HSC 312: Final Project –Complied Case Analysis Scoring Rubric
The following criteria will be used to grade your Complied Case Analysis. Keep in mind that the score requirement described
under each score point on the scale defines the minimum performance that must be demonstrated in order to achieve that score.
Evaluation
Criteria
A
20 points
B
17 points
C
15 points
D
13 points
F
11 points
1.) Introduces
the case
analysis by
describing
the ethical
dilemma
requiring
resolution
Introduction is:
• Comprehensive
• Includes a
thorough, clear and
concise description
of the case and
ethical dilemma
proposed.
Introduction:
• Includes minor
omissions in
description of
either the case
or ethical
dilemma.
Introduction:
• Lacks detail in
part
• Includes minor
omissions in
both the
description of
the case and the
ethical dilemma.
Introduction:
• Lacks detail
• Includes major
omissions in
either
description of
the case or the
ethical
dilemma.
Description is either
missing or contains
major omissions
throughout.
2.) Identifies
the
primary
stakeholder
(s) and
provides a
description
of the
situation
from the
stakeholder
perspective
Description is:
• Comprehensive
• Includes
identification of
stakeholder
• Provides clear
stakeholder
Description:
• Has minor
omissions or
errors in
identification of
stakeholders or
in describing the
stakeholder
perspective.
Description:
• Lacks detail
• Omits some
significant
content or
contains several
minor errors.
Description:
• Lacks detail.
• Is superficial
and contains
multiple errors.
Description is:
• Missing or
incorrect
• Inconsistent
with selected
stakeholder
Does not
identify any
or identifies
irrelevant
stakeholders.
3.) Analyzes the
scenario
from the
perspective
of the
primary
stakeholder
and includes
a description
of at least
two ethical
theories that
relate to the
issue being
identified
Analysis and Description
are:
• Comprehensive
• Include responses
to all
subcomponents of
the question.
• Provides clear
description of two
or more ethical
theories and their
relation to the
issue.
Analysis and
Description:
• Include minor
omissions.
• Includes 1-2
minor errors in
regards to the
scenario of the
stakeholder or
the description
of the ethical
theories.
Analysis and
Description:
• Include a major
omission, OR
• Includes
several errors in
regards to the
scenario of the
stakeholder or
the description
of the ethical
theories.
Analysis and
Description:
• Includes a
major omission,
AND
• Includes
several errors in
regards to the
scenario of the
stakeholder or
the description
of the ethical
theories.
Analysis and
Description are:
• Missing
OR ...
IHP 610 Final Project Guidelines and Rubric Overview MalikPinckney86
IHP 610 Final Project Guidelines and Rubric
Overview
Healthcare is a field dominated by complex regulation, limited resources, highly charged debates, changing reimbursement, expensive education barriers to
entry, and knowledge imbalances. Healthcare decision-makers often have to review information about an issue, analyze the applicable law, and make a decision.
Those decisions are often not founded on clearly right or clearly wrong “answers.” Nonetheless, after decision makers conduct or review a policy analysis and a
legal analysis and arrive at a conclusion, they must be able to support and defend that decision. Stakeholder values are often in conflict; decision makers working
in the field of healthcare and health law have many opportunities to defend their decisions!
The final project for this course will give you an opportunity to build policy and legal analysis skills. You will choose from one of three issue prompts at the
beginning of the course. Throughout the course, you will draft a memo containing an overview and analysis of your selected issue, as well as a series of
recommendations for a healthcare executive. You will experience some of the challenges of reconciling competing values, demands for resources, and
organizational needs. Each issue prompt is based on “real world” scenarios, so take this opportunity to practice developing health law and policy analysis skills.
This final project addresses your mastery with regard to the following course outcomes:
Assess the impact of stakeholder needs on decision making for ensuring effective implementation of health law and policy
Assess the impact of current healthcare laws, policies, and financing practices on affected key stakeholders for informing policy recommendations
Determine the extent to which legal risks and potential malpractice issues influence policy decision making
Recommend appropriate strategies for resolving value conflicts among key healthcare stakeholders
Analyze the role of key stakeholders in shaping, implementing, and evaluating health law and policy for improving population health outcomes
Prompt
You will write a policy memorandum, with recommendations, paper in which you will analyze a health law and policy issue and make a series of
recommendations to a healthcare executive. At the beginning of this course, you chose one of three issue scenarios. Now, you will create each section of the
policy memorandum using the tools and strategies you developed in this course. You have developed those tools and strategies in a stepwise fashion in each
module. Remember that the purpose of the policy memorandum is to analyze the issue scenario, make thoughtful arguments about the issue, and make
recommendations based on your analysis.
Your policy memorandum with recommendations paper must contain the following critical elements. Most of the critical elements align with a particular course
outcome (shown in brackets).
I ...
These slides accompany Chapter 7 from Leadership for Pharmacists. It lays out different types of problems faced by pharmacists and issues to consider. It identifies some cognitive biases and bad decision-making processes that can prevent good solutions. A systems approach using a step-by-step process for making good decisions is presented.
Main Post Discussion BEthical Challenges Related to Record Kee.docxsmile790243
Main Post Discussion B
Ethical Challenges Related to Record Keeping/Report
A professional counselor uses record keep for a number of different reasons, when treating clients. Their primary purpose of keeping records is to assist in providing clients best possible counseling service (Remly & Herlihy, 2014). Record keeping helps counselors to refresh their memory prior to their sessions. Record keeping is not only beneficial to the counselor but the client as well, it helps to measure their progress and change during their sessions. There are also some ethical challenges or dilemmas related to record keeping and reporting in which records are subpoenaed by a judge or any legal representative requests records of a client. ACA code of ethics in section B.4.e. and Section B.4.c. Standard B4.e. requires counselors to obtain written permission from clients to disclose or transfer records to legitimate third parties unless exceptions to confidentiality exist (ACA, 2014). This is an ethical challenge when a counselor is subpoenaed for record legally even if a client has not signed off on it. Standard B.4.c addresses the issue of informed consent (ACA, 2014). This has became an ethical challenge in the legal system when it comes to electronically recording or observing a session.
Addresses The Challenges
In Remly and Herlihy (2014) textbook they recommend a counselor to always consult with their own attorneys before turning over records or appearing at a deposition hearing, or trail in response to a subpoena. Although a subpoena is a legal court order, counselors have to be mindful of what information to turn over. Many attorneys will accept summaries of notes or any other compromises (Remly & Herlihy, 2014), When counselors turn over records to legitimate third parties written document is always best, the Standard of Practice (SP-15) requires a clients consent to disclose information but does not have to be written. Writing consent shows evidence confidently is not broken if a client or other parties denies the consent.
References
American Counseling Association (ACA). (2014). 2014 ACA code of ethics [White Paper]. Retrieved from http://www.counseling.org/docs/ethics/2014-aca-code-of-ethics.pdf?sfvrsn=4.
Remley, T. P., Jr., & Herlihy, B. (2014). Ethical, legal, and professional issues in counseling (4th ed.). Upper Saddle River, NJ: Pearson Education.
PAGE
6
Insert your header here by using “Insert” then “Header” then “Edit” PUT IT ALL IN CAPS
Running head: INSERT HERE
1
This is the Title of My Ethical Autobiography
My Name
Course Name
Walden University
Abstract
Put 50 to 100 word abstract here. An abstract is a short overview of what the paper will address.
Repeat Your Title Here
You will begin your Ethical Autobiography with an introduction. Do not type the word “Introduction.” The following outline is for reference only. You will not include the numbers or letters of your main points, but will follow standar ...
IHP 610 Final Project Guidelines and Rubric Overview MalikPinckney86
IHP 610 Final Project Guidelines and Rubric
Overview
Healthcare is a field dominated by complex regulation, limited resources, highly charged debates, changing reimbursement, expensive education barriers to
entry, and knowledge imbalances. Healthcare decision-makers often have to review information about an issue, analyze the applicable law, and make a decision.
Those decisions are often not founded on clearly right or clearly wrong “answers.” Nonetheless, after decision makers conduct or review a policy analysis and a
legal analysis and arrive at a conclusion, they must be able to support and defend that decision. Stakeholder values are often in conflict; decision makers working
in the field of healthcare and health law have many opportunities to defend their decisions!
The final project for this course will give you an opportunity to build policy and legal analysis skills. You will choose from one of three issue prompts at the
beginning of the course. Throughout the course, you will draft a memo containing an overview and analysis of your selected issue, as well as a series of
recommendations for a healthcare executive. You will experience some of the challenges of reconciling competing values, demands for resources, and
organizational needs. Each issue prompt is based on “real world” scenarios, so take this opportunity to practice developing health law and policy analysis skills.
This final project addresses your mastery with regard to the following course outcomes:
Assess the impact of stakeholder needs on decision making for ensuring effective implementation of health law and policy
Assess the impact of current healthcare laws, policies, and financing practices on affected key stakeholders for informing policy recommendations
Determine the extent to which legal risks and potential malpractice issues influence policy decision making
Recommend appropriate strategies for resolving value conflicts among key healthcare stakeholders
Analyze the role of key stakeholders in shaping, implementing, and evaluating health law and policy for improving population health outcomes
Prompt
You will write a policy memorandum, with recommendations, paper in which you will analyze a health law and policy issue and make a series of
recommendations to a healthcare executive. At the beginning of this course, you chose one of three issue scenarios. Now, you will create each section of the
policy memorandum using the tools and strategies you developed in this course. You have developed those tools and strategies in a stepwise fashion in each
module. Remember that the purpose of the policy memorandum is to analyze the issue scenario, make thoughtful arguments about the issue, and make
recommendations based on your analysis.
Your policy memorandum with recommendations paper must contain the following critical elements. Most of the critical elements align with a particular course
outcome (shown in brackets).
I ...
These slides accompany Chapter 7 from Leadership for Pharmacists. It lays out different types of problems faced by pharmacists and issues to consider. It identifies some cognitive biases and bad decision-making processes that can prevent good solutions. A systems approach using a step-by-step process for making good decisions is presented.
Main Post Discussion BEthical Challenges Related to Record Kee.docxsmile790243
Main Post Discussion B
Ethical Challenges Related to Record Keeping/Report
A professional counselor uses record keep for a number of different reasons, when treating clients. Their primary purpose of keeping records is to assist in providing clients best possible counseling service (Remly & Herlihy, 2014). Record keeping helps counselors to refresh their memory prior to their sessions. Record keeping is not only beneficial to the counselor but the client as well, it helps to measure their progress and change during their sessions. There are also some ethical challenges or dilemmas related to record keeping and reporting in which records are subpoenaed by a judge or any legal representative requests records of a client. ACA code of ethics in section B.4.e. and Section B.4.c. Standard B4.e. requires counselors to obtain written permission from clients to disclose or transfer records to legitimate third parties unless exceptions to confidentiality exist (ACA, 2014). This is an ethical challenge when a counselor is subpoenaed for record legally even if a client has not signed off on it. Standard B.4.c addresses the issue of informed consent (ACA, 2014). This has became an ethical challenge in the legal system when it comes to electronically recording or observing a session.
Addresses The Challenges
In Remly and Herlihy (2014) textbook they recommend a counselor to always consult with their own attorneys before turning over records or appearing at a deposition hearing, or trail in response to a subpoena. Although a subpoena is a legal court order, counselors have to be mindful of what information to turn over. Many attorneys will accept summaries of notes or any other compromises (Remly & Herlihy, 2014), When counselors turn over records to legitimate third parties written document is always best, the Standard of Practice (SP-15) requires a clients consent to disclose information but does not have to be written. Writing consent shows evidence confidently is not broken if a client or other parties denies the consent.
References
American Counseling Association (ACA). (2014). 2014 ACA code of ethics [White Paper]. Retrieved from http://www.counseling.org/docs/ethics/2014-aca-code-of-ethics.pdf?sfvrsn=4.
Remley, T. P., Jr., & Herlihy, B. (2014). Ethical, legal, and professional issues in counseling (4th ed.). Upper Saddle River, NJ: Pearson Education.
PAGE
6
Insert your header here by using “Insert” then “Header” then “Edit” PUT IT ALL IN CAPS
Running head: INSERT HERE
1
This is the Title of My Ethical Autobiography
My Name
Course Name
Walden University
Abstract
Put 50 to 100 word abstract here. An abstract is a short overview of what the paper will address.
Repeat Your Title Here
You will begin your Ethical Autobiography with an introduction. Do not type the word “Introduction.” The following outline is for reference only. You will not include the numbers or letters of your main points, but will follow standar ...
The purpose of this paper is to apply information gathered from th.docxoreo10
The purpose of this paper is to apply information gathered from the Family Genetic History and Milestone 1 assignments to identify one modifiable risk factor and develop an evidence-based teaching plan that promotes health as well as improves patient outcomes.
Course Outcomes
This assignment enables the student to meet the following Course Outcomes.
· CO4: Identify teaching/learning needs from the health history of an individual. (PO2)
Points
This assignment is worth a total of 225 points.
General Directions & Project Guidelines
· This paper is expected to be no more than four pages in length (not including the title page and reference list).
· Please use the categories listed below as the first level headings for each section of your paper (Exception: Instead of "Introduction" please use the title of your paper).
Content Guidelines
Using the information gathered in your Genetic Family History and Milestone 1 assignments, you will identify and research one modifiable risk factor. You will develop an evidence-based teaching plan that promotes health, with the aim of improving patient outcomes related to this modifiable risk factor.
A. Introduction (1 paragraph): The introduction should be interesting and capture the reader's attention.
· State one preventable disease your adult participant is at risk for developing (obesity, Type 2 Diabetes, etc.), based on the information you have gathered during this course.
· Introduce onemodifiable risk factor (diet, smoking, sedentary lifestyle, etc.) associated with the preventable disease you described.
· Clearly state the purpose of your paper. The purpose statement should relate to developing a patient teaching plan.
B. Preventable Disease Overview (1-2 paragraphs): Please use course materials and scholarly sources to complete this section. Be sure to paraphrase and include citations as needed!
· Describe briefly the preventable disease you identified in the introduction.
· What are the signs and symptoms associated with this disease?
· How is it diagnosed? Notable information from Health History and General Survey? Signs and symptoms? Risk assessments? Lab values?
· What physical assessment findings would be associated with this disease?
· How did you identify your adult participant's risk for this disease?
· Specific information gathered in the Genetic Family History?
· Specific information gathered in the Milestone 1 assignment?
C. Evidence Based Intervention (1-2 paragraphs):
· Choose and describe one evidence based interventionrelated to the modifiable risk factor you have chosen. (One that has been shown to be effective at reducing an individual's risk for developing the preventable disease.)
· Describe this intervention in detail, and provide rationale for your intervention utilizing:
· At least one scholarly peer-reviewed journal article. Go to the Chamberlain library at http:/library.chamberlain.edu (Links to an external site.)Links to an external site.. Search peer reviewed journals to find ...
Strategic Decision MakingComprehensive Capstone Case Study Instr.docxsusanschei
Strategic Decision Making
Comprehensive Capstone Case Study Instructions
The aim of this assignment is to provide students the opportunity to perform a thorough case analysis. Select your company and get approval from your course professor before working on it. The case analysis should include the following elements:
Title Page
Executive Summary
Background
· Introduce the company and provide the reader with background information about the company.
Situation Analysis
· The Environment – PESTLE Analysis
1. Political environment
2. Economic environment
3. Social environment
4. Technological environment
5. Legal/Regulatory environment
6. Environmental environment
· The Industry – Porter’s Five Forces Analysis
1. Bargaining power of suppliers
2. Threat of new entrant
3. Rivalry among existing competitors
4. Bargaining power of competitors
5. Threat of substitutes
· The Firm
1. What is the mission and vision of the firm?
2. What are the strengths of the firm?
3. What is the firm’s financial condition?
4. What are the constraints and weaknesses of the firm (i.e. financial condition, organizational conflict)?
5. What is the management philosophy?
6. What does the organizational structure tell you about how decisions are made?
· The Product
1. What good and/or service does the organization offer?
2. What consumer need does the product solve?
3. What promotional mix, channels of distribution, and pricing strategies are being used by the organization?
4. What competitive advantage does the marketing strategy offer?
SWOT Analysis
· Strengths
· Identify strengths of the organization and answer the following questions:
· How does this strength affect the operations of the organization?
· How does this strength assist the company in meeting the needs of its target market(s)?
· Weaknesses
· Identify weaknesses of the organization and answer the following questions:
· How does this weakness affect the operations of the organization?
· How does knowledge of this weakness assist the organization in meeting the needs of its target market(s)?
· Opportunities
· Identify opportunities in the industry (and/or external environment) and answer the following questions:
· How is this opportunity related to serving the needs of our target market?
· What actions must the organization take to capitalize on this opportunity?
· Threats
· Identify threats in the industry (and/or external environment) and answer the following questions:
· How is this threat related to serving the needs of our target market?
· What actions must the organization take to prevent this threat from limiting the capabilities of the organization?
Problem Statement
· What is the primary problem in the case? Secondary problems? What are the ramifications of these problems in the long run? Short run? Include quantitative and qualitative analysis in your response.
Strategic Plan
· Based on the problem identified, develop a 5-year strategic plan for the company. This plan should i.
Week 3 Assignment Addressing BiasGuidelines with Scoring Rubric.docxcockekeshia
Week 3 Assignment: Addressing BiasGuidelines with Scoring Rubric
Purpose
In today’s current healthcare settings, the increasing diversity, globalization, and expanding technologies produce complex ethical pressures that influence nursing practice and practice outcomes. To be effective in a master’s-prepared advanced nurse practice role it is important to understand personal values, beliefs, strengths, and limitations. The purpose of this assessment is to promote introspective reflection related to implicit and/or explicit personal biases. Students will develop a plan to reduce bias and promote personal and professional growth.
Course Outcomes
Through this assessment, the student will meet the following Course Outcomes.
CO 1: Examine roles and competencies of master’s-prepared nurses essential to performing as leaders and advocates of safe and quality care.
CO 2: Apply concepts of person-centered care to nursing practice situations.
Total Points Possible
This assessment is worth 125 points.
Due Date
Submit your file(s) by 11:59 p.m. MT Sunday at the end of Week 3.
Requirements
Criteria for Content
Complete a self-inventory on personal biases you hold. The biases might be implicit or explicit.
1. In a one to two-page summary, address the following.
a. Identify your selected specialty track (education, executive, family nurse practitioner, healthcare policy, or nursing informatics).
b. Discuss how biases can impact outcomes in selected nursing practice settings.
c. Identify personal biases and attitudes toward people with various cultural, gender, sexual orientation, age, weight, and religions that are different than your own.
d. Select one bias that you have.
e. Develop one strategy to reduce this bias.
Preparing the paper
Submission Requirements
1. Application: Use Microsoft Word 2013™ to create the written assessment.
2. Length: The paper (excluding the title page and reference page) is at maximum two pages.
3. A minimum of two (2) scholarly literature references must be used.
4. Submission: Submit your files: Last name_First initial_Wk3Assignment_Addressing Bias
Best Practices in Preparing the Project
The following are best practices in preparing this project.
