Exam 2

Question 1

o Passive: another person withholds or withdraws life-sustaining treatment allowing the patient to die as a result of the underlying illness
o The patient explicitly chooses this; clearly their desire
o Direct permission either in a living will or in person

Answer 1

Voluntary passive euthanasia

Question 2

o Passive: another person withholds or withdraw life-sustaining treatment allowing the patient to die because of the underlying illness
o The patient is unable to communicate her/his wishes, so someone else makes the choice on the person’s behalf and in their best interest

Answer 2

Non-voluntary passive euthanasia

Question 3

o Active: another person administers a lethal dose or otherwise does something to directly cause the patient’s death
o Another person does something to end the patient’s life on their request
o Considered similar to murder and against the law

Answer 3

Voluntary active euthanasia

Question 4

o Active: another person administers a lethal dose or otherwise does something to directly cause the patient’s death
o The patient is unable to communicate her/his wishes, so someone else makes the choice on the patient’s behalf

Answer 4

Non-voluntary active euthanasia

Question 5

o A physician provides the means for the patient to actively bring about his or her own death
o Basically, the physician prescribes a drug and the patient takes it themselves
o This can only be voluntary!

Answer 5

Physician aid in dying (referred to in the text as Physician Assisted Suicide)

Question 6

o If an action has two likely consequences (one good and one bad) the morality is determined by the agent’s intent
o Comes up often in hospice care and the distribution of morphine and pain killers

Answer 6

Principle of Double Effect

Question 7

o Mainly to see if something is justified if the intent was for good, but had bad consequences.
o EX: using morphine to relieve pain even though it can cause death

Answer 7

How is the principle of double effect applied in end-of-life care?

Question 8

The principle of non-maleficence is fundamental to a physician’s professional duty. In arguments regarding PAD, however, both sides appeal to this principle in the context of professional duties in support of their positions. Explain how each side (the pro and the con) apply non-maleficence in support of their positions on PAD

Answer 8

o PRO:
Duties of the doctor to alleviate suffering
By ignoring and refusing this is considered abandonment
o CON:
Primary job of the doctor is to care for the patient, not end their life
• This can be considered abandonment too

Question 9

• According to Angell (in “The Supreme Court and Physician-Assisted Suicide – The Ultimate Right”) how is assisted suicide sharply contrasted with both active and passive euthanasia? (see p56, column 2)

Answer 9

o The sharp contrast is voluntary vs. non-voluntary
o With euthanasia someone else shuts off the machine or injects the medication so this can be questioned if it was voluntary or non-voluntary. With PAS since it has to be self-administered therefore it is always voluntary

Question 10

• Angell argues that the “overriding duties of doctors to relieve suffering and to respect their patients’ autonomy” (p56, c1) outweigh the objections to PAS, and therefore PAS should be legal in certain circumstances. In her argument, she considers and rejects the several objections to PAS, including the following:

Answer 10

 “Assisted suicide is not necessary. All suffering can be relieved if care givers are sufficiently skillful and compassionate, as illustrated by the hospice movement.” (p57, c1)
 Suffering can be relieved: if expert palliative care were available then there would be fewer requests for PAS
 There will always be a few patients whose suffering cannot be adequately alleviated and others who prefer suicide over other means available
 “Permitting assisted suicide would put us on a moral ‘slippery slope.’” (p57, c1)
 Slippery slopes are unavoidable
 Need to make sure PAS is voluntary and the request is thoughtful and made freely
 “Assisted suicide would be a threat to the economically and socially vulnerable.” (p57, c1-2)
 Some may be coerced into doing this by family or doctors but this is at least as likely when it comes to withdrawing treatment
 The question is not about whether a perfect system can by devised, but whether abuses are rare
 “Doctors should never participate in taking life.” (pp57-58)
 Doctors should be committed to life; PAS violates the profession’s mission
 The highest ethical imperative of doctors should be to provide care in whatever way best serves the patient’s interest, in accord with each patient’s wishes, not with a theoretical commitment to preserve life no matter what the cost in suffering.
 “People do not need assistance to commit suicide. With enough determination, they can do it themselves.” (p58, c1-2)
 Most patients who are at the end of life are unable to commit suicide and need assistance
 Angell tells the story of her own dad committing suicide, saying that if PAS was legal he would have chosen that
For each of the objections listed above, explain both the objection (how is that reason used in an argument against PAS) and Angell’s response (why, according to Angell, is that reason not a strong argument against PAS).

