Menjadi koas.

Menjadi koas adalah suatu periode pendidikan dokter yang ditekankan pada penerapan
(aplikasi) teori-teori yang sebelumnya sudah didapat dari periode praklinik. Menjadi koas bukanlah
menjadi dokter mandiri. Koas memiliki hak dan kewajibannya sendiri dan serupa-tak-sama dengan hak
dan kewajiban dokter. Koas dan dokter punya kewajiban untuk menghormati pasien, bersikap
profesional sesuai keilmuan, dan lainnya. Namun koas tidak ada hak untuk berpraktik mandiri. Semua
apa yang dilakukan koas harus berada dibawah supervisi dokter pembimbingnya. Namun dibalik itu
mereka pun dituntut untuk memiliki profesionalisme layaknya dokter mandiri. Jadi, saya kira ketika
masyarakat awam berhadapan dengan koas, maka sudah sesuai aturan yang ada, bila mereka tidak
dapat menegakkan diagnosis dan memberi terapi secara mandiri di depan pasien tanpa dikonsultasikan
dengan pembimbingnya.

Kasus Dr. Ira Simatupang

Berawal dari tahun 2006, ketika dia (dr. Ira) mengalami pelecehan seksual dan percobaan
perkosaan oleh seorang oknum dokter inisial JT, di RSUD Tangerang. Peristiwa itu baru
dilaporkan Ira pada tahun 2008 kepada Direktur Umum RSUD Tangerang, tempat dia juga
bekerja sebagai ahli kandungan. Tidak puas karena tidak mendapatkan tanggapan berarti dari
direktur rumah sakit, Ira lantas melaporkan kasus itu ke pihak kepolisian.

Setelah ditangani oleh polisi pada tahun 2009, penyidikan kasus itu telah di SP3 (Perintah
Penghentian Penyidikan) oleh kepolisian dengan alasan tidak cukup bukti. ”Begitu juga dengan
pemecatan, RSUD Tangerang tidak pernah memecat dr Ira. Justru dia yang meminta agar Surat
Ijin Praktek (SIP) dicabut. Agar bisa berpraktek di rumah sakit lain,” ucap dokter Bambang.
Apalagi, saat dr Ira mengajukan permohohan pencabutan SIP, Dirut RSUD Tangerang, dr
Mamahit yang juga suami Menkes Endang Rahayu Sedyaningsih mencegahnya. Itu dibuktikan
dengan surat yang dibuat pada 6 Desember 2008 lalu. Pasalnya, dokter honorer itu masih terikat
kontrak perjanjian kerja dan tengah mengikuti studi S3 di FKUI. ”Jadi surat permohonan
pencabutan SIP itu tidak dikabulkan. Artinya Ira tidak dipecat dari RSUD Tangerang,” tegas
Bambang juga. Tapi, dr Ira mengurus sendiri pencabutan SIP itu ke Dinas Kesehatan (Dinkes)
Kota Tangerang. Akhirnya, permohonan pencabutan SIP itu dikabulkan pada 14 November
2008. ”Karena yang bersangkutan sudah mencabut SIP-nya di RSU Tangerang, maka pihak kami
melaporkan ke FKUI bahwa yang bersangkutan bukan lagi karyawan honorer di RSUD
Tangerang,” cetus Bambang juga. Karena itulah, program S3 bidang Kanker Kandungan yang
tengah digeluti ira secara otomatis gugur atau berhenti kuliah.
Dokter Ira yang kecewa kemudian menulis surat ke sejumlah pihak termasuk Bupati Tangerang,
Komisi Nasional Hak Asasi Manusia, dan Kementerian Kesehatan, kembali keluhannya itu tidak
ditanggapi. Penolakan-penolakan itu kemudian mendorong Ira menulis sejumlah email kepada
dokter yang terlibat kasus dugaan pelecehan seksual pada 2006. Email-email itu, yang juga
dikirim Ira ke sejumlah rekannya, belakangan menjadi bukti pencemaran nama baik yang
menjerat dirinya sendiri.
Akan tetapi, cerita Ira itu, dibantah oleh Dokter Bambang Gunawan yang melaporkan Ira ke
kepolisian Tangerang. Dia melaporkan Ira ke polisi karena namanya dicemarkan dalam email-
email yang dikirim Ira, padahal dia sama sekali tidak terlibat dalam kasus pelecehan seksual
yang terjadi pada 2006. “Pada 2010 dia masih mengirim email-email kepada dokter yang terlibat
kasus pelecehan seksual pada 2006, tetapi saat itu dia mulai menyebut-nyebut nama saya,” keluh
Bambang.
Bambang bercerita isi email-email itu cenderung “mencemarkan”, “tidak senonoh” dan menuduh
dia “berselingkuh”, padahal Bambang sama sekali tidak terlibat dalam kasus yang terjadi pada
tahun 2006 itu.”Bahkan sampai tanggal 6 atau 7 Januari kemarin dia masih mengirim email-
email yang menyebut nama saya kepada dokter itu (yang terlibat dugaan pelecehan seksual itu),”
jelas Bambang.
Menurut Bambang kasus yang membelit Ira kini berawal dari hubungan asmara dokter
perempuan itu dengan seorang dokter di RSUD Tangerang. Hubungan yang tidak berakhir
bahagia itu yang kemudian membuat Ira melaporkan dokter tersebut ke Direktur RSUD
Tangerang dan sejumlah pihak lain. Karena tidak puas laporannya tidak ditanggapi, Ira lantas
mengirim email-email ke sejumlah rekannya, termasuk kepada dokter yang terlibat hubungan
asmara dengannya.
“Tetapi apa urusannya dengan saya? Mengapa saya dibawa-bawa?” ketus Bambang. Merasa
dirinya dirugikan dan namanya dicemarkan dalam email-email itu, Bambang lantas melaporkan
mantan rekan sejawatnya itu ke kepolisian pada Juli 2010. lalu Polres Metro Tangerang Kota
melimpahkan berkas penyidikan kasus dugaan pencemaran nama baik dengan tersangka dr Ira ke
Kejaksaan Negeri (Kejari) Tangerang. dr Ira dijerat dengan UU ITE dengan ancaman 6 tahun
penjara. Kasus itu akan disidangkan pekan depan di PN Tangerang.
Sementara, dr Bambang Gunawan yang tak lain adalah mantan atasan Ira di RSUD Kabupaten
Tangerang dalam kesaksiannya mengungkapkan, bahwa ada sebanyak 867 email yang
disebarkan oleh dr Ira kepadanya. Penetapan dr Ira Simatupang tersangka terkait curhat lewat
email tentang percobaan pemerkosaan oleh mantan rekan satu kerjanya di RSUD Tangerang
terus berpolemik. Akibat keluh kesahnya itu membuat dokter kandungan itu dijerat Pasal 27 ayat
3 Undang-Undang No 11 Tahun 2008 tentang Informasi dan dan Transaksi Elektronik (ITE) oleh
Polres Metro Tangerang Kota dengan ancaman 6 tahun penjara.
Profesionalisme Kedokteran
Aborsi atau keguguran kandungan merupakan suatu isu yang kontroversial.

