger and has no other option but to protect themselves. The force used should be proportional to the threat.  Key factors: o Imminent threat: The person must face a real and immediate danger. o Proportional response: The force used should not exceed what is necessary to stop the threat. o No other choice: Self-defense is only justified if there are no other reasonable ways to escape or avoid harm. In most legal systems, self-defense is a legal defense to charges of killing, as long as the conditions are met. However, the specific rules vary by jurisdiction. The viability argument in the context of abortion refers to the idea that a fetus’s ability to survive outside the womb should determine when it gains moral or legal rights.  Viability means the point at which a fetus can live on its own, without the need for support from the mother’s body (usually around 24 weeks of pregnancy).  Supporters of this argument believe that before viability, a woman should have the right to choose an abortion, as the fetus cannot survive independently.  After viability, when the fetus can survive outside the womb, some argue that it has more rights, making abortion less acceptable. The viability argument is often used to frame legal and ethical debates about abortion, with the idea that a fetus’s right to life becomes stronger as it becomes capable of living independently. Analogical thought experiments use comparisons to explore ideas or solve problems. They work by comparing a situation you don’t fully understand to one that is familiar, helping you see things more clearly. Here’s how it works:  Step 1: Find a situation that is similar to the one you're trying to understand.  Step 2: Analyze how the two situations are alike and how they are different.  Step 3: Use the similarities to make conclusions or explore ideas in the unfamiliar situation. For example, to explain the fairness of a law, you might compare it to how rules work in a game you're familiar with. By drawing parallels, you can understand the new concept better. Contrasting terminologies: 1. Violinist Analogy (used in abortion debates): o Imagine you're connected to a famous violinist who needs your body to survive for 9 months. Should you be forced to stay connected to them to save their life, or should you be allowed to disconnect and end their life?  Page 10 of 17 o This analogy argues that a woman should have the right to decide what happens to her own body, even if it means ending a pregnancy. 2. Rapidly Growing Child Analogy (also in abortion debates): o Imagine a child grows inside your house and starts taking up all the space, threatening to destroy your home. You can’t stop the child from growing, but can you kick them out? o This analogy is used to argue that, while a fetus may be growing inside a woman, she shouldn’t be forced to let it stay if it harms her. 3. Carpet See Children Analogy (used in discussions of ethics and justice): o Imagine a carpet is being rolled up, and it’s taking up space that children need to live. If the carpet keeps growing, should the children be forced to give up their space? o This analogy is about the idea of balancing the needs of different groups—like children and others in society—and how resources (like space or opportunity) should be shared fairly. Each analogy uses a familiar scenario to explore complex ethical issues, like bodily autonomy, the right to life, and resource distribution. Session 13 Surrogacy and in vitro fertilization (IVF) are both methods to help people have children, but they work in different ways: 1. Surrogacy: o A woman (the surrogate) carries and gives birth to a baby for someone else (the intended parents). o There are two types:  Traditional surrogacy: The surrogate's egg is used, so she is the biological mother.  Gestational surrogacy: The surrogate carries a baby created using the intended parents' or a donor's egg and sperm, so she is not the biological mother. o Surrogacy involves a third party who is pregnant with the child but not necessarily the biological parent. 2. In Vitro Fertilization (IVF): o A process where an egg and sperm are combined outside the body in a lab (in vitro). Once an embryo forms, it is implanted into a woman's uterus. o IVF is typically used when a woman or couple has trouble getting pregnant naturally. The woman carrying the baby is often the biological mother (if her eggs are used). WAG KAKALIMUTAN!  Surrogacy involves another woman carrying and giving birth to the baby, while IVF is about fertilizing eggs outside the body and implanting them in a woman’s uterus to carry the pregnancy. IVF can be part of the surrogacy process, but they are not the same. Pro-life activists and Pro-choice activists are two groups with opposing views on abortion: 1. Pro-life Activists: o Belief: They believe that life begins at conception, and therefore, abortion is morally wrong. o Goal: To protect the unborn and advocate for laws that restrict or ban abortion. o Position: They argue that every life has intrinsic value and should be protected from the moment of conception.  