Question 11

• Foley (in “Competent Care for the Dying Instead of Physician-Assisted Suicide”) argues that “Physicians do not know enough about their patients, themselves, or suffering to provide assistance with dying as a medical treatment for the relief of suffering.” (p63, c1-2) How does she support the components of this claim? (explain her arguments)

Answer 11

o The lack of education and training for end of life care
 It’s not a big part of medical school
o There is more than physical pain that these patients are going through

Question 12

• Explain why Foley thinks that legalized PAS would undermine care for the dying.

Answer 12

o If PAS was legalized it violate and undermine the respect for life perspective
o If PAS was legalized there wouldn’t be much incentive to care for the dying

Question 13

Based on the text and class discussion, explain what you take to be the strongest reasons both for and against legalizing physician assisted suicide.

Answer 13

FOR:
• The patient won’t have to endure the pain of dying from serious illnesses
• Patient has the right to choose (autonomy)
• Even with good palliative care some suffering cannot be alleviated
• If it’s not legal, some people will end their own lives in a violent way or prematurely
• Duties of the doctor to listen to their patients wishes and alleviate pain and suffering
AGAINST:
• Lack of education when it comes to end of life patients; they don’t know enough to justify participating
• Slippery slope will lead to abuse of the vulnerable
• How do you know if it’s out of depression or not?
• Fundamental duty of doctors is to save/prolong life
o To aid in dying is violating nonmaleficence
o If you help them die, you are abandoning your patient

Question 14

What ethical principle (or principles) supports the claim that access to healthcare is a basic human right?

Answer 14

o Respect for persons

o Respect for life

Question 15

Explain the connection between the right to life and the right to health care.

Answer 15

o Right to life:
 Right to be treated with respect and dignity
o Right to health care:
 Assuring all people have their basic needs met
 Food, shelter, water, health care
o Access to health care and basic quality of life coexist

Question 16

Explain three reasons why access to emergency rooms does not provide adequate access to healthcare for people who are uninsured. (ER= assess and stabilize)

Answer 16

o Don’t provide follow-up care
o Don’t provide access to maintenance care
o Don’t provide access to preventative care
o Are required to see anyone who walks in the door, but only until they are stabilized

Question 17

Explain the difference between a single-payer system and a multi-payer system for healthcare. Which type of system does the US have under the Affordable Care Act?

Answer 17

o A lot of the countries that have universal coverage have a single-payer system.
 System in which the state, rather than private insurers, pays for all healthcare costs
o In the US, we have a multi-payer system
 Two or more providers administer insurance and are usually in competition with each other
 Private health insurance

Question 18

Identify 3 aspects of The Patient Protection and Affordable Care Act (ACA) that were intended to provide better access to health care in the US.

Answer 18

o Young adults (up to age 26) can stay on their parent’s coverage
o Income-based subsidies
o Gender-neutral pricing
o Basically trying to make sure everyone is covered by something

Question 19

What are “healthcare exchanges” (a.k.a. marketplaces)? How are these exchanges related to access to healthcare?

Answer 19

o Aspect of the Affordable Care Act to make it easier for people to pay for their own health insurance
o Healthcare exchanges (marketplaces)
 Set up for the people that don’t get health care insurance through their employers
 Places to compare plans
 Gives you the subsidies (how much the government will cover)
o Related to access
 Supposed to make it easier to compare and more affordable

Question 20

Explain what is meant by health disparities and healthcare disparities. What ethical concerns are raised by these disparities?

Answer 20

o Disparities: when there are sufficient outcomes between groups
 People who are insured vs. people who aren’t insured
o Health disparities: differences in health, itself
o Healthcare disparities: differences in access to health care
o Ethical Concerns:
 Justice

Question 21

Negative rights are rights against interference (e.g., freedom of speech, freedom of the press, freedom of religion, right to privacy). Positive rights are rights that impose a specific duty on some person or entity (e.g., right to education)

Answer 21

o Explain the difference between positive and negative rights and explain how this distinction, =when considered in terms of the “right to healthcare” is related to the discussion of whether the government (or some other entity) has a responsibility to ensure universal access to healthcare.
 Negative rights are sort of a hands-off
• Government cannot interfere
 Positive rights imply that there is some obligation that comes with the right
• EX: right to education; acknowledging the responsibility to provide the means for educationgovernment pays for the building, teachers, books (until college)
 Right to healthcare
• Negative: everyone has a right to health care
• Positive: someone is obligated to provide it; just don’t know who yet

Question 22

In the US, we have great facilities and highly trained professionals; yet many people don’t have access to regular preventative and maintenance care. Based on the lecture, online resources, and class discussion, explain at least two reasons for this lack of access in our current system.

