EHS 4

Speaking Supplementary Material

This supplementary material will teach you how to approach, analyze and respond to an ethical
case study in healthcare. You do not need to have deep knowledge of medicine at this stage to
answer these questions.

First, we are going to read one case in which ethics is seriously compromised:

Case 0 (Taken and adapted from Medical Ethics Manual, 2005).

Dr. Snchez is becoming increasingly frustrated with patients who come to her either before or
after consulting another health practitioner for the same ailment. She considers this to be a
waste of health resources as well as counterproductive for the health of the patients. She decides
to tell these patients that she will no longer treat them if they continue to see other practitioners
for the same condition. She intends to approach her national medical association to lobby the
government to prevent this form of misallocation of healthcare resources.

You can see that the case is one paragraph long, and it consists of 4 sentences. Cases are
presented this way for the sake of clarity, specificity and immediacy. Right after you read the
paragraph, you are going to find a question like this:

Question 1 - Do you think Dr. Snchez is acting correctly?

Question 2 - Would you act as Dr. Snchez or differently?
Question 3 - What would you suggest her to do? Would you recommend that she keeps
acting that way? Why or why not?

In order for you to answer this question, you need to identify the key words and terms that
comprise it.

Lets analyze the first sentence. In it you can see that Dr. Snchez is a woman:

Dr. Snchez is becoming increasingly frustrated with patients who come to her either before or
after consulting another health practitioner for the same ailment.

You can see that the sentence states that she is increasingly frustrated with patients. This
statement indicates that the doctor is going through a change in her approach or that she is
becoming more adamant in her position. It is also very important to bear in mind that Dr.
Snchez is a woman, therefore you will need to refer to her when you give your answers.
Therefore, it is very important to listen for *pronouns. Finally, you can see the main idea of the
case consulting another health practitioner for the same ailment.
The sentence that follows supports Dr. Snchezs opinion: She considers this to be a waste of
health resources as well as counterproductive for the health of the patients.
Now you can start to structure your answer. Lets begin with question one:

Question 1 - Do you think Dr. Snchez is acting correctly?

This is a Yes/No question. You can begin your response with a short answer such as: Yes, I do/
No, I dont, but its not necessary. You can begin stating your opinion. To answer this question,
you can use information from the case, plus the expression that corresponds to the question (I
think, I believe). In addition, you will probably need modal verbs** and transition words***.
Your response could look like this:

(No, I dont)
- I think that
o consulting another health practitioner for the same ailment
o shouldnt make**
o her* feel frustrated

Once you have restated the question, you can provide your reasons referring to the supporting
ideas from the doctor. Thus:

- because

- ***First, patients have the right to a second opinion

- ***Second, practitioners can see cases from different perspectives and offer patients a
better-informed diagnosis.
- ***Finally, I dont think consulting different practitioners is a waste of resources because
patients pay a lot of money in their taxes, and therefore they have the right to consult
other doctors. ***Although I believe there should be a limit.

Lets see the different modal verbs, transition words and pronouns. Lets analyze another case.

- Modal Verbs

Modal Verbs are Can, Could, May, Might, Shall, Should, Will, Would, Must. If you dont know
or remember any of these verbs, you can look them up in a dictionary and write one idea with
each so you will remember it.

According to the British Council website, we use modal verbs to show if we believe something
is certain, probable or possible (or not). We also use modals to do things like talking about
ability, asking permission, making requests and offers.
 - Personal Pronouns

There are two kinds of personal pronouns: subject and object.

Subject pronouns are located on the Subject side of the sentence (S V - O), and they are:

I, You, He, She, It, We, They, You

Object pronouns are located on the Object side of the sentence (S V - O), and they are:

Me, You, Him, Her, It, Us, Them, You

- Transition words

You can see them here in detail: https://msu.edu/~jdowell/135/transw.html

Lets analyze the second question:

Question 2 - Would you act as Dr. Snchez or differently?