1. Review directions thoroughly.
2. Follow submission requirements.
3. Make sure all elements on the grading rubric are included.
4. Rules of grammar, spelling, word usage, and punctuation are followed and consistent with formal, scientific writing.
5. Title page, running head, body of paper, and reference page must follow APA guidelines as found in the 6th edition of the manual. This includes the use of headings for each section of the paper except for the introduction where no heading is used.
6. Ideas and information that come from scholarly literature must be cited and referenced correctly.
7. A minimum of two (2) scholarly literature references must be used.
8. Abide by CCN academic integrity policy.
Grading Criteria
Category
Points
%
Description
Introduc.
Bioethics Case Study1.1.Bioethics Case Study This assignment .docxmoirarandell
Bioethics Case Study
1.
1.Bioethics Case Study: This assignment asks you to examine a current ethical controversy case study. The paper is informal, but should be in APA style, and does not need an abstract or cover page. With a minimum of two pages and a maximum of four pages A reference page is needed. In-text citations should be in APA format. Papers will be graded on a 0 to 25-point scale.
Case Study in Primary care:
One hypothetical case study involves Jim a 54, year old patient who has recently diagnose with hypertension and his Creatinine and BUN laboratory results are elevated, if left untreated, will result in kidney failure. The patient refuses to take the medication because he said it will affect his sex life The NP must work with the patient to respect the fact that he doesn’t want the medication (autonomy), and needs to find a solution that would prevent him from going into kidney failure and other complications, which is in his best interest (beneficence). Although medications are the best choice, forcing the patient to accept the medication will result in probably patient leaving the care (non-maleficence). Finally, the NP needs to consider the impact that the patient’s choices might have on others if he starts to go into preventable kidney failure, he’ll need dialysis, which affects other people who need the same treatment (justice). So before making the final decision the NP must consider all four principles of health care ethics, which will help the NP make the choice that will have the best possible benefits for both the patient and society.
Questions?
1. What are the skills necessary for the provider to identify, address, and assess this clinical ethical issue?
2. What are the provider’s obligations when a patient discloses does he not intent to follow the treatment?
3. What are the ethical considerations in evaluating a patient’s failure to adhere to a prescribed therapy?
4. Will you terminate care for this patient? What are the implications?
Case Study Rubric
Criterion
Outstanding (25)
Very Good (22)
Average (18)
Unacceptable (15)
Score
Completeness
Complete in all respects; reflects all requirements
Complete in most respects; reflects most requirements
Incomplete many respects; reflects few requirements
Incomplete in most respects; does not reflect requirements
Understanding
Demonstrates excellent understanding of the topic(s) and issue(s)
Demonstrates an accomplished understanding of the topic(s) and issue(s)
Demonstrates an acceptable understanding of the topic(s) and issue(s)
Demonstrates an inadequate understanding of the topic(s) and issue(s)
Analysis
Presents an insightful and through analysis of the issue (s) identified
Presents a thorough analysis of most of the issue(s) identified
Presents a superficial analysis of some of the issue(s) identified
Presents an incomplete analysis of the issue(s) identified.
Evaluation
Makes appropriate and powerful connections between the issue(s) identified and the con.
Selection and formulation of a research problem.pptxGeorgeKabongah2
One of the greatest challenges faced by researchers is resource and time constraints. This makes it difficult to involve the entire population of interest and so researchers only use a subset of a population to represent the whole population. This is called a sample. The use of samples however involves other big class of problems: given that your measurements are credible, how much of the world do they represent? How far can you generalize the results of your research? The answer depends, first, on the kind of data in which you are interested. There are two kinds of data of interest to social scientists: individual attribute data and cultural data. These two kinds require different approaches to sampling and that is the focus of this week.
Discussion QuestionWilliam Ford Jr., Chairman of Ford Motor C.docxedgar6wallace88877
Discussion Question:
William Ford Jr., Chairman of Ford Motor Co. said, "A good company delivers excellent products and services, and a great company does all that and strives to make the world a better place."
Supported by evidence from your textbook, the Starbucks case study, and other research, describes two forces that you believe shape the relationship between business and society. Provide two examples, one for each force you select. Be specific in your answer and discuss strengths and weaknesses via examples and applications. Be certain to cite in APA format all sources used. Respond to at least two of your classmates’ discussion posts.
MBA 525 - Module 4 AVP - Decision Making and Ethics
Slide 1
Title slide
Slide content:
MBA 525 Module 4
Slide 2
Slide title:
Decision Making and Ethics
Narrator:
In this presentation, we will discuss the decision making process and how it is informed by ethics. We will
highlight common errors in decision making, rationality, and ethical decision making.
Slide 3
Slide title:
Decision-Making Steps
Slide content:
• Define the task
• Delegate tasks
• Seek out information and determine its accuracy
• Establish criteria for evaluating specific courses of action
• Discover and evaluate alternative options
• Prepare and present the group’s choice persuasively to the target audience
Narrator:
There are six steps in the decision making process.
First, define the task.
Second, delegate tasks.
Third, seek out information and determine its accuracy.
Fourth, establish criteria for evaluating specific courses of action.
Fifth, discover and evaluate alternative options.
And lastly, prepare and present the group’s choice persuasively to the target audience.
Slide 4
Slide title:
Errors of Poor Decision Making
Slide content:
• Improper assessment of the situation
• The establishment of inappropriate goals and objectives
• Improper assessment of the strengths and weaknesses of various alternatives
• The establishment of a flawed information base
Narrator:
The most common errors in this process include:
Improper assessment of the situation,
The establishment of inappropriate goals and objectives,
Improper assessment of the strengths and weaknesses of various alternatives, and,
The establishment of a flawed information base.
Consider the last decision you made that was faulty. Reflect on which error in decision making was
present. We are all guilty of making the “wrong” decision at some point due to errors in judgment.
Slide 5
Slide title:
Steps of Rational Decision Making
Slide content:
• Recognize the problem
• Discuss the problem with all relevant persons
• Decide on alternative courses of action
• Choose an optimal solution and implement it
• Monitor the impact of the solution
Narrator:
The steps to rational decision making vary a bit from the general model. There are only five, not six steps.
First, recognize the problem. This is a different starting point. It is important to first understand the
problem.
Next, disc.
Complete and submit your Comprehensive Psychiatric Evaluation, i.docxzollyjenkins
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.
Incorporate the following into your responses in the template:
Subjective:
What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective:
What observations did you make during the psychiatric assessment?
Assessment:
Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Reflection notes:
What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
.
Top of FormViewG View Grading RubricsCounselor Ethics and Re.docxturveycharlyn
Top of Form
ViewG View Grading Rubrics
Counselor Ethics and Responsibilities Paper
1
Unsatisfactory
0.00%
2
Less Than Satisfactory
74.00%
3
Satisfactory
79.00%
4
Good
87.00%
5
Excellent
100.00%
70.0 %Content
15.0 %Counselor Values
Analysis of the criteria is not outlined or outlined poorly. Fails to formulate and clearly express own point of view.
Ignores or superficially evaluates the ethical issues. Formulates a vague and indecisive point of view.
Surface level of evaluation of the ethical issues is offered. Minimal rationale presented. Expresses a preference in a personal point of view, but lacks details. Discusses a counseling plan for the client, but lacks supporting rationale.
Describes the process/plan in which counseling would or would not be provided, considering all ethical implications. Subject knowledge appears to be good. Formulates a clear and precise personal point of view. Includes essential knowledge about personal values and attitudes with supporting details and resources.
Comprehensively describes the process/plan in which counseling would or would not be provided, considering all ethical implications. Subject knowledge is excellent. Formulates a clear and precise personal point of view. Clearly describes personal values and attitudes in depth with extensive details and resources.
20.0 %Client Rights
Includes little knowledge about the topic. Subject knowledge is not evident.
Includes little knowledge about the topic with few supporting details. Little subject knowledge is evident. Ignores or superficially evaluates the criteria.
Lists the five ethical principles and discusses how they relate to client rights. Explains how these rights will be incorporated into professional practice with minimal details and/or rationale. Some subject knowledge is evident. Surface level of evaluation of the content is offered.
Presents a detailed outline of the relationship between the five ethical principles and how they relate to client rights. Explains how these principles will be incorporated into professional practice with supporting details, and/or rationale. Informed consent is explicitly and thoroughly addressed in this description. Subject knowledge appears to be good. Analysis is direct, competent, and appropriate for the criteria.
Presents a full detailed in-depth description of the relationship between the five ethical principles and client rights. Explain show these principles will be incorporated into professional practice with extensive details and/or rationale. Informed consent is explicitly and thoroughly addressed in this description. Subject knowledge is excellent. Thoughtfully analyzes and evaluates major points of the criteria.
20.0 %Responsibility to Warn and Protect
Includes little knowledge about the topic. Subject knowledge is not evident. Factors involved in decision making are vague or not present.
Includes little knowledge about the topic with few supporting details. Little subject knowledge is evi ...
Assignment #2- Policy Implementation (17.5 points)Build on Assig.docxdavezstarr61655
Assignment #2- Policy Implementation (17.5 points)
Build on Assignment #1. You will cover the same health problem and the same policy Some remedial action on Assignment #1 may be required in order for students to proceed to Assignment #2.Complete the following using the format provided. Except for titles, narrative format is expected with complete sentences. The table should be single spaced maximum 2.5 pages. Also include a cover page and a reference page in APA Format.
HGMT 310 Assignment #2
Student Name:
Type your name here.
Assignment #2 Title:
Provide a short name and the official title of the legislation.
Agency Responsible:
Identify the agency and subunit (such as a bureau or office) responsible for implementing the policy. If multiple agencies are involved indicate who is responsible for what.
Enforcement:
What federal or state agency is responsible for enforcement? What are the key areas for enforcement?
Implementation:
How is the legislation implemented? What federal or state agency is charged with its implementation? Are local public health departments involved? Are collaborating organizations engaged to achieve the aims of the policy? Are citizen’s involved? Are health provider organizations? Are grants awarded?
Impact on Health Service Organizations:
What does a Health Care Manager need to know about this legislation and the related implementation? Include five bullets of how this legislation impacts health services organizations operating in your home state.
Resource:
What resource would a health organization utilize to find updates regarding the impact policies have on them?
All sections of Assignment #2 are required.
Rubric Name: Written Assignment Rubric
Criteria
Outstanding
Superior
Good
Below Standard
Failure
Critical Thinking/Reasoning
35 points
demonstrates a high degree of critical thinking, is consistent in accurately interpreting questions & material; provides solid assumptions, reasoning & claims; provides thorough analysis & evaluation with sound conclusions
31.5 points
shows good critical thinking; accurately interprets most questions & material; usually identifies relevant arguments/reasoning/claims; offers good analysis & evaluation with fairly sound conclusions
24.5 points
shows occasional critical thinking; questions & material is at times accurately interpreted; arguments/reasoning/claims are occasionally explained; offers fair analysis & evaluation with a conclusion
21 points
shows little critical thinking, misinterprets questions or material; ignores or superficially evaluates; justifies little and seldom explains reasoning; draws unwarranted conclusions
0 points
lacks critical thinking consistently offers biased interpretations; ignores or superficially evaluates; argues using poor reasoning, and/or unwarranted claims
Application of Concepts/Development
35 points
arguments or positions are well-supported with evidence from the readings/experience; ideas go beyond the course material and reco.
According to the NASW Code of Ethics section 6.04 (NASW, 2008), .docxaryan532920
According to the NASW Code of Ethics section 6.04 (NASW, 2008), social workers are ethically bound to work for policies that support the healthy development of individuals, guarantee equal access to services, and promote social and economic justice.
For this Discussion
, review this week’s resources, including
Working with Survivors of Sexual Abuse and Trauma: The Case of Rita
and “The Johnson Family”. Consider what change you might make to the policies that affect the client in the case you chose. Finally, think about how you might evaluate the success of the policy changes.
By Day 3
Post
an explanation of one change you might make to the policies that affect the client in the case. Be sure to reference the case you selected in your post. Finally, explain how you might evaluate the success of the policy changes.
Working With Survivors of Sexual Abuse and Trauma: The Case of Rita
Rita is a 22-year-old, heterosexual, Latina female working in the hospitality industry at a resort. She is the youngest of five children and lives at home with her parents. Rita has dated in the past but never developed a serious relationship. She is close to her immediate and extended family as well as to her female friends in the Latino community. Although her parents and three of her siblings were born in the Dominican Republic, Rita was born in the United States.
A year ago, Rita was sexually assaulted by an acquaintance of a male coworker. Rita and a female coworker met Juan and Bob after work at a local bar for a light meal and a few drinks. Because Rita had to get up early to work her shift the next day, Bob offered to drive her home. Instead of taking Rita directly home, however, he drove to a desolate spot nearby and assaulted her. Afterward, Bob threatened to harm her family if she did not remain silent and proceeded to drive her home. Although Rita did not tell her family what happened, she did call our agency hotline the next day to discuss her options. Because Rita’s assault occurred within the 5-day window for forensic evidence collection of this kind, Rita consented to activation of the county’s sexual assault response team (SART). Although she agreed to have an advocate and the sexual assault nurse examiner (SANE) meet her at the hospital, Rita tearfully stated that she did not want to file a police report at that time because she did not want to upset her family. The nurse examiner interviewed Rita, collected evidence, recorded any injuries, administered antibiotics for possible sexually transmitted infections, and gave Rita emergency contraception in case of pregnancy. The advocate stayed with Rita during the procedure, supporting her and validating her experience, and gave her a referral for individual crisis counseling at our agency.
My treatment goals for Rita included alleviation of rape trauma syndrome symptoms that included shame and self-blame, validation of self-worth and empowerment, and processing how it would feel to discl.
According to the text, crime has been part of the human condition si.docxaryan532920
According to the text, crime has been part of the human condition since people began to live in groups. Ancient documents indicate that conduct we now call murder, theft, or robbery was identified as criminal by civilizations that existed thousands of years ago. Criminal laws regulate human conduct and tell people what they can and cannot do and, in some instances, what they must do under certain circumstances. In this assignment, you will explore different types of criminal conduct and the goals of criminal law.
Write a four to six (4-6) page paper in which you:
Determine whether or not the Ex Post Facto Clause can be used as a defense to prohibit the increase in federal minimum/mandatory sentencing guidelines after a federal defendant has committed the crime. Provide a rationale to support your position.
Explain the distinction between criminal, tort, and moral wrongs. Next, support or criticize the premise that the standards set by moral laws are higher than those set by criminal law.
Identify and discuss the differences between solicitation of another to commit a crime and a conspiracy to commit a crime. Next, support or criticize the use of the unilateral approach to conspiracy convictions.
Identify the four (4) goals of criminal law, and discuss the manner in which these four goals effectuate the purpose of protecting the public and preventing the conviction of innocent persons.
Use at least three (3) quality academic resources in this assignment.
Note:
Wikipedia and similar types of websites do not qualify as academic resources.
Your assignment must follow these formatting requirements:
This course requires use of new
Strayer Writing Standards (SWS
). The format is different than other Strayer University courses. Please take a moment to review the SWS documentation for details.
Be typed, double spaced, using Times New Roman font (size 12), with one-inch margins on all sides; citations and references must follow SWS or school-specific format. Check with your professor for any additional instructions.
Include a cover page containing the title of the assignment, the student's name, the professor's name, the course title, and the date. The cover page and the reference page are not included in the required assignment page length.
The specific course learning outcomes associated with this assignment are:
Describe the nature and history of American criminal law.
Explain the role of individuals and federal, state, and local government agencies in crime fighting and prosecution of criminal offenses.
Analyze the essential legal elements of criminal conduct.
Use technology and information resources to research issues in criminal law.
Write clearly and concisely about criminal law using proper writing mechanics.
.
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The purpose of this paper is to apply information gathered from th.docxoreo10
The purpose of this paper is to apply information gathered from the Family Genetic History and Milestone 1 assignments to identify one modifiable risk factor and develop an evidence-based teaching plan that promotes health as well as improves patient outcomes.
Course Outcomes
This assignment enables the student to meet the following Course Outcomes.
· CO4: Identify teaching/learning needs from the health history of an individual. (PO2)
Points
This assignment is worth a total of 225 points.
General Directions & Project Guidelines
· This paper is expected to be no more than four pages in length (not including the title page and reference list).
· Please use the categories listed below as the first level headings for each section of your paper (Exception: Instead of "Introduction" please use the title of your paper).
Content Guidelines
Using the information gathered in your Genetic Family History and Milestone 1 assignments, you will identify and research one modifiable risk factor. You will develop an evidence-based teaching plan that promotes health, with the aim of improving patient outcomes related to this modifiable risk factor.
A. Introduction (1 paragraph): The introduction should be interesting and capture the reader's attention.
· State one preventable disease your adult participant is at risk for developing (obesity, Type 2 Diabetes, etc.), based on the information you have gathered during this course.
· Introduce onemodifiable risk factor (diet, smoking, sedentary lifestyle, etc.) associated with the preventable disease you described.
· Clearly state the purpose of your paper. The purpose statement should relate to developing a patient teaching plan.
B. Preventable Disease Overview (1-2 paragraphs): Please use course materials and scholarly sources to complete this section. Be sure to paraphrase and include citations as needed!
· Describe briefly the preventable disease you identified in the introduction.
· What are the signs and symptoms associated with this disease?
· How is it diagnosed? Notable information from Health History and General Survey? Signs and symptoms? Risk assessments? Lab values?
· What physical assessment findings would be associated with this disease?
· How did you identify your adult participant's risk for this disease?
· Specific information gathered in the Genetic Family History?
· Specific information gathered in the Milestone 1 assignment?
C. Evidence Based Intervention (1-2 paragraphs):
· Choose and describe one evidence based interventionrelated to the modifiable risk factor you have chosen. (One that has been shown to be effective at reducing an individual's risk for developing the preventable disease.)
· Describe this intervention in detail, and provide rationale for your intervention utilizing:
· At least one scholarly peer-reviewed journal article. Go to the Chamberlain library at http:/library.chamberlain.edu (Links to an external site.)Links to an external site.. Search peer reviewed journals to find ...
Strategic Decision MakingComprehensive Capstone Case Study Instr.docxsusanschei
Strategic Decision Making
Comprehensive Capstone Case Study Instructions
The aim of this assignment is to provide students the opportunity to perform a thorough case analysis. Select your company and get approval from your course professor before working on it. The case analysis should include the following elements:
Title Page
Executive Summary
Background
· Introduce the company and provide the reader with background information about the company.
Situation Analysis
· The Environment – PESTLE Analysis
1. Political environment
2. Economic environment
3. Social environment
4. Technological environment
5. Legal/Regulatory environment
6. Environmental environment
· The Industry – Porter’s Five Forces Analysis
1. Bargaining power of suppliers
2. Threat of new entrant
3. Rivalry among existing competitors
4. Bargaining power of competitors
5. Threat of substitutes
· The Firm
1. What is the mission and vision of the firm?
2. What are the strengths of the firm?
3. What is the firm’s financial condition?
4. What are the constraints and weaknesses of the firm (i.e. financial condition, organizational conflict)?
5. What is the management philosophy?
6. What does the organizational structure tell you about how decisions are made?
· The Product
1. What good and/or service does the organization offer?
2. What consumer need does the product solve?
3. What promotional mix, channels of distribution, and pricing strategies are being used by the organization?
4. What competitive advantage does the marketing strategy offer?
SWOT Analysis
· Strengths
· Identify strengths of the organization and answer the following questions:
· How does this strength affect the operations of the organization?