Pertimbangan pelaksanaan aborsi harus dilihat dari aspek etika dan profesionalisme

kedokteran, hukum yang berlaku, serta agama. Pelaksanaan aborsi harus melalui

pertimbangan berbagai pihak yang terlibat.

Aborsi adalah pengeluaran hasil konsepsi secara prematur dari uterus─embrio,

atau fetus yang belum dapat hidup. Dengan kata lain, aborsi adalah berhentinya

kehamilan sebelum usia kehamilan 20 minggu yang mengakibatkan kematian janin.

Ada dua macam aborsi, yaitu aborsi spontan dimana aborsi terjadi secara alami,

tanpa intervensi tindakan medis (aborsi spontanea), dan aborsi yang direncanakan

melalui tindakan medis dengan obat-obatan, tindakan bedah, atau tindakan lain yang

menyebabkan pendarahan lewat vagina (aborsi provokatus).

Contoh Kasus :

Seorang siswi kelas I SMP berumur 13 tahun, hamil 1 bulan akibat perkosaan.

Akibatnya korban mengalami depresi. Orangtua ingin agar janin diaborsi, kemudian

berkonsultasi ke dokter. Dokter setelah mengadakan pertimbangan dengan tim ahli

(dokter, ahli agama dan psikiater) memutuskan setuju untuk melakukan aborsi. Namun,

walaupun tim ahli telah setuju, orang tua masih bingung karena menurutnya agama dan

hukum melarang aborsi.

Analisa

Menurut etika kedokteran, setiap dokter harus menghormati setiap makhluk hidup.

Namun karena masih terdapat pertentangan maksud pasal dan sumpah dokter yang

berkaitan dengan waktu dimulainya suatu awal kehidupan, maka dalam etika

kedokteran, pelaksanaan aborsi dalam kasus ini diserahkan kembali kepada hati nurani

masing-masing dokter.

Dalam etika profesionalisme, apabila seorang dokter tidak memberanikan dirinya

untuk melaksanakan tindakan aborsi, maka dokter tersebut dapat merekomendasikan

pelaksanaan aborsi tersebut kepada dokter lain yang kompeten di bidangnya, dengan

tetap memantau dan bertanggung jawab atas keselamatan dan perkembangan pasien

selanjutnya.

Republik Indonesia yang berdasarkan hukum telah membuat hukum yang mengatur

aborsi, dalam KUHP dan UU Kesehatan. KUHP menyatakan segala macam bentuk

aborsi dilarang, bahkan dengan tujuan menyelamatkan nyawa Ibu. Sementara UU

Kesehatan menyatakan pembolehan aborsi apabila nyawa Ibu dapat terancam apabila

kehamilan diteruskan lebih lanjut.

 Dilihat dari sudut pandang agama, secara umum agama Islam tidak membolehkan

pelaksanaan aborsi. Namun, fatwa Majelis Ulama Indonesia (MUI) menyatakan antara

lain, kehamilan akibat perkosaan dapat digugurkan, apabila usia kehamilan tidak lebih

dari 40 hari. Hal ini pun harus ditetapkan oleh tim yang berwenang yang terdiri dari

keluarga korban, dokter, dan polisi. Hal ini mungkin didasarkan pada pertimbangan

bahwa depresi yang diderita pasien akan mencapai tahapan yang lebih buruk, misalnya

mengarah ke percobaan bunuh diri, jika kehamilan diteruskan.

Depresi pada kehamilan memang mempengaruhi perkembangan janin dan

perkembangan bayi pada tahap-tahap awal kelahiran, namun tidak berpengaruh luas

pada tumbuh kembang anak selanjutnya. Masalah mungkin hanya berupa masalah

psikologis, namun secara fisik ibu hamil yang depresi tidak mempunyai dampak yang

membahayakan selain bunuh diri apabila memang tingkat depresinya sudah

menngkhawatirkan.

Kesimpulan:

Menurut etika dan profesionalisme kedokteran, serta agama, pelaksanaan aborsi

pada kasus ini dapat diperbolehkan, karena memenuhi syarat-syarat tertentu yang telah

ditetapkan. Namun menurut hukum hal ini masih rancu. Ada ketidakcocokan antara

KUHP dengan UU Kesehatan, padahal sebagai dokter ada aturan-aturan hukum

tertentu yang wajib dipatuhi.

 Dengan alasan medis tertentu yang berhubungan dengan keselamatan nyawa ibu,

memang tindakan aborsi diperbolehkan. Aborsi yang dibenarkan secara hukum adalah

apabila kehamilan mengancam jiwa dan keselamatan ibu. Sehingga, dalam kasus ini

pasien sebaiknya disarankan untuk meneruskan kehamilannya. Depresi dan trauma

psikologis selanjutnya dapat ditangani dengan terapi psikologis.

Edwin Timothy Sihombing (2,5 bulan) terpaksa kehilangan separuh jari telunjuk kanannya
setelah digunting oleh dokter rumah sakit, tempat bayi itu dirawat, Selasa (9/4/2013). Ia diduga
menjadi korban malpraktik.
TERKAIT:

 Orangtua Edwin Khawatirkan Kondisi Anaknya

 RSHB: Ayah Edwin Setuju Dilakukan Amputasi
 RS Harapan Bunda Salahkan Orangtua Edwin
 RS Harapan Bunda: Telunjuk Edwin Lepas Sendiri
 Ini Alasan Dokter Gunting Telunjuk Bayi Edwin

JAKARTA, KOMPAS.com — Profesi dokter kembali jadi sorotan. Tuduhan malapraktek

kembali dilayangkan kepada profesi yang identik dengan layanan kesehatan ini.

Adalah Edwin Timothy Sihombing, bayi berusia 2,5 bulan, yang diduga menjadi korban
malapraktek setelah dua ruas jari telunjuk kanannya diamputasi oleh seorang dokter di Rumah
Sakit Harapan Bunda, Ciracas, Jakarta Timur. Padahal, sebab amputasi masih belum jelas.
Proses amputasi juga diduga tanpa obat bius yang mengakibatkan Edwin menjerit keras.

Hebohnya dugaan kasus malapraktik pada kasus Edwin membuat Pengurus Besar Ikatan Dokter
Indonesia (PB IDI) angkat bicara. Menanggapi kasus ini, Sekretaris Jenderal PB IDI dr Daeng M
Faqih mengatakan, kasus tersebut belum tentu dikategorikan sebagai malapraktik, melainkan
masuk dalam kejadian tidak diinginkan.

