Year 3 Semester 1 2008-2009: CONTRACEPTION/LEANNE COOPER 04-08-08

Background

Ms X, a slightly retarded teenager, had a complicated history with contraception. As a 14-year old teenager she was exposed to a lot of sexual messages in cinema, television, teenager magazines, and various forms of advertisement. At school there was peer pressure to engage in sex and those who were virgins were the laughing stock of the class. At age 15 she became pregnant from one episode of unprotected sex. She told did not tell her mother about the incident but went the next morning straight to her aunt who worked as a nurse. The aunt took her to a gynecologist who refused to prescribe a morning after pill without parental consent. The aunt however was able to find another gynecologist who was sympathetic and prescribed the pill. The aunt advised her to use some method of contraception in the future to avoid unwanted pregnancy. X lost three boyfriends in a year because all refused to use condoms. She became desperate and went to the family planning clinic.  She was advised to use oral contraceptives. Her parents discovered the contraceptive pills inn her room and saw the address of the clinic. X refused to talk to them about the pills. The parents took the clinic to court. The court ruled that according to the Gillick vs. West Norfolk case, X was competent to consent to contraception. The parents appealed on the grounds that X had some mental retardation and was in special education so she could not have fully understood the implications of contraception to give consent. She was also obese from overeating, had familial hypercholesterolemia, and was under treatment for congenital heart disease. At age 16 she became pregnant within 6 months because of irregularity in taking the pill. She asked for and got an abortion in a foreign country where it was legal with expenses being paid by a pro-choice foundation and without the knowledge of her parents. A neighbor who saw her going to the offices of the foundation informed her parents who proceeded to take the foundation to court for helping their daughter obtain an abortion without parental consent. While the case was going through the courts. X became pregnant again and she said she did not even know the father. She was treated for sexually transmitted disease 4-5 times during the pregnancy and she admitted to being sexually active with people she did not know. Her parents took her to a psychiatrist who diagnosed mental retardation and was of the opinion that she should be sterilized to prevent further unwanted pregnancies. The parents preferred use of depot provera but the family doctor as well as the gynecologist refused because of known side effects of depo provera that include causing cancer. The parents thought of asking for hysterectomy because they were concerned about X’s lack of menstrual hygiene as her mental retardation got worse with the years. The gynecologist was not sure what to do and decided to refer the case to a court of law. In depositions to the court the gynecologist pointed out that X was 8 weeks pregnant.

Discussion

1.      List and explain all ethico-legal issues in this case

2.      Imagine you are the judge in the suit brought by the parents for abortion without parental consent. What would be your judgment?. Give the justification.

3.      Imagine you are the judge in the suit brought to seek court permission to carry out a hysterectomy on Leanne. What would be your judgment?. Give the justification.

Year 3 Semester 1: ABNORMAL UTERINE BLEEDING

Background

X’s husband had sought divorce from the civil court on grounds of mental and physical abuse. His lawyers presented details of the marital relation in the past 5 years. X had on turning 40 changed her behavior. She became moody and quarrelsome. She started attacking her husband verbally at the beginning and physically as time went on. Being a tall and big women she inflicted injury on her thin and physically weak husband. The husband dared not complain because it would socially be embarrassing to be beaten and injured by the wife. She also refused him sexual favors. She claimed that she was in prolonged menstruation all the time and it was against religious teachings to engage in sexual activities during menstruation. Once in a while she consented to sexual intercourse but then complained that the husband had infected her because she had pain during intercourse and for 3-4 days later. Douching had become very painful. She accused him of having affairs with other women from who he had contracted STD. The husband denied all this and had more beatings. Meanwhile prolonged and irregular bleeding made X’s life very miserable. A friend advised her to ask her gynecologist for hysterectomy since it was the uterus that was the source of all the problems. She subsequently had the hysterectomy done but was not put on any hormonal treatment because the surgeon took care to preserve the ovaries. One day while running after the husband fleeing from her beating, she fell suddenly. She experienced much pain and could not stand up. The husband called for an ambulance that took her to hospital where a hip fracture was diagnosed. Hip replacement surgery was carried out and she was started on hormonal replacement treatment and calcium supplements. Two years later she developed pain in the right groin and examination revealed cancer of the ovary. The cancer was too advanced for surgery and she was put on palliative radiotherapy and chemotherapy. She decided to take the hospital and all doctors who had treated her to court for medical malpractice.

Discussion

1. List and explain all ethico-legal issues in this case
2. Imagine you are the judge in the divorce court, what would your ruling be regarding the divorce request.