· How does this strength assist the company in meeting the needs of its target market(s)?
· Weaknesses
· Identify weaknesses of the organization and answer the following questions:
· How does this weakness affect the operations of the organization?
· How does knowledge of this weakness assist the organization in meeting the needs of its target market(s)?
· Opportunities
· Identify opportunities in the industry (and/or external environment) and answer the following questions:
· How is this opportunity related to serving the needs of our target market?
· What actions must the organization take to capitalize on this opportunity?
· Threats
· Identify threats in the industry (and/or external environment) and answer the following questions:
· How is this threat related to serving the needs of our target market?
· What actions must the organization take to prevent this threat from limiting the capabilities of the organization?
Problem Statement
· What is the primary problem in the case? Secondary problems? What are the ramifications of these problems in the long run? Short run? Include quantitative and qualitative analysis in your response.
Strategic Plan
· Based on the problem identified, develop a 5-year strategic plan for the company. This plan should i.
Week 3 Assignment Addressing BiasGuidelines with Scoring Rubric.docxcockekeshia
Week 3 Assignment: Addressing BiasGuidelines with Scoring Rubric
Purpose
In today’s current healthcare settings, the increasing diversity, globalization, and expanding technologies produce complex ethical pressures that influence nursing practice and practice outcomes. To be effective in a master’s-prepared advanced nurse practice role it is important to understand personal values, beliefs, strengths, and limitations. The purpose of this assessment is to promote introspective reflection related to implicit and/or explicit personal biases. Students will develop a plan to reduce bias and promote personal and professional growth.
Course Outcomes
Through this assessment, the student will meet the following Course Outcomes.
CO 1: Examine roles and competencies of master’s-prepared nurses essential to performing as leaders and advocates of safe and quality care.
CO 2: Apply concepts of person-centered care to nursing practice situations.
Total Points Possible
This assessment is worth 125 points.
Due Date
Submit your file(s) by 11:59 p.m. MT Sunday at the end of Week 3.
Requirements
Criteria for Content
Complete a self-inventory on personal biases you hold. The biases might be implicit or explicit.
1. In a one to two-page summary, address the following.
a. Identify your selected specialty track (education, executive, family nurse practitioner, healthcare policy, or nursing informatics).
b. Discuss how biases can impact outcomes in selected nursing practice settings.
c. Identify personal biases and attitudes toward people with various cultural, gender, sexual orientation, age, weight, and religions that are different than your own.
d. Select one bias that you have.
e. Develop one strategy to reduce this bias.
Preparing the paper
Submission Requirements
1. Application: Use Microsoft Word 2013™ to create the written assessment.
2. Length: The paper (excluding the title page and reference page) is at maximum two pages.
3. A minimum of two (2) scholarly literature references must be used.
4. Submission: Submit your files: Last name_First initial_Wk3Assignment_Addressing Bias
Best Practices in Preparing the Project
The following are best practices in preparing this project.
1. Review directions thoroughly.
2. Follow submission requirements.
3. Make sure all elements on the grading rubric are included.
4. Rules of grammar, spelling, word usage, and punctuation are followed and consistent with formal, scientific writing.
5. Title page, running head, body of paper, and reference page must follow APA guidelines as found in the 6th edition of the manual. This includes the use of headings for each section of the paper except for the introduction where no heading is used.
6. Ideas and information that come from scholarly literature must be cited and referenced correctly.
7. A minimum of two (2) scholarly literature references must be used.
8. Abide by CCN academic integrity policy.
Grading Criteria
Category
Points
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Description
Introduc.
Bioethics Case Study1.1.Bioethics Case Study This assignment .docxmoirarandell
Bioethics Case Study
1.
1.Bioethics Case Study: This assignment asks you to examine a current ethical controversy case study. The paper is informal, but should be in APA style, and does not need an abstract or cover page. With a minimum of two pages and a maximum of four pages A reference page is needed. In-text citations should be in APA format. Papers will be graded on a 0 to 25-point scale.
Case Study in Primary care:
One hypothetical case study involves Jim a 54, year old patient who has recently diagnose with hypertension and his Creatinine and BUN laboratory results are elevated, if left untreated, will result in kidney failure. The patient refuses to take the medication because he said it will affect his sex life The NP must work with the patient to respect the fact that he doesn’t want the medication (autonomy), and needs to find a solution that would prevent him from going into kidney failure and other complications, which is in his best interest (beneficence). Although medications are the best choice, forcing the patient to accept the medication will result in probably patient leaving the care (non-maleficence). Finally, the NP needs to consider the impact that the patient’s choices might have on others if he starts to go into preventable kidney failure, he’ll need dialysis, which affects other people who need the same treatment (justice). So before making the final decision the NP must consider all four principles of health care ethics, which will help the NP make the choice that will have the best possible benefits for both the patient and society.
Questions?
1. What are the skills necessary for the provider to identify, address, and assess this clinical ethical issue?
2. What are the provider’s obligations when a patient discloses does he not intent to follow the treatment?
3. What are the ethical considerations in evaluating a patient’s failure to adhere to a prescribed therapy?
4. Will you terminate care for this patient? What are the implications?
Case Study Rubric
Criterion
Outstanding (25)
Very Good (22)
Average (18)
Unacceptable (15)
Score
Completeness
Complete in all respects; reflects all requirements
Complete in most respects; reflects most requirements
Incomplete many respects; reflects few requirements
Incomplete in most respects; does not reflect requirements
Understanding
Demonstrates excellent understanding of the topic(s) and issue(s)
Demonstrates an accomplished understanding of the topic(s) and issue(s)
Demonstrates an acceptable understanding of the topic(s) and issue(s)
Demonstrates an inadequate understanding of the topic(s) and issue(s)
Analysis
Presents an insightful and through analysis of the issue (s) identified
Presents a thorough analysis of most of the issue(s) identified
Presents a superficial analysis of some of the issue(s) identified
Presents an incomplete analysis of the issue(s) identified.
Evaluation
Makes appropriate and powerful connections between the issue(s) identified and the con.
Selection and formulation of a research problem.pptxGeorgeKabongah2
One of the greatest challenges faced by researchers is resource and time constraints. This makes it difficult to involve the entire population of interest and so researchers only use a subset of a population to represent the whole population. This is called a sample. The use of samples however involves other big class of problems: given that your measurements are credible, how much of the world do they represent? How far can you generalize the results of your research? The answer depends, first, on the kind of data in which you are interested. There are two kinds of data of interest to social scientists: individual attribute data and cultural data. These two kinds require different approaches to sampling and that is the focus of this week.
Discussion QuestionWilliam Ford Jr., Chairman of Ford Motor C.docxedgar6wallace88877
Discussion Question:
William Ford Jr., Chairman of Ford Motor Co. said, "A good company delivers excellent products and services, and a great company does all that and strives to make the world a better place."
Supported by evidence from your textbook, the Starbucks case study, and other research, describes two forces that you believe shape the relationship between business and society. Provide two examples, one for each force you select. Be specific in your answer and discuss strengths and weaknesses via examples and applications. Be certain to cite in APA format all sources used. Respond to at least two of your classmates’ discussion posts.
MBA 525 - Module 4 AVP - Decision Making and Ethics
Slide 1
Title slide
Slide content:
MBA 525 Module 4
Slide 2
Slide title:
Decision Making and Ethics
Narrator:
In this presentation, we will discuss the decision making process and how it is informed by ethics. We will
highlight common errors in decision making, rationality, and ethical decision making.
Slide 3
Slide title:
Decision-Making Steps
Slide content:
• Define the task
• Delegate tasks
• Seek out information and determine its accuracy
• Establish criteria for evaluating specific courses of action
• Discover and evaluate alternative options
• Prepare and present the group’s choice persuasively to the target audience
Narrator:
There are six steps in the decision making process.
First, define the task.
Second, delegate tasks.
Third, seek out information and determine its accuracy.
Fourth, establish criteria for evaluating specific courses of action.
Fifth, discover and evaluate alternative options.
And lastly, prepare and present the group’s choice persuasively to the target audience.
Slide 4
Slide title:
Errors of Poor Decision Making
Slide content:
• Improper assessment of the situation
• The establishment of inappropriate goals and objectives
• Improper assessment of the strengths and weaknesses of various alternatives
• The establishment of a flawed information base
Narrator:
The most common errors in this process include:
Improper assessment of the situation,
The establishment of inappropriate goals and objectives,
Improper assessment of the strengths and weaknesses of various alternatives, and,
The establishment of a flawed information base.
Consider the last decision you made that was faulty. Reflect on which error in decision making was
present. We are all guilty of making the “wrong” decision at some point due to errors in judgment.
Slide 5
Slide title:
Steps of Rational Decision Making
Slide content:
• Recognize the problem
• Discuss the problem with all relevant persons
• Decide on alternative courses of action
• Choose an optimal solution and implement it
• Monitor the impact of the solution
Narrator:
The steps to rational decision making vary a bit from the general model. There are only five, not six steps.
First, recognize the problem. This is a different starting point. It is important to first understand the
problem.
Next, disc.
Complete and submit your Comprehensive Psychiatric Evaluation, i.docxzollyjenkins
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.
Incorporate the following into your responses in the template:
Subjective:
What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective:
What observations did you make during the psychiatric assessment?
Assessment:
Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Reflection notes:
What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
.
Top of FormViewG View Grading RubricsCounselor Ethics and Re.docxturveycharlyn
Top of Form
ViewG View Grading Rubrics
Counselor Ethics and Responsibilities Paper
1
Unsatisfactory
0.00%
2
Less Than Satisfactory
74.00%
3
Satisfactory
79.00%
4
Good
87.00%
5
Excellent
100.00%
70.0 %Content
15.0 %Counselor Values
Analysis of the criteria is not outlined or outlined poorly. Fails to formulate and clearly express own point of view.
Ignores or superficially evaluates the ethical issues. Formulates a vague and indecisive point of view.
Surface level of evaluation of the ethical issues is offered. Minimal rationale presented. Expresses a preference in a personal point of view, but lacks details. Discusses a counseling plan for the client, but lacks supporting rationale.
Describes the process/plan in which counseling would or would not be provided, considering all ethical implications. Subject knowledge appears to be good. Formulates a clear and precise personal point of view. Includes essential knowledge about personal values and attitudes with supporting details and resources.
Comprehensively describes the process/plan in which counseling would or would not be provided, considering all ethical implications. Subject knowledge is excellent. Formulates a clear and precise personal point of view. Clearly describes personal values and attitudes in depth with extensive details and resources.
20.0 %Client Rights
Includes little knowledge about the topic. Subject knowledge is not evident.
Includes little knowledge about the topic with few supporting details. Little subject knowledge is evident. Ignores or superficially evaluates the criteria.
Lists the five ethical principles and discusses how they relate to client rights. Explains how these rights will be incorporated into professional practice with minimal details and/or rationale. Some subject knowledge is evident. Surface level of evaluation of the content is offered.
Presents a detailed outline of the relationship between the five ethical principles and how they relate to client rights. Explains how these principles will be incorporated into professional practice with supporting details, and/or rationale. Informed consent is explicitly and thoroughly addressed in this description. Subject knowledge appears to be good. Analysis is direct, competent, and appropriate for the criteria.
Presents a full detailed in-depth description of the relationship between the five ethical principles and client rights. Explain show these principles will be incorporated into professional practice with extensive details and/or rationale. Informed consent is explicitly and thoroughly addressed in this description. Subject knowledge is excellent. Thoughtfully analyzes and evaluates major points of the criteria.
20.0 %Responsibility to Warn and Protect
Includes little knowledge about the topic. Subject knowledge is not evident. Factors involved in decision making are vague or not present.
Includes little knowledge about the topic with few supporting details. Little subject knowledge is evi ...
Assignment #2- Policy Implementation (17.5 points)Build on Assig.docxdavezstarr61655
Assignment #2- Policy Implementation (17.5 points)
Build on Assignment #1. You will cover the same health problem and the same policy Some remedial action on Assignment #1 may be required in order for students to proceed to Assignment #2.Complete the following using the format provided. Except for titles, narrative format is expected with complete sentences. The table should be single spaced maximum 2.5 pages. Also include a cover page and a reference page in APA Format.
HGMT 310 Assignment #2
Student Name:
Type your name here.
Assignment #2 Title:
Provide a short name and the official title of the legislation.
Agency Responsible:
Identify the agency and subunit (such as a bureau or office) responsible for implementing the policy. If multiple agencies are involved indicate who is responsible for what.
Enforcement:
What federal or state agency is responsible for enforcement? What are the key areas for enforcement?
Implementation:
How is the legislation implemented? What federal or state agency is charged with its implementation? Are local public health departments involved? Are collaborating organizations engaged to achieve the aims of the policy? Are citizen’s involved? Are health provider organizations? Are grants awarded?
Impact on Health Service Organizations:
What does a Health Care Manager need to know about this legislation and the related implementation? Include five bullets of how this legislation impacts health services organizations operating in your home state.
Resource:
What resource would a health organization utilize to find updates regarding the impact policies have on them?
All sections of Assignment #2 are required.
Rubric Name: Written Assignment Rubric
Criteria
Outstanding
Superior
Good
Below Standard
Failure
Critical Thinking/Reasoning
35 points
demonstrates a high degree of critical thinking, is consistent in accurately interpreting questions & material; provides solid assumptions, reasoning & claims; provides thorough analysis & evaluation with sound conclusions
31.5 points
shows good critical thinking; accurately interprets most questions & material; usually identifies relevant arguments/reasoning/claims; offers good analysis & evaluation with fairly sound conclusions
24.5 points
shows occasional critical thinking; questions & material is at times accurately interpreted; arguments/reasoning/claims are occasionally explained; offers fair analysis & evaluation with a conclusion
21 points
shows little critical thinking, misinterprets questions or material; ignores or superficially evaluates; justifies little and seldom explains reasoning; draws unwarranted conclusions
0 points
lacks critical thinking consistently offers biased interpretations; ignores or superficially evaluates; argues using poor reasoning, and/or unwarranted claims
Application of Concepts/Development
35 points
arguments or positions are well-supported with evidence from the readings/experience; ideas go beyond the course material and reco.
According to the NASW Code of Ethics section 6.04 (NASW, 2008), .docxaryan532920
According to the NASW Code of Ethics section 6.04 (NASW, 2008), social workers are ethically bound to work for policies that support the healthy development of individuals, guarantee equal access to services, and promote social and economic justice.
For this Discussion
, review this week’s resources, including
Working with Survivors of Sexual Abuse and Trauma: The Case of Rita
and “The Johnson Family”. Consider what change you might make to the policies that affect the client in the case you chose. Finally, think about how you might evaluate the success of the policy changes.
By Day 3
Post
an explanation of one change you might make to the policies that affect the client in the case. Be sure to reference the case you selected in your post. Finally, explain how you might evaluate the success of the policy changes.
Working With Survivors of Sexual Abuse and Trauma: The Case of Rita
Rita is a 22-year-old, heterosexual, Latina female working in the hospitality industry at a resort. She is the youngest of five children and lives at home with her parents. Rita has dated in the past but never developed a serious relationship. She is close to her immediate and extended family as well as to her female friends in the Latino community. Although her parents and three of her siblings were born in the Dominican Republic, Rita was born in the United States.
A year ago, Rita was sexually assaulted by an acquaintance of a male coworker. Rita and a female coworker met Juan and Bob after work at a local bar for a light meal and a few drinks. Because Rita had to get up early to work her shift the next day, Bob offered to drive her home. Instead of taking Rita directly home, however, he drove to a desolate spot nearby and assaulted her. Afterward, Bob threatened to harm her family if she did not remain silent and proceeded to drive her home. Although Rita did not tell her family what happened, she did call our agency hotline the next day to discuss her options. Because Rita’s assault occurred within the 5-day window for forensic evidence collection of this kind, Rita consented to activation of the county’s sexual assault response team (SART). Although she agreed to have an advocate and the sexual assault nurse examiner (SANE) meet her at the hospital, Rita tearfully stated that she did not want to file a police report at that time because she did not want to upset her family. The nurse examiner interviewed Rita, collected evidence, recorded any injuries, administered antibiotics for possible sexually transmitted infections, and gave Rita emergency contraception in case of pregnancy. The advocate stayed with Rita during the procedure, supporting her and validating her experience, and gave her a referral for individual crisis counseling at our agency.
My treatment goals for Rita included alleviation of rape trauma syndrome symptoms that included shame and self-blame, validation of self-worth and empowerment, and processing how it would feel to discl.
According to the text, crime has been part of the human condition si.docxaryan532920
According to the text, crime has been part of the human condition since people began to live in groups. Ancient documents indicate that conduct we now call murder, theft, or robbery was identified as criminal by civilizations that existed thousands of years ago. Criminal laws regulate human conduct and tell people what they can and cannot do and, in some instances, what they must do under certain circumstances. In this assignment, you will explore different types of criminal conduct and the goals of criminal law.
Write a four to six (4-6) page paper in which you:
Determine whether or not the Ex Post Facto Clause can be used as a defense to prohibit the increase in federal minimum/mandatory sentencing guidelines after a federal defendant has committed the crime. Provide a rationale to support your position.
Explain the distinction between criminal, tort, and moral wrongs. Next, support or criticize the premise that the standards set by moral laws are higher than those set by criminal law.
Identify and discuss the differences between solicitation of another to commit a crime and a conspiracy to commit a crime. Next, support or criticize the use of the unilateral approach to conspiracy convictions.
Identify the four (4) goals of criminal law, and discuss the manner in which these four goals effectuate the purpose of protecting the public and preventing the conviction of innocent persons.
Use at least three (3) quality academic resources in this assignment.
Note:
Wikipedia and similar types of websites do not qualify as academic resources.
Your assignment must follow these formatting requirements:
This course requires use of new
Strayer Writing Standards (SWS
). The format is different than other Strayer University courses. Please take a moment to review the SWS documentation for details.
Be typed, double spaced, using Times New Roman font (size 12), with one-inch margins on all sides; citations and references must follow SWS or school-specific format. Check with your professor for any additional instructions.
Include a cover page containing the title of the assignment, the student's name, the professor's name, the course title, and the date. The cover page and the reference page are not included in the required assignment page length.
The specific course learning outcomes associated with this assignment are:
Describe the nature and history of American criminal law.
Explain the role of individuals and federal, state, and local government agencies in crime fighting and prosecution of criminal offenses.
Analyze the essential legal elements of criminal conduct.
Use technology and information resources to research issues in criminal law.
Write clearly and concisely about criminal law using proper writing mechanics.
.
According to Ronald Story and Bruce Laurie, The dozen years between.docxaryan532920
According to Ronald Story and Bruce Laurie, “The dozen years between 1968 and 1980 marked more than the beginning of Republican ascendency; they also saw the breakup of the New Deal coalition and the advent of conservative domination of American politics.” (CP 139).
In this essay, you should explain,
first
, how it is that conservatives came to dominate American politics by the 1980s and,
second
,
how the ideas and policies they embraced shaped American society into the twenty first century.