"Jangan disebut malapraktik karena ada ciri yang menentukan perbuatan malapraktik dokter,"
katanya dalam launching perayaan Hari Bakti Dokter Indonesia di Jakarta, Kamis (11/4/2013)
kemarin.

Daeng menjelaskan, setidaknya ada tiga syarat seorang dokter dikategorikan melakukan tindakan
malapraktik. Tiga syarat tersebut adalah bila seorang dokter melakukan tugasnya di luar tujuan
kemanusiaan, tidak bekerja dengan integritas dan kedisiplinan sesuai kode etik, serta tidak
profesional. Di luar tiga hal tersebut, kata Daeng, perlu diselidiki dan pertanyakan, alasan proses
pengobatan yang dilakukan dokter.

Menurut Daeng, masyarakat tidak perlu tergesa-gesa menyalahkan dokter. Pasalnya, dokter
memiliki mekanisme dan sanksi sendiri bila dinilai melanggar kode etik profesi kedokteran.
Sanksi tersebut misalnya pencabutan surat izin praktik. Masyarakat juga bisa mengadu ke konsil
kedokteran, apabila menemukkan kejadian yang tidak diinginkan.

Sistem pelayanan buruk

Kasus malapraktik, lanjut Daeng, sebenarnya dapat dihindari, apabila sistem pelayanan rumah
sakit lebih baik. Sistem ini juga yang akan melindungi pasien dari berbagai kejadian yang tidak
diinginkan.

"Sistem pelayanan yang buruk menjadi faktor laten berbagai kejadian tidak diinginkan," ujar
Daeng.

Padahal, dengan sistem yang baik, pasien bisa mendapatkan pelayanan yang lebih profesional
menggunakan sistem rujukan. Sistem pelayanan yang baik juga menghindarkan pasien dari
pemberian obat terlalu banyak, atau ditolak dokter.

Buruknya sistem pelayanan juga diakui Ketua Umum PB IDI dr Zainal Abidin, MH.
Menurutnya, kualitas seorang dokter tidak akan terlihat dalam sistem pelayanan yang buruk.

Zaenal menambahkan, kasus ini membuktikan masih lemahnya pengawasan yang dilakukan
organisasi profesi. "Pengawasan idealnya dilakukan bersama organisasi profesi, dinas kesehatan,
dan konsil kedokteran," ujarnya.

Pengawasan maksudnya adalah pelaksanaan kode etik kedokteran ketika sedang berpraktik.
Etika tersebut akan membimbing dokter dalam bertindak menghadapi pasien. Etika juga menjadi
dasar utama pengambilan keputusan. "Dokter yang baik akan memegang teguh etika, yang
terwujud dalam cara kerjanya," kata Zaenal.
 Maulana adalah seorang anak berusia 18 tahun. Dulunya adalah anak yang
mengemaskan dan pernah menjadi juara bayi sehat. Namun makin hari tubuhnya makin
kurus. Dan organ tubuhnya tidak bisa berfungsi secara normal. Tragedi ini terjadi ketika
Maulana mendapat imunisasi dari petugas kesehatan. Diduga korban Maulana adalah
korban Malpraktek.
Maulana kini berusia 18 tahun namun ia hanya bisa terbaring lemah di tempat tidur
tragedi ini bermula saat usianya empat puluh lima hari, Seperti balita pada umumnya
Maulana mendapatkan imunisasi dari petugas Dinas Kesehatan Petugas memberikan tiga
imunisasi sekaligus, yaitu imunisasi BCG, imunisasi DPT dan imunisasi Polio.
Namun setelah dua jam menerima imunisasi Maulana mengalami kejang-kejang dan suhu
tubuhnya naik tajam Sehingga orang tuanya panik dan langsung membawanya ke rumah
sakit namun kondisinya justru makin memburuk, Setelah lima hari dirawat Maulana malah
tidak sadarkan diri, selama tiga minggu sejak itu, tubuh Maulana selalu sakit sakitan dan
hampir seluruh organ tubuhku tidak berfungsi normal. Dokter mendiagnosa Maulana
mengalami radang otak namun setelah itu, satu persatu penyakit menggerogoti
kesehatannya. Semakin hari badannya semakin kecil, dan mengerut Maulana sering
mengalami sesak nafas, dan kejang kejang. Orangtuanya yakin Maulana menjadi korban
malpraktek. Karena beberapa dokter yang perawat Maulana menyatakan, anaknya
mengalami kesalahan imunisasi.
Kasus dugaan mal praktek seperti kasus Maulana merupakan kesalahan dalam
etika profesi sebagai dokter karena memberikan pelayanan yang buruk dan melakukan
kelalaian berat sehingga membahayakan pasien. Ketua Umum Ikatan Dokter Indonesia,
Fachmi Idris menyatakan, profesi dokter, diikat oleh sebuah etika profesi dalam sebuah
payung Majelis Kode Etik Kedokteran atau MKEK. Seorang dokter dapat dikatakan
melakukan pelanggaran saat praktek, jika sudah dibuktikan dalam suatu sidang majelis
kode etik.
Dari kasus Maulana , dapat dicermati bahwa tudingan dokter yang melakukan malpraktik
dapat ditujukan terhadap suatu tindakan kesengajaan ataupun kelalaian seorang dokter
dalam menggunakan keahlian dan profesinya yang bertentangan dengan SOP yang lazim
dipakai di lingkungan kedokteran yaitu Kode Etik Kedokteran Indonesia (Kodeki) dan
Undang Undang No. 23 Tahun 1992 tentang Kesehatan. Namun, jika kesalahan tersebut
dikategorikan malpraktik maka Lembaga yang berwenang memeriksa dan memutus kasus
pelanggaran hukum hanyalah lembaga yudikatif dalam hal ini lembaga peradilan jika
ternyata terbukti melanggar hukum maka dokter yang bersangkutan dapat dimintakan
pertanggungjawabannya
SARAN:
Sudah saatnya pihak berwenang mengambil sikap proaktif dalam menyikapi fenomena
maraknya gugatan malpraktik. Dengan demikian kepastian hukum dan keadilan dapat
tercipta bagi masyarakat umum dan komunitas profesi. Dengan adanya kepastian hukum
dan keadilan pada penyelesaian kasus malpraktik ini maka diharapkan agar para dokter
tidak lagi menghindar dari tanggung jawab hukum profesinya dan memegang etika profesi
.

KESIMPULAN:
Fenomena Malpraktik seharusnya tidak terjadi jika tiap profesional memegang etika
profesi dan memiliki kepekaan moral. Kepekaan dalam bersikap kepada sesama
profesional, atau rasa tanggung jawab atas profesinya kepada masyarakat.
Etika profesi akan berguna jika dirasakan manfaatnya oleh profesional sendiri. Selain itu,
kegunaan itu akan terwujud jika dirasakan pula oleh pengguna jasa profesional. Tapi disisi
lain kita tidak bisa juga menanggap dokter sebagai “penjahat” medis karena kita sadar
bahwa dokter juga manusia yang bisa melakukan kesalahan.
 Maulana adalah seorang anak berusia 18 tahun. Dulunya adalah anak yang
mengemaskan dan pernah menjadi juara bayi sehat. Namun makin hari tubuhnya makin
kurus. Dan organ tubuhnya tidak bisa berfungsi secara normal. Tragedi ini terjadi ketika
Maulana mendapat imunisasi dari petugas kesehatan. Diduga korban Maulana adalah
korban Malpraktek.
Maulana kini berusia 18 tahun namun ia hanya bisa terbaring lemah di tempat tidur
tragedi ini bermula saat usianya empat puluh lima hari, Seperti balita pada umumnya
Maulana mendapatkan imunisasi dari petugas Dinas Kesehatan Petugas memberikan tiga
imunisasi sekaligus, yaitu imunisasi BCG, imunisasi DPT dan imunisasi Polio.
Namun setelah dua jam menerima imunisasi Maulana mengalami kejang-kejang dan suhu
tubuhnya naik tajam Sehingga orang tuanya panik dan langsung membawanya ke rumah
sakit namun kondisinya justru makin memburuk, Setelah lima hari dirawat Maulana malah
tidak sadarkan diri, selama tiga minggu sejak itu, tubuh Maulana selalu sakit sakitan dan
hampir seluruh organ tubuhku tidak berfungsi normal. Dokter mendiagnosa Maulana
mengalami radang otak namun setelah itu, satu persatu penyakit menggerogoti
kesehatannya. Semakin hari badannya semakin kecil, dan mengerut Maulana sering
mengalami sesak nafas, dan kejang kejang. Orangtuanya yakin Maulana menjadi korban
malpraktek. Karena beberapa dokter yang perawat Maulana menyatakan, anaknya
mengalami kesalahan imunisasi.
Kasus dugaan mal praktek seperti kasus Maulana merupakan kesalahan dalam
etika profesi sebagai dokter karena memberikan pelayanan yang buruk dan melakukan
kelalaian berat sehingga membahayakan pasien. Ketua Umum Ikatan Dokter Indonesia,
Fachmi Idris menyatakan, profesi dokter, diikat oleh sebuah etika profesi dalam sebuah
payung Majelis Kode Etik Kedokteran atau MKEK. Seorang dokter dapat dikatakan
melakukan pelanggaran saat praktek, jika sudah dibuktikan dalam suatu sidang majelis
kode etik.
Dari kasus Maulana , dapat dicermati bahwa tudingan dokter yang melakukan malpraktik
dapat ditujukan terhadap suatu tindakan kesengajaan ataupun kelalaian seorang dokter
dalam menggunakan keahlian dan profesinya yang bertentangan dengan SOP yang lazim
dipakai di lingkungan kedokteran yaitu Kode Etik Kedokteran Indonesia (Kodeki) dan
Undang Undang No. 23 Tahun 1992 tentang Kesehatan. Namun, jika kesalahan tersebut
dikategorikan malpraktik maka Lembaga yang berwenang memeriksa dan memutus kasus
pelanggaran hukum hanyalah lembaga yudikatif dalam hal ini lembaga peradilan jika
ternyata terbukti melanggar hukum maka dokter yang bersangkutan dapat dimintakan
pertanggungjawabannya
SARAN:
Sudah saatnya pihak berwenang mengambil sikap proaktif dalam menyikapi fenomena
maraknya gugatan malpraktik. Dengan demikian kepastian hukum dan keadilan dapat
tercipta bagi masyarakat umum dan komunitas profesi. Dengan adanya kepastian hukum
dan keadilan pada penyelesaian kasus malpraktik ini maka diharapkan agar para dokter
tidak lagi menghindar dari tanggung jawab hukum profesinya dan memegang etika profesi
.

KESIMPULAN:
Fenomena Malpraktik seharusnya tidak terjadi jika tiap profesional memegang etika
profesi dan memiliki kepekaan moral. Kepekaan dalam bersikap kepada sesama
profesional, atau rasa tanggung jawab atas profesinya kepada masyarakat.
Etika profesi akan berguna jika dirasakan manfaatnya oleh profesional sendiri. Selain itu,
kegunaan itu akan terwujud jika dirasakan pula oleh pengguna jasa profesional. Tapi disisi
lain kita tidak bisa juga menanggap dokter sebagai “penjahat” medis karena kita sadar
bahwa dokter juga manusia yang bisa melakukan kesalahan.
Difficult Birth: Navigating Language and Cultural Differences

By Karen Peterson-Iyer

Ana Lopez is 17 years old and works in the U.S. as a farm laborer. Ana speaks no English and
very little Spanish; she is an immigrant from Oaxaca, Mexico, and her primary language is
Mixteco. She is illiterate. Roughly estimated to be 36 weeks pregnant, she is admitted through
the emergency room to East Valley Hospital with cramping and vaginal bleeding. Upon
examination, placental abruption is diagnosed, and the medical team recommends a Cesarean
section. Ana is also discovered to be severely anemic. Toward the start of these exams, a nurse
offers Ana ice chips (a normal procedure for laboring women), which Ana quietly refuses.
Although the medical team considers Ana's C-section to be an emergency measure (thus not
requiring explicit consent), the hospital staff nevertheless do attempt to obtain Ana's consent
before the surgery; she replies "yes" to all questions and appears to acquiesce to everything the
medical team suggests. However, since no one on staff speaks Mixteco, they cannot be sure that
Ana fully understands her (or her child's) situation. After the C-section, the baby boy's APGAR
scores, which measure the vital signs of a newborn, are quite low. He is immediately transferred
to the neonatal intensive care unit (NICU) with diagnoses of neonatal encephalopathy, a disease
of the brain, and being small for gestational age (SGA).

Ana had arrived at the hospital early in the morning with her mother and sister, neither of whom
speaks English or Spanish. She does have a husband, Hugo, but he was not present at the
admission or the time of the birth since he feared losing his job if he missed work for the day.
Hugo eventually arrives at the hospital later in the afternoon. He speaks no English but is
haltingly conversant in Spanish.

