Introduction to
Medical Ethics
Paul Dassow, MD, MSPH
MD 815
November 15, 2006
Objectives
1. Explain the difference between morality
2.
3.
4.
5.
and ethics
Describe the Standard Medical Ethic in
place in today’s medical environment
Apply this Ethic to a real world situation
Understand the inherent difficulties with
the current medical ethic
Know alternatives to the standard ethic
The case of Terri Schiavo

The facts:



Born Theresa Marie Schindler December 3,
1963
In 1983, Terri met Michael Schiavo at Bucks
County Community College and the two
began dating. He was the first romantic
interest Terri had.
The couple was engaged within a few months
and married a year later at Terri’s church in
Southampton, Pa. She was 21.
The case of Terri Schiavo

The facts:

In 1990, at the age of 26, Terri suffered a
mysterious cardio-respiratory arrest for which
no cause has ever been determined. She was
diagnosed with hypoxic encephalopathy –
neurological injury caused by lack of oxygen
to the brain. Terri was placed on a ventilator,
but was soon able to breathe on her own and
maintain vital function. She remained in a
severely compromised neurological state and
was provided a PEG tube to ensure the safe
delivery of nourishment and hydration
Terri Schiavo

Video clips from the last year of Terri’s life:
The case of Terri Schiavo

The facts:

On March 18, 2005, Terri Schiavo had her
feeding tube removed under the order of
Circuit Court Judge, George W. Greer of the
Pinellas-Pasco’s Sixth Judicial Court. On March
31, 2005, Terri Schindler Schiavo died of
marked dehydration following more than 13
days without nutrition or hydration. Terri was
41.
What was the right thing
to do here?
Morals and Ethics


Moral: Of or concerned with the judgment
of the goodness or badness of human
action and character
Ethic: A principle of right or good conduct
or a body of such principles
1. What was the morality
of the decision to pull
Terri’s feeding tube?
2. How do we decide what
is the moral choice?
The Standard Medical Ethic


Rooted in the 1979 Belmont Report from
the Committee on the use of Human
Subjects in research
Principles:

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Autonomy
Beneficence
Non-malfeasance
Justice
Autonomy

The principle that persons should be able
to decide for themselves what action, if
any, should be taken in regards to their
medical care



Assumes appropriate informed consent
Assumes capacity
Needs clarification when a patient cannot
speak (or think) for themselves
Beneficence

The principle that physicians should
always do what is in the best interest of
the patient


May vary from physician to physician
(Kevorkian)
Is this what the physician would want done to
them (the golden rule), or what they think the
patient would want for themselves?
Non-malfeasance

The principle that physicians should not
harm patients nor treat with intent to
harm


Often decisions must be made regarding
which course of action will likely cause the
least harm
Again, physician dependent
Justice

The principle that persons should be
treated equally and fairly, without
prejudice in regard to gender, race, or
personal creed.

Very difficult in our present system
So, back to Terri
Autonomy
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Did Terri want her feeding tube removed?
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No living will
Conflicting reports from husband and parents
regarding “what Terri would have wanted.”
Since Terri deemed not to have the capacity
to make decisions for herself, her next of kin
(husband) is assigned the duty to make these
decisions for her.
Terri’s next of kin said, “Yes.”
Capacity

Involves the demonstration of 3
characteristics:



Can understand the diagnosis and prognosis
for a given condition
Can understand the treatment options
Can understand the possible consequences
involved in the various treatment options
Beneficence

What would be the right course of action
to benefit Terri?

Can death ever be considered a benefit for a
patient?

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Would pulling Terri’s feeding tube benefit her?


Consider the Hippocratic Oath
If so, how?
Was artificially feeding Terri just prolonging
her suffering?
Non-malfeasance

Would pulling Terri’s feeding tube cause
her harm?



Suffering from dehydration?
Is death the ultimate harm?
Were other motives at play in this decision
Money
 Husband’s desire to “get on with life.”

Justice

Is there precedent for this decision. That
is, are other similar patients treated the
same way?


Neurologically impaired vs persistent
vegetative state vs brain dead
Is there a national policy regarding how to
treat these patients (only brain death)
What happens when
principles conflict?
What happens when
principles conflict?

In life and death decisions, typically
Autonomy trumps others

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Exception: Assisted suicide in most states not
legal
In Terri’s situation, the legal case
surrounded whether she was in a
persistent vegetative state or not.
From this medical ethics framework, if
autonomy trumps others, then pulling the
tube was the right decision
A side note: Why did they
pull the tube? Why not just
not feed her?
So you’re the physician.
Do you comply with the
court decision?
The embattled physician

If you disagree with the court’s decision,
most states would allow you to “opt out”
of performing the act.

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Examples: As a physician, you do not have to
provide contraception or abortion services
However, some states do force behavior
deemed essential to the job (eg, pharmacists
must dispense emergency contraception)