Page 11 of 17 2. Pro-choice Activists: o Belief: They believe that women should have the right to choose whether to have an abortion. o Goal: To protect women's autonomy and ensure access to safe and legal abortion. o Position: They argue that a woman has the right to make decisions about her own body, including whether to continue or end a pregnancy. WAG KAKALIMUTAN!  Pro-life focuses on the rights of the unborn child, advocating for restrictions on abortion.  Pro-choice emphasizes a woman’s right to decide about her own reproductive health, including having an abortion. Session 14 1. Biological Life (Physical Existence)  Refers to the basic physiological functions of a living organism, such as: o Heartbeat o Breathing o Metabolism o Reflexes  A person in a persistent vegetative state or on life support may still have biological life but lack awareness or higher brain function.  Example: A brain-dead patient kept on a ventilator has biological life but no meaningful consciousness. 2. Biographical Life (Personal Identity & Experiences)  Encompasses a person’s memories, relationships, personality, and consciousness—essentially what makes them who they are.  Requires higher brain function (thinking, awareness, emotions).  When biographical life ends (e.g., in advanced dementia, severe brain damage, or brain death), a person may still be biologically alive but no longer have personal identity or experiences.  Example: A patient with severe late-stage Alzheimer's may have biological life but lost their biographical life, as they no longer recognize loved ones or form new memories. Key Differences Aspect Biological Life Biographical Life Definition Physical survival Consciousness, identity, and experiences Functions Heartbeat, breathing, reflexes Thinking, emotions, awareness Severe dementia, permanent loss of End of Life Example Brain death, vegetative state consciousness Ethical Medical interventions can Determines quality of life and dignity Considerations sustain it Ethical Implications  Life Support Decisions: Should a person be kept alive if only biological life remains?  Personhood: Does personhood depend on biographical life (memory, relationships)?  End-of-Life Care: Families must decide when to withdraw treatment if only biological life persists without meaningful recovery. Definition of Brain Death Brain death is the irreversible loss of all brain function, including the brainstem, which controls essential life functions such as breathing and consciousness. A person who is brain dead has no chance of recovery and is legally considered dead, even if their heart is still beating with the help of machines. Key Features of Brain Death:  Page 12 of 17 1. Permanent and Irreversible – Unlike a coma or vegetative state, brain death is final. 2. No Brain Activity – The brain, including the brainstem, shows no function. 3. No Response to Stimuli – No reaction to pain, light, or sound. 4. No Breathing – The patient cannot breathe without mechanical ventilation. 5. Fixed Pupils – Pupils do not react to light. 6. No Brainstem Reflexes – No gag reflex, cough reflex, or eye movement. Diagnosis of Brain Death: Doctors perform a series of clinical tests, which may include:  Apnea test (checking if the patient can breathe independently)  Neurological exams (assessing brainstem reflexes)  EEG (Electroencephalogram) (confirming no brain activity)  Blood flow studies (proving no blood circulation to the brain) Brain Death vs. Coma vs. Vegetative State: Condition Brain Activity? Can Breathe? Chance of Recovery? Brain Death No No No (Legally Dead) Coma Some Yes Possible Vegetative State Some (No awareness) Yes Possible (depends on cause) Ethical and Legal Significance:  Organ Donation: Brain-dead patients can be organ donors since their organs remain functional with artificial support.  End-of-Life Decisions: Once declared brain dead, life support can be legally removed.  Legal Death: In most countries, brain death is equivalent to death. A persistent vegetative state (PVS) is a medical condition in which a person loses most or all of their cognitive functions but still has some basic bodily functions, like breathing, heartbeat, and sleep-wake cycles. Here’s what it means:  Unconsciousness: The person is awake but unaware of their surroundings, and they don't show signs of meaningful awareness or interaction.  No purposeful movement: They may make random movements (like moving limbs), but these are not purposeful or controlled.  Long-term condition: If a person remains in this state for an extended period (usually over a month), they are diagnosed with PVS.  