A social worker, fluent in Spanish but not Mixteco, meets with Ana and Hugo and discovers (to
the best of her abilities) that Ana has no health insurance and had not been able to obtain any
regular prenatal care (which would explain why her anemia had gone undiagnosed). She had no
money even for vitamins, which (the social worker surmised) Ana may nevertheless have taken
intermittently, when she could obtain them from a mobile health clinic. The social worker
guesses that Ana had worked in the fields right up until the previous day. She wonders privately
about Ana's exposure to harmful pesticides during her pregnancy. She is fairly certain that Ana
has no legal immigration papers.

Once Ana is stabilized after the birth she is allowed to go to the NICU to see her baby. Her
husband Hugo remains with her in the NICU, along with a Spanish-language translator called for
by the social worker. Through this translator, Hugo is able to communicate imperfectly on and
off with the medical team.

Throughout this process, Ana shows very little emotion, at least publicly, and the nurses present
are bothered by her flat, unemotional affect. The nurse manager of the NICU in particular
wonders (aloud, to her co-workers) why Ana "doesn't seem really to care about" her sick baby.
Ana's mother and sister, meanwhile, speak quietly but urgently with Hugo whenever they get the
chance.
Late that evening, Hugo tentatively interrupts a nurse and asks her (via the translator) whether
the baby might be visited by a "curandero," a traditional healer from their community. He
suggests (apparently at the insistence of his mother-in-law) that the baby should be "cleaned with
an egg." The nurse in charge is clearly uncomfortable with his request (and a treatment
unfamiliar to her) and responds that the baby may be too unstable to be subjected to any
"alternative" treatments. She reminds Hugo, somewhat sharply, that his baby is very sick but
under the care of the best medical experts. When Ana's relatives appear chagrinned and
distressed by this response, the nurse's demeanor softens, and she gently asks them if they have
had anything to eat recently and suggests that they pay a visit to the hospital cafeteria. Hugo
looks at the ground and utters a polite refusal. He does not repeat the request.

After three days, Ana herself is discharged from the hospital, though the baby remains in the
NICU. Over the course of the next few weeks, the baby stabilizes. The extent of brain
impairment is unclear and, according to the medical team, will only make itself known over time.
During these few weeks, Hugo is unable to be present at the hospital much during the day, but
Ana is regularly accompanied by her mother and other family members, who bring food and sit
with her as much as possible. The social worker pays special attention to Ana and Hugo's
situation, particularly making an effort to get them signed up with a Medicaid-sponsored
program. While ultimately successful, this move proves challenging, since they initially fear
discovery of their undocumented status. Ana and Hugo eventually are able to take their baby boy
home, unsure of what long-term complications he may encounter.

Does the staff at East Valley Hospital approach Ana's situation in a manner that is sufficiently
respectful of her culture (sometimes called a "culturally competent" manner)?
Cancer: A Failure to Communicate

by Karen Peterson-Iyer

Farhad Tabrizi, a 69-year-old immigrant from Iran, is brought to the emergency room at St.
Vincent's Medical Center (a private urban hospital) after coughing up blood. He presents with
severe coughing, fatigue, chest pain, shortness of breath, and headaches. After stabilizing Mr.
Tabrizi, the emergency room team admits him to the hospital, where he is given (over the course
of a few days) a thorough workup, including chest x-rays, CT scans, mediastinascopy, and a PET
scan.

At the start of the visit, the nurses attempt to gather a detailed health history; but this proves
difficult, since Mr. Tabrizi speaks almost no English. He does speak fluent Farsi, but there are no
Farsi-speaking medical personnel readily available. However, Mr. Tabrizi is accompanied on-
and-off by his adult son, who is reasonably fluent in both English and Farsi. He is also
accompanied intermittently by his wife, who speaks only Farsi. (The wife makes it a point of
regularly offering prayers for her husband's health.) The nurses attempt to gather a health history
whenever the son is present, which is not always easy, since his visits are unpredictable. Even
when his son is present to help translate, Mr. Tabrizi seems extremely uncomfortable offering up
any detailed information about his own or his family's health history, causing high levels of
frustration among the medical staff.

Additionally, Mr. Tabrizi appears extremely reluctant to eat whatever food is offered him in the
hospital. This is most pronounced when he is alone-if neither his son nor his wife is present at a
mealtime. On the second day of his stay, his son explains to the flustered nurses that Mr. Tabrizi
is fearful that the hospital food may contain hidden pork by-products. Since he is a devout
Muslim, he feels it is safest to refuse the food altogether unless he is absolutely certain. Although
the son has attempted to persuade Mr. Tabrizi that he (as a sick person) must eat, Mr. Tabrizi
apparently is determined to eat as little as possible. The chief nurse curtly replies that, while
religious belief is important, Mr. Tabrizi needs to keep his strength up if he hopes ever to go
home; thus he will need to nourish himself by eating more. She says that she will "see what we
can do" about ensuring that there is no pork used in the hospital's food preparation. The son
thanks her for her help. From then on he and his mother attempt to bring outside food to Mr.
Tabrizi whenever they visit.

After almost three days in the hospital, the results of the various scans are in; and the attending
physician, Dr. Looke, sits down with Mr. Tabrizi to discuss his situation. His son and wife are
also present. Dr. Looke first offers a handshake to Mr. Tabrizi's son. He inquires explicitly about
the extent of his English skills and asks if the son would be willing to translate what he is about
to say to Mr. Tabrizi. He agrees, while Mr. Tabrizi and his wife sit by. The doctor then gazes
directly into Mr. Tabrizi's eyes and tells him that he has extensive small cell lung cancer.

After a moment of stunned silence, the son turns to his father and tells him in Farsi that the
doctor believes that he is very sick, with some "growths" in his body. Dr. Looke goes on to say
that Mr. Tabrizi most likely does not have long to live. The doctor holds up two fingers (at which
point the patient grows increasingly alarmed and agitated), describing that there are basically
"two possible treatments" available for this cancer: chemotherapy and radiation; Dr. Looke
strongly prefers beginning with the first (chemotherapy). In spite of Mr. Tabrizi's alarm and
confused expression, the doctor presses on that, given the apparently advanced stage of the
disease, even chemotherapy would be very unlikely to provide a complete cure, but it could
provide some relief and lengthen the remainder of his life. The son, again silent for several
moments, then turns to his father and also holds up two fingers. He tells him that the doctor says
he must do two things to care for himself: eat well and get more rest. He also relays that his
father could take some "strong medicines" which would most likely help him to get better. Mr.
Tabrizi looks extremely uncomfortable but says nothing.