Year 3 Semester 1: HIV DISCLOSURE IN OBSTETRIC UNIT

Background

X, a midwife in the obstetric unit who conducted normal deliveries, was HIV+ve but she kept her status secret. She observed all universal precautions when dealing with patients. Over the past 5 years no patient has been reported to have been infected with HIV in her unit. Her status had been discovered when she donated blood while working as a volunteer during an earthquake disaster overseas. One day after a family argument her husband decided to ruin her career by revealing her HIV status to the head obstetrician. He also informed the local newspaper editor. The newspaper editor failed to get an interview with the nurse. He contacted the obstetrician for confirmation before publishing the news. The obstetrician refused to be interviewed by the paper. He sought the advice of the hospital lawyer who told him essentially that he was between a rock and a hard place. Refusing to disclose the HIV status would be putting the public at risk. Disclosing would be violating the duty of confidentiality. The newspaper sued the obstetrician under the freedom of information law. The Attorney-General was forced to take over the case and sued the hospital for failure to report a notifiable disease. During the discovery phase of the trial prosecutors requested medical records of the nurse and the obstetrician said he did not have them. The nurse also refused an HIV test. She threatened to sue the hospital if they suspended her from her work.

Discussion

1. List and explain ethico-legal issues in this case
2. What will be your decision if you were the judge. Give your ethico-legal reasoning.

Year 3 Semester 1: INVITRO FERTILIZATION

Background

Mr. and Mrs. X had been married for 10 years but failed to conceive naturally. They decided to try IVF. During preliminary tests Mrs. X was found to have the SS genotype for sickle cell but the condition had not manifested clinically all her adult life. Since the father had an AS genotype, a decision was made to seek a paid ovum donor who had normal hemoglobin. Before an ovum donor was found, Mr. X was involved in a car accident that left him unconscious and was later declared to be in a persistent vegetative state (PVS). The wife asked the hospital to remove semen from him and use it in the IVF procedure. The donor who was found had an AA genotype, had a history of psychiatric illness, insisted that the child should know her, and that she should be paid USD10, 000. Mrs. X also insisted on pre-implantation genetic testing to rule out the AS genotype in the offspring. The hospital was not sure of what to do in the face of so many complications and lack of consent from Mr. X. The first wife of Mr. X who had a girl from him before  their divorce 15 years ago heard about Mr. X’s frozen semen when the newspapers reported the court case brought by the hospital seeking legal guidance on what to do. She made an application to the court to allow her to use some of the semen in an IVF procedure in an attempt at having a baby that could be a source of compatible bone marrow to treat multiple myeloma in her child. She applied for court approval of pre-implantation genetic testing and tissue matching as well as for gender selection because she wanted a girl and not a boy.

Discussion

1. List and explain ethico-legal issues in this case
2. Imagine you are the judge in this case. What would be your decisions? Give your ethical and legal reasoning

Year 3 Semester 1: URINARY FLOW PROBLEMS

Background

Mr. X complained to his family physician that over the past 3-4 years he had experienced increasing difficulty in passing urine and had resorting to entering the toilet with a newspaper to read while he struggled to empty his bladder. The physician asked him to drink a lot of water and took ultrasound images of the urinary bladder before and after urination. He discovered considerable urinary retention of 50-80 ml. A digital rectal examination (DRE) revealed an enlarged but smooth middle lobe of the prostate. Serum taken for assessment of prostate specific antigen (PSA) revealed normal levels. Mr. X was reassured that there was nothing threatening and that he should be treated medically using proscar. He refused medical treatment and insisted on immediate surgery to relieve his urinary symptoms. The surgeons refused to carry out the surgery. Mr. X heard of clinics in another country that carried out any operation requested by a patient on payment of a high sum of money. Mr. X traveled overseas. Surgery was carried out and histopathological examination revealed a low grade prostate carcinoma confined within the prostate capsule.

Discussion

1. Explain ethico-legal issue(s) in this case
2. Can a claim of medical negligence be sustained in this case?

Year 3 Semester 1: MENOPAUSE

Background

Hjh X fell in her kitchen. She experienced considerable pain and could not stand up. Her husband handicapped by polyarthritis could not help her. He managed to call an ambulance that took her to hospital where surgery was carried out and she was discharged 3 months later able to walk on her own. At a follow up appointment at the gynecology clinic she refused to accept that her fall was due to osteoporosis and that she should start treatment with hormone replacement and calcium. Her husband who accompanied her supported her view that it was the fall that broke her bones and not the broken bone that caused the fall. Attempts to change her mind were made by calling in religious officials, social workers, and relatives. She returned home and within a year had another hip fracture for which she was hospitalized for 4 months. In view of the deterioration of her health and that of her husband her grown up children suggested that she moves in to say with her daughter. She refused to leave her house because she wanted to maintain her independence. She also refused admission to a nursing home for the elderly. The children engaged the services of a psychiatrist to assess her mental capacity.