Rules:
1. 3-4 pages
2. Double spaced, 12-point font
3. Standard margins—Approximately 1.25 on left and right margins and 1 on top and bottom
4. In crafting your essay, you will want to construct a clear thesis and draw on evidence from the sources described below.
5.
Only
use these sources below.
Sources:
Context: The Close of the 1960s
1. The black cat tavern and the LGBT Movement
Link:
https://www.npr.org/2017/02/13/514935126/stonewall-riots-grab-the-spotlight-from-black-cat-protests
2. ESPN Sport center on Katherine Switzwer
Link:
https://www.youtube.com/watch?v=U6CoScOIK_I
3. Crisis in the Cities and 1968.pdf (attachment)
4. Excerpt from MLK’s final Speech in 1968
Link:
https://www.youtube.com/watch?v=Oehry1JC9Rk
5. Vietnam-The path to war.pdf (attachment)
The Rediscovery of the Market: Conservative Politics and Policies
6. Alfred Kahn’s Legacy: Cheap Flights
Link:
https://www.npr.org/2010/12/29/132422495/alfred-kahns-legacy-cheap-flights
7. A Second Gilded Age?.pdf (attachment)
.
According to Kirk (2016), most of your time will be spent work with .docxaryan532920
According to Kirk (2016), most of your time will be spent work with your data. The four following group actions were mentioned by Kirk (2016):
Data acquisition: Gathering the raw material
Data examination: Identifying physical properties and meaning
Data transformation: Enhancing your data through modification and consolidation
Data exploration: Using exploratory analysis and research techniques to learn
Select 1 data action and elaborate on the actions performed in that action group.
Reference: Kirk, A. (2016). Data Visualisation: A Handbook for Data Driven Design (p. 50). SAGE Publications.
.
According to the Council on Social Work Education, Competency 5 Eng.docxaryan532920
According to the Council on Social Work Education, Competency 5: Engage in Policy Practice:
Social workers understand that human rights and social justice, as well as social welfare and services, are mediated by policy and its implementation at the federal, state, and local levels. Social workers understand the history and current structures of social policies and services, the role of policy in service delivery, and the role of practice in policy development. Social workers understand their role in policy development and implementation within their practice settings at the micro, mezzo, and macro levels and they actively engage in policy practice to effect change within those settings. Social workers recognize and understand the historical, social, cultural, economic, organizational, environmental, and global influences that affect social policy. They are also knowledgeable about policy formulation, analysis, implementation, and evaluation.
Walden’s MSW program expects students in their specialization year to be able to:
Evaluate the implication of policies and policy change in the lives of clients/constituents.
Demonstrate critical thinking skills that can be used to inform policymakers and influence policies that impact clients/constituents and services.
This assignment is intended to help students demonstrate the behavioral components of this competency in their field education.
To prepare
: Working with your field instructor, identify a social problem that is common among the organization (or its clients) and research current policies at that state and federal levels that impact the social problem. Then, from a position of advocacy, identify methods to address the social problem (i.e., how you, as a social worker, and the agency advocate to change the problem). You are expected to specifically address how both you and the agency can effectively engage policy makers to make them aware of the social problem and the impact that the policies have on the agency and clients.
The Assignment (2-3 pages): Social Problems is Ex-cons finding Jobs Opportunities in State of California. The Agency is Called "Manifest" the website is Manifest.org
Identify the social problem
Explain rational for selecting social problem
Describe state and federal policies that impact the social problem
Identify specific methods to address the social problems
Explain how the agency and student can advocate to change the social problem
You are expected to present and discuss this assignment with your agency Field Instructor. Your field instructor will be evaluating your ability to demonstrate this competency in their field evaluation. In addition, you will submit this assignment for classroom credit. The Field Liaison will grade the assignment “PASS/FAIL,” see rubric for passing criteria.
.
According to Kirk (2016), most of our time will be spent working.docxaryan532920
According to Kirk (2016), most of our time will be spent working with our data. The four following group actions were mentioned by Kirk (2016):
Book: Kirk, A. (2016). Data visualisation a handbook for data driven design. Los Angeles, CA: Sage.
Data acquisition: Gathering the raw material
Data examination: Identifying physical properties and meaning
Data transformation: Enhancing your data through modification and consolidation
Data exploration: Using exploratory analysis and research techniques to learn
Select 1 data action and elaborate on the actions preformed in that action group.
.
According to Kirk (2016), most of your time will be spent working wi.docxaryan532920
According to Kirk (2016), most of your time will be spent working with your data. The four following group actions were mentioned by Kirk (2016):
Data acquisition: Gathering the raw material
Data examination: Identifying physical properties and meaning
Data transformation: Enhancing your data through modification and consolidation
Data exploration: Using exploratory analysis and research techniques to learn
Select 1 data action and elaborate on the actions preformed in that action group.
.
According to Davenport (2014) the organizational value of healthcare.docxaryan532920
According to Davenport (2014) the organizational value of healthcare analytics, both determination and importance, provide a potential increase in annual revenue and ROI based on the value and use of analytics. To complete this assignment, research and evaluate the challenges faced in the implementation of healthcare analytics in the Health Care Organization (HCO) or health care industry using the following tools:
The paper must also address the following:
Application of PICO (problem, intervention, comparison group, and outcomes) to the challenge identified in your research.
The paper:
Must be two to four double-spaced pages in length (not including title and references pages) and formatted according to APA style as outlined in the
Ashford Writing Center. (Links to an external site.)
Must include a separate title page with the following:
Title of paper
Student’s name
Course name and number
Instructor’s name
Date submitted
Must use at least three scholarly sources in addition to the course text.
Must document all sources in APA style as outlined in the Ashford Writing Center.
Must include a separate references page that is formatted according to APA style as outlined in the Ashford Writing Center.
.
According to the authors, privacy and security go hand in hand; .docxaryan532920
According to the authors, privacy and security go hand in hand; and hence, privacy cannot be protected without implementing proper security controls and technologies. Today, organizations must make not only reasonable efforts to offer protection of privacy of data, but also must go much further as privacy breaches are damaging to its customers, reputation, and potentially could put the company out of business. As we continue learning from our various professional areas of practice, its no doubt that breaches have become an increasing concern to many businesses and their future operations. Taking Cyberattacks proliferation of 2011 into context, security experts at Intel/McAfee discovered huge series of cyberattacks on the networks of 72 organizations globally, including the United Nations, governments and corporations.
Q: From this research revelation in our chapter 11, briefly state and name the countries and organizations identified as the targeted victims?
.
According to Gilbert and Troitzsch (2005), Foundations of Simula.docxaryan532920
According to Gilbert and Troitzsch (2005), Foundations of Simulation Modeling, a simulation model is a computer program that captures the behavior of a real-world system and its input and possible output processes.
Briefly explain what the simulation modeling relies upon?
-500 words at least.
-No Plagiarism.
-APA Format.
.
According to Klein (2016), using ethical absolutism and ethical .docxaryan532920
According to Klein (2016), using ethical absolutism and ethical relativism in ethical decision making can lead to different outcomes. How can moral reasoning about a specific situation differ based on relativism or absolutism? Can you provide an illustration or example of an accounting procedure/situation whose outcome may differ based on absolutism or relativism? Is ethical relativism a more suitable standard within a global IFRS Environment? Why or why not?
at least 250 words
.
According to Franks and Smallwood (2013), information has become.docxaryan532920
According to Franks and Smallwood (2013), information has become the lifeblood of every business organization, and that an increasing volume of information today has increased and exchanged through the use of social networks and Web2.0 tools like blogs, microblogs, and wikis. When looking at social media in the enterprise, there is a notable difference in functionality between e-mail and social media, and has been documented by research – “…that social media differ greatly from e-mail use due to its maturity and stability.” (Franks & Smallwood, 2013).
Provide a page response identifying and clearly stating what the difference are? APA Standard, 2 page response, not including front page and references.
.
According to the Council on Social Work Education, Competency 5.docxaryan532920
According to the Council on Social Work Education, Competency 5: Engage in Policy Practice:
Social workers understand that human rights and social justice, as well as social welfare and services, are mediated by policy and its implementation at the federal, state, and local levels. Social workers understand the history and current structures of social policies and services, the role of policy in service delivery, and the role of practice in policy development. Social workers understand their role in policy development and implementation within their practice settings at the micro, mezzo, and macro levels and they actively engage in policy practice to effect change within those settings. Social workers recognize and understand the historical, social, cultural, economic, organizational, environmental, and global influences that affect social policy. They are also knowledgeable about policy formulation, analysis, implementation, and evaluation. Social workers:
Identify social policy at the local, state, and federal level that impacts well-being, service delivery, and access to social services;
Assess how social welfare and economic policies impact the delivery of and access to social services;
Apply critical thinking to analyze, formulate, and advocate for policies that advance human rights and social, economic, and environmental justice.
This assignment is intended to help students demonstrate the behavioral components of this competency in their field education.
To prepare: Working with your field instructor, identify, evaluate, and discuss policies established by the local, state, and federal government (within the last five years) that affect the day to day operations of the field placement agency.
The Assignment (1-2 pages): (In The States California. The Good Seed is a Drop-In center for 18-25 years!
Describe the policies and their impact on the field agency.
Propose specific recommendations regarding how you, as a social work intern, and the agency can advocate for policies pertaining to advancing social justice for the agency and the clients it serves.
.
According to the authors, privacy and security go hand in hand; and .docxaryan532920
According to the authors, privacy and security go hand in hand; and hence, privacy cannot be protected without implementing proper security controls and technologies. Today, organizations must make not only reasonable efforts to offer protection of privacy of data, but also must go much further as privacy breaches are damaging to its customers, reputation, and potentially could put the company out of business. As we continue learning from our various professional areas of practice, its no doubt that breaches have become an increasing concern to many businesses and their future operations. Taking Cyberattacks proliferation of 2011 into context, security experts at Intel/McAfee discovered huge series of cyberattacks on the networks of 72 organizations globally, including the United Nations, governments and corporations.
From this research revelation in our chapter 11, briefly state and name the countries and organizations identified as the targeted victims?
Use the APA format to include your references. Each paragraph should have different references and each para should have at least 4 sentences.
.
According to recent surveys, China, India, and the Philippines are t.docxaryan532920
According to recent surveys, China, India, and the Philippines are the three most popular countries for IT outsourcing. Write a short paper (4 paragraphs) explaining what the appeal would be for US companies to outsource IT functions to these countries. You may discuss cost, labor pool, language, or possibly government support as your reasons. There are many other reasons you may choose to highlight in your paper. Be sure to use your own words.
Must be in APA format with references and citations.
.
According to the authors, countries that lag behind the rest of the .docxaryan532920
According to the authors, countries that lag behind the rest of the world’s ICT capabilities encounter difficulties at various levels. Discuss specific areas, both within and outside, eGovernance, in which citizens living in a country that lags behind the rest of the world in ICT capacity are lacking. Include in your discussion quality of life, sustainability, safety, affluence, and any other areas that you find of interest. Use at least 8-10 sentences to discuss this topic.
.
According to Peskin et al. (2013) in our course reader, Studies on .docxaryan532920
According to Peskin et al. (2013) in our course reader, "Studies on early health risk factors, including prenatal nicotine/alcohol exposure, birth complications, and minor physical anomalies have found that these risk factors significantly increase the likelihood of anti-social and criminal behavior throughout life." What policy changes might you suggest to help curtail the occurrence or effects of these risk factors? Remember to think about public health policy, not just criminal policy.
.
According to Franks and Smallwood (2013), information has become the.docxaryan532920
According to Franks and Smallwood (2013), information has become the lifeblood of every business organization, and that an increasing volume of information today has increased and exchanged through the use of social networks and Web2.0 tools like blogs, microblogs, and wikis. When looking at social media in the enterprise, there is a notable difference in functionality between e-mail and social media, and has been documented by research – “…that social media differ greatly from e-mail use due to its maturity and stability.” (Franks & Smallwood, 2013).
Q: Please identify and clearly state what the difference is?
Use the APA format to include your references. Each paragraph should have different references and each para should have at least 4 sentences.
.
According to Ang (2011), how is Social Media management differen.docxaryan532920
According to Ang (2011), how is Social Media management different than traditional Customer Relationship Management (CRM)? Define the four pillars of social media (connectivity, conversations, content creation and collaboration) and analyze how each pillar can be used to aid Social Media management. Identify the benefits Social Media management. Provide examples to illustrate each point.
The paper must be 1-2 pages in length (excluding title and reference page) and in APA (6th edition) format. The paper must include the Ang (2011) article in correct APA format.
.
According to (Alsaidi & Kausar (2018), It is expected that by 2020,.docxaryan532920
According to (Alsaidi & Kausar (2018), "It is expected that by 2020, around 25 billion objects will become the part of global IoT network, which will pose new challenges in securing IoT systems. It will become an easy target for hackers as these systems are often deployed in an uncontrolled and hostile environment. The main security challenges in IoT environment are authorization, privacy, authentication, admission control, system conformation, storage, and administration" (p. 213).
Discuss and describe the difference between a black hole attack and a wormhole attack.
.
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
Introduction to AI for Nonprofits with Tapp NetworkTechSoup
Dive into the world of AI! Experts Jon Hill and Tareq Monaur will guide you through AI's role in enhancing nonprofit websites and basic marketing strategies, making it easy to understand and apply.
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
The French Revolution Class 9 Study Material pdf free download
HSC 312 Final Project –Complied Case Analysis Scoring Rubr.docx
1. HSC 312: Final Project –Complied Case Analysis Scoring
Rubric
The following criteria will be used to grade your Complied Case
Analysis. Keep in mind that the score requirement described
under each score point on the scale defines the minimum
performance that must be demonstrated in order to achieve that
score.
Evaluation
Criteria
A
20 points
B
17 points
C
2. 15 points
D
13 points
F
11 points
1.) Introduces
the case
analysis by
describing
the ethical
dilemma
requiring
resolution
Introduction is:
• Comprehensive
• Includes a
thorough, clear and
3. concise description
of the case and
ethical dilemma
proposed.
Introduction:
• Includes minor
omissions in
description of
either the case
or ethical
dilemma.
Introduction:
• Lacks detail in
part
• Includes minor
omissions in
both the
4. description of
the case and the
ethical dilemma.
Introduction:
• Lacks detail
• Includes major
omissions in
either
description of
the case or the
ethical
dilemma.
Description is either
missing or contains
major omissions
throughout.
2.) Identifies
the
5. primary
stakeholder
(s) and
provides a
description
of the
situation
from the
stakeholder
perspective
Description is:
• Comprehensive
• Includes
identification of
stakeholder
• Provides clear
stakeholder
Description:
6. • Has minor
omissions or
errors in
identification of
stakeholders or
in describing the
stakeholder
perspective.
Description:
• Lacks detail
• Omits some
significant
content or
contains several
minor errors.
Description:
7. • Lacks detail.
• Is superficial
and contains
multiple errors.
Description is:
• Missing or
incorrect
• Inconsistent
with selected
stakeholder
identify any
or identifies
irrelevant
stakeholders.
3.) Analyzes the
scenario
8. from the
perspective
of the
primary
stakeholder
and includes
a description
of at least
two ethical
theories that
relate to the
issue being
identified
Analysis and Description
are:
• Comprehensive
• Include responses
to all
9. subcomponents of
the question.
• Provides clear
description of two
or more ethical
theories and their
relation to the
issue.
Analysis and
Description:
• Include minor
omissions.
• Includes 1-2
minor errors in
regards to the
scenario of the
stakeholder or
the description
10. of the ethical
theories.
Analysis and
Description:
• Include a major
omission, OR
• Includes
several errors in
regards to the
scenario of the
stakeholder or
the description
of the ethical
theories.
Analysis and
Description:
• Includes a
major omission,
11. AND
• Includes
several errors in
regards to the
scenario of the
stakeholder or
the description
of the ethical
theories.
Analysis and
Description are:
• Missing
OR
• Response
contains
significant
errors or
omissions
12. throughout the
response.
4.) Provides a
reasonable
recommendat
ion based
upon the
analysis
presented
Recommendation is:
• Comprehensive.
• Clear and logical
• Summarizes key
points.
Recommendation
has:
• Minor
omissions or
13. errors
• Is clear and
logical
• Summarizes
most key points.
Recommendation:
• Omits some
significant
content and
contains several
minor errors
• Is clear or
logical but not
both
• Summarizes
minimal
points.
Recommendation:
14. • Is superficial
and contains
multiple errors
• Is not clear or
logical
• Summarizes 1-
2 points.
Recommendation is:
• Missing or
incorrect.
5.) Format Format is:
• Clear and
consistent.
• contains accurate
and proper
16. omissions.
Format is:
• Clear but not
concise.
• Contains
multiple errors
of accuracy.
• Follows
specific
instructions
with multiple
omissions.
Format is:
• Not clear or
concise.
• Contains
serious errors.
• Specific
17. instructions are
barely followed.
Format:
• Is not clear.
• Does not
follow specific
instructions.
Final Project – Compiled Case Studies
Jane Doe
HSC312
May 2013
Professor X
18. HSC312 - Final Project: Compiled Case Studies May 2013
Jane Doe
Case Analysis: Sally & the DNR
Case Analysis Template for use with each of the four scenarios
in the final project:
1. Copy/paste the title of the question
2. Describe the most relevant ethical dilemma(s) presented (no
more than two).
3. Briefly describe the primary issue or issues that are relevant
in the scenario w/respect to
the dilemma.
4. Identify the most relevant stakeholder(s) (no more than 3)
and briefly describe the
situation from their perspective.
5. Analyze the dilemma, using scholarly discussion, from the
perspective of the primary
stakeholder (typically the patient). Include a discussion of at
least two ethical theories
or bioethics principles studied in the course that relate to the
19. dilemma and issues you
identified. Include any relevant legal concerns or requirements
outlined in the readings.
6. Present your assessment, resolution or potential solutions for
resolving the issue.
Remember that there are no right answers, per se, so reflective
questions can be as
appropriate as a firm conclusion.
7. Title page + APA formatted reference(s)
The following example provides further insight into what is
required for each element of the
template. Although the response is intentionally somewhat
longer than what is expected, it
should help clarify the specific requirements.
1. Ethical Dilemma
Prompt objective: Identify the ethical dilemma and state the
dilemma as a “should” question.
Note: there may be several relevant dilemmas that could be
addressed; use the prompt question
as a guide to an issue to analyze. The objective is to present a
cogent analysis of a relevant issue.
ISSUE: Should the attending physician sign a DNR without
20. Sally’s consent?
2. Primary issues related to the identified dilemma
Prompt objective: Identify the relevant issues related to your
dilemma. You should identify at
least two, but limit your selection of issues to a manageable
number within the scope of the
assignment.
Informed consent; Surrogate decision making & substituted
judgment; healthcare decision
making capacity; autonomy and the right to refuse treatment
3. Primary Stakeholders & Stakeholder positions:
Question objective: Identify 2-3 primary stakeholders including
the patient, and briefly describe
their position:
Sally: 62 yr old woman with Stage IV breast cancer that is
unresponsive to standard and
experimental treatment presents with shortness of breath
requiring a Thorentisis, a difficult
procedure given her condition. Sally wants to live and refuses
21. to discuss the terminal nature of
her condition.
