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The following format is advised for the systematic analysis of rhe cases presented. This outllne can be used whether an individual case is used over one or more sessions. This outline is taken from JC Flercher, cA Hire, PA Lombardo, MF Marsha (eds.). Introduction ro crinicar Ethics, University Publishing Group Inc., Frederick, Md. 1995. I. Asse ssment L what is the patient's medical condition and prognosis? what reatment options exist? 2. Who is the appropriate decision maker? 3. What are the parient's preferences? 4. What are the preferences of her family or surrogate decision makers? 5' Are rhere inreresrs orher rhan, and potenriary conflicting wirh, those of the patient which need ro be considered? 6' Are there institutionar, regar or other factors which need to be considercd? Identification of rhe Erhica.l probtem(s) 7. What are the ethical problems in the case? (If appropriate, rank by magrrirude.) 8. Whar ethical consideradons arc most rclevanr? 9- Arc therc analogous cases? 10. What arc the rclevant guidelines for clinicians regarding the problem(s)? m. Decision Making and Implemcntation I l. What are the ethically acceptable options? 12. what justifications can be givcn for the ethicalry preferrcd rcsolution of rhe case? 13. How is a sadsfactory rcsorution to rhe case to bc accomplished? Is ethics consulrarionecessary or desirabre? Is judiciar rcview necessary or deiirabre?
III. Case Comments (bv Roben F. Nelson, MD) A. Assessment l. What is the patient's medical condition and prognosis? Wat treatment options exist? The patent has acute optic neuritis, and probably because of multiple sclerosis. Strictly speaking, the diagnosis of multiple sclerosis requires the occurrence of more than one attack and at the time of her presentation there appeared to have been only one episode. However, the patient recalled that she had had previous neurological symptoms. Thus, the optic neuritis was probably the second event, and the criteria for the diagnosis were met. Had the ophthalmologist and the patienr been more fonhright, funher tests such as an MRI or CSF studies might have been carried, which would have helped to confirm the diagnosrs. The prognosis is unpredictable, but cenain staristics may give some idea ofthe possibilities. For example, there is a 33Vo chance that the disease will remain benign for ar least f0 years: although there is a lo-2ovo chance thar rhe disease may be progressive from its onset, in the great majority of cases it will consist of relapses and remissions for the first decade. After rha\ 4ovo of cases will become secondarily progressive, and only 45?o will continue the pattem ofrelapses and remissions. Relapses may occur at arateof 0.1 to l.l5 per year ( O.Alyear). The treatment option ofthe acute optic neuritis includes high dose methylprednisolone. Patients with early symptoms and signs of MS may benefit from ongoing treatment wirh various forms of interferon or with copolymer, which may reduce the likelihood of subsequent attacks by up to one third. Patients should be told about such treatment options and about the possible adverse effects that rhey should weigh againsthe porential benefits. By not revealing the diagnosis the physician is preventing the patient from making informed decisions abour her own health care. 2. Wo is the appropriate decision maker? The appropriate decision maker in this case is rhe parient herself. She is adult and presumably competent. The father is the not the decision maker in this case, and the physician was in error to give him informarion. ln this situation, the physician decided not to disclose cenain information to the patient, and disclosed information to another, apparently without the patient's consent. 3. What are the patient's preferences? It may be valuable to discuss whether or not the parienr would have prcferred full disclosure at the time of initial visit. As the case progresses, it is clear that the patient preferred to keep some information about prior symptoms a secrct. This was because of fear that she had MS, and she thought that if this was confirmed it might jeopardize her career and her chance for obtaining insurance. 4. Wat are the preferences of her family or surrogate decision makers. It is imponant to stress that the preferences of the family are not relevanr in this situation.
Page 1 and 2: AMERJC,{N ACADEMY OF NETJROLOGY ETI
Page 3 and 4: TABLE OF CONTENTS l. Introduction 2
Page 5 and 6: Followrng each case is a proposed o
Page 7 and 8: CODE OF PROFESSIONAL CONDUCT PREFAC
Page 9 and 10: arrange transfer ofthe patient's ca
Page 11 and 12: items as long as this practice prov
Page 13 and 14: 2 AmericanAssociationofNeurological
Page 15: II. Case Ms. JA is a 24 year old wo
Page 19 and 20: 8. What ethical considerations are
Page 21 and 22: HUNTINGTON'S DISEASE - PRESYMPTOMAT
Page 23 and 24: PROPOSED OUTLINE FOR ETHICAL ANALYS
Page 25 and 26: 6. Are there institutional, legal,
Page 27 and 28: AMENCAN ACADEMYOF NEUROLOGY Page I
Page 29 and 30: CARE OFAN HIV.INFECTED PATIENT IN A
Page 31 and 32: The following format is advised for
Page 33 and 34: B. Idenrification ofthe Ethical Pro
Page 35 and 36: 9. t0. Are there analogous cases? W
Page 37 and 38: Ethical Role of Ncurologisrs io AID
Page 39 and 40: OPIOID TREATMENT OF CHRONIC NONMALI
Page 41 and 42: and mexilitene. Finally, Mr. Jones
Page 43 and 44: III. Case Commenb (by Glenn A. Mack
Page 45 and 46: Ponenoy has extensively reviewed ex
Page 47 and 48: defined "rescue" doses or hospitali
Page 49 and 50: