CASE TEACHING NOTES
for
“Shannon and Jake: An Application of Medical Ethics Principles”

INTRODUCTION / BACKGROUND

The Ohio State University medical school curriculum includes a two-year course titled “Patient Centered Medicine.” The course is structured around different content areas, such as ethics, palliative medicine, professionalism, violence, sexuality, addiction, etc., and is a mix of lectures and small group sessions. This case has been used in the course to teach first-year students the basics of medical ethics. Before working through this case, the students have had an introductory lecture covering basic ethical principles and should be ready to apply those principles to “real life” medical situations.

Objectives

After completing this case, students will be able to:

• Discuss the choices that the doctor in the case could potentially make, using the ethical principles of autonomy, beneficence, non-maleficence, and justice.
• Develop a rationale for the physician acting according to one of the ethical principles identified, and prepare a debate for the class supporting the rationale.
• Explore potential legal issues related to this case, and discuss the physician’s approach to these issues.

BLOCKS OF ANALYSIS

Medical ethics training involves the exploration of four major ethical principles (Erlanger Medical Ethics Orientation Manual. 2000; McCormick 1998). These principles help guide a physician’s behavior and response to various situations in the medical setting. The four principles are outlined and defined below:

• Non-maleficence: Physicians should not make decisions resulting in patient harm, either through acts of commission or omission. Historically, this has been the premier medical principle: “Above all, do no harm.”
• Beneficence: This concept involves the physician making the decisions that are best for the patient, without regard to personal gain or the interests of others. This concept can be applied to individual patients or to society as a whole.
• Autonomy: This concept is based on the principle of respect for others, and the idea that people should make their own independent decisions. Of key importance is that the patient understands the consequences of his/her decisions, and makes choices without controlling influences that would limit voluntary action. In healthcare, this often relates to “informed consent.”
• Justice: This concept involves the blending of ethical and legal principles, and is usually defined as a form of “fairness.” In addition, it involves physicians following the law when making decisions.

The students working through this case can apply any of the ethical principles, individually or in combination, to determine what the physician should do. However, each principle, when applied, may lead the physician to a different decision.

• Non-maleficence: The principle of non-maleficence is seen as a constant duty for physicians. The physician using non-maleficence as a decision-making principle will be most concerned about causing harm or injury to the patient. In fact, it is considered negligence if a physician imposes unreasonable risk or harm. In terms of this case, by not counseling Shannon on responsible sexual behavior, the physician would be opening the door to other sexually transmitted infections, potentially with long-term or fatal consequences. The physician may apply this principle to society at large in addition to the individual doctor-patient relationship. For example, the character’s boyfriend in this case has an untreated sexually transmitted infection (STI). He is putting others in society, including Shannon, at risk. The physician may feel that “doing no harm” means giving Shannon medication to give to her boyfriend and potentially save others. Alternatively, the physician may feel that the biggest “harm” in this case is the fact that Shannon is sneaking out of her house to defy her parents and their rules. He may notify the parents of Shannon’s actions so that they can watch her more closely, thus avoiding harm in the future. It is important to note that societal norms and standards of care are guidelines when considering non-maleficence. Therefore, the physician must consider these norms and standards when acting to guide what he or she thinks is best.
• Beneficence: The physician using beneficence as a guiding principle will try to do what is best for the patient and or society as a whole. However, what the patient thinks is “best” may be different than what the physician thinks is “best.” The physician may think that it’s best for the patient to eliminate her exposure to pregnancy or sexually transmitted diseases, and therefore may counsel the patient to abstain from sex until married. Alternatively, the physician may feel it’s best for the patient to have an open and honest relationship with her parents, and may therefore counsel the patient to discuss the situation with them. The physician may feel that a discussion on responsible sexual behavior is in the patient’s best interests. The physician may feel that it’s best for the patient to end her relationship with the older man, and may counsel in that regard.
• Autonomy: The physician using autonomy as a guiding principle may decide that Shannon needs information on responsible sexual behavior. But, once given this information, she is free to make her own decisions and live with the consequences. Using this principle, personal viewpoints of the parents and physician should not enter into the physician’s decision.
• Justice: The physician using justice as a guiding principle may be most concerned with the fact that the character in the case is a minor and the person she is seeing is over the age of 18. The physician may choose to notify the police or Shannon’s parents in order to ensure justice is done. Of course, this course of action depends on specific laws regarding emancipated minors in the location where the physician practices. Justice as a guiding principle has also been associated with fairness, especially in medical situations where limited resources are an issue.
• Conflicting principles: In some situations, principles may conflict. For example, if a physician has a patient with liver failure, the beneficence principle may indicate that he/she should have a liver transplant. However, there are a limited number of livers available for transplant. Transplant banks have developed a system, based on the justice principle, which rank-orders patients for transplant based on the severity of their illness and other factors. In this case, non-maleficence may lead a physician to protect Shannon from the risks she faces. However, as a teen like Shannon reaches adulthood, the principle of autonomy must also be considered, leading her physician to inform Shannon of her risks and let her make her own decisions. Conflicts like these are common, and physicians must navigate the complex legal, societal and ethical landscape when making treatment decisions and choices.