After a few more moments, Mr. Tabrizi, somewhat confused, asks (via his son) what the "strong
medicines" would consist of. The doctor replies by describing (in some detail) what the course of
chemotherapy would look like-how often it would be administered and that the treatments would
last for several weeks. He also describes that it may produce severe side effects such as nausea,
vomiting, increased fatigue, and elevated risk of infection. In spite of his hesitations, the son
attempts to translate the bare outlines of this information (leaving out the term "chemotherapy"),
at which point Mr. Tabrizi declares flat-out that he doesn't want any such cumbersome
treatments; they would compromise his relationships with his family and friends and place too
heavy a burden on his wife. Further, he doesn't really know what might be in such a strong
medication that could help him get better. Instead, he will simply do the two things the doctor
had recommended-improve his diet and get more rest.

What could/should the doctor/hospital have done differently in order to handle this case in a
more helpful and culturally competent manner?
Cases in Medical Ethics: Student-Led Discussions

by Chris Cirone

I was a Hackworth Fellow for the Markkula Center for Applied Ethics at Santa Clara University.
I was also a pre-medical student, and am currently attending the Loyola University Chicago
Stritch School of Medicine. During my senior year at Santa Clara, I led discussions on medical
ethics with students interested in medicine. The purpose of these discussions was two-fold. First,
they were created to help bring current ethical issues onto our campus. Second, they were
intended to help students who were interested in a career in the health sciences determine
whether or not medicine is their correct calling. Most of the discussions followed a simple
format. One to two cases were formulated for the students to read. Then I presented the students
with various questions related to some of the ethical issues contained in the situations described.
The following cases are the ones that I presented to the groups. Each case also has a short history
and summary of the ethical issues being reviewed. The questions I asked of the students are
included as well. These cases and questions are public domain, and can be re-used or modified
for educational purposes. I hope that you find them useful, and that they spawn the same
thoughtful enjoyment in you as they did in me.

Note: The cases were not based on specific events. However, it is possible that they share
similarities with actual events. These similarities were not intended.

Autonomy

Autonomy essentially means "self rule," and it is a patient's most basic right. As such, it is a
health care worker's responsibility to respect the autonomy of her patients. However, at times
this can be difficult because it can conflict with the paternalistic attitude of many health care
professionals. The following two cases address patient autonomy. The first involves the rights of
an individual to decide her own fate, even against her physicians' judgments. The second case
involves the rights of a parent to care for her child in the manner that she sees fit.

Case 1:

A woman enters the emergency room with stomach pain. She undergoes a CT scan and is
diagnosed with an abdominal aortic aneurysm, a weakening in the wall of the aorta which causes
it to stretch and bulge (this is very similar to what led to John Ritter's death). The physicians
inform her that the only way to fix the problem is surgically, and that the chances of survival are
about 50/50. They also inform her that time is of the essence, and that should the aneurysm burst,
she would be dead in a few short minutes. The woman is an erotic dancer; she worries that the
surgery will leave a scar that will negatively affect her work; therefore, she refuses any surgical
treatment. Even after much pressuring from the physicians, she adamantly refuses surgery.
Feeling that the woman is not in her correct state of mind and knowing that time is of the
essence, the surgeons decide to perform the procedure without consent. They anesthetize her and
surgically repair the aneurysm. She survives, and sues the hospital for millions of dollars.

Questions for Case 1:

  Do you believe that the physician's actions can be justified in any way?
 Is there anything else that they could have done?
 Is it ever right to take away someone's autonomy? (Would a court order make the
physicians' decisions ethical?)
 What would you do if you were one of the health care workers?

Case 2:

You are a general practitioner and a mother comes into your office with her child who is
complaining of flu-like symptoms. Upon entering the room, you ask the boy to remove his shirt
and you notice a pattern of very distinct bruises on the boy's torso. You ask the mother where the
bruises came from, and she tells you that they are from a procedure she performed on him known
as "cao gio," which is also known as "coining." The procedure involves rubbing warm oils or
gels on a person's skin with a coin or other flat metal object. The mother explains that cao gio is
used to raise out bad blood, and improve circulation and healing. When you touch the boy's back
with your stethoscope, he winces in pain from the bruises. You debate whether or not you should
call Child Protective Services and report the mother.

Questions for Case 2:

 Should we completely discount this treatment as useless, or could there be something

gained from it?
 When should a physician step in to stop a cultural practice? (If someone answers "when it
harms the child" remind that person that there is some pain in many of our medical
procedures, for example, having one's tonsils removed)
 Should the physician be concerned about alienating the mother and other people of her
ethnicity from modern medicine?
 Do you think that the physician should report the mother?

Autonomy Part 2

Maintenance of patient autonomy is one of the major ethical focuses of physicians. Therefore, a
second discussion was also held that focused primarily on patient autonomy. This discussion also
took a superficial look at euthanasia. For this discussion, a 58 minute video, Dax's Case
(produced by Unicorn Media, for Concern for Dying ; produced by Donald Pasquella, Keith
Burton ; directed by Donald Pasquella New York : Filmakers Library, c1984) was used. The
video tells the story of Dax Cowart, a man who was severely burned by an accidental propane
explosion. The burns disabled Dax, and the physicians forced treatment on him. Though he
survived the treatment, he still argues that he should have been allowed to refuse it so that he
could die. The video is very useful; however, the videos of Dax's burn treatments are very
graphic and the video should be reviewed before it is shown to a group of students.

Questions:
  In the video, one of the physicians says that burn patients are incompetent to make
decisions when they first enter the hospital because they are in such a great deal of pain.
However, patients such as Dax can be in a great deal of pain for a very long time. In such
cases, what should be done to determine competence, and when should this be done?
 Do you think the fact that Dax could not see a future for himself should have been taken
into account when determining his competency? Could this have clouded his judgment?
(He thought that he would end up on the street corner selling pencils)
 Do you think that the fact that Dax was going to recover, and had the possibility of living
a happy life, made not treating Dax like suicide… or murder? What if he did not have this
possibility?
 After his recovery, Dax attempted suicide. Should the physicians have let him die? Is it
ever correct for a doctor to allow a patient to kill himself?
 Do you ever think that it is correct for a physician to break a competent patient's
autonomy? If so, is this one of those cases?
 Do you think that in this case, that the ends justified the means?

Euthanasia

The word "euthanasia" draws its roots from Greek meaning "good death." As it is used in this
discussion, it means "the act of ending the life of a person suffering from either a terminal
illness, or an incurable disease." The AMA is against physicians assisting in euthanasia. There is
currently only one state in the US that allows for euthanasia, and that is Oregon, where in 1997,
the "Death With Dignity Act" went into effect. Euthanasia advocates stress that it should be
allowed as an extension of a person's autonomy. Those who are against euthanasia often say that
it can lead to the devaluation of human life, and to a slippery slope in which the old and disabled
will be killed on the whims of healthy people. We examined one case and the Oregon law to
view the ethics of euthanasia.