This is a Yes/No question; therefore, you should respond it with a Yes, I would act differently/
No, I wouldnt act differently type of response. It can be a short answer first, but then you will
need to expand. Imagine you need to answer why. No matter if the teacher does not ask why
explicitly, he or she will be expecting that you elaborate on your response.

An example of a response for that answer could be like:

- Yes, I would act differently.

o I believe that patients have a right to a second opinion
o because they may feel uncertain about the diagnosis
o and they should have the right to confirm that diagnosis

Question 3 - What would you suggest her to do? Would you recommend that she keeps acting
that way? Why or why not?

This is an information question. You need to begin your response with a sentence that responds
information. For example, the following response is a clear, detailed and good suggestion:

- She should ask her colleagues what they think about patients looking for second
opinions and ask them what they think are the pros and cons of this behavior.
Next, you need to address the question Would you recommend that she keeps acting that way?
Why or why not?

To answer this question, you can begin with a sentence that refers to the first question and then
expand on the why/why not. For example:

- I would recommend that she stops acting that way because her patients might perceive
her to be insecure and she doesnt want to feel embarrassed in front of other colleagues
who might think of her as a bad doctor based on a wrong diagnosis. On the contrary, she
should encourage her patients to look for a second opinion, so they will realize she was
right from the beginning and she is a good doctor indeed.

Lets analyze another response. In this one, you are going to underline the personal pronouns,
modal verbs, and transition words that you encounter.

- I believe Dr. Snchez is right to consider the impact on society of her patients behavior.
Even if the consultations with the other health practitioner occur outside of the health
system in which Dr. S works and therefore do not entail any financial cost to society, the
patient is taking up Dr. Ss time that could be devoted to other patients in need of her
services. However, physicians such as her must be cautious in dealing with situations
such as this. Patients are often unable to make fully rational decisions for a variety of
reasons and they may need considerable time and health education to come to an
understanding of what is in the best interests of themselves and of others. She is also
right to approach her medical association to seek a societal solution to this problem,
since it affects not just herself and this one patient, but other physicians and patients as
well.

Those were examples of two complete and good responses for one case.

Now, lets analyze another case:

Case 00 (Taken and adapted from Medical Ethics Manual, 2005).

Dr. Cox, a newly appointed anesthetist in a city hospital, is alarmed by the behavior of the senior
surgeon in the operating room. The surgeon uses out-of-date techniques that prolong operations
and result in greater post-operative pain and longer recovery times. Moreover, he makes
frequent crude jokes about the patients that obviously bother the assisting nurses. As a more
junior staff member, Dr. Cox is reluctant to criticize the surgeon personally or to report him to
higher authorities. However, he feels that he must do something to improve the situation.
Again, here we have a one-paragraph, five-sentence case. Lets analyze this case:
Sentence one: Dr. Cox, a newly appointed anesthetist in a city hospital, is alarmed by the
behavior of the senior surgeon in the operating room. This sentence presents the context of the
case.

Sentences two and three: The surgeon uses out-of-date techniques that prolong operations and
result in greater post-operative pain and longer recovery times. Moreover, he makes frequent
crude jokes about the patients that obviously bother the assisting nurses. These sentences present
the details of the case.

Sentences four and five: As a more junior staff member, Dr. C is reluctant to criticize the
surgeon personally or to report him to higher authorities. However, he feels that he must do
something to improve the situation. These sentences express how Dr. C feels about the situation
and his limitations to act upon it.

In a case like this, it is highly likely that your questions be based on the doctors limitations and
his or her situation, and what he or she could or should do, and what you would do if you were
him or her. Questions could be:

- Question 1 - Should the anesthetist speak directly to the senior surgeon and demand
respect from him? Why or Why not?
- Question 2 - What would you do if you were the anesthetist?
- Question 3 - Would you report the anesthetist to higher authorities?

Lets analyze a possible response for the first question

- Question 1 - Should the anesthetist speak directly to the senior surgeon and demand
respect from him? Why or Why not?

