Case No.

1: A doctor has a disease that interferes with his

ability to treat patients.
An anesthesiologist on staff at a hospital went to see a fellow
doctor as a patient. He was having brief lapses of
consciousness related to complex partial seizures, a form of
epilepsy that had gone unrecognized during his residency. He
admitted to having at least one seizure in the OR that was so
brief that no one observed it. The condition was treatable but
left the second doctor uncertain about whether to uphold the privacy of the doctor-patient
relationship or to inform the hospital staff.

The Issues
Hospitals have systems in place to ensure that doctors dont operate while intoxicated, and the
same standards apply here: The protection of patients in the OR trumps doctor-patient
privilege. Unless proper treatment is certain to allow the anesthesiologist to practice safely,
his condition should be disclosed to the hospital. The threat of serious harm to the patients
goes beyond the limits of confidentiality, says Dan Sulmasy of St. Vincents. Its then up to
hospital administrators, says Deborah Korzenik of Beth Israel, to decide whether the doctor
should be allowed to treat patients and under what conditions. In this case, the doctor treating
the anesthesiologist would ideally encourage the anesthesiologist to report himself. Its less
contentious for everyone, says Rosamond Rhodes of Mount Sinai. If the anesthesiologist
refuses to cooperate, however, his doctor would be obliged to go to the hospital
administration against his patients wishes. Theres a risk of scaring other doctors away from
seeking medical treatment, notes Rhodes. But again, that risk is outweighed by concerns for
patient safety.
The Outcome
Though the anesthesiologists condition was treatable, his doctor told him it was serious
enough that he could not honor his privacy if the anesthesiologist did not notify his chairman.
The anesthesiologist did and subsequently resigned his position. A note in his file ensured that
this information would be forwarded to any hospital he might apply to for a position. It would
be up to that hospital to further evaluate the anesthesiologist to see if he was capable of
working safely with patients.
Case No. 2: A family fights over continuing their mothers
care.
Amother of four children entered the hospital after suffering a
massive stroke and was put on a ventilator. Doctors believed
that she would not regain brain function. One of her sons got
to the hospital first and told doctors that should his mother
suffer heart failure or any other irreversible complication, no
measures should be taken to save her life. Doctors worked
under that assumption until one of the womans daughters arrived and claimed that her
brother wasnt interested in helping their mother. He had pushed to put their mother in a


nursing home, the sister said, and added that she wanted to do everything possible to extend
her mothers life. The mother was widowed and hadnt specified which of her children was to
make decisions on her behalf. Doctors had to choose whose wishes to follow.

The Issues
Without a spouse involved, the responsibility for end- of-life decisions falls on a patients
children, and without a designated health-care proxy in place, all the children hold equal
weight. In cases like this, doctors have to focus on what the patient, not her children, would
want, says Nancy Dubler of Montefiore. That means looking for examples of substituted
judgment, or statements that the patient may have made that give clues about her wishes. If,
while watching ER, say, the mother had commented that she would rather be unplugged than
be kept in a vegetative state, that sentiment would hold more weight than any of her childrens
opinions on the matter. Everyone should be asked to contribute recollections about her, says
Dubler. What was her relationship to medical care? Did she express wishes about what she
would want in this sort of circumstance? If no good evidence emerges as to the patients
wishes, the hospitals dispute-mediation team has to step in.
The Outcome
Until the legal and ethical issues could be resolved, the ethics team told the children that a Do
Not Resuscitate order would not be put in place. They also told the children that there was
nothing more that could be done for the mother to reverse her condition. In the course of the
consultation, the siblings discussed how their mother responded to the Terri Schiavo case.
They remembered their mother saying she thought it was terrible. They should let that girl
die in peace, they recalled her saying. Everyone, including the sister who had initially
rejected the idea, agreed that the mother should not be resuscitated in the case that her heart
failed. She died shortly thereafter.
Case No. 3: A girlfriend wants to retrieve her dying
boyfriends sperm.
A25-year-old man was out drinking with friends when he fell
and hit his head on the bar. He was rushed to the hospital,
where doctors discovered he had severe swelling and
bleeding of the brain. Before the doctors declared him legally
brain-dead, the mans girlfriend arrived and asked for a
testicular biopsyshe wanted to retrieve his sperm before he
died so she could conceive his child. The doctors had to decide whether the patient would
have granted her request.