HSC312 - Final Project: Compiled Case Studies May 2013
Jane Doe
Sally’s husband: Sally’s husband recognizes that Sally is dying
and wants everything done for
Sally to make her comfortable. He agrees with the attending
physician that CPR would make
Sally less, rather than more comfortable. He is Sally’s surrogate
decision maker.
The attending physician: Believes that further testing and
treatment for Sally is futile. He
questions whether Sally has the capacity to understand her
condition and consent to the DNR.
4. Potential
Solution
Analysis:
22. Prompt objective: Analyze the ethical dilemma from the
perspective of the primary stakeholder
(typically the patient), using the ethical theories and/or the
bioethics principles that relate to the
dilemma. Keep your analysis focused on at least two or three
moral theories or bioethics
principles, but do not attempt to address them all. There will
generally be more issues and
principles/theories that would apply than you can cover in a
short analysis. Include in your
discussion any known legal issues presented by the readings
that may influence a decision. Apply
the facts to the theories discussed. Keep in mind that there may
be several issues and theories to
discuss, but you are not required to find or address them all.
The essay below is purposefully
more involved than the assignment requires providing a few
23. examples of an ethical analysis.
Under the ethical and legal doctrine of informed consent
provided by the Patient Self-
Determination Act, an adult patient with healthcare decision-
making capacity has the right to
make an informed, autonomous choice to accept or reject
medical treatment. (Munson, 2012).
The right to self-determination is defined by the bioethics
principle of
Autonomy and refers to the patient’s right to make a voluntary
choice that is meaningful to them
and free from external or personal influences. (Tong, 2007).
Such influences may include fear,
denial, medication side effects, pain and guilt, among others.
Healthcare decision-making
capacity requires that the patient can articulate and understand
24. the nature of their condition and
the risks, benefits and consequences of accepting or rejecting
treatment. Assessing decision-
making capacity requires an evaluation of the patient’s
decision-making process, rather than an
evaluation of the choice itself. “…[T]he mere fact that a patient
does not accept a health care
professional’s recommendation does not necessarily mean that
the patient is incompetent" (Tong,
2007, p 53).
In order for a patient to evaluate the risks and benefits of an
available option is the understanding
that a physician will provide complete and honest disclosure of
all the associated medical facts
that may be pertinent to the patient (Canterbury vs. Spence,
1979). The need for such veracity in
25. caring for a patient is also a primary component of a physician’s
ethical responsibility, according
to the American Medical Association (AMA, 2012). Performing
a procedure without consent, or
withholding a viable treatment without disclosure, is a direct
violation of the AMA mandate,
Informed Consent doctrine and a patient’s trust.
A patient’s right to self-determination is foundational in
bioethics. If the patient loses decision-
making capacity, laws and policies are in place to ensure that
the patients’ expressed or implied
wishes are respected. Prior to losing capacity, a patient can
appoint a healthcare proxy agent who
will make decisions for the patient, based upon the patient’s
wishes and instructions. Critical to
26. the concept of a Health Care agent is the agent’s requirement
that any decisions reflect the
patients’ known and implied wishes, rather than the agent’s own
wishes for the patient. If no
HSC312 - Final Project: Compiled Case Studies May 2013
Jane Doe
such agent is named, a surrogate decision maker is appointed by
state statute or facility policy to
make decisions for the patient, using their knowledge of the
patient and the patient’s wishes,
values and spiritual beliefs.
Sally appears to be in denial about her condition and terribly
afraid of death, as evidenced by her
general state of “panic” and her refusal to talk to the Resident
27. about her condition. Most
importantly, Sally has stated that she wants to live, which may
reflect any number of thoughts
and emotions from a sense of grief at her circumstances to
denial of her terminal condition.
Because the physicians seem more focused on discussing their
inability to help Sally, rather than
being ‘competent’ in her mind to perform the thorientsis, Sally
may not see a value in discussing
her condition with them. Far from an irrational thought process,
Sally’s refusal to talk may
actually be a heartbreaking testament to her ability to assess a
situation and reach a rational
conclusion based on the facts. Further proof may be Sally’s
insistence that she “…wanted the
emergency squad called to attempt resuscitation if she arrested
at home” (Crigger, 1998). Given
28. her desire to live as long as possible, it would make sense that
she would want every chance
available to live.
Presuming Sally does have capacity, she is entitled to receive
full disclosure regarding anything
to do with her medical care—a right that extends to her
rejection of a proposal that is in conflict
with her own goals. Consequently, if the attending physician
institutes a DNR order without
Sally’s consent would constitute a violation of Sally’s right to
self-determination. Important in
the discussion of full disclosure in Sally’s case is the fact that it
no one has explained the
potential adverse consequences of performing CPR (Cardio-
pulmonary resuscitation) on
29. someone in her current medical condition. From the facts
presented, it is unclear how Sally
would respond if she knew there was a significant chance that if
she survived CPR, she could
end up in a Permanent Vegetative State, permanently
unconscious and kept alive by artificial life
support as a result.
The physician’s position that CPR is futile given the potential
for harm and what he perceives as
negligible benefit, does not override Sally’s right to define what
is and is not beneficial for her.
Acting on his own subjective values and interpretations, and
ignoring Sally’s values and desires
would constitute an act of Paternalism, a direct violation of
autonomy (Tong, 2007). While it is
true that a patient cannot demand an inappropriate treatment—
30. one that would produce more
harm than benefit— it could be argued that CPR as a standard
emergency procedure to ward off
imminent death does not pass the “inappropriateness” test. If a
patient with capacity is provided
with full disclosure of the potential harms, it is the patient’s
right to weigh the risks and benefits,
and make an informed choice. (Munson, 2012).
Similarly, if it is determined, that Sally lacks capacity; the
doctor would still be potentially
outside his authority to institute the DNR without informing
Sally’s surrogate decision maker.
While it is unclear whether Sally’s husband is her Healthcare
proxy agent, as a person who
knows her best and her spouse, he would still have the
presumptive right to use substituted
31. judgment and make the decision he believes Sally would make,
if she could. Knowing Sally’s
express position on the issue of aggressive treatment, he has an
obligation as the healthcare agent
to reject the DNR, regardless of his personal opinion and desire
that Sally just receive comfort
care.
HSC312 - Final Project: Compiled Case Studies May 2013
Jane Doe
In addition to the ethical principle of Autonomy and the
doctrine of informed consent, Care-
based Ethics also supports Sally’s right to reject the DNR. Care-
based Ethics emphasizes values
and virtues such as compassion, empathy, kindness and most
32. important, sensitivity to each
patient’s unique perspective and circumstances (Tong, 2007).
Because Sally is adamant she
wants everything done right now to help keep her alive as long
as possible, a physician
empathetic to Sally’s concerns and circumstances would not
sign the DNR without at least
informing her and addressing her fears about death and her
desire to preserve her life.
5. Recommedation:
Prompt objective: Present your assessment, resolution or
potential solutions for resolving the
issue. Remember that there are no right answers, per se, so
reflective questions can be as
appropriate as a firm conclusion.
33. Based on my analysis, the attending physician should not
institute the DNR against Sally’s
express wishes and without her knowledge. Doing so would
violate the ethical and legal
principles of autonomy and informed consent. I also recommend
that Sally be seen by a
Palliative Care specialist or a medical professional trained in
end-of-life care to help determine
whether Sally’s statements and behaviors demonstrate a lack of
capacity, or are understandably
motivated by denial and fear. Minimally, the consult should
help promote Sally’s overall well-
being by addressing her concerns in a compassionate and caring
way. Lastly, only if Sally lacks
capacity should Sally’s husband, as her healthcare agent, be
allowed to speak for Sally and
34. refuse the DNR. Because we do not know how Sally feels about
remaining on life support should
CPR fail, Sally’s husband must adhere to the doctrine of
substituted judgement and base a
decision upon his knowledge of Sally’s values and wishes,
including her known spiritual beliefs.
Bibliography
4 H A S T I N G S C E N T E R R E P O R T January-
February 2012
To the Editor:The traditional “in-
formed consent” process for medical
treatment is badly broken. As patients
face fateful medical decisions, they of-
tendonotknowthebasic“gist”oftheir
optionsorthelikelihoodofthepossible
35. outcomes, good and bad. The shared
decision-makingmovementaimstoim-
provethatsorrysituationbyhavingpa-
tients and clinicians work more closely
together when there is more than one
reasonablemedicaloption,asisthecase
formanyifnotmostsituations.Byen-
suring both that patients are informed
about their choices and that clinicians
areinformedaboutpatientpreferences,
thequalityofmedicaldecisionsshould
be improved. Patient decision aids are
notthemselvesshareddecision-making;
instead, they are tools to help make
shareddecision-makingpracticalinthe
busyworldofclinicalmedicine.
Inhisprovocativearticle(“Question-
ing the Quantitative Imperative: Deci-
sionAids,Prevention,andtheEthicsof
Disclosure,” March-April 2011), Peter
Schwartz seems to acknowledge the
need to improve the current informed
consent process but worries that pro-
viding quantitative information about
36. possible outcomes as part of a shared
decision-makingprocessmightbemis-
leadingtoorunwantedbypatients.He
proposesthe“default”optionshouldbe
to withhold this quantitative informa-
tion unless and until a patient asks for
it.Hisprimaryargumentsarethatmany
patientshavepoornumeracyskillsand
might not understand—or might even
be misled by—the quantitative facts,
andthatoutcomeshavenotbeenshown
tobebetterasaresultofprovidingpa-
tientswithquantitativeinformation.
Problemswithstatisticalnumeracy—
which have been shown to be an issue
for clinicians, too—do make it more
challenging to communicate risks and
benefits. However, just because a task
is difficult doesn’t mean it shouldn’t be
done.MostpeopleintheUnitedStates
don’twanttoplayapassiveroleintheir
health care, and the proportion isn’t
conditioned by assessed numeracy (M.
37. Galesic and R. Garcia-Retamero, “Do
Low-Numeracy People Avoid Shared
DecisionMaking?”Health Psychology30
[2011]:336-41).Moreover,asnotedin
PeterUbel’scompanioneditorial(“The
Experimental Imperative”), research
on the communication of quantitative
healthinformationisrevealingthatnew
strategies and technologies can help
overcome these barriers. For example,
visualaids,commonlyusedindecision
aids,canhelpevenpeoplewithfewnu-
meracy skills better understand health
statistics (R. Garcia-Retamero and M.
Galesic,“WhoProfitsfromVisualAids?
Overcoming Challenges in People’s
UnderstandingofRisks,”Social Science
Medicine 70 [2010]: 1019-25). Many
oftheinterventionsforwhichinformed
consentisnecessaryinhealthcare,such
as open-heart surgery and organ trans-
plantation, had to overcome numerous
barrierstoenterthemedicalarmamen-
tarium. It’s time to bring a similar in-
38. tensityofefforttoovercomethebarriers
of literacy and numeracy in communi-
catingimportanthealthinformationto
thepeoplewhomustlivewiththecon-
sequencesoftheirhealthdecisions.
Holding informed consent to an
outcome standard is an interesting ar-
gument. Schwartz acknowledges that
decision aids that present quantitative
outcomeprobabilitieshavebeenshown
to give patients more accurate percep-
tionsoftheirhealthrisks.Isputtingthe
“informed” in informed consent not
an important goal in itself? Would the
ethicalandlegalimperativeofinformed
consent hold up under scrutiny in a
trialwherepatientsfacingsurgerywere
randomized to an informed consent
process versus none? Would the whole
notionofinformedconsentbescrapped
iffunctionalstatusscoreswerenodiffer-
entinasecondtrial?Ithinknot.
Thekeyissuehereiswhetherthede-
39. faultoptionininformedconsentshould
be withholding quantitative informa-
tionunlesspatientsaskforitorprovid-
ingitunlesstheysaytheydon’twantit.
For too long, the medical system has
kept patients largely in the dark about
whatclinicianshaveplannedforthem.
Given this history, perhaps it’s time to
make giving more information—in-
cluding quantitative information—the
default position, and to work much
harderatdoingitwell.
Michael J. Barry
TheFoundationforInformed
MedicalDecisionMaking
To the Editor: Every day people
tell me about the challenges they face
in finding safe, decent health care and
making the most of it. Facing tough
letters
40. TooMuchInformation?
It’s time to overcome the barriers of literacy and
numeracy in communicating important health
information to the people who must live with
the consequences of their health decisions.
DOI:10.1002/HAST.4
January-February 2012 H A S T I N G S C E N T E R R E P O
R T 5
oN tHe WeB
nBioethicsforum
http://www.bioethicsforum.org
AdministrationRevealsLackofCLASS
By Peter S. Arno, Michael K.
Gusmano, and Deborah Viola
41. Just as the baby boomers are entering
retirement, the first real step toward a
national long-term care policy in forty-five
years has been cast asunder.
WhatisHumane?APleaforPlain
LanguageintheDebatesonAnimal
Experimentation
By Joel Marks
“Humane” is implicitly defined as
meeting accepted standards of care and
use according to legal and institutional
guidelines. What this means in practice is
that anything can be done to a laboratory
animal, provided it is necessary to carry
out an experiment or other procedure that a
committee has deemed worthy on scientific
and perhaps humanitarian grounds. I
submit that this is an illegitimate use of the
term “humane.”
Also:michaelK.Gusmanopointsout
misinformationaboutU.S.poverty;
CarolLevinesuggeststhatwe’dallbetter
startsavingnowforourbabies’future
43. toguidethemoftentopstheirlistofdif-
ficulties.Ihavefrequentlyexperienced
thismyselfasIrecoverfromtreatment
ofmyfourthcancerdiagnosis.
I appreciate Peter Schwartz’s recog-
nitionoftheburdenplacedonpatients
andlovedonestoincorporatecomplex
risk information into decisions about
our care. And I welcome any con-
cern—however tangential—about the
shiftofresponsibilitiesfromclinicians
to patients, who are often ill-prepared
tofulfillthem.However,Ifindhisar-
gumentoverlyprotectiveinlightofthe
rushed, confusing demands of health
care today, increased public access to
health information, and the shared
decision-making policies imbedded in
theAffordableCareAct.
Schwartzdescribesthegeneralinnu-
meracyoftheAmericanpublicwitha
particularemphasisonourinabilityto
understandthedifferencebetweenrel-
44. ativeandabsoluterisk.Yetheneglects
to mention that we share this deficit
with many of our clinicians. He also
summarizestheliteratureoncognitive
heuristicsbutagainexemptsclinicians
from discussion. Does he believe that
cliniciansareimmunefromthesesame
biases? My doctor might withhold a
decision aid because she doesn’t have
timeforthiscumbersomeshareddeci-
sion-making nonsense or she believes
sheknowswhatIshoulddotorealize
thebestoutcome.Shewouldvieweach
oftheseasrationalchoices.
More puzzling is the importance
Schwartz assigns to risk information
indecisionswemakeaboutourhealth
care, preference-sensitive or not. Em-
piricalinformationisalways only oneof
manyfactorsthatinfluenceourchoic-
es. Scant relevant risk information is
available for most of the health care
decisionswemakenow.Wejustwing
it, based on anxiety, our neighbor’s
45. experience, and our sense of what the
rightchoiceistoday,whichcanbein-
fluencedbyourdoctor’smoodaseasily
asitcanbyfamilyandworkevents.
It is thus oddly shortsighted for
Schwartz to recommend withholding
decision aids for some patients (based
on the clinician’s assessment of our
competence) in the relatively few in-
stances where these aids are available
forpreference-sensitivecare,astheyare
for decisions about early-stage breast
cancertreatmentorgettingaprostate-
specific antigen test. Even if we don’t
fully understand what’s at stake, well-
presented risk information powerfully
communicates that we have choices:
that multiple treatment options are
possible,thattherearetrade-offstobe
considered,andthatnoguaranteesex-
ist,regardlessofourchoice.Theseare
sobering but important messages for
ustograspaswe,regardlessofournu-
46. meracy skills and cognitive biases, are
routinely forced to make critical deci-
sionsaboutourhealthcare.
It’s too late to argue that our clini-
cians should selectively provide de-
cision aids: the ACA provisions for
shared decision-making will likely
eventuallytieclinicianreimbursement
toprovidingthem.Andtheimpetusfor
thatargument—thatprovidingthisin-
formationimposesmandatoryautono-
my—isakintodiscussingthebenefits
ofclosingthebarndoorafterthecows
havewanderedaway:Ourautonomyis
alreadymandatedbydefault.
Jessie Gruman
CenterforAdvancingHealth
To the Editor: In his article, Peter
Schwartzeloquentlydiscussestheben-
efits and potential harms of providing
patients with numeric risk informa-
tion. He describes how—despite our
47. best efforts to inform patients about
therisksandbenefitsofscreeningtests
and preventive treatments and to im-
prove understanding of probability—
people “have persistently irrational
responses to quantitative information
aboutrisksandbenefits,”regardlessof
their level of numeracy. For decades,
6 H A S T I N G S C E N T E R R E P O R T January-
February 2012
decision scientists, economists, and
psychologists have struggled to under-
standwhyeventhemostknowledgeable
andnumeratepeoplemakesuboptimal
healthdecisions.
It seems that in our attempts to
educate patients about probability, we
sometimes fail to appreciate that un-
derstanding numeric facts and figures
is not an exclusively cognitive effort;
48. rather, it is often heavily influenced by
affect, which in turn influences one’s
abilitytoreason.Awell-knownexperi-
ment conducted in 1994 by Veronika
Denes-Raj and Seymour Epstein illus-
trates how affect can trump rational-
ity, even for well-educated people. In
it,subjectswoniftheydrewaredjelly
beanfromoneoftwobowls.Thesmall
bowlcontainedoneredandninewhite
beans,andthelargebowlcontainedfive
totenredbeansandatotalofonehun-
dred beans in all. Despite the fact that
eachbowlwaslabeledwiththepercent
of red beans it contained, the majority
of subjects drew a bean from the large
bowl, which was clearly the inferior
choice.Subjectsreportedthatthey“felt”
theyhadabetterchanceofwinningby
selectingthebowlwiththegreaterabso-
lutenumberof“winning”beans.
Theinteractionofaffectandnumer-
acy in health decisions has been dem-
onstrated in several studies examining
49. choices of medical treatments that in-
cludepotentialsideeffects.Inone2006
studyconductedbyJenniferAmsterlaw
and colleagues, people were presented
with two surgical scenarios: one had a
20percentmortalityrate,andtheother
had a 16 percent mortality rate along
witha1percentchanceoffourunpleas-
ant side effects (colostomy, chronic di-
arrhea, intermittent bowel obstruction,
orwoundinfection).Mostpeoplechose
thesurgicaloptionwiththehighermor-
tality,presumablybecauseoftheiraffec-
tiveresponsetothesideeffectsandtheir
tendencytooverweightlowprobability
events. Indeed, the mere presence of a
small side effect may decrease willing-
ness to undergo treatment, even if the
treatment offers substantial benefit.
Erika Waters and colleagues found in
2007 that side-effect aversion occurred
regardless of how probability was pre-
sentedorwhethergraphicformatswere
used to convey risk information, sug-
50. gestingthatdecisionswereguidedbyan
affective response to the possibility of
sideeffects,ratherthanbynumericrisk.