Again, you can begin with an expression that states your opinion. Notice how the question is
used in the response:

- I believe that the anesthetist should not speak directly to the senior surgeon.

Then state your reasons using transition words:

- First, because senior surgeons are usually very arrogant and highly influential in hospitals
and healthcare centers, and the anesthetist, being a junior doctor, might feel threatened
by the senior doctor
- and second, the senior doctor might damage the junior doctors reputation by spreading
gossip about him in retribution, which is a common case in healthcare.

You can close your response with a concluding remark:

- For those reasons, I believe it is not a good idea to speak directly to him.
Lets analyze another good response to this case:

Dr. Cox should act upon the behavior of the senior surgeon in the operating room. Not only is he
endangering the health of the patient but he is being disrespectful to both the patient and his
colleagues. First, he should not indicate any support for the offensive behavior, for example, by
laughing at the jokes. Second, if he thinks that discussing the matter with the surgeon might be
effective, he should go ahead and do this. Otherwise, he may have to go directly to higher
authorities in the hospital. If they dont want to deal with the situation, then he can approach the
appropriate physician licensing body and ask it to investigate. (Taken and adapted from Medical
Ethics Manual, 2005).

Hypothetical Situations Conditional

Another possibility to answer a question like this is by using hypothetical conditionals. One
classic example of these is:

If I were

In this structure, the personal subject pronoun I is not accompanied by was (be-simple past
tense). Instead, it is accompanied by were, which is only used with I to indicate that this is
an unreal situation. The if clause needs to be accompanied by an independent clause with
would.

For example:

If I were Dr. Snchez, I would not accept a patient who has seen another doctor before me.

If I were the anesthetist, I would report the senior surgeons behavior to the higher
authorities.

EXERCISES

Now, it is your turn to practice. You are going to read, analyze and respond to questions about 3
cases.

Case 1 (Taken and adapted from Medical Ethics Manual, 2005).

Dr. Rutgers, a general practitioner in a small rural town, is approached by a contract research
organization (C.R.O.) to participate in a clinical trial of a new non-steroidal anti-inflammatory
drug (NSAID) for osteoarthritis. She is offered a sum of money for each patient that she enrolls
in the trial. The C.R.O. representative assures her that the trial has received all the necessary
approvals, including one from an ethics review committee. Dr. Rutgers has never participated in
a trial before and is pleased to have this opportunity, especially with the extra money. She
accepts without inquiring further about the scientific or ethical aspects of the trial.
 1. How many sentences does this case have? ___________________________

2. What is the function or the purpose of each sentence? What can you do with each
sentence? _____________________________________________________
______________________________________________________________
______________________________________________________________
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______________________________________________________________
3. Identify the key words or content words of the case. Write them down in the space
below.

4. Write a plan to answer the following questions based on Case 1.

Should Dr. Rutgers accept the proposal and the money from the C.R.O without questioning?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

What would you do if you were Dr. Rutgers?

______________________________________________________________________________
______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________
Now, record your response and listen to it. Review your response with the rubric.

Case 2 (Taken and adapted from Medical Ethics Manual, 2005).

Sara is 15 years old. She lives in a town where sexual assaults are becoming more and more
frequent. She comes to your clinic asking for a prescription for oral contraceptives to protect her
from pregnancy in case she is the victim of a sexual assault. Pregnancy would terminate her
education and make it very difficult to find a husband. Sara tells you that she does not want her
parents to know that she will be using contraceptives because they will think that she intends to
have sex with a boyfriend. You are suspicious of Saras motives but you admire her
determination to avoid pregnancy. You advise her to come to the clinic with her parents for a
general discussion of the issue with you. Three days later she returns alone and tells you that she
tried to speak to her parents about the issue but they refused to discuss it.

1. How many sentences does this case have? ___________________________

2. What is the function or the purpose of each sentence? What can you do with each
sentence?
______________________________________________________________
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______________________________________________________________
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______________________________________________________________
______________________________________________________________
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______________________________________________________________
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______________________________________________________________
______________________________________________________________
 3. Identify the key words or content words of the case. Write them down in the space
below.

