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Great moments in medical ethics teaching.

"I have an ethical problem with one of my patients," said Dr. Russell toward the middle of the weekly ethics conference. Dr. Russell is extraordinarily alert at all times (not always the case among the ICU house staff and medical students, who are often running on less than half a night's sleep and use the ethics conference to catch a few Zs). He is not only alert; he also appears to be intensely interested in everything that happens, everything that everyone says, although he does not himself talk much. But he makes a lot of eye contact.

I invited Dr. Russell to tell me about his problem and he proceeded to describe his case:

"The patient is a fifty-one-year-old woman with metastatic breast cancer. She has been kept alive for the past five months primarily with experimental treatments, but there's really nothing left for her to try. She's been in the unit for three days now and she drifts in and out of consciousness, but even when she's conscious, she's minimal."

"Yes," I said encouragingly, letting him know I was listening, doing my own eye contact.

"Well," he continued, "she has this boyfriend, this fiance. They've been together for seven or eight years. And she has this son who is some kind of fugitive...drugs, apparently. He's some kind of no-goodnik. And she has an ex-husband who is going into her house while she's in the hospital and walking out with furniture and stuff

"Yes," I said, a little less encouraged. This case is beginning to sound like a daytime soap.

"Well, the patient and the fiance were going to get married. He says that was really important to her-that she knew she was going to die but she wanted them to be married before she died. Except they hadn't done it yet. So he comes in here every day with this marriage license that he wants her to sign. And also, she wrote a new Kill. Well, an attorney wrote the will, but I guess he didn't get it done as fast as he was supposed to and she was supposed to sign it last Friday, but that was the day she came into the hospital, so she never got to sign it. So, actually, he comes in here with both these papers that he wants her to sign. He showed them to me and she left everything to him in the will. The fiance comes in real regular and he's always really concerned, and really hopeful, and he says, `I think she's a lot better today, don't you? Don't you think she could sign these papers?'"

There was a distinct pause, with eye contact, indicating that Dr. Russell believed he had now explained his ethical problem to me. I didn't get it, though.

"Well," Dr. Russell paused, apparently trying to articulate the problem in the correct format. "I think it might be in my patient's best interests if I said that she was competent to sign the papers. I think the fiance is really straight and really cares about her, and it was something she really wanted."

I still didn't get it. "Where do you see the conflict?" I added, "Do you think she might be competent to sign the papers?"

"Oh, no," he quickly answered. "She's never been competent to sign anything since she's been here."

So, you would have to say something that wasn't true if you said she could sign the papers?" (I felt like I had been reduced to kindergarten teaching at this point.)

"Yeah, I guess that's it," he pondered. "I guess it would be lying, but it would be lying for her benefit."

Now, in my time I have used deontological and consequentialist analyses to discuss the ethics of truth telling, but today I was inspired to dabble in casuistry, to approach the problem from a paradigmatic case, pace Al Jonsen.

"Well, Dr. Russell," I went on, "I see your conflict. I think we can resolve it if we look at another case. Suppose you had a patient-an outpatient, a clinic patient-who comes to see you and says, `Gee, Dr. Russell, I was going to go to New York last week, but I got really busy and decided just to let it go, but now the airline won't refund the money from my ticket or even rewrite it. I told them I was sick and that's why I couldn't go, and they said I would need a letter from my doctor. So that's the story, and I was wondering if you would write a letter for me to tell them that I was sick last week and then I could get my money back?'"

Without a moment's hesitation, Dr. Russell, ever alert, gave me full eye contact, and said without moral qualm of any son, "Oh, sure. I'd write the letter."

It was at that moment, at 10,000 feet without a parachute, that I first realized the limits of casuistry as a teaching device. -Judith Wilson Ross, Associate Director of the Program in Medical Ethics, UCLA Medical Center.
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Author:Ross, Judith Wilson
Publication:The Hastings Center Report
Date:Jan 1, 1991
Words:847
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