There are, of course, potential dan-
gers associated with providing patients
with too much quantitative informa-
tion.Inthiseraofshareddecision-mak-
ingandunprecedentedaccesstohealth
information, it is easy to experience
dataoverload.Providingpeoplewithall
available information can actually hin-
derdecision-making,andoften,lessnu-
mericinformationismorewhenhelping
people make quality health decisions.
Amongthepotentialdangersofprovid-
ing too much information is that pa-
tientsmaynotbeabletodiscernuseful
informationfromthemerelyrelevantor
altogetherirrelevant.However,thereare
also potential dangers associated with
providingtoolittleinformation.AsAn-
thonyBastardiandEldarShafirdemon-
stratedin1998,whenpeoplearefaced
51. with a preference-sensitive decision,
they often seek additional information
regardless of whether that information
iscriticaltotheirdecision.Inaseriesof
experiments,theyobservedthatpeople
whopursuedmissinginformationtend-
ed to endow it with greater value than
theywouldhaveifithadbeenavailable
initially. Somehow the act of pursuing
a missing but nonessential piece of in-
formation lent greater psychological
weight and salience to it. In a health
context, such misguided information-
seekingmightleadpatientstobaseim-
portanthealthdecisionsonfactorsthat
may be relevant but nonessential to an
effective decision. Clearly, more work
is needed to understand the possible
unintended consequences of providing
toomuchortoolittleriskinformation.
Attheveryleast,providersshouldkeep
in mind how affect can be attached to
numbersandrisksareperceived.
52. Wendy Nelson
NationalCancerInstitute
To the Editor:Thereisagreatdeal
of merit in Peter Schwartz’s important
andusefularticle,anditwilldoubtless
prompt considerable debate. I would
liketoaddtwobriefcomments.
First, Schwartz’s target—the quan-
titative imperative—can be viewed as
a specific instance of a broader target.
In Rethinking Informed Consent (Cam-
bridge University Press, 2007), Onora
O’Neill and I, like Schwartz, were
struckbytheconsiderableevidencethat
patients and research subjects often do
not comprehend what is disclosed. As
a result, “informed consent” is often
considered obtained even when, rela-
tive to contemporary standards, it is
substandardorinvalid.Toimprovethis
situation, we argued—amongst other
things—thatweneedtobeclearabout
53. the distinction between consent and
informed consent. The former is a fa-
miliar form of action that involves the
settingasideofrightsortheremovalof
certain kinds of prohibitions. Consent
isofconsiderable,butnotfoundational,
ethical importance for clinical actions.
Whilethosewhoconsentneedtoknow
something of the action to which they
consent,itdoesnotrequire“disclosure”
of large amounts of information about
proposed actions or risks. Informed
consent, in contrast, has its roots in
negligence law in the clinical context
andsharesbiomedicalethics’particular
The quantitative imperative is simply part of an
unjustified informative imperative that places
unfeasible demands upon those consenting.
January-February 2012 H A S T I N G S C E N T E R R E P O
54. R T 7
focus on the importance of individual
decision-making. We argued that bio-
medical ethics has, without sufficient
justification,takeninformedconsentto
be of key ethical importance. Matters
are made worse by the prevalence of a
widerangeofmetaphorsthatshapeour
thinkingaboutknowledgeandcommu-
nication,suchthatinformationisread-
ilycastasatypeof“stuff ”tobepassed
on,stored,disclosed,orpickedup.
Putting these elements together and
aligning with Schwartz’s terminology,
there is a ubiquitous informative im-
perative that pervades biomedical eth-
ics. This informative imperative rests
uponarangeofdistortionsandconfu-
sions. Once the ethical arguments are
clarified, the informative imperative
canbeseenasmuchlessdemandingin
its scope than is typically assumed.We
would thus agree with Schwartz’s con-
55. clusion—that quantitative information
ofcertainkindsneednotbedisclosed—
but for a different set of reasons. The
quantitativeimperative,onourview,is
simplyapartofawidespreadbutunjus-
tifiedinformativeimperativethatistoo
broadinitsscopeandplacesunfeasible
demandsuponthoseconsenting.
Second, it is important to note that
there may be reasons other than en-
suring validity of consent for disclos-
ing quantitative information. Given
the legal context of informed consent,
Schwartz’s proposals might raise wor-
riesforclinicians.Supposeinformation
aboutcertainrisksismerelymadeavail-
able, rather than being communicated
(andacknowledgedassuchby,say,sign-
ingaconsentform).Supposethatoneof
therisksnotcommunicated,butmade
available,happens.Thepatientsueson
thebasisthathadshebeeninformedof
therisk,shewouldnothaveconsented.
Thequantitativeimperativecanthusbe
57. Neil C. Manson
LancasterUniversity
Peter Schwartz replies:
I must correct Jessie Gruman’s sug-
gestion that my article supports with-
holdingdecisionaidsorquestionstheir
importance. Like Michael Barry and
Gruman, I agree that patients often
want or need more information than
theyreceive,andIbelievethatdecision
aidscanhelpaddressthisproblemand
will most likely play a growing role in
medicine. But the question is whether
decision aids can best help patients by
always providing quantitative infor-
mation—in particular, complex data
framedinmultipleways,astheInterna-
tional Patient Decision Aids Standards
andmanyexpertsrecommend.
Research has not established that
such disclosure improves patients’ un-
derstanding or decision-making in the
58. range of situations where decision aids
mightbeused.Therearemanypossible
negative impacts, mostly stemming
frominnumeracyandheuristicsandbi-
asesinhumanthought,asdescribedin
myarticleandintheexcellentaddition-
alexamplesprovidedbyWendyNelson
inherletter.Givenallthis,Iarguethat
the quantitative imperative must be
subjectedtomorecarefultesting,inthe
spiritofevidence-basedmedicine.
Barry’sletterandPeterUbel’seditori-
althataccompaniedthearticlesupport
research to investigate innovative ways
to provide quantitative information to
inform patients, including innumer-
ateones,withoutcreatingconfusionor
engendering irrational responses. Such
researchiscertainlyimportant,butmy
article emphasizes that the question is
not just how to present certain types
of data, but whether to present data at
all, and in what situations. Researchers
59. shouldnotassumethatallrelevantdata
shouldbegivenallthetime:itmayturn
out that in at least some cases, less is
more (for example, see B.J. Zikmund-
Fisher, A. Fagerlin, and P.A. Ubel, “A
Demonstration of ‘Less Can Be More’
in Risk Graphics,” Medical Decision
Making30[2010]:661-71).
My article is thus a call to keep an
open mind as research goes forward. It
aimstoplayarolethattheoreticalethi-
cal and philosophical analysis should
play:identifyingandcritiquingassump-
tions that guide behavior or research
in unrecognized or unexamined ways.
The assumption that all quantitative
information should be provided all the
timeisexactlythatsortofphilosophical
commitment.
I agree with Gruman that patients
too often cannot get information they
want, but I believe that decisions aids
maybestaddressthatproblembymak-
60. ing the information available to those
who want it, rather than presenting
it to everybody. She raises the excel-
lent question of how to choose who
will receive additional data, and she is
right, of course, to reject the idea that
thedecisionshouldbebasedsimplyon
a clinician’s impression of the patient’s
competence.
But what about a system where pa-
tientsareofferedadditionalinformation
Letterstotheeditormaybesentbye-mail
to [email protected], or to
Managing Editor, Hastings Center Report,
21MalcolmGordonRoad,Garrison,NY
10524; (845) 424-4931 fax. Letters ap-
pearing in the Report may be edited for
lengthandstylisticconsistency.
8 H A S T I N G S C E N T E R R E P O R T January-
February 2012
61. of various sorts? This idea is far from
radical: recommendations for discus-
sionsbetweenhealthcareprovidersand
patients suggest that some information
shouldbegiveninitially,andadditional
informationshouldbeofferedasanop-
tiontothosewhowantit(see,forexam-
ple,R.M.Epstein,B.S.Alper,andT.E.
Quill, “Communicating Evidence for
Participatory Decision Making,” Jour-
nal of the American Medical Association
291 [2004]: 2359-66). The amazing
capabilitiesofcomputer-baseddecision
aidsmaytemptdesignerstoprovidetoo
muchinformationupfront,andtofor-
getthewisdomoftailoringdisclosureto
thepatient’sinterestandunderstanding.
I agree with Neil Manson that
the quantitative imperative is part of
a larger “informative imperative” in
medicine that should be questioned
and challenged as Manson, O’Neill,
Carl Schneider, and others have done.
62. Considering how to provide the right
information,totherightpatients,atthe
right time, by way of a decision aid or
personal interaction, raises important
ethical and empirical questions, as the
articleemphasizes.
Doctors and Torture
To the Editor:In“TheTorturedPa-
tient: A Medical Dilemma” (May-June
2011), Chiara Lepora and Joseph Mil-
lum raise the issue of whether a physi-
cian may be justifiably complicit in
torture and answer in the affirmative.
Their argument is predicated on there
being a litany of moral considerations,
of which the wrongness of complicity
in torture is merely one; this wrong-
ness competes against other values
and sometimes is outweighed. While I
disagree with some of the authors’ as-
sumptions—for instance, that torture
is always unethical in the cases that
physicians are forced to countenance,
63. orthatcomplicityinanimmoralactis
primafacieimmoral—Iagreewiththeir
conclusion. Surely those who trumpet
deontological constraints would think
otherwise,butthisconclusionnaturally
follows from a pluralistic set of moral
values.
Whiletheyciteawiderangeofdec-
lamations against physicians’ involve-
mentintorture,onethattheyleaveout
comesfromsection2.067oftheAmeri-
canMedicalAssociation’sCode of Medi-
cal Ethics. What makes section 2.067
interesting is not just what it says, but
alsothefactthatitcomeshierarchically
nestedundersection2.06,whichspeaks
tophysicianinvolvementincapitalpun-
ishment. From the Code’s perspective,
the issues pertaining to capital punish-
mentandtortureareisomorphic:what
mattersismerelythatphysicianinvolve-
mentcouldmakethepatientworseoff.
In the case of capital punishment, the
64. upshotisobviousand,inthecaseoftor-
ture, resuscitation in order to facilitate
moretortureissimilarlydepraved.
This argument fails in both cases,
andthereasonhelpselucidatewhyLe-
poraandMillumareontherighttrack.
Thequestiontoaskislesswhatwould
happen if physicians were present,
but rather what would happen if they
were not. For example, imagine that
physicians were disallowed from these
settingsandaprospectivepatientexpe-
rienced complications: the abolitionist
would just settle for this person being
worseoff.Aphysician’spresenceensures
thateasilyremediablesituationsberem-
edied, which is precisely what I would
advocate.Thisisnottosaythatthereare
nocapacitiesinwhichphysicianscould
make people worse off, just that there
are some in which those people could
be made better off; therefore, a whole-
saleabolitiononphysicianparticipation
misses the mark. (There’s also an open
65. question about whether such agents
should be conceived of as “physicians”
atall—asopposedtomedicallytrained
militarypersonnel—butIshallnotpur-
suethatdiscussionhere.)
Tobesure,thoseopposingphysician
involvement in either capital punish-
mentortortureare,almostalways,not
just opposing physician involvement,
but rather those practices themselves.
When the Code says that physicians
must “oppose . . . torture for any rea-
son,” it is clearly making a political
claim and not one narrowly tied to
medicalethics;itisforpreciselythisrea-
son that I find such statements by the
Codetobeinappropriate.AsLeporaand
Millum acknowledge, some debate the
appropriateness of torture in “narrowly
specified, extreme cases.” It is a credit
to their essay that such a debate is left
open,ratherthanforeclosedbyfiat.
67. happen if they were not.
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individual use.
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68. Final Case Analysis: The Emily Dilemma - Abortion
Introduction to the Activity
Recall, that an ethical dilemma can be defined as two morally a
cceptable choices, both of
which will result in morally disturbing and unwelcome conseque
nces. Often when we
considering our position regarding an ethical dilemma, it is help
ful to consider not only the
issue presented, but whether we can justify our position based o
n an extreme, yet realistic
set of conditions. Abortion is perhaps one of the most disturbing
and confounding of issues
for engaging in such an exercise, as it is sometimes difficult to j
ustify the inconsistencies in
our moral intuitions when confronted with situations that define
an ethical dilemma.
Related Reading from Module 7:
Module notes and assigned textbook pages
Videos:
Ankele, J. (Producer), & Macsoud, A. (Producer) (2010). Beyon
69. d the politics of
life and choice: A new conversation about abortion (link availab
le in Mod 7)
Tsiaras, A. (Director) (2011, November 14). Alexander Tsiaras:
Conception to
birth -- visualized TedTalks. [Video file][9 min 37 sec]. Retriev
ed from
http://www.youtube.com/watch?v=fKyljukBE70 (apprx. 10min)
Iadarola , J. (Performer) (2012, November 25). Study: What hap
pens to women
denied abortions? [Video file][5 min 17 sec] The Young Turks.
Retrieved from
http://www.youtube.com/watch?v=dWBjQ7P9SSs (apprx. 5 min
)
Instructions to Learners
Please read the case scenario:
Twenty year old Emily who suffers from Bi-polar disorder and
Schizophrenia lives at home
with her parents, but is fairly independent. Last year, Emily had
a breakdown while living
away at school and required hospitalization. Due to a complex
mix of anti-psychotics,
70. antidepressants and other medications to control her condition,
Emily is now working part-
time at a local bookstore and taking two classes at the communit
y college. Emily loves
children and hopes eventually to become a kindergarten teacher.
Although Emily is on
birth control pills, she had missed some days over the past few
months during a brief
‘lapse’ in her mood, but insisted throughout that time that her b
oyfriend wear a condom.
The condom failed at some point and Emily is now eight weeks'
pregnant.
http://www.youtube.com/watch?v=fKyljukBE70
http://www.youtube.com/watch?v=dWBjQ7P9SSs
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Emily’s doctors insist that the baby is at an exceptionally high r
71. isk for severe physical and
mental impairments, including incomplete limb and/or brain dev
elopment. At best, there is
no solid data detailing teratogenicity risk for all of her medicati
ons, but the combinations
and inability to incorporate less harmful substitutes raise signifi
cant concern. Because she
is within the first trimester, there are no legal concerns based on
the Roe v. Wade decision
so the doctors, her parents and her boyfriend are insisting that E
mily have an abortion to
spare the burden on the child. Emily, a devote Catholic, insists
on carrying the baby and
raising it once it is born. She has also personalized the argumen
ts, finding that by
devaluing the life of her baby, her family and others devalue her
as well.
Emily’s parents have threatened to file for guardianship over he
r so that they can force the
abortion, under their belief that she lacks decision-making capa
city and the abortion is in
her best interests. Although the doctors have no standing to join
the suit, they have agreed
to serve as expert witnesses for the parents. Emily’s boyfriend i
s considering petitioning
72. the court--after the baby is born--for the right to be released fro
m any parental
responsibilities, given his lack of a position in the decision to a
bort.
Emily’s Psychiatrist, Dr. Heady is very troubled by the case bot
h for Emily and for the
developing fetus. Knowing that you are a famous ethicist, he co
ntacts you informally and
presents the case as a hypothetical, maintaining Emily’s confide
ntiality. Dr. Heady is
unsure whether the parents can legally force the abortion, but he
is troubled on a much
more fundamental level, which is why he is seeking your counse
l.
Please respond to the following questions (approx. 500-700 wor
ds) using the
template format provided for the assignment:
Presuming that Emily has decision-making capacity, Dr. Heady
would like to hear your
thoughts on the following:
Ethically, should Emily be able to reject the abortion in the first
73. trimester, knowing
that it is highly probable that continuing to take her necessary
medications will
severely and permanently impair the baby?
In reflecting upon the question, recall the court’s arguments in
Roe v. Wade, and any
counter arguments provided in your materials. Also, consider th
e question of the
fetus (encompassing all stages from conception through prebirth
development) and
the concept of moral standing.
Use the following template for your assignment:
1. Use Microsoft Word to create a document.
2. Copy/paste the title of the question.
3. Describe the most relevant ethical dilemma(s) presented (no
more than two).
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4. Briefly describe the primary issue or issues that are relevant i
n the scenario with
respect to the dilemma.
5. Identify the most relevant stakeholder(s) (no more than 3) an
d briefly describe the
situation from their perspective.
6. Analyze the dilemma, using scholarly discussion, from the pe
rspective of the primary
stakeholder (typically the patient). Include a discussion of at lea
st two ethical theories
or bioethics principles studied in the course that relate to the dil
emma and issues you
identified. Include any relevant legal concerns or requirements
outlined in the
readings.
7. Present your assessment, resolution or potential solutions for
resolving the issue.
Remember that there are no right answers, per se, so reflective q
uestions can be as
75. appropriate as a firm conclusion.
8. Title page + APA formatted reference(s).
10/27/2016 Final Case Analysis: Paternalism vs Autonomy
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Final Case Analysis: Paternalism v.s. Autonomy – Dax Cowart
Introduction to the Activity
I would like to introduce you to the story of Dax Cowart. Attach
ed is an excerpt from a
speech that Dax Cowart made several years ago, a speech that re
mains poignant for
contemporary reflection. The story is heart breaking and challen
ges all the bounds of
ethics and health care. As you listen to Dax, or read the transcri
pt of his talk, think about
76. the issues Dax discusses, especially in connection with capacity
and the right to decline
medical treatment (which we will discuss in greater detail later
on in the course). These are
the stories and circumstances where ethics and health care colli
de and individuals are
forced to make tough decisions. In thinking over your responses
to the Discussion Board
questions, consider the concepts we have talked about in this M
odule and in Module I,
such as personal moral values; bioethical principles; the need to
weigh and prioritize
competing moral interests; a physician’s charge to provide ethic
al care and a patient’s right
to self-determination.
Related Reading from Module 2:
Munson text: pp. 36; 38-40 (end at State Paternalism); 41-42 (e
nd at Informed
Consent); 891904;
UVA News Makers - Dax Cowart
(Note: you may either watch the video part 1 [Video file] [09 mi
n 30 sec], and
77. video part 2 [Video file] [07 min 53 sec] or read the transcript a
nd Hastings
Center Report: Confronting Death: who chooses, who controls?)
Instructions to Learners
Please respond to the following questions (approx. 500-700 wor
ds) using the
template format provided for the assignment:
You are Dax’s physician. How would you respond to Dax’s requ
ests that you “let him die”?
Would you continue to treat him against his wishes? Why or Wh
y Not?
Use the following template for your assignment:
1. Use Microsoft Word to create a document.
2. Copy/paste the title of the question.
3. Describe the most relevant ethical dilemma(s) presented (no
more than two).
4. Briefly describe the primary issue or issues that are relevant i
n the scenario with
respect to the dilemma.
79. st two ethical theories
or bioethics principles studied in the course that relate to the dil
emma and issues you
identified. Include any relevant legal concerns or requirements
outlined in the
readings.
7. Present your assessment, resolution or potential solutions for
resolving the issue.
Remember that there are no right answers, per se, so reflective q
uestions can be as
appropriate as a firm conclusion.
