Ethical Challenges

Since the mid-1960s, there has been an increased awareness of and interest in medical ethics. With the first human heart transplant operation by Dr. Christiaan Barnard in 1967, the U.S. Supreme Court's declaration in 1973 that state laws prohibiting abortion were unconstitutional, and the controversy in 1975 over removing the respirator from a patient with irreversible brain damage in the case of Karen Ann Quinlan, modern medical ethics was born. Touching on three key issues—organ transplantation, abortion, and the standards of death—these landmarks set the stage for current thoughts about the ethical dimensions of health care.

Since then, there have been many other ethical challenges to the health-care system. In 1978, the first baby to be conceived in a test tube, Louise Brown, was born. In 1982, Dr. Barney Clark was the first person to receive a mechanical artificial heart, the Jarvik-7. In 1984, the infant Baby Fae received a heart transplanted from a baboon. In 1988, the Baby M case involved the ethical issues of Mary Beth Whitehead's ''surrogate motherhood'' for William Stern. From 2003 to 2005, legal and political conflict raged around the maintenance of life support (tube feedings) for Terri Schiavo, a severely brain-damaged woman who had been kept alive for 15 years.

As clinicians in the 21st century, you will be faced with many ethical issues: standards of brain death, physician-assisted suicide, in vitro fertilization, autonomy, informed consent, ''do-not-resuscitate'' orders, surrogate motherhood, euthanasia versus letting-die issues, rights of disabled persons, confidentiality, coerced surgery, abortion, ''Baby Doe'' regulations, interracial transplantation, surrogacy arrangements, allocation of scarce medical resources, whistle-blowing on unethical colleagues, use of patients as research subjects, mandatory

This Epilogue was written in collaboration with Talia H. Swartz, MD, PhD, Department of Internal Medicine, Mount Sinai Medical Center, New York, New York.

testing for acquired immunodeficiency syndrome (AIDS), and genetic manipulation. One of the first ethical issues you may face is the use of patients as ''teaching tools.''

A current ethical issue is the mandatory testing for human immunodeficiency virus (HIV). Should an HIV test be required as part of premarital testing, preadmission to hospitals, pre-insurance examinations, or preemployment testing? Several arguments have been made in its favor, including a person's right to donate blood, the tracing of potential infected contacts, determination of the incidence and rate of spread of HIV, quarantine of infected persons, and tattooing of infected persons. Some of the arguments against mandatory testing concern discrimination, ''social purification,'' violation of a person's privacy, false-positive test results, and health insurance difficulties.

An ethical problem is one in which two or more norms or principles create a challenge about what to do. There are many types of ethical problems. These problems can be divided into four main groups:

1. Ethical distress: An individual knows the course of action, but a barrier prevents its accomplishment.

2. Ethical dilemma: There exist two or more courses of action, each of which is right or wrong, and selecting one will compromise the end result.

3. Distributive justice: Benefits are given to several individuals, but not to everyone. On what basis should the distribution be made?

4. Locus of authority: There are two or more authorities, all believing that they know which outcome will best benefit the patient, but only one will prevail.

Consider the following examples of contemporary issues in medical ethics:

Avia and Hal are newlyweds. They want to have children, but each is from a family with a known inherited illness. Any or all of their children may be affected. Genetic alteration may be an option. Is it right for such couples to endeavor to change their future children's genetic makeup? Is modification of natural biology a human right?

• Florence is 31 years of age. When Florence became pregnant, she was overjoyed. She is now in her second month of pregnancy. Recently she developed fever, tender lym-phadenopathy, rash, and sore throat. Rubella was diagnosed. Although Florence dreads the thought of giving birth to a retarded, blind, or congenitally malformed child, her religion does not allow abortion. Nonetheless, she questions whether it is right to bear a child that she knows will live a life of suffering.

• Baby John is born with significant birth defects. As his condition continues to deteriorate, is there a point when aggressive therapy should be discontinued?

• Natalie and Marshall have been unsuccessful in conceiving a child, and evaluation indicates that Natalie is unable to bear a child. The couple decides on a surrogate pregnancy with Marshall's sperm. They meet the surrogate mother, whom they like, and she conceives their child. During a conversation in her second trimester, the surrogate mother-to-be indicates that she would be unwilling to undergo a cesarean section if the child's life were in jeopardy. Who has the right to make that decision?

• Sam, a major benefactor to the hospital, is 76 years of age. He has Parkinson's disease and diabetes mellitus. Sam is in the emergency department complaining of severe chest pain. Brittany is a 41-year-old nurse with a history of angina who is also in the emergency department complaining of severe chest pain. There is only one bed left in the coronary intensive care unit. Who should get the bed?

Jack is a 42-year-old man who has sex with only men and is HIV-positive. Although counseled about his promiscuous sexual behavior, he is unwilling to curb his unprotected sexual encounters, posing a threat to his partners and to the community at large. What is your role as his physician as it relates to confidentiality and the ''politics'' of disease?

• Maria is 20 years of age and is the single mother of two children. She is in the first trimester of her third pregnancy. Recent symptoms of severe weakness and gingival bleeding brought her to medical attention. A work-up revealed acute monomyelocytic leukemia and anemia with a hemoglobin measurement of 7.8 g/dL. Therapy for the leukemia would be a great risk to the life of the fetus, but the patient refuses to terminate her pregnancy. To complicate the issue, her fiance, a Jehovah's Witness, has persuaded the patient to refuse any transfusion of blood or blood products. How do you, as her physician, handle this situation?

• Lynn is a 62-year-old woman with a 2-year history of lung cancer. Because of severe back pain for the past 3 months, she is evaluated, and it is determined that she has multiple metastases to her spine impinging on nerve roots. Despite analgesic therapy, she continues to have debilitating, unrelenting pain. She now consults you, requesting physician-assisted suicide.

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