Answer 22

o Access to health insurance
 Not everyone can afford health insurance and this is your entry into most healthcare
o Demographics (your location)
o Ability to pay

Question 23

Some reasons against the claim that government should ensure that everyone has access to basic healthcare include:

Answer 23

o It would be too costly
 People can’t afford it
 It would cost too much to cover everyone
o It would reduce the quality of care for those who currently have access.
 If everyone had access, there would be problem with resources
 Might not have enough time with their doctors, so increase in waiting time
o It is not fair that people who have more have to pay for people who have less.
 Why should my taxes pay for other’s health care
 I work hard to provide for my family, why aren’t other people
o Explain one response (or counter-argument) to each of the claims listed above.
 1. If everyone had access to care then in the long run it will reduce cost since there won’t be a need for expensive care;
 2. More mid-level providers, EX: PA who can help provide the basic care
 3. If people had access they would be able to contribute more which would reduce the burden; the nature of the economy or nature of the jobs won’t let them afford it (they’re still working hard)

Question 24

Some reasons in favor of the claim that government should ensure that everyone has access to basic healthcare include:

Answer 24

o Respect for persons includes ensuring all people have basic needs, including access to basic healthcare, met.
 Everyone has the right to life and that coexists with healthcare
o Increasing access to preventative and maintenance care will reduce the overall costs of healthcare.
 Fewer people needing to go back to the hospital
o Reliable access to care will allow people to get well faster and be healthier thus allowing them to continue working.
 This would help contribute to society therefore putting money back into the economy
o Explain one response (or counter-argument) to each of the claims listed above.
 1. Costs; can’t afford to add just everyone
 2. Limited resources
 3. The illegal immigrants are stealing citizens jobs

Question 25

In “Survivors – Dialysis, Immigration, and U.S. Law” Raghavan and Nuila argue that restricting undocumented immigrants’ access dialysis to emergency treatment is “good for nobody” (p230, c1) – how do they support this claim? What conclusion do they draw about access to care for undocumented immigrants with renal disease based on these considerations?

Answer 25

o If these people are getting regular care, then some of them would be able to work and be more positive contributors to society
o It costs more for emergency treatment than regular scheduled dialysis
o They usually wait until they are extremely sick to go to the ER

Question 26

In “Toussaint v. Attorney General of Canada” Stratas argues that the decision to refuse to provide non-emergency treatment for the appellant is not a case of unjust discrimination because the appellant does not fit the standard of “enumerated or analogous grounds” – how does he defend this claim? (see p232, paragraph [99] and p233, paragraph [104])

Answer 26

o It’s not unjust to exclude someone because of their immigration status
 Something they actually have control over
o Conclusion: they are justified in refusing treatment to the women

Question 27

In both the “yes” and “no” articles in this section the authors mention concerns about being perceived as a healthcare “safe haven” (see p230, middle of c1 and p234, c1).

Answer 27

o Explain how this concern is used in an argument against providing access to non-emergency healthcare for undocumented immigrants.
 If people in other countries see the US provide free healthcare they will come
 The concern would be that it would encourage people to come to the US illegally and they would be sick so they couldn’t contribute by working
o Explain how one might respond to (or counter) the argument above.
 The majority of people are coming here in seek of opportunities

Question 28

Based on the text and class discussion, explain the strongest arguments both for and against the claim that undocumented immigrants should have access to healthcare in the U.S.

Answer 28

FOR:
• The principle of human dignity and respect for person
o All lives have value
• Reliable access reduces cost
• Healthier people can work and contribute to bettering society
AGAINST:
• Costs
o Cant afford it and adding people will increase the cost even more
• Resources are limited
• People who are paying taxes and working hard would be spending their money for people who aren’t doing anything to help society and the economy
• Avoid healthcare tourism and heath care safe havens

Question 29

Organ Transplantation is a problem because

Answer 29

(demand is much greater than supply)

Question 30

No brain function

Answer 30

Brain death

Question 31

Irreversibly stopped heart

Answer 31

Circulatory (aka Cardiac) death

Question 32

Donation after death

Answer 32

Cadaveric donation

Question 33

Living donation

Answer 33

Donation from the living (donating a kidney)

Question 34

Presumed consent

Answer 34

o Donation after death

o Automatically a donor unless explicitly opt out

Question 35

What is the main source of the ethical issues related to organ transplantation?