Causes: It can result from severe brain injury due to trauma, stroke, or lack of oxygen. While some people might recover, many remain in a persistent vegetative state, and the condition raises ethical and medical questions about care and decision-making. The Karen Ann Quinlan case is one of the most significant legal and ethical cases in medical history regarding end-of-life decisions and the right to refuse extraordinary treatment. Background  Karen Ann Quinlan was a 21-year-old woman who fell into a persistent vegetative state in April 1975 after consuming a combination of alcohol and tranquilizers.  She was unable to breathe on her own and was placed on a mechanical ventilator.  Her parents, believing there was no hope for recovery, requested that the ventilator be removed so she could die naturally.  The hospital refused, fearing legal consequences for removing life support. Legal Battle  The case went to the New Jersey Supreme Court in 1976.  The court ruled in favor of Karen’s parents, allowing them to withdraw the ventilator, stating that patients (or their guardians) have the right to refuse extraordinary treatment.  The ruling emphasized the "right to die with dignity" and set a precedent for patient  Page 13 of 17 autonomy in medical decision-making. Outcome  After being removed from the ventilator, Karen continued breathing on her own.  She lived in a vegetative state for nine more years, receiving basic care, before passing away in 1985. Ordinary vs. Extraordinary Treatment in This Case Ordinary Treatment Extraordinary Treatment Aspect (Morally Obligatory) (Optional) Considered extraordinary, as it Not necessary for basic Ventilator only prolonged life without care recovery Nutrition & Not considered "extraordinary" at Provided as basic care Hydration the time Pain Given to ensure comfort No high-risk interventions used Management Impact of the Case  Influenced laws on advance directives and living wills.  Helped establish the principle that patients (or their families) can refuse extraordinary treatment.  Laid the foundation for future cases, such as Terri Schiavo. This case remains a cornerstone in bioethics, shaping modern discussions on medical treatment and patient rights. Session 15 Example: A Patient with Advanced Cancer A 75-year-old patient has terminal cancer and is experiencing difficulty breathing due to pneumonia. Ordinary Treatment (Morally Obligatory & Standard Care)  Antibiotics: Giving the patient antibiotics to treat the pneumonia is considered ordinary treatment because it is a common, non-burdensome, and proportionate measure that could reasonably improve the patient's condition.  Oxygen Therapy: Providing oxygen to ease breathing is also considered ordinary care.  Pain Management: Administering pain relief (e.g., morphine) is standard care to ensure comfort. Extraordinary Treatment (Optional & Potentially Burdensome)  Mechanical Ventilation: If the patient is in respiratory failure, placing them on a ventilator might be considered extraordinary treatment, especially if it only prolongs suffering without significantly improving quality of life.  Aggressive Chemotherapy: If chemotherapy would cause severe side effects and is unlikely to extend life meaningfully, it could be considered extraordinary treatment.  Experimental Surgery: A high-risk, experimental surgery with a low chance of success may be deemed extraordinary if it imposes undue suffering or financial burden. Key Differences Criteria Ordinary Treatment Extraordinary Treatment Effectiveness Likely to benefit the patient Uncertain or minimal benefit Minimal physical, emotional, or financial Causes significant pain, cost, or Burden burden distress Obligation Generally required Morally optional  Page 14 of 17 Criteria Ordinary Treatment Extraordinary Treatment Purpose Maintains basic care and comfort Often prolongs life artificially Advanced directives are legal documents that outline a person’s wishes about medical treatment in case they become unable to communicate or make decisions for themselves in the future. There are two main types: 1. Living Will: Specifies what medical treatments a person does or does not want, like life support, if they are seriously ill or injured. 2. Durable Power of Attorney for Health Care: Appoints someone (a trusted person) to make medical decisions on your behalf if you can’t. Advanced directives help ensure that a person's healthcare wishes are followed, even if they can't express them later. Background  Nancy Cruzan was a 25-year-old woman involved in a car accident in 1983.  She suffered severe brain damage and was left in a persistent vegetative state (PVS).  She was kept alive through a feeding tube, but had no awareness or ability to recover. Legal Battle  1988: Nancy’s parents requested to have her feeding tube removed, arguing she would not have wanted to live in such a state.  The hospital refused, stating that without clear evidence of Nancy’s wishes, removing the feeding tube would be unlawful.  The case went to the U.S. Supreme Court in 1990 (Cruzan v. Director, Missouri Department of Health). Supreme Court Ruling  The Court ruled 5-4 that states could require "clear and convincing evidence" of a patient's wishes before withdrawing life-sustaining treatment.  