He found that she was globally competent intellectually but that she was incompetent for specific decisions like decisions on how to take care of herself.

Discussion

1. List and explain ethico-legal issues arising in this case
2. What would be your decision If you are asked as judge to issue an in injunction confining Hjh Aishah to a nursing home

Year 3 Semester 1 PBL: COSMETIC SURGERY

Background

X an aspiring actor was advised by her media consultants to change her facial features in order to succeed in landing major and lucrative acting roles. She found a plastic surgeon who advertised his services on television and several women magazines. She visited him and he gave her photographs showing changes made by various cosmetic surgeries he had performed in the past. He suggested, without taking history or examination, several operations costing in total MYR1, 500,000 and requiring 6 months’ treatment. X took a 6-month leave from her job and started treatments. Intra-dermal procedures were used to change her skin color to become 50% lighter as measured by a colorimeter. Both breasts were enlarged using silicon implants to twice their original size. The shape of her nose was changed. She had a face lift, plepharoplasty, a brow lift, and chin augmentation. A cosmetic dentist was invited to carry out molar and submolar augmentation. At the end of 6 months Lin was not happy with her appearance. She noticed that her whole face and the nose were asymmetric. She had developed several highly visible hypertrophic scars and keloids on her face. Her breasts were not of the same size and the nipples were obviously asymmetric. Her eye lids dropped and made her very uncomfortable. She confronted the cosmetic surgeon who told her that those were normal side effects of the operations. She was angry that he had not disclosed this information at the beginning and had given her false promises of beauty. She also asked for his licence as a plastic surgeon. He told her he was a general surgeon who had interest in plastic or cosmetic surgery. With her career ruined she decided to take him to court.

Discussion

1. List and explain ethico-legal issues in this case
2. If you are the judge, would you find the cosmetic surgeon negligent?

Year 3 Semester 1: PSYCHOSIS AND SCHIZOPHRENIA

Background

Y was from a family known in the village for abnormal behavior including some members being frankly mad. Y was different from the rest of his siblings. He managed to complete primary school and proceed to secondary school in the capital. His behavior was normal until the final year of High School when he started behaving abnormally. The teachers took him to the hospital where a schizoid illness was diagnosed and he was put on appropriate medication. He stabilized and was able to pass his examinations and was admitted to medical school. He then proposed to his high school fiancé but she was reluctant having noticed bizarre behavior from him towards the end of high school. Her parents decided to investigate. They talked to several people in the village who told them about Y’s good behavior different from the rest of the family. The parents then decided to confront Y’s mother telling her they had a proposal from him but that they were worried about going ahead because of bizarre behavior in the last year of high school. The mother explained that her son is very stable mentally and that the bizarre behavior was due to an episode of cerebral malaria which was controlled quickly by anti-malarial therapy. The family were not convinced and advised their daughter to cancel the engagement. Y was devastated by the cancellation and it could not have come at a worse time because he was anxious about the first year examinations that would determine whether he would continue with his medical studies or would have to look elsewhere. He started smoking and drinking alcohol to forget but to no avail. A friend who found him agitated advised him to try illicit drugs that would be powerful enough to make him forget his misery. He tried cocaine only once and was very sick with a lot of vomiting and decided not to try again. His depression and anxiety continued for 2-3 weeks until he experienced a nervous breakdown and was admitted to a normal ward. While on the ward he became violent abusing and physically attacking patients and doctors. When calmed down by sedation he refused admission to the psychiatric ward claiming that he was not crazy. The doctors not wanting to get into too much trouble just left him alone. They started him on anti-psychotic drugs but he refused to take any more because of side effects. He was not interested in therapy sessions for his drug abuse and often quarreled with the therapist. Two weeks from his admission he left the ward without telling anyone and went and killed his former fiancée at her home. He later became very agitated and depressed and within 10 hours he also committed suicide. His parents and the parents of his ex-fiancée jointly sued the hospital for negligence.

Discussion

1. List ethico-legal issues in this case
2. If you are the judge in this case, what would be your opinion about finding the hospital guilty of medical negligence. Justify your answer.