CLASSROOM MANAGEMENT

Prior to working through this case, the students must be familiar with the principles of medical ethics. This background information may be given in a lecture format, through a reading assignment, or in a self-study format via the web. The students should come to class ready to apply the ethical principles.

This case is intended for a group of 16 to 24 students. Within the class, the students should further break into four smaller groups of between four and six students. This is easily accomplished by assigning the smaller groups before the class, or counting the class off by “4’s” and putting all the 1’s together, 2’s together, and so on.

A selected student may then read the case aloud to the class. Once the reader is finished, the group facilitator should ask all the students to brainstorm some of the actions that the physician might pursue in this case. Let the students know that they do not necessarily have to support the actions, but this is just brainstorming possible alternatives. This exercise should take no more than three to five minutes. Specific examples include:

• Counsel Shannon on responsible sexual behavior.
• Give Shannon the number for the free clinic to get free condoms and birth control pills.
• Give Shannon medications to give to her boyfriend so that he is treated.
• Ask Shannon to make an appointment for her boyfriend to see you.
• Call the police, or children’s protective services, to report the rape of a minor.
• Call Shannon’s parents and let them know about Shannon’s diagnosis.
• Ask Shannon to tell her parents about her activities.

Then, the facilitator should assign each of the smaller groups one of the ethical principles:

• Group 1: Autonomy
• Group 2: Beneficence
• Group 3: Non-maleficence
• Group 4: Justice

Give each small group 10 minutes to engage in a two-part task:

1. Ask each group to apply their assigned ethical principle to the case and determine physician actions based on that principle. Each group should be prepared to report and defend their decisions to the larger group.
2. Each group should then discuss how they anticipate Shannon would react to the decision. Additionally, they should discuss how they anticipate Shannon’s parents would react to the decision.

After 10 minutes, ask each group to appoint a spokesperson to present their group’s discussion to the rest of the class. The facilitator can list each principle on a board or flipchart, with the actions that the physician will take below the principle. For example:

• Autonomy
  
  • Counsel on responsible behavior
  • Offer birth control pills
  • Etc.
• Beneficence
  
  • Direct Shannon to free condoms
  • Counsel Shannon to end the relationship with Jake
  • Etc.
• Non-maleficence
  
  • Treat Jake for Chlamydia
  • Counsel on responsible behavior
  • Etc.
• Justice
  
  • Tell Shannon’s parents
  • Find out Jake’s address and report him to the police
  • Etc.

This task should take no more than five minutes.

Questions in the Classroom

Once the principles and actions are listed on the board or chart, have the class as a whole discuss the conflicts that are apparent based on the different principles involved in directing the physician’s actions. This discussion may take just a few minutes or may be a lengthier exercise, based on classroom time or the divergent opinions of the students in the class. The following questions may guide the discussion, but the facilitator may have the students ask their own questions and follow up with discussion.

• Which ethical principle is the most important (is non-maleficence the over-riding principle? Is autonomy? What about the others?)? How might you rank the principles based on importance?
• As a physician, what if what you think is “best” is different than what your patient thinks is “best”? How would you resolve that conflict?
• Who is your patient? Shannon? Her parents? Society?
• How would you counsel a patient who is doing something that you feel is wrong (for example, if you believe pre-marital sex is wrong, how would you counsel Shannon)? How do you balance your personal “ethics” with medical ethics?
• If you keep the visit with Shannon a secret from her parents, but then her parents find out (insurance explanation of benefits form, receipt from the office, etc), how would you approach that situation with the parents?

Closure

In closing, the facilitator may wish to summarize the ethical principles and recap decisions that could be made based on each. The facilitator should stress that when dealing with ethics, there may not be one “right” answer—and dealing with ambiguity is often a part of medical practice. Also, it should be stressed that although there may be several “right” answers, there are also several “wrong” answers based on standards of care, societal norms, and the interplay between the ethical principles.

REFERENCES

• Erlanger Medical Ethics Orientation Manual. 2000.
  http://www.utcomchatt.org/Docs/biomedethics.pdf
  Last accessed: 12/21/05.
• McCormick TR. University of Washington School of Medicine: Principles of Bioethics. 1998.
  http://eduserv.hscer.washington.edu/bioethics/tools/princpl.html
  Last accessed: 12/21/05.

Acknowledgements: This case was developed with support from the National Science Foundation under CCLI Award #0341279. Any opinions, findings and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the National Science Foundation.

Date Posted: 01/06/06 nas

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