8. Title page + APA formatted reference(s).
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Final Case Analysis: Morally Wrong or Ethically Challenging?
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80. Final Case Analysis: Morally Wrong or Ethically Challenging?
Introduction to the Activity
Many states have considered enacting PAS legislation since Ore
gon first legalized the practice in 1994, but as of yet, only
Oregon and Washington have laws allowing for Physician Assist
ed Suicide (PAS) 127.800; RCW 70.245). In Montana,
although there is no current legislation regarding PAS, the Mont
ana Supreme Court provided protection for doctor’s
providing lethal medication to terminally ill patient’s upon requ
est (Baxter v. Montana, 2009 MT 449). Currently, forty-three
states have specific laws (either statutory or common law (case
law) prohibiting assisted suicides, but four states (Hawaii,
Nevada, Utah, Wyoming) and the District of Columbia have no l
aw regarding the subject. Just recently, Massachusetts
voters defeated a ballet initiative based upon the Oregon statute
by a marginal 51% majority.
Related Reading from Module 5:
Module notes and assigned textbook pages
Arras, J. (1997). Physician-assisted suicide: a tragic view. The J
ournal Of Contemporary Health Law And Policy,
13(2), 361-389. (28)
81. *The New York State Task Force on Life and the Law, (1997).
When death is sought assisted suicide and
euthanasia in the medical context supplement to report. Retrieve
d from website:
http://wings.buffalo.edu/bioethics/suppl.html.
*Scroll down and read until the end of the passage “IV The Dist
inction Between Administering High Doses of
Opioids to Relieve Pain and “Physicianassisted Death.”
Public Health, (1997). Oregon revised statute: Death with dignit
y act (Chapter 127). Retrieved from Oregon Health
Authority website:
http://public.health.oregon.gov/ProviderPartnerResources/Evalu
ationResearch/DeathwithDignityAct/Pages/ors.
rules: 127.800 s.1.01. Definitions - 127.875 s.3.13. Insurance or
annuity policies.
Dep’t of Public Health, Annual Report on Oregon’s Death with
Dignity Act (2012) [PDF file size 197 KB]
http://public.health.oregon.gov/ProviderPartnerResources/Evalu
ationResearch/DeathwithDignityAct/Documents/year15.pdf
*Scan through the report to get an idea on how the statistics are
compiled and trends recorded
Instructions to Learners
82. Please read the case scenario:
You are a physician-ethicist at Hope hospital in Nirvana, USA.
Your state is voting this month whether to allow PAS, under
the exact guidelines and safeguards instituted in Oregon. The lo
cal news station has asked you to join a televised multi-
disciplinary panel and discuss the following questions:
Reviewing the safeguards included in the Oregon Statute, which
one(s ) potentially raise the most concerns in terms of
their ability to protect patients in Nirvana, USA? In developing
your response, consider whether the concerns are morally
founded or policy oriented. Also keep in mind the rules of profe
ssional responsibility, patient rights and the principles of
bioethics we have studied throughout the course.
NOTE: Please use the modified template below when considerin
g your response with respect to completing the template,
remember that a stakeholder can be described as many entities,
such as but not limited to an individual, a professional
society, the public at large or a subset of the population.
Modified Template:
1. Use Microsoft Word to create a document
83. 2. Copy/paste the title of the question
3. State the safeguards that you find most concerning.
4. Identify the most relevant stakeholder(s) (no more than 3) pot
entially affected by the safeguards you listed.
http://www.lexisnexis.com.vlib.excelsior.edu/lnacui2api/api/ver
sion1/getDocCui?lni=3S3T-V110-00CV-
P0S8&csi=138724&hl=t&hv=t&hnsd=f&hns=t&hgn=t&oc=0024
0&perma=true
http://wings.buffalo.edu/bioethics/suppl.html
http://public.health.oregon.gov/ProviderPartnerResources/Evalu
ationResearch/DeathwithDignityAct/Pages/ors.aspx
http://public.health.oregon.gov/ProviderPartnerResources/Evalu
ationResearch/DeathwithDignityAct/Documents/year15.pdf
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5. Analyze the concerns, using scholarly discussion from the per
spective of the primary stakeholder. Include a
84. discussion of at least two ethical theories or bioethics principles
studied in the course that relate to the dilemma and
issues you identified. Include any relevant legal concerns or req
uirements outlined in the readings.
6. Present your assessment, resolution or potential solutions for
resolving the concern. Remember that there are no
right answers, per se, so reflective questions can be as appropria
te as a firm conclusion.
7. Title page + APA formatted reference(s)
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birds
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Final Case Analysis: Confidentiality, Disclosure and Livid Love
birds
85. Informed consent requires not only that a patient receive all of t
he information necessary to
make a reasoned decision, but also that they are able to process
and understand the
information provided. Language or cultural differences may imp
ede understanding, and a
blanket reliance on a doctor’s judgment may subvert the intent o
f the disclosure. Other
barriers to informed consent, such as denial, fear and even famil
y dynamics are often
more difficult to spot, but equally if not more detrimental. Relat
ionships between patients,
family members and healthcare providers often morph over time
into roles and role
reversals that present special challenges in healthcare ethics and
the doctor-patient
relationship. In this activity, you will consider the standards of
professional responsibility,
medical ethics and the doctor-patient relationship as they apply
when the boundaries
between the roles become blurred.
Related Reading from Module 3:
86. Module Notes
Munson text: (end at Parents & Children).
AMA Opinion 10.01 - Fundamental Elements of the Patient-Phy
sician Relationship
Mitnick, S., Leffler, C., & Hood, V. (2010). Family caregivers,
patients and physicians:
ethical guidance to optimize relationships. Journal Of General I
nternal Medicine,
25(3), 255-260.
Principles of Medical Ethics. (2001).
Schwartz, P. H. (2011). Questioning the Quantitative Imperative
: Decision Aids,
Prevention, and the Ethics of Disclosure. The Hastings Center R
eport, (2), 30.
doi:10.2307/41059016
Instructions to Learners
Please read the case scenario:
Mr. and Mrs. Lovebird were approaching their 65th wedding an
niversary when it was
discovered that Mr. Lovebird was battling Stage IV lung cancer,
with metastasis to his
colon. Vowing to “Fight this thing!” the Lovebirds sought out th
87. e best specialists and Mr.
Lovebird underwent two surgeries, chemotherapy and several ro
unds of radiation. Mr.
Lovebird did quite well for a while, but lately he has experience
d severe fatigue and
discomfort. He has also lost his appetite, resulting in a 15lb wei
ght loss in just two months.
Concerned, the Lovebirds went to see Dr. Friendly, their primar
y care physician for over 30
years, whom they trust implicitly. Knowing that the Lovebirds a
re in denial to some extent,
but also believing that medicine is an inexact science, Dr. Frien
dly told them both about an
http://www.ama-assn.org/ama/pub/physician-resources/medical-
ethics/code-medical-ethics/opinion1001.page
http://www.ama-assn.org/ama/pub/physician-resources/medical-
ethics/code-medical-ethics/principles-medical-ethics.page
http://eds.a.ebscohost.com.vlib.excelsior.edu/eds/detail?vid=2&
sid=3a5595c1-f673-4a7c-9b34-
ff2409ff1a33%40sessionmgr4001&hid=4105&bdata=JnNpdGU9
ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#db=rzh&AN=201
1703087
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experimental treatment option that might be worth “checking int
o,” even though the
chances were slim that it would provide much benefit.
At a dinner party for a mutual acquaintance, Dr. Friendly is app
roached by Lancelot, the
Lovebird’s only child. Dr. Friendly is aware of the close relatio
nship between Lancelot and
the Lovebirds, so he is concerned for their welfare when Lancel
ot approaches him. Once
alone, Lancelot appears upset and tells Dr. Friendly that he is co
ncerned about the
experimental treatment option Dr. Friendly mentioned to the Lo
vebirds, given Mr.
Lovebird’s fatigue and weight loss. From Lancelot’s perspective
, it is obvious that even if
successful, it would only buy Mr. Lovebird a few months and th
89. ose months may not be
very good ones. He is also concerned that Mr. Lovebird is tired
of treatments, but goes
along to please Mrs. Lovebird. Dr. Friendly smiles and shakes h
is head “Your mother has
always been a force to be reckoned with,” he says “But, in realit
y, a few months is better
than no months!” He also assures Lancelot that if the Oncologis
t does not think Mr.
Lovebird is a good candidate for the procedure, the Oncologist
will tell them so.
When Lancelot suggests that Dr. Friendly’s professional judgme
nt may be colored by the
Lovebird’s denial, Dr. Friendly becomes defensive, stating that
as their doctor all he can do
is provide them with information and statistics on the disease pr
ognosis and the benefits
and risks of any potential options. He admonishes Lancelot, stat
ing “if your parents want to
believe in miracles, I am not going to take that away from them,
and you shouldn’t either!”
Visibly upset, Lancelot insists that Dr. Friendly discuss the Hos
pice option with the
Lovebirds, preferably with Mr. Lovebird, first. Although Dr. Fri
90. endly is concerned that the
idea of Hospice could be more lethal to the Lovebirds than any
experimental treatment, he
agrees, on the condition that Lancelot raise it with the Lovebird
s first. “If your parents seem
open to the conversation, give me a call or have them call me, a
nd I will sit down with them
to discuss the options.”
The next day, Lancelot goes to see Mr. and Mrs. Lovebird, and s
hares his conversation
with Dr. Friendly, telling them that both he and Dr. Friendly agr
ee that it may be time for
Hospice services. Both the Lovebirds become very angry that he
was discussing them with
Dr. Friendly without them knowing it. They are also devastated
that Dr. Friendly would
conspire with Lancelot to force a decision on them that is clearl
y premature. When he
leaves, Mrs. Lovebird calls Dr. Friendly and tells him that she i
s furious with his breach of
confidentiality and that he should stick to family practice, as he
is not an oncology expert.
Please respond to the following questions (approx. 500-700 wor
91. ds) using the
template format provided for the assignment:
Given Dr. Friendly’s longstanding relationship with the Lovebir
ds, his insight into their
processing and coping mechanisms, and the close family relatio
nship he has witnessed
between the Lovebirds and their son, did Dr. Friendly’s breach
his professional
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responsibility to Mr. and Mrs. Lovebird by suggesting that Lanc
elot discuss the Hospice
option with the Lovebirds first?
Use the following template for your assignment:
92. 1. Use Microsoft Word to create a document.
2. Copy/paste the title of the question.
3. Describe the most relevant ethical dilemma(s) presented (no
more than two).
4. Briefly describe the primary issue or issues that are relevant i
n the scenario with
respect to the dilemma.
5. Identify the most relevant stakeholder(s) (no more than 3) an
d briefly describe the
situation from their perspective.
6. Analyze the dilemma, using scholarly discussion, from the pe
rspective of the primary
stakeholder (typically the patient). Include a discussion of at lea
st two ethical theories
or bioethics principles studied in the course that relate to the dil
emma and issues you
identified. Include any relevant legal concerns or requirements
outlined in the
readings.
7. Present your assessment, resolution or potential solutions for
resolving the issue.
93. Remember that there are no right answers, per se, so reflective q
uestions can be as
appropriate as a firm conclusion.
8. Title page + APA formatted reference(s).
A MEDICAL ETHICS ASSESSMENT OF THE CASE
OF TERRI SCHIAVO
TOM PRESTON
University of Washington, Seattle, Washington, USA
MICHAEL KELLY
Swedish Medical Center and University of Washington,
Seattle, Washington, USA
The social, legal, and political discussion about the decision to
stop feeding and
hydration for Terri Schiavo lacked a medical ethics assessment.
The authors used
94. the principles of medical indications, quality of life, patient
preference, and
contextual features as a guide to medical decision-making in
this case. Their
conclusions include the following: (a) the use of a feeding tube
inserted directly
in to the stomach constituted artificial treatment; (b) the
treatment prolonged
biological life but did not lead to a cure and did not restore
health; (c) quality
of life was absent for the patient, with no sensation and no
motor or cognitive
functioning; and (d) by preponderance of medical opinion, she
would have chosen
not to live in a persistent vegetative state. The authors find the
withdrawal of
treatment was permissible and correct. It was not a choice
between living and
dying, but a decision of when to allow dying consistent with the
patient’s choice.
The case of Terri Schiavo, vexing as it was, holds lessons for us
all.
The forceful public reactions to the medical and legal
proceedings
95. leading to her demise showed a deep schism over the moral=
religious issues inherent in how we die in the modern age of
medi-
cine. In our opinion, the political and legal wrangling detracted
from the public understanding of the medical and bioethical
issues
involved in the case.
Some might further argue that the case exposed a severe fault
line in the bioethics approach to issues of this sort, or at least a
limi-
tation of the usefulness of bioethics. After all, the case never
went
under the scrutiny of a bioethics committee and there was no
This article was written prior to release of the autopsy report on
Terri Schiavo.
Address correspondence to Tom Preston, 1128 22nd Ave. E.,
Seattle, WA 98112.
E-mail: [email protected]
121
Death Studies, 30: 121–133, 2006
Copyright # Taylor & Francis Group, LLC
96. ISSN: 0748-1187 print/1091-7683 online
DOI: 10.1080/07481180500455608
formal statement of medical ethics conveyed to the public in
support of letting Terri die. The public media presentation of
the
case was in social, political, and legal terms, with sparse, if
any,
discussion of how bioethical principles might apply to the
difficult
issues involved. The absence of a classic medical ethics
assessment
was a lost opportunity to educate the public.
In this article we apply the basic tenets of medical ethics to the
medical decision-making process in the Schiavo case. Medical
ethics, or bioethics, began as a means of giving physicians and
other health care providers guidelines for handling ethical pro-
blems that occur in the practice of medicine. It then developed
as a method for dealing with new ethical issues, particularly
those
arising from procedures such as artificial kidney treatment
(dialy-
97. sis), resuscitation, and withdrawal of life-sustaining treatment
( Jonsen, Siegler, & Winslade, 1992). We use the technique of
Jonsen, Siegler, and Winslade (2002), which focuses on four
topics
clinicians should take into account in assessing the ethical
aspects
of a medical decision: medical indications, patient preference,
quality of life, and contextual features.
Medical Indications
Medical ethics begins by asking whether the proposed treatment
or procedure is medically indicated—does it fulfill the goals of
medicine? Using the principle of beneficence, we ask does this
treatment maintain life, restore health, and prevent symptoms?
Do the benefits outweigh the potential harm of the treatment?
What were the medical ‘‘facts’’ of the Terri Schiavo case, and
what can bioethics teach us about how to proceed when a next
similar case occurs? Removing Terri Schiavo’s feeding tube was
not a treatment per se, but rather the discontinuation of
treatment
with hydration and nutrition. Terri did not sense food in her
mouth
and did not have a swallowing reflex. Because she was unable
98. to
swallow, she could not be fed through her mouth without a
strong
likelihood of choking to death, so the feeding tube was the only
means of keeping her alive. The treatment under analysis is
there-
fore the continuation of fluids and nutrients through Terri’s
feeding
tube. The central question was whether continued treatment
with
the feeding tube was medically indicated. Was this treatment of
122 T. Preston and M. Kelly
benefit to Terri, or was the treatment disproportionately burden-
some and harmful to her?
One of the goals of medicine is to maintain life or to prevent
death. The goal, however, is not to prevent all death but to
prevent
untimely or inappropriate death. In this case, continued feeding
certainly would have kept Terri alive, as it had done for 15
years.
99. Although in many cases the goal of maintaining life is pre-
eminent,
when the ethical issue is whether life should continue or be
allowed
to end, this goal is subsumed under other considerations.
Whether
death from stopping the treatment would have been considered
timely or untimely depends on factors such as perceived patient
preference, judgment of what would be best for her, and
opinions
about the quality of her life.
Would continued treatment have relieved symptoms of pain
and suffering? No. Terri had only involuntary reflexes, with no
function above the brain stem. She had no cognitive function or
awareness of her surroundings, and no physical or mental
sensation
of pain or suffering. Therefore treatment was not relieving
suffering.
Would continued treatment have restored health? Would it
have cured the disease or improved functional status? Two
neurol-
ogists selected by Terri’s parents (who opposed ending
treatment)
100. suggested that Terri’s smiles and movements represented
cognition
and sensation, whereas two neurologists selected by Terri’s
husband and one selected independently by the court testified
that
Terri’s reflexes were involuntary and she was in a persistent
veg-
etative state from which she would never recover (see
Cerminara’s
introductory article for a detailed review of the related history).
All five neurologists agreed that Terri had suffered enormous
damage to her brain, such that most of her cerebral cortex,
which
controls conscious thought, was gone, replaced by spinal fluid.
The
biological probability for a cure of her condition was so
minimal as
to be effectively zero.
In the second trial, the court heard conflicting evidence as to
whether new therapy might succeed in restoring Terri’s brain
func-
tion and found no credible evidence that Terri would ever
recover
significant function. This finding was unanimously upheld on
101. appeal. Undeniably, the prognosis in this case was crucial to a
sound ethical judgment, and any disagreement makes the
decision
difficult. We agree with the trial courts that claims of potential
improvement with new therapies were without merit. The
treatment
Medical Ethics Assessment 123
offered no chance for restoring health. Because treatment was
not
relieving symptoms, and it held no reasonable chance for a cure
or
clinical improvement, there was no medical indication for
contin-
ued treatment with the feeding tube.
Germane to the discussion is a related question: Was Terri
Schiavo on life support, or was she merely being fed through a
tube? Some argued that treatment with food and fluids should
never be withdrawn from dying or permanently unconscious
patients (e.g., Pope John Paul II, 2004). Feeding is natural, they
said, and ‘‘merely being fed through a tube’’ is not life
102. support—it
is different from stopping treatments such as artificial breathing
with a mechanical ventilator.
We all understand the emotion behind this argument when
it is made to keep a loved one alive, but from a medical ethics
perspective it is not correct. Medically, stopping feeding is no
different from stopping a breathing machine that is keeping
some-
one alive. Air is also natural, and breathing is a natural
function.
Food and air are equally natural and essential to life. If a person
is permanently unable to breathe, we can delay death with
artificial
breathing. If a person is permanently unable to swallow we can
delay death by placing a feeding tube into the stomach and
bypass-
ing the need to swallow.
It is as unnatural to pierce through the abdomen and place a
tube into a patient’s stomach, and then pour food through the
tube
or pump it into the stomach with a machine, as it is to use a
machine to blow air into a patient’s lungs. With artificial
breathing,
103. the air at least goes in and out through the natural wind-pipe,
while
artificial feeding bypasses the natural process of swallowing
food
through the esophagus to the stomach. The mechanisms of arti-
ficial feeding and breathing are different, but one is not more or
less natural than the other.