4. Write a plan to answer the following questions based on Case 2.

What should you do?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Now, record your response and listen to it. Review your response with the rubric.

Case 3 (Taken and adapted from Medical Ethics Manual, 2005).

Max was born during the 23rd week of pregnancy. He is ventilated because his lungs are very
immature. Moreover, he suffers from cerebral bleeding because his vessel tissue is still unstable.
It is unlikely that he will actually survive the next few weeks. If he does, he will probably be
severely handicapped both mentally and physically. Maxs condition worsens when he develops a
serious infection of the bowel. It might be possible to extract the inflamed part of the bowel
operatively, which would preserve his small chance of survival. His parents refuse to consent
because they do not want Max to suffer from the operation and they feel that his quality of life
will never be sufficient.

Plan an answer for the following question in the space provided below.

As the treating physician, do you think that the operation should be done? If so, how would you
deal with the parents refusal?

Now, record your response and listen to it. Review your response with the rubric.
Case 4 (Taken and adapted from Medical Ethics Manual, 2005).

Mr. Sullivan is married and the father of two school children. He is treated in your clinic for a
rare form of pneumonia that is often associated with AIDS. His blood test results show that he is
indeed HIV-positive. Mr. Sullivan says that he wants to decide himself if and when he will tell his
wife about the infection. You indicate that it could be life-saving for his wife to protect herself
from infection. Besides, it would be important for her to have an HIV test herself. In case of a
positive test result, she would then have the opportunity to take drugs to slow down the outbreak
of the disease and thereby prolong her life. Six weeks later, Mr. Sullivan comes into your clinic
for a control investigation. Answering your question, he says that he hasnt informed his wife yet.
He doesnt want her to know about his homosexual contacts because he fears that she would end
their relationship and the family would shatter. But to protect her he has had only safer sex
with her.
Question:

- As the treating physician, would you inform Mrs. Sullivan of the HIV status of her
husband against his will so that she would have the opportunity to start treatment if
needed?

Now, record your response and listen to it. Review your response with the rubric.

Case 5 - (Taken and adapted from Medical Ethics Manual, 2005).

As part of your medical duties you spend one day every two weeks seeing inmates in a nearby
prison. Yesterday you treated a prisoner with multiple abrasions on his face and trunk. When you
asked what caused the injuries, the patient replied that he had been attacked by prison staff
during interrogation when he refused to answer their questions. Although this is the first such
case you have experienced, you have heard of similar cases from your colleagues. You are
convinced that you should do something about the problem but the patient refuses to authorize
you to disclose information about himself for fear of retaliation from the prison authorities.
Furthermore, you are not certain that the prisoner has told you the truth; the guard who brought
him to you said that he had been in a fight with another prisoner. You have a good relationship
with the prison staff and do not want to harm it by making unsubstantiated accusations of
mistreatment of prisoners.

Question:

- What should you do?

Now, record your response and listen to it. Review your response with the rubric.

Case 6 - (Taken and adapted from Medical Ethics Manual, 2005).

An 80-year old woman is admitted to your hospital from a nursing home for treatment of
pneumonia. She is frail and mildly demented. You treat the pneumonia successfully but just
before she is to be discharged back to the nursing home, she suffers a stroke that leaves her
paralyzed on her right side and unable to feed herself. A feeding tube is inserted that apparently
causes her discomfort and after she has made several attempts to pull it out with her left arm, a
restraint is placed on the arm. She is otherwise unable to express her wishes. A search for
children or other relatives who could help make decisions about her treatment is unsuccessful.
After several days, you conclude that her condition is unlikely to improve and that the only ways
to relieve her suffering are to sedate her or to withdraw the feeding tube and allow her to die.
Question:

- What would you do?

Now, record your response and listen to it. Review your response with the rubric.