The Issues
The first thing to determine, the ethicists agree, is whether the man has an end-of-life plan in
placeand if so, whether it mentions anything about his girlfriend. Since the man had no
such plan, the question becomes, Was there any reason to believe he would have given her his
sperm? The girlfriend would have little claim to the patients sperm, says Rosamond Rhodes
of Mount Sinai, unless theres compelling evidence about this mans desire to participate in

his own posthumous reproduction. If there is a written document about it, for example, or if
the man had been discussing IVF before his death, the girlfriend might have the right to a
retrieval. But even if the girlfriend suddenly remembered a conversationIf I pass out
drunk one night and hit my head, you can have my spermthat doesnt mean physicians
must accept this as clear evidence of a patients wishes, says Nancy Berlinger of the
Hastings Center. Of course, the request would be stronger coming from a wife, or some other
person to whom the man (and his estate) is already legally bound. For all these physicians
know, the girlfriend is hoping to secure a piece of the patients estate by producing an heir,
says Berlinger.
The Outcome
Because there was no end-of-life plan in place, the final decision fell to the mans family, who
were initially open to the retrieval as a way to continue their sons legacy. The ethics team
met with the girlfriend and family and explained their concerns about the girlfriends request.
They also suggested that another way of giving new life was through organ donation. The
patient was officially declared brain-dead later that day. The girlfriend and parents thought
about the decision overnight and came to the conclusion that they didnt want to harvest the
sperm. Instead, they consented to organ donation, and aCase No. 4: A man dying of AIDS
doesnt want his family to know of his disease.
Aman managed to live with HIV and aids for fourteen years
without revealing his condition to his family. He was
admitted to the hospital with pneumonia, and instructed his
doctors not to disclose his illness to his family or friends. His
condition rapidly deteriorated, and he fell into a coma.
Several family members arrived at the hospital, including the
patients brother, who was his health-care proxy agent. Were
the doctors obligated to honor the patients wishes, or should they have informed his brother
of his condition?

The Issues
The duty to maintain confidentiality is a strong but not absolute principle, says Dan
Sulmasy of St. Vincents. In this case, that duty has to be weighed against the possibility that
telling the brother might influence the treatment choices he makes on the patients behalf.
Say, for example, the man had misled his family into thinking he had cancer or diabetes,
leaving the proxy to push for a course of treatment that would be futile. Several ethicists
believe that by selecting a proxy, the patient designated at least one person to make decisions
for him, and that person (and that person alone) should therefore be informed about his
disease. I think if we expect the health-care agent to act on his behalf, the agent needs to
know his condition, says Kathleen Powderly of the SUNY Downstate Medical Center. But
thats not an absolute principle, either. If the patient has only 24 hours to live, there would be
little reason to disclose his condition and go against his wishes; his health-care proxys
decisions would be immaterial. But if doctors think there are still viable options to prolong the
patients life, then informing the proxy would become more important.

The Outcome
New York State has especially strong confidentiality laws pertaining to AIDS. Under those
codes, doctors are required not to disclose a patients condition unless they have reason to
believe he may have infected others. Because no person was known to be at risk of
contracting the virus in this case, the hospitals ethicists, lawyers, and doctors agreed that the
family didnt need to know that the patient had AIDS. They told the family that the patient
was suffering from an underlying fatal disease that they were not at liberty to disclose.
fter the ventilator was discontinued, the mans organs were transplanted into four people.
Case No. 5: A dying homeless man refuses treatment.
Ahomeless man entered the hospital with chronic gangrene,
osteomyelitis, and diabetes. Doctors could tell that he had a
psychiatric condition, but the patient refused to have
interventions of any kind; he didnt allow doctors to treat him
with medication or submit to a psychiatric evaluation. He
claimed to want simply to be fed, given his insulin, and given
a bed. He was also difficult with the nurses, throwing urine at
them and making them generally uncomfortable. Doctors tried to coax him into accepting
intravenous antibiotics, but he refused. The choice: send him back to the street, a possible
violation of the First do no harm oath, or seek a court order declaring the man incapable of
making decisions for himself, essentially forcing him into the doctors care.