Case One:
A woman was diagnosed with motor neurone disease (the same
disease that Stephen Hawking has) 5 years ago. This is a condition that destroys motor nerves,
making control of movement impossible, while the mind is virtually unaffected. People with
motor neurone disease normally die within 4 years of diagnosis from suffocation due to the
inability of the inspiratory muscles to contract. The woman's condition has steadily declined. She
is not expected to live through the month, and is worried about the pain that she will face in her
final hours. She asks her doctor to give her diamorphine for pain if she begins to suffocate or
choke. This will lessen her pain, but it will also hasten her death. About a week later, she falls
very ill, and is having trouble breathing.

Questions for Case 1:

 Does she have a right to make this choice, especially in view of the fact that she will be
dead in a short while (say six hours)? Is this choice an extension of her autonomy?
  Is the short amount of time she has to live ethically relevant? Is there an ethical difference
between her dying in 6 hours and dying in a week? What about a year, and how do you
draw this distinction?
 Is the right for a patient's self-determination powerful enough to create obligations on the
part of others to aid her so that she can exercise her rights? She clearly cannot kill herself.
She can't move, but should someone be FORCED to help her, or to find someone to help
her?
 Should the money used to care for this woman be taken into account when she is being
helped? Do you think that legalizing euthanasia could create conflicts of interest for the
patient/ or the doctor? Will people feel that they need to end their lives earlier to save
money?
 Ask each student: If you were the physician, what would you do? Note: if you would pass
her off to another doctor knowing he or she would do it, does this free you from you
ethical obligations?

Oregon's Death With Dignity Act:

Students were given the two paragraphs that are found on the following web page:
http://www.nightingalealliance.org/htmdocs/iss_a_p.htm. We then discussed the following
questions pertaining to the Death With Diginity Act.

Death With Dignity Questions:

 Look at the requirements for the request. Do you see any problems with them? (The
woman from case 1 would not qualify.)
 Why would they put in these guidelines? Should they be there, if they keep a competent
person like the woman above from living her autonomy? (Is it to protect the doctors so
they will not have to GIVE the medication?)
 Is there a moral difference between prescribing the drug and actually giving it to the
patient? If not, why put in the rules?
 Why do you think they wouldn't let a person who is terminally ill and in pain with
possibly more than 6 months receive assistance in dying? Say someone is diagnosed with
HIV?
 Does the justification of euthanasia necessarily justify the assisted suicide of a healthy
person?
 Do you think a weakness of this law is the probability of patients being influenced by
family members? (For example, for financial or other reasons?) Note: Approximately
60% of Oregonians in 2000 said (before they died) that they used the prescription at least
in some part due to fear of being a burden on their family.
 The AMA says that euthanasia is fundamentally incompatible with the physician's role as
healer. What do you think about this statement? Why should a physician have to be the
one who does this?

Assisted Reproduction:
This is a difficult subject because it involves reproductive issues. In our culture, reproductive
liberty, the freedom to decide when and where to conceive a child is highly protected, and this
can make these cases much more difficult.

Case 1:
There are two types of surrogacy. One type involves a surrogate mother who uses her own egg
and carries the baby for someone else. The other type is a "gestational surrogacy" in which the
mother has no genetic tie to the child she carries. In the case presented, a gestational surrogate is
used.

A woman, after a bout with uterine cancer had a hysterectomy (surgical removal of the uterus).
Before, its removal, however, she had several eggs removed for possible fertilization in the
future. Now married, the woman wishes to have a child with her husband. Obviously she cannot
bear the child herself, so the couple utilizes a company to find a surrogate mother for them. The
husband's sperm is used to fertilize one of the wife's eggs, and is implanted in the surrogate
mother. The couple pays all of the woman's pregnancy-related expenses and an extra $18,000 as
compensation for her surrogacy. After all expenses are taken into account the couple pays the
woman approximately $31,000 and the agency approximately $5,000. Though the surrogate
passed stringent mental testing to ensure she was competent to carry another couple's child, after
carrying the pregnancy to term, the surrogate says that she has become too attached to "her" child
to give it up to the couple. A legal battle ensues.

Questions for Case 1:

 In the United States it is illegal to pay a person for non-replenishable organs. The fear is
that money will influence the poor to harm their bodies for the benefit of the rich. Do you
see a parallel between this case and this law? Can allowing surrogate mothers to be paid
for their troubles allow poorer women to be oppressed?
 Does paying the surrogate harm her and/or the child's dignity?
 Is it selfish/conceited for this couple to want children of their own genetic make-up? If
yes, does this change if you can "easily" have a child? (Note: Over 100,000 children in
the U.S. are waiting to be adopted. However, most are older, have several siblings, or
have special needs.)
 On their website, the AMA says "that surrogacy contracts [when the surrogate uses her
own egg], while permissible, should grant the birth mother the right to void the contract
within a reasonable period of time after the birth of the child. If the contract is voided,
custody of the child should be determined according to the child's best interests." Do you
see any problems with this? (What's a reasonable time? In a way can you steal the
surrogate's child?)
 One of the main arguments against the use of surrogate mothers is that carrying and
giving birth to a child is such an emotional event that it is impossible to determine if the
surrogate will be able to give up the child. Though adults enter into the contract, the child
could ultimately suffer if a long custody battle ensues (as it could in states where
surrogacy contracts hold no legal value, such as Virginia). With the possibility of such
battles, do you think it is acceptable for parents to use a surrogate mother?
  Do you think that if the surrogate is awarded the baby, this could cause emotional harm
to the child?
 Who do you think should receive the child, and why?

Case 2:

A married couple wishes to have a child; however, the 32 year old mother knows that she is a
carrier for Huntington's disease (HD). HD is a genetic disorder that begins showing signs at
anywhere from 35-45 years of age. Its symptoms begin with slow loss of muscle control and end
in loss of speech, large muscle spasms, disorientation and emotional outbursts. After 15-20 years
of symptoms HD ends in death. HD is a dominant disorder which means that her child will have
a 50% chance of contracting the disorder. Feeling that risking their baby's health would be
irresponsible, the couple decides to use in vitro fertilization to fertilize several of the wife's eggs.
Several eggs are harvested, and using special technology, only eggs that do not have the
defective gene are kept to be fertilized. The physician then fertilizes a single egg, and transfers
the embryo to the mother. Approximately 9 months later, the couple gives birth to a boy who
does not carry the gene for the disorder.

 Is this a case of eugenics? "Eugenics" is defined as "the hereditary improvement of the

human race controlled by selective breeding" (dictionary.com)
 Would it be acceptable for the parents to select for sex as well, or should they only select
an embryo that does not have HD? How would this be different?
 Is it ethical for this couple to have a baby when the mother could begin showings signs of
HD when the baby is just a few years old?
 With this technology possible, would it be ethical for this couple to have a child without
genetically ensuring it would not have the disease? What if we did not have this
technology, would it be ethical for a known carrier to have a child? (If not, how far
should this carry? a carrier for cystic fibrosis ( which is recessive)? )
 Weighing everything we have discussed, do you believe the couple acted ethically?