Since no written advance directive existed, the court upheld Missouri’s decision to keep Nancy on the feeding tube. Final Outcome  Later, new evidence was presented that Nancy had previously expressed wishes not to be kept alive artificially.  In December 1990, her feeding tube was removed, and she passed away 12 days later. Ethical and Legal Significance 1. Right-to-Die: Reinforced the importance of patient autonomy in end-of-life decisions. 2. Advance Directives: Highlighted the need for living wills or healthcare proxies to document a person’s wishes. 3. Distinction Between Ordinary vs. Extraordinary Treatment: o Ordinary: Basic care (e.g., pain relief, hygiene). o Extraordinary: Artificial life support (e.g., feeding tube in a vegetative state). 4. Led to the Passage of the Patient Self-Determination Act (1991), which requires hospitals to inform patients of their right to refuse treatment. Session 16 A health proxy is a person you choose to make medical decisions for you if you're unable to do so yourself.  The person you appoint is usually called a healthcare agent or proxy.  They make decisions based on your wishes, which should be outlined in an advanced directive  Page 15 of 17 or discussed with them beforehand.  This is helpful if you are in a situation where you're unconscious or unable to communicate (like during surgery or in a coma). A health proxy ensures that your healthcare choices are respected, even when you're not able to speak for yourself.  Page 116 of 17 DNR (Do Not Resuscitate) guidelines are instructions for healthcare providers to not perform CPR (Cardiopulmonary Resuscitation) or other life-saving measures if a person’s heart stops beating or they stop breathing. These guidelines are meant to respect a patient’s wishes when they no longer want to receive aggressive medical interventions. Here’s how DNR guidelines generally work: 1. Patient’s Wishes: A DNR order is typically based on a patient’s request, which can be documented in an advanced directive or a DNR order signed by the patient or their healthcare agent. 2. Legal and Medical Oversight: A DNR must be written by a doctor and legally recognized. In some places, a formal document or bracelet may be used to indicate the DNR status. 3. When It Applies: A DNR order applies in cases where the patient’s heart stops beating or they stop breathing, and the patient is in a terminal condition, a coma, or has no chance of recovery. 4. Exceptions: If a patient is in a hospital or care facility and their condition changes (e.g., the patient improves or recovers), the DNR order might be revisited or changed. Key Points:  DNR does not mean the patient is being denied comfort care, pain relief, or other supportive treatments.  It is about not using aggressive, life-saving measures like CPR when the patient has indicated they do not want those efforts. The goal of a DNR order is to respect the patient’s autonomy and wishes regarding end-of-life care. lizabeth Bouvia Case – Right to Refuse Medical Treatment (1983–1986) Background  Elizabeth Bouvia was a 26-year-old woman with severe cerebral palsy and chronic pain.  She was mentally competent but physically dependent on others for care.  In 1983, she was hospitalized and requested medical assistance to die by refusing food and hydration. Legal Battle  The hospital refused her request and force-fed her through a nasogastric tube.  Bouvia sued the hospital, arguing that she had the right to refuse medical treatment (including forced feeding).  In 1986, the California Court of Appeal ruled in her favor, affirming her right to refuse forced feeding under the principles of bodily autonomy and dignity. Key Legal and Ethical Issues 1. Right to Refuse Treatment – The ruling established that mentally competent adults have the right to refuse medical interventions, even if it results in death. 2. Distinction from Assisted Suicide – Bouvia was not seeking active euthanasia, just the right to refuse treatment. 3. Disability Rights vs. Right-to-Die – The case sparked debate among disability rights advocates, who argued that she needed better support, not assistance in dying. Outcome  Despite winning the case, Bouvia chose to live and did not withdraw her feeding tube.  Her case set a legal precedent that influenced later rulings, including the Cruzan and Schiavo cases. Comparison to Other Right-to-Die Cases Final Case Condition Request Court Ruling Outcome Elizabeth Cerebral palsy, Right to refuse Bouvia Right upheld Chose to live chronic pain force-feeding (1986) Karen Ann Persistent Removal of Lived 9 more Right upheld Quinlan vegetative ventilator years  Page 117 of 17 Final Case Condition Request Court Ruling Outcome (1976) state Persistent Nancy Cruzan Removal of Initially denied, Passed away in vegetative (1990) feeding tube later upheld 1990 state Persistent Long legal Terri Schiavo Removal of Passed away in vegetative battle, right (2005) feeding tube 2005 state upheld