But, some argued, food and fluids are ordinary and natural
and stopping them is ‘‘killing,’’ it is ‘‘starving’’ a person to
death
(e.g., Pope John Paul II, 2004). On the other hand, they said, it
is
allowable to disconnect a patient from a breathing machine
because
it is an extraordinary medical measure (see also, President’s
Commission for the Study of Ethical Problems in Medicine and
Biomedical and Behavioral Research, 1983). But one is not
extra-
ordinary, whereas the other is ordinary. In its landmark report,
the President’s Commission for the Study of Ethical Problems
in
124 T. Preston and M. Kelly
104. Medicine concluded: ‘‘There is no basis for holding that
whether
a treatment is common or unusual, or whether it is simple or
com-
plex, is in itself significant to a moral analysis of whether a
treatment
is warranted or obligatory’’ (p. 87). Also, according to Florida
stat-
ute, a ‘‘Life-prolonging procedure means any medical
procedure,
treatment, or intervention, including artificially provided
sustenance
and hydration, which sustains, restores, or supplants a
spontaneous
vital function’’ (Health Care Advance Directives, Definitions,
x765.101, 2004, emphasis added; see also xx765.301-309). This
is
consistent with medical understanding and the tenets of medical
ethics. Terri Schiavo was on life-support because she could not
survive without the fluid and nutrition treatment she was
receiving.
Nonmaleficence
105. Application of the principle of nonmaleficence (do no harm)
leads
us to ask, would continued feeding have been good treatment
for
Terri, or would it have harmed her? Would either maintaining
or discontinuing the treatment cause harm out of proportion to
benefit for her?
Would removing Terri’s feeding tube be inhumane by causing
‘‘starvation’’ and pain? In comparison to withdrawing artificial
breathing with a ventilator, stopping tube-feeding appears to be
a
long, drawn-out procedure during which the patient may suffer.
But Terri had no sensation of thirst or hunger. She did not
suffer
when the feeding tube was withdrawn, and the absence of food
and fluids did not cause suffering (Multi-Society Task Force on
PVS, 1994).
There is an important emotional difference between slow
dying after withdrawal of food and water and the rapid death
following disconnecting a patient from a respirator. One
watches
the patient dying slowly from absence of food and water and
106. might
conclude, ‘‘They are starving her to death.’’ But families do not
usually watch their loved one being disconnected from a
breathing
machine. If they did, they would say, ‘‘They are suffocating
him to
death.’’ Discomfort or pain is possible in the latter procedure
only
if the patient is not given sufficient sedative or pain medicine to
obliterate symptoms. On the other hand, there is no discomfort
associated with dehydration after withdrawal of a feeding tube
in
a patient with persistent vegetative state.
Medical Ethics Assessment 125
Would continued treatment have harmed Terri? Unfortunately,
many relatives or loved ones of patients on life-supporting
therapy
do not understand the consequences of continued treatment.
Although Terri would not have perceived suffering had she
remained alive, over the years or decades to come she inevitably
would have acquired illnesses associated with aging and being
107. bed-ridden, which would have increased the psychological
burden
on her family.
The larger question was whether Terri benefited or was
harmed by dying. The answer to this rests in part on her quality
of life if feeding had been continued. Certainty on this point is
impossible and must take into account the complexity of the
judg-
ment of the value of living indefinitely in a persistent
vegetative
state. Whether Terri benefited or was harmed by dying also
depends on determination of her personal preference, or her
valuation of continued living in that condition.
Autonomy, or Patient Preferences
In our opinion, this is probably the most important ethical
determi-
nant of the case. There is little question that had Terri had an
advance directive with a clear statement on whether she would
want to continue living in a persistent vegetative state, the
medical
decision would have been according to her stated desire and
there
108. would have been little or no controversy. Perhaps the most
daunt-
ing problem in medical ethics is a life or death decision when
the
patient cannot state her choice, and the patient’s loved ones
have
conflicting wishes of what to do. This brings us to the concept
of
substituted judgment wherein the individual(s) who speaks for
the patient must make decisions according to the beliefs and life
style of the patient. The judgment should reflect not what the
loved
ones would want for the patient, but what the patient would
want.
Should we consider a patient’s known religious or social
beliefs? Indeed, we give much weight to any known such beliefs
or affirmations as indicative of a person’s fundamental values
and wishes. To this end, an explicit understanding of Terri’s
religious or social beliefs, such as from recorded statements,
would
have helped in determining whether she would have wanted
treatment to be continued or stopped. There was nothing
conclusive
on this point.
109. 126 T. Preston and M. Kelly
We believe no one can be absolutely certain what Terri would
have wanted, or how much thought she gave before her injury to
what would have been for her a remote and hypothetical matter.
Lacking explicit evidence, we cannot gainsay the findings of the
courts. By the best evidence we have, Terri Schiavo would not
have wished to continue living in the condition of persistent
vegetative state (see Cerminara’s introduction).
Autonomy is exceedingly important in medical ethics, and
ordinarily trumps the wishes of others. The person involved in
the proposed procedure or treatment should in most cases be
able
to make medical decisions for herself, or, as in this case,
through a
surrogate or guardian.
But autonomy cannot be absolute if a medical decision hurts
others disproportionately to the gain of the person making the
autonomous decision. In this case, the decision should take into
account the preferences of others, notably Terri’s closest
110. relatives
or loved ones. However, the disagreement between Terri’s
parents
and her husband meant that the wishes of the two sides of the
dispute were diametrically opposed. If we give equal weight to
the opposing parties, this consideration is a net sum zero,
leaving
the patient’s desire as the sole determinant. Although some
disagree with the determination of what Terri would have
wanted,
it is based on the best evidence possible, and to go against the
best
evidence would be unwise.
Quality of Life
Future quality of life assessment is contingent on accurate
prognosis.
The finding that with continued treatment Terri would have
remained indefinitely in a persistent vegetative state means
there
was no reasonable hope for a cure, awareness of sensation, the
ability to move voluntarily, or to have cognitive function. With
no
awareness, she had no quality of life. Therefore, continued
111. treatment
would not have changed her quality of life status—it would not
have
made it better or worse.
Whether continuing with no quality of life would be seen as
favorable or unfavorable devolves upon assessment of whether
Terri would have wanted to continue existing in a persistent
vegetative state. This in turn hinges on medical prognosis.
Although
we acknowledge some difference of opinion regarding Terri’s
Medical Ethics Assessment 127
prognosis, by the preponderance of expert opinion, further
treatment would have been futile, and she would have had no
qual-
ity of life. By the quality of life criterion, therefore, it was
ethically
permissible to allow her to die.
Contextual Features—Socio-Economic, Personal,
and Institutional
112. Vital medical decisions are never made in a social vacuum, but
within the context of an individual’s upbringing, her family and
friends, social and cultural institutions, the law, and economic
influ-
ences. It is important to consider all contextual elements in
reaching
an important medical decision, as the decision can have a
lasting
effect on other persons and institutions, as well as on the
patient.
Should a medical decision take into account the considera-
tions of others? Yes, it should, and in particular it should
account
for close family members. However, here we come to the most
wrenching aspect of the case: the conflict and antagonism
between
Terri’s parents and her husband. Terri’s parents said they
desper-
ately wanted to keep her alive, so stopping treatment and
allowing
her to die would have hurt them deeply. On the other hand, if
Terri’s husband believed strongly that she should not be kept
alive,
113. a decision contrary to that wish would have hurt him. Can we
say
the parents’ emotional pain at seeing her die was greater than
the
husband’s pain would have been had she been kept alive? From
reports in the public media, and from the lengths to which her
par-
ents went to keep Terri alive, we can say ‘‘perhaps so.’’ Did
years
of continued treatment after Terri’s husband first asked to have
the
tube removed cause him pain? Perhaps so. What matters is
whether a decision one way or the other would cause undue
emotional harm to either of the parties.
The perception, by outsiders like us looking at the case, of
harm to either Terri’s parents or to her husband, is undoubtedly
influenced by characteristics, beliefs and values, and economic
or social gain or loss of the opposing personalities in the case.
For example, the personal religious convictions of Terri’s
parents
may have played a large role in wanting to keep her alive. Also,
the relationships of the loved ones to Terri, and observers’
ability
to identify with either the parents or the husband, may influence
114. outside observers’ views of right and wrong.
128 T. Preston and M. Kelly
Our perception of emotional harm is also influenced by our
own personal values and beliefs. Assessing harm to others
intimately
involved in the case also would involve value judgments based
on
information gleaned from the public media. It would be wrong,
we
believe, to judge the degree of harm to the parents or husband
based on our opinion of the reasons or underpinnings of their
wishes, or perceived personal characteristics of the disputants.
Further, this concern for others is disproportionately small com-
pared with what was best for Terri.
We must also consider the impact of our ethics decision on
institutions and religious or cultural groups that may believe
they
will be impacted by the decision. In July 2004, based on a
speech
in which Pope John Paul II said it is obligatory for physicians to
115. tube-feed patients in persistent vegetative states, Terri’s parents
filed a motion aimed at stopping withdrawal of the feeding tube
(see Cerminara’s article). This statement was contrary to what
was then a near consensus in the medical ethics community in
the United States—namely, it is ethically permissible to
withdraw
food and hydration in a patient in a persistent vegetative state if
the patient or the patient’s surrogate so desires. This finding
was
also affirmed by the U.S. Supreme Court (Cruzan v. Director,
Missouri Department of Health, 1990). Would a decision to stop
treat-
ment through a feeding tube cause harm to the Church? Many
‘‘right to life’’ advocates objected strenuously to removal of the
feeding tube, often on ideological grounds. Would removing the
feeding tube harm these groups and individuals?
These are contextual ‘‘macro-issues’’ of how individual medical
decisions can influence or alter institutions and policies that
affect
large groups of people or entire populations. Although macro-
issues
introduce important considerations, we cannot give them great
weight in this case. Unless there is a clear and overwhelming
public
116. consensus, there are usually multiple opposing forces
concerning a
contentious social issue. For example, although ‘‘right to life’’
indivi-
duals may feel harmed by a policy permitting cessation of
feeding
for a patient in a persistent vegetative state, ‘‘right to die’’
individuals
may perceive harm from a converse policy. One of the primary
goals of medical ethics is to protect the individual patient from
pub-
lic policies and institutions potentially harmful to the
individual’s
values or goals. The prime consideration must be the welfare
and
desires of the patient, not of social policy or institutions.
Medical Ethics Assessment 129
Another macro-issue is the allocation of scarce resources.
Using a ‘‘utilitarian’’ approach, we would make medical
decisions
to create the most good for the most people. Thus, one might
117. argue
that the resources necessary to keep someone alive for 15 years
in a
persistent vegetative state would be better allocated to provide
basic health care for others who have no health insurance or
can-
not get adequate health care. The expenditure of resources of
this
order and magnitude is not trivial. However, although
individual
cases may bring national attention to social inadequacies,
broader
societal issues such as allocation of scarce resources are better
handled on a macro scale of policy-making. The preponderance
of weight in individual medical ethical decisions must be
directed
to considerations of what is best for the individual patient.
If contextual factors (perceived harm to the relatives of one
side or the other; religious beliefs; political, economic, and
legal
desires) were overwhelming, they might tilt our judgment. Such
not being the case, however, the ethical decision must rest
firmly
on assessment of what was best for the patient. In the end, in
118. Terri’s case all these contextual factors are minimal or are sub-
sumed under the ethical considerations of beneficence and the
patient’s preference.
Comment and Conclusions
By applying the classic elements of medical ethics, we find that
it
was ethically permissible and appropriate to stop Terri
Schiavo’s
treatment by use of a feeding tube. After 15 years with no sign
of
improvement, it is unreasonable to conclude that continued tube
feeding would have led to clinical improvement. When the out-
come is uncertain we should err on the side of maintaining life.
But a helpful ethical maxim is that it is better to stop a
treatment that
was tried and did not work than to not start a treatment that has
an
uncertain outcome. This maxim was definitely followed in this
case!
The ramifications of the case are numerous if not legion by
now and deserve the attention of all Americans. We believe the
case’s most important lesson is the need for advance directives.
119. The immense hostility and divisiveness engendered,
individually
and nationally, may be even more likely to recur in a future case
of a patient in similar circumstances. The case has caused an
unnecessary social divide.
130 T. Preston and M. Kelly
In future cases involving care of patients in persistent
vegetative
states, violent disagreements as in the Schiavo case may be
avoided
by a full and early application of the principles of medical
ethics.
Just as importantly, the public needs to be informed of this
approach to ethically difficult medical decisions, and the media
should make use of it in their reporting. In our opinion, the
inor-
dinate and sensationalist media attention to the Schiavo case,
with
the marked emotional reactions of so many individuals and
groups, detracted greatly from an understanding of the ethical
principles that should have been applied to a determination of
120. what was best for Terri.
The medical ethics approach is not intended as an all-encom-
passing set of rules for clinical decision-making. In a rare
public
reference to bioethics, a syndicated columnist said the
discipline
had become a secular tool and blamed ‘‘left-leaning bioethics’’
for justifying the ‘‘killing’’ of people such as Terri Schiavo
(Leo,
2005). We acknowledge the secular basis of medical ethics as
necessary to establish guidelines for all physicians without
imposing specific religious or spiritual beliefs on those who do
not share them. How physicians and others superimpose their
religious or spiritual beliefs on medical ethics is a matter of
indi-
vidual values and goals. One may supplement medical ethics
with personal principled beliefs, but we urge all to understand
that in medical ethics ‘‘one size does not fit all.’’ There must be
room to apply the principles of medical ethics within diverse
sub-cultures.
Part of the problem, we believe, has been a misplaced focus
on ‘‘pulling the feeding tube,’’ rather than on the basic ethical
question of the treatment Terri was receiving. By focusing only
121. on the final act of withdrawing food and fluids, with its
attendant
symbolism to some of ‘‘killing,’’ one cannot understand the
patient’s medical condition, the role of prior medical decisions,
and the need for medical ethics in reaching a decision.
Fundamental to an understanding of dying patients is the
nature of earlier decisions, particularly treatments. Any life-
extend-
ing treatment decision is a choice to defer dying to a later date
and,
most likely, under different conditions. Continued provision of
artificial nutrition and hydration to Terri would not have
fulfilled
the ethical goals of medical treatment—it could have only
postponed,
not prevented death.
Medical Ethics Assessment 131
Dyinghasbeenpostponedbyhumanchoicewhenweartificially
feed or breathe for a patient. The treatment is the key ethical
issue,
122. as without it the patient dies; however, with continuous
treatment
there is a continuous deferral of dying to a later date. The
problem
with continuing treatment after the prognosis is clear is exactly
what happened to Terri. Once natural death is overcome medi-
cally, and there is no medical reason to expect recovery,
someone
must make the decision about how and when to allow death to
pro-
ceed.
The issue is not ‘‘killing,’’ or depriving a disabled person of
life,
but when to stop an unsuccessful treatment in order to allow
death
that has been unnaturally postponed. Medically, it seems
reasonable
to continue treatment for up to a year after a patient is
diagnosed as
being in a persistent vegetative state, although many
neurologists
might argue it is futile to treat after six months, or even less.
But after
the long-term outlook is clear, the choice is whether to allow a
123. patient to die, as would have been Terri’s choice based on the
best
evidence, or to wait and let her die years later, as her parents
wished.
Either way it is a human decision someone had to make.
Most Americans still die in institutions such as hospitals and
nursing homes where decisions are made whether to resuscitate,
to treat life-threatening complications, to try more curative
ther-
apy, or to withdraw life-sustaining treatments (Faber-
Langendoen
& Lanken, 2000; Field & Cassel, 1997). When patients are at
the
end of life and not capable of making medical decisions, loved
ones often make decisions to stop treatments and let them die
instead of extending ‘‘life’’ to the limits of modern technology.
This
is not killing, it is allowing death to proceed rather than
extending
the dying process. After life is first prolonged by medical
manage-
ment, it is allowed to end sometime later. It was the same for
Terri
Schiavo, and it is ethically correct.
124. References
Cruzan v. Director. Missouri Department of Health, 476 U.S.
261 (1990).
Faber-Langendoen, K. & Lanken, P. N. (2000). Dying patients
in the intensive
care unit: Forgoing treatment, maintaining care. Annals of
Internal Medicine,
133, 886–893.
Field, M. J. & Cassel, C. K. (Eds.). (1997). Approaching death:
Improving care at the
end of life. Washington, DC: National Academy Press.
132 T. Preston and M. Kelly
Health Care Advance Directives, Definitions. (2004). Fla. Stat.
Title XLIV, Chap-
ter 765.101.
Jonsen, A. R., Siegler, M., & Winslade, W. J. (1992). Clinical
125. ethics (3rd ed.).
New York: McGraw Hill.
Jonsen, A. R., Siegler, M., & Winslade, W. J. (2002). Clinical
ethics (5th ed.).
New York: McGraw Hill.
Leo, J. (March 29, 2005). Left-leaning bioethics at core of the
Schiavo debate.
Seattle Times, p. B7.
Multi-Society Task Force on PVS. (1994). Medical aspects of
the persistent
vegetative state—second of two parts. New England Journal of
Medicine, 330,
1572–1579.
Pope John Paul II. (2004, March 20). Address of John Paul II to
the participants in
the International Congress on ‘‘Life-Sustaining Treatments and
Vegetation State:
Scientific Advances and Ethical Dilemmas.’’ Retrieved
September 9, 2005 from
http://www.vatican.va/holy_father/john/paul_ii/speeches/2004/
march/
126. documents/hf_jp-ii_spe_20040320_congress-fiamc_en.html.
President’s Commission for the Study of Ethical Problems in
Medicine and
Biomedical and Behavioral Research. (1983). Deciding to forgo
life-sustaining
treatment: A report on the ethical, medical, and legal issues in
treatment decisions.
Washington, DC: GPO (Government Printing Office).
Medical Ethics Assessment 133
WHAT WOULD TERRI WANT?
ON THE PSYCHOLOGICAL CHALLENGES
OF SURROGATE DECISION MAKING
PETER H. DITTO
University of California, Irvine, California, USA
127. The Terri Schiavo case was unique in the media attention it
garnered, but the
decision making challenges faced by Terri’s family are common
ones encountered
by all families who must make choices about the use of life-
sustaining medical
treatment for an incapacitated loved one. This article highlights
three key issues
that were particularly problematic in the Schiavo case, but that
represent general
psychological challenges inherent to the task of surrogate
decision making. The 3
central points of uncertainty, and therefore conflict, in the
Schiavo case concerned:
(a) the appropriate standard by which medical decisions for
Terri should be
made, (b) the specific nature of Terri’s wishes about the use of
life-sustaining
medical technology, and (c) the true extent of disability and
prognosis for recovery
represented by Terri’s medical condition. No simple remedy is
possible that will
resolve all of the uncertainties inherent to surrogate decision
making, but some
128. general strategies for improving the quality of end-of-life
medical decisions are
discussed.
The tragic final chapter of Terri Schiavo’s life story was unique
in
many ways. Even in an era saturated with celebrity trials and
confessional television talk shows, seldom has such an
exquisitely
personal decision been elevated to the level of full-blown, 21st-
century style public spectacle. Discussions normally held in
rever-
ent tones within the dimly lit corridors of hospitals and hospices
were magnified by a 24-hour news cycle and an ongoing culture
war into a national conversation. The situation seemed uniquely
cursed with every difficulty that might befall a family striving
to
make the right decisions for an incapacitated loved one.
Irreconcil-
able differences between family members about the appropriate
course of action, the lack of any written documentation of
Terri’s
Address correspondence to Peter H. Ditto, Department of
Psychology and Social