The Issues
For a busy staff dealing with an uncooperative patient, the instinct might be to send him back
to the street. But theres no gray area here: Discharging this very sick man to the street to die
is ethically unacceptable, says Nancy Dubler of Montefiore. The dilemma becomes how to
respect the patients desires and treat his illness. A patient has a right to be mentally ill, says
Nancy Berlinger of the Hastings Center, but we dont want a mentally ill person to suffer
because his illness tends to make him say no. Doctors have to determine if the man can make
his own decisions; if not, a surrogate must be found. In this case, psychiatrists can be called
in, even against a patients wishes. Under New York law, patients certified by two
physicians to be a danger to themselves or others can be held against their will in a psychiatric
unit, says Deborah Korzenik of Beth Israel. A court order can then be obtained to treat the
mental illnesses. In the best-case scenario, the man would respond to that treatment, then
agree to medical care. If he still refuses, doctors can seek another court order to appoint a
surrogate to oversee his continued care.
The Outcome
The ethics team enlisted the help of a psychiatrist to determine whether the patient had
decision-making capacity. She was able to have a conversation with the patient that made
clear he was not capable of making decisions. During that conversation, the man allowed
doctors to call his mother. She confirmed the mans mental illness and encouraged the
hospital to force him into care. The hospital sought, and was granted, permission to treat the
man against his will. After seven weeks of medical and psychiatric treatment, he was released

into a chronic-care facility under the supervision of his doctor, who continued to act as his
surrogate.
Case No. 6: A woman with terminal cancer tries to
commit suicide but fails.
A58-year-old woman with terminal cancer had already made
one suicide attempt. When friends didnt hear from her for a
few days, they called her buildings superintendent, who
found her alive but barely breathing. She was taken to the
hospital, where she was put on a ventilator and slipped into a
coma. She didnt have a living will, but her health-care proxy
asked doctors to discontinue the ventilator to finish the suicide. Clearly, the proxy reasoned,
the patient didnt want to live. Doctors had to consider whether by doing so they were simply
withdrawing extraordinary means or committing an illegal act by assisting suicide.

The Issues
Suicide attempts can create especially tricky ethical situations because they raise complicated
questions about a patients intent. In a case like this, the patients suicidal behavior cannot
automatically be considered an expression of her true wishes, because her actions to harm
herself were potentially related to her depression, says Deborah Korzenik of Beth Israel.
Assisted suicide is also illegal in New York State; doctors therefore cant participate in
finishing the suicide. Instead, they have to figure out what course of action the patient
would have wanted. Doctors tend to balk if they feel like theyre aiding a suicide, says Nancy
Dubler of Montefiore Medical Center. Their objections are heartfelt, she says, but they must
put these feelings aside. The point isnt to assist or not assist a suicide; its to respect the
wishes of a previously capable patient.
The Outcome
When the patient arrived at the hospital, doctors were not fully aware of the extent of her
cancer or the brain damage from her suicide attempt. They therefore decided to leave her on
the ventilator until they could determine whether her situation was reversible and what her
previously stated wishes were, if she had made any. According to the proxy, the patient had
stated that life with incurable cancer wasnt worth living. It is therefore easy to imagine that
she would find life with brain damage and cancer to be even less worth living, says
Rosamond Rhodes of Mount Sinai. Once the doctors learned the full extent of the damage
that she was experiencing organ failure and other irreversible problemsthey reasoned that
they were simply prolonging her inevitable death. Removing the ventilator would not be
assisted suicide, but rather a fulfillment of her end-of-life wishes. The proxy was informed
and assented. Before the ventilator could be removed, the patients heart stopped, and she was
not resuscitated.