Randy M. Rosenberg, MD FAAN FACP
Clinical Assistant Professor of Neurology
Temple University School of Medicine
What is good and bad
What is right and wrong
Based on value system
Ethical norms are not universal –
depends on the sub culture of the
Ethics is not the same as feelings
Ethics is not religion
Ethics is not following the law
Ethics is not following culturally
Ethics is not science
To be ethically correct does not
imply a painless outcome.
Saving of life and promotion of health above all
Make every effort to keep the patient as
comfortable as possible and preserve life when
possible or feasible.
Respect the patient’s choices when all options
have been discussed.
Treat all patients equally.
Principles and Duties
of Physicians are the
Central Elements of
Provide for all individuals to the best of your
Maintain competent level of skill.
Stay informed and up-to-date.
Primum Non Nocere !
3 criteria for judging ethical dilemmas:
1. Obligations – rights, rules, oaths.
2. Ideals – goals, concept of excellence, fairness,
loyalty, forgiveness, peace.
3. Consequences – may be beneficial or harmful
effects that result from the action and the people
involved. Can be physical, emotional, obvious, or
Several parts of the oath have been
revised over the years
“To consider dear to me, as my parents,
him who taught me this art; to live in
common with him and, if necessary, to
share my goods with him…”
“Nor will I give a woman a pessary to
“I will not cut for stone, even for patients
in whom the disease is manifest; I will
leave this operation to be performed by
practitioners, specialists in his art.”
The right to participate in and decide on a
course of action without undue influence.
Self-Determination: which is the freedom to
act independently. Individual actions are
directed toward goals that are exclusively
Actions or inactions are for the good of the
Maximize possible benefits
Direct benefit to subject
Overall benefits to society
Guard that actions or inactions do not result
Physicians must refrain from providing
harmful or ineffective treatments or acting
with malice toward patients.
Possible benefits outweighs potential harm
Taking action when harmful consequence are
Admitting wrong (“apologies”) ?
Fair distribution of benefits
Equal individual need
Equal individual effort
Equal societal contribution
Key Elements of the Standard Approach and the Presumptive Approach to Counseling Potential
Death is implicit. The challenge is to make death
Death is a biological phenomenon
Death is a term applied to living organisms
Death is irreversible
Death is univocal among higher animal species
Death is an event and not a process
Physicians should be able to determine death
with accuracy and reproducibility
Greek physicians held that the heart was the seat
of life, the first organ to live and the first organ
Neither respiration nor brain function was
essential for life
Hippocrates held that the brain was the source
of reason, sensation and motion
Can be regarded as the father of
Hebrew law had provided that breathing
and not heartbeat was the essence of life
Argued that a decapitated person was
immediately dead, despite movement of
Muscle movements after decapitation
were not indicative of central control
THEREFORE BELIEVED THAT THE
(BRAIN FUNCTION) WERE AS
ESSENTIAL TO LIFE AS WAS
Suddenly the brain became important and
death was no long just the irreversible
cessation of cardiopulmonary function
Provides comprehensive basis for determining death in all
situations and recommended for all states.
Adopted by all except New Jersey and New York (modifications)
Clinicians in all but those two states can terminate ventilation without
consent of family
Based on a 10 year effort to unify medical and legal opinion
that began with the Kansas laws on brain death (1970)
Proposes the legal standard but not the mechanisms for
determination of death or time of death.
Death is defined as “irreversible cessation of circulatory and
respiratory functions” or “irreversible cessation of all
functions of the entire brain, including the brain stem.”
Underwent tonsillectomy for OSA in
December 9, 2013
Post op bleeding followed by cardiac arrest
Declared brain dead on December 12, 2013
Hospital believes it has followed letter of
California law on brain death
Family believes the Jahi is still alive and she
has been transferred to facility to be treated as
a brain injured patient rather than brain dead.
A parent’s love of their child is not
a controversy but efforts made to
protect that child complicate the
How far can parent seek to protect the safeguards of
their child’s interest?
Can life support be given to a patient who is dead?
Where does the physician’s ethical responsibility
begin when asked to provide treatment with no
The principal of autonomy means that patients or
their surrogates can decline treatment. By the same
token is the inverse true ie can family demand
treatment options not endorsed by physicians, law or
How long is it appropriate to give life support to a
brain dead patient to permit the family to accept a
On November 26, 2013, Erick Muñoz found his 33-year-old
wife Marlise unconscious in their family home
Workup revealed pulmonary emboli as cause of CP
failure. Also found to be 14 weeks pregnant
Declared brain dead on November 28, 2013
Marlise, a paramedic like her husband, had previously
told him that in case of brain death, she would not want to
be kept alive artificially
Hospital acknowledgedthat the patient was legally dead
(consistent with Texas law) on November 28, 2013
Texas law prohibits discontinuation of life support on a
Erick Muñoz petitioned for Marlise to be removed from all life-sustaining measures once
brain death had been declared consistent with the wishes of the patient.
The hospital refused, citing a Texas law which required that lifesaving measures be
maintained if a female patient was pregnant--even if there was written documentation
that this was against the wishes of the patient or the next of kin.
While Marlise had been declared dead, the condition of her fetus was unknown. In
January 2014, Erick Muñoz's attorneys argued that the fetus had suffered from anoxia
and was suspected to be non-viable. The fetus' lower extremities were deformed to the
extent that the gender couldn't be determined and there was evidence of hydrocephalus
On January 24, 2014, Judge R. H. Wallace Jr. ruled that the hospital must disconnect
Munoz's life support by January 27, 2014
How can the decision be viewed if it is not a ruling against the constitutionality of Texas
Where does this leave future patients?
Marlise Muñoz was disconnected from life support at 11:30 AM on January 26, 2014.
By 2012, 37 states had pregnancy consideration in their advance
directive statutes. In assessing them, the Center placed the
statutes into five major categories:
1. The law states that pregnancy at any stage automatically invalidates
the advance directive;
2. The law contains pregnancy restrictions similar to those in the model
Uniform Rights of the Terminally Ill Act (1989)
Basis of legality of “living will”
Withholding of life sustaining treatment continues in case of most pregnancy
unless there is severe fetal anomaly.
3. The law uses a viability standard to determine enforceability of the
4. The law is silent with regard to pregnancy.
5. Patient may have specific written instructions regarding end of life
care if she is pregnant.
Pennsylvania law Act 169, that addresses living wills and
health-care decision-making, requires that a pregnant patient
be kept on life support "unless, with a reasonable degree of
medical certainty, the fetus cannot develop to live birth."
How can state mandated “life support” be given to a patient
who is legally dead?
State appears to be violating:
The individual's interest in a dignified death
Ethical principle that a physician no long is required to provide
treatment to a patient declared dead.
Does the state have the responsibility to protect its citizen (the
citizen) from a certain death?
At 14 weeks gestation the fetus would not have been viable
outside of the womb. Thus the patient’s constitutional privilege
for abortion would have been protected?
How does the fact that the fetus was likely severely malformed?
If so what is the husband’s rights to reject the imposition of raising a
handicapped child as a widower?
How much liability does the state have to avoid actions that add
to the personal tragedy and grief suffered by the husband
during forced life sustaining measure?
May I be moderate in
everything except in the
knowledge of this science;
grant me the strength and
opportunity always to correct
what I have acquired, for
knowledge is boundless and
the spirit of man can also
extend infinitely…Today he
can discover his errors of
yesterday, and tomorrow he
may obtain new light on what
he thinks himself sure of