Universal Health Care:

The United States is the only industrialized nation that does not offer some form of universal
health care, and each year the number of uninsured Americans is increasing. Many people look
to Canada's health care system as a possible means of fixing our current woes. However, some of
the fears associated with universal health care are:

 Drug/medical technology companies fear that they will not make a profit.
 There will be a large tax increase.
 Quality of care will decrease.

The following cases and their corresponding questions address some of the problems and fears.

Case 1:
A mother brings her son into the emergency room during an asthma attack. Though both of his
parents work, they cannot afford medical insurance for themselves or him. They also earn too
much money to qualify for state or federal aid. He is treated for his asthma attack at the hospital
and he and his mother leave. Two weeks later, they return to the hospital in a virtually identical
scenario.

Questions for Case 1:

 Do you think that this boy is receiving adequate care?…Shouldn't he be able to see a
primary care physician before his condition gets so acute that he must visit the ER?
 Should everyone be entitled to a basic "minimum of health care"… or to the exact same
health care?
 Do you think that health care is a right? If so, are we forced to honor this right?
 (If students answer "yes" to the above question) Is this right relative or universal? Does
this right exist because of the wealth of the United States, or is it applicable everywhere?
Is health care a luxury?
 Does having money entitle a person to better health care? (they may have worked harder
for their greater wealth)

Case 2:
An upper middle class, middle aged, Canadian man is playing racket ball when he suddenly feels
a pop in his knee. In pain, he makes an appointment with his general practitioner and is seen the
next day. He is given pain medication, and is referred to an orthopedic surgeon (he has no choice
of who he will see). After a week wait, he is seen by the orthopedic surgeon and is told he will
need surgery. Two weeks later surgery is performed on the man's knee. The physician, who is
not very good, does a poor job on the knee, and the man walks with a slight limp for the rest of
his life. The surgery costs the man no money directly, however, he pays for it with higher taxes.

Questions For Case 2:

 What do you think of this man's experience in comparison to case 1? Which situation
seems worse, and why?
 Does it seem like it took too long for him to receive care? (The physicians will perform
surgery on the more urgent patients first and then on the less serious.)
 What do you think about not being able to choose your own physician? (Note: In the
United States, many insurance companies limit which physicians you choose.)
 One suggested solution for our current health care woes is that care for the elderly be
decreased/eliminated. For example, people over the age of 80 will no longer be placed on
life support, which costs approximately $10,000 per day to operate. What do you think of
this?
 What do you think could be a good middle ground solution to this problem?

Response To Bio-Terrorism

The possibility of terrorists using biological weapons on the citizens of the United States has
been a major topic in the press for the last several years. Smallpox has been speculated to be the
perfect biological terror agent because of the potency of the virus, and because of the lack of
herd immunity present in the US population. The following case presents a possible way in
which the virus could be released in the population and a possible response. The questions
following the case involve the ethics surrounding the government's response.

Smallpox Facts:

 Smallpox initially has flu-like symptoms, which are recognizable 7-19 days after
exposure. After 2-4 days of flu-like symptoms, the fever begins to decrease, and pox will
form.
 An infected person is contagious one day before the characteristic pox appear.
 Approximately 30-50% of unvaccinated people exposed to smallpox will contract the
disease.
 The mortality rate for smallpox was approximately 20-40%.
 The vaccine that was used was approximately 90% effective.
 It is possible that if terrorists were to use the smallpox virus, that they would genetically
modify it. If this were the case, then the vaccine may not prevent all of the disease
symptoms for those vaccinated.

Facts gathered from: http://www.vbs.admin.ch/ls/e/current/fact_sheet/pocken/

Case:

Date: June 22, 2005. A 27-year-old man is brought into a New York City emergency room with
a 101-degree fever, and what he believes is chickenpox (Varicella). After a brief examination,
the 35-year-old physician is puzzled because the pox do not appear to be typical of the varicella-
zoster virus. Worried, he calls in another physician for her opinion. She takes one look at the
patient, determines he has small pox, and immediately orders him to be quarantined. She notifies
the Centers for Disease Control and Prevention (CDC) and asks them what should be done.
While doing background on the patient, he tells the physicians that he is a flight attendant and
that he has flown to Orlando, FL, Los Angeles, CA, Chicago, IL, and Seattle, WA in the past few
weeks while working. Though he is given excellent treatment, and had been in perfect health a
few days earlier, the patient dies 7 hours after admittance to the hospital.

The CDC decides that mandatory small pox vaccines will be administered to all workers in the
NYC hospital, and to all patients who were in the ER. His co-workers are all given mandatory
vaccines as well, as are all people living in his apartment complex. They also ship stored
quantities of the vaccine to all of the cities where the man had flown to for work. The vaccines
are offered to citizens of these cities. Finally, all people, along with their families who had been
on the man's flights in the weeks preceding the appearance of the disease are forced to receive
the vaccine.

Questions:
Note: The flight attendant was most likely given small pox by a bio terrorist who flew on his
plane sometime during the past week/week and a half. The terrorist would have been contagious
but would not have shown symptoms. Virtually every person the man came into contact with
would have gotten the virus.
  Is it ethical for the CDC to force people to get the vaccine?
 An LA woman on the flight is religiously opposed to vaccines. Under California law she
can normally refuse vaccines on religious or personal grounds. However, the government
says she must receive the vaccine or face mandatory quarantine. What do you think of
this?
 Do you think that for more common diseases, for example measles, that it is ethical for
the state to allow people to refuse vaccines (even for religious grounds)? What if their
refusal can harm others who cannot have the vaccine, such as people who are
immunocompromised like AIDS patients?
 Is it ethical for someone to refuse the vaccine?
 You had driven down to Los Angeles 5 days ago to visit a friend for the weekend. While
in town, you visited many tourist attractions. You are worried and you try to get the
vaccine, but are denied it because of limited resources. What do you think of this?
 Citizens begin calling for the mandatory quarantining of people directly exposed to the
victim, i.e those living in his apartment complex, those working in the ER, those who
flew on the plane in the prior week. What do you think of this?
 The smallpox vaccine, like many other vaccines (example: oral polio vaccine) can
actually transmit the virus to others. In light of this, is it ethical for people to get the
vaccine? (Note: they are vaccinating those who may not want to be vaccinated)
 Today, should health care workers be allowed/forced to get the smallpox vaccine? What
about non-health care worker citizens?

- See more at: http://www.scu.edu/ethics/publications/submitted/cirone/medical-

ethics.html#sthash.2z8n8yNd.dpuf