Answer 35

o The supply and demand issue
 So much demand for organs but we don’t have enough to go around
 The gap just keeps growing larger and larger

Question 36

In Nebraska, under what circumstances would the closest relative have the final say with respect to whether a deceased (or dying) loved one will be an organ donor?

Answer 36

o Donation after death
o 18 or older:
 Only can make the choice if you AREN’T on the donor list
 If checked yes on your driver’s license, that is the final say in Nebraska

Question 37

What solid organs can be donated from a living donor?

Answer 37

o It’s pretty limited:

 A kidney, lobe of liver, lobe of lung (sometimes)

Question 38

Why are hospital staff personnel not allowed to approach patient families about donation after death?

Answer 38

o It doesn’t come across very well. They can’t approach due to conflict of interests; they are supposed to be focused on doing whatever it takes to keep the patient alive. So, if a doctor asks about donation is makes it seem like they didn’t try hard to keep that person alive. Hospitals bring in organ donation organizations (3rd party) to talk to the family

Question 39

Using the video “The Cruelest Cut: Pakistan’s Kidney Mafia” for illustration, explain the ethical concerns raised by an unregulated market in organ sales.

Answer 39

o Concerns related to the mistreatment of the vulnerable populations
o Not the proper information is giving so their consent isn’t informed
o There wasn’t any follow-up care

Question 40

According to Satel (in “Kidney for Sale: Let’s Legally Reward the Donor”) what effect would a regulated market for kidney sales have on organ trafficking and illicit markets? How does she support this claim? (see p261, c2)

Answer 40

o The black market is bad
o Out-lawing this will not make it go away; we need to make a legal market
 People are going to other countries for organs
 People are still selling illegally or doing it for cheaper because of no taxe

Question 41

Satel suggests that “many people are uneasy about offering lump-sum cash payments.” (p262, c1)

Answer 41

o Explain why people are uneasy about lump-sum payments.
 May cause people to donate for wrong reasons
 Could violate the respect for human dignity
o What alternatives for compensation are suggested by Satel?
 Thought about offering other incentives
• EX: down payment on house; full college tuition paid for
o In your opinion, would these alternative forms of compensation avoid the concerns raised by lump-sum cash payments? (explain why)
 No, I don’t think so. These are all temporarily compensations. This type of balance will only have people asking for more

Question 42

In “Organ Donation: Opportunities for Action” the authors raise the issues of distributional inequity and imperfect information with respect to sales from live donors. (pp263-264)

Answer 42

o Explain the ethical concerns related to “distributional inequity.”
 All related to the nature of the market
 The poor will most likely donate and the wealthy will receive
o Explain the ethical concerns related to “imperfect information.”
 The donor may not know the extent of the surgery or consequences
 The recipient might not know the extent of where the organ is coming from or how it became available

Question 43

Explain two of the concerns about purchasing organs from dead donors raised by the Institute of Medicine Committee on Increasing Rates of Organ Donation in the article “Organ Donation: Opportunities for Action.

Answer 43

o If paying for dead donation, you are either paying before the death (future market) or you are paying the family after death (undermines human dignity and looks sketchy)
o Family may be more likely to be coerced into pulling the plug

Question 44

Explain what you take to be the strongest ethical reasons both for and against the creation of a regulated market for human organs in the US.

Answer 44

FOR:
• A form of payment would increase the number of organs
• The only way to stop black markets is to create legal ones
AGAISNT:
• Vulnerable people will be coerced
• Lack fully informed choices and consent
o People might not be thinking of the long term implications
• Too complicated to adequately regulate

Question 45

Explain what protections would have to be enacted to ensure an ethical market for human organs.

Answer 45

o In-kind rewards rather than case
 EX: Down payment on a house
o Guaranteed follow-up care for any complications from donation
o Create systems for screening and fully informing potential seller
o Special protections for children and the vulnerable populations