Year 3 Semester 1: ANXIETY DISORDER

Background

Y was the only child of a professional couple. He was using to consistently being on top of his class from kindergarten to the end of high school. On entry into medical school he found that there were many clever students and he started worrying about topping the class. In the first examination he scored 85% but that was the lowest score in the class. His worries became worse. He started studying very hard, missing meals, and missing sleep. He started falling asleep in class and missing some of the lectures requiring him to study even more a night to catch up. He started losing his ability of concentration in prayer and developed obsessive disorders about maintaining his wudhu thinking that he passes flatus all the time. When he explained his difficulties to a waiter at the canteen who advised him to try stimulant drugs that would stop him from falling asleep at night. This soon developed into an addiction and his behavior deteriorated to the point that university authorities referred him to the psychiatrist. The psychiatrist prescribed anxiolytic drugs that were effective for 1 week and soon themselves became drugs of addiction for which Y craved. After 2 years of using the drugs, Y started developing symptoms of cognitive malfunction. Y’s father was informed about his son’s deteriorating situation. He applied for a 6-month medical leave for his son. Y was taken to a religious scholar who asked him to get off all chemical therapies. He started him on cognitive therapy. He had sessions with him to discuss the concepts of pre-determination, the role of human effort, the causes and appropriate reactions to success and failure. After 2 months of therapy Y had changed his overall world-view and lost all his anxiety. He expressed his desire to return to university and continue his studies.

Discussion

1. Identify and explain manifestations of anxiety in this case
2. Explain how faith can be used to treat cases of anxiety

Year 3 Semester 1: DEPRESSION

Background

X was a brooding type who was always sad. The beginning of his marriage was stormy with the wife feeling that he had no interest in marriage at all. Always quiet, despondent, and dozing or sleeping all the time. He could sit for hours on end doing nothing. He also was very slow in whatever activity he undertook. The wife insisted that he see a psychiatrist. The psychiatrist concluded after several meetings that this was a case of endogenous depression. He referred him to a physician for assessment of thyroid and pituitary function. No physiological anomaly was found.  The condition got worse with virtual loss of speech spending 2-3 days without uttering a word. There was also deterioration in self care missing meals, poor personal hygiene, dirty and unkempt hair and clothes. He had a mental break down when his wife had a spontaneous abortion of a 3-month pregnancy. He was taken to the hospital emergency room. The attending physician finding nothing physically wrong with him decided to discharge him. The physician ignored the repeated talk of the patient about following his dead baby into the grave and just gave him valium and sent him home. When the effect of valium wore off at home he became agitated. His wife found him 10 minutes later lying unconscious on the bed with a half-empty bottle of detergent next to him. She called an ambulance that arrived in record time. By the time he was seen by the physician in the emergency room, he had recovered some consciousness and could talk. He told the physician that he wanted to die. He categorically refused to consent to the procedure of gastric lavage to remove the detergent from his stomach. A psychiatrist called to assess his mental competence concluded that he was competent to make decisions.

Discussion 

1. List and explain ethico-legal issues in this case
2. Was there any medical negligence? Give your reasons
3. What would you do if you were the physician in the emergency room who wanted to carry out emergency gastric lavage? Justify your decision

Year 3 Semester 1: NEUROLOGICAL CONDITIONS / ABNORMAL MOVEMENTS

Background

X was a healthy 9-year old school boy when he was struck on the head by a stone thrown by a grass mover on the school field. He had a small scalp wound and was unconscious for 2 days. He recovered uneventfully. At the age of 12 an epidemic of meningitis swept the country and mass immunization of all children was ordered. The father hid X from the immunization team. Three months later X developed a severe meningo-coccal meningo-encephalitis rendering him unconscious for a week but he eventually recovered.  At age 15 he was diagnosed to have major epilepsy. He avoided any major seizures for the next 10 years by being very compliant with his anti-seizure medication. He was able to accompany his patents on pilgrimage to Makka. He was not able to continue school because of poor performance and he decided to look for work. He was rejected by several employers once he told them about his history of epilepsy. He continued living as a dependent on his parents until they became too old to care for him properly. He started missing his medication and epileptic fits became frequent. Neighbors took him to the hospital where he was diagnosed to have Parkinson’s disease with dementia and considerable intellectual incompetence. He was admitted to an institution to care for him. He was put on specific treatment for Parkinsonism. He experienced episodes of vertigo which he ascribed to the anti-Parkinsonism treatment but the doctors did not pay attention to his complaints. One morning while walking up the stairs he fell and fractured his cervical spine becoming quadriplegic after that. He was distressed because of fecal and urinary incontinence that interfered with his prayers. A distant cousin who was a lawyer helped X’s parents take the institution to court for negligence that resulted in X’s quadriplegia. The trial was a difficult one because X and his parents could not recollect accurately past events that could throw light on what eventually happened to X.

Discussion

1. List and explain ethico-legal issues that arise from this case
2. If you are the judge in this case what would be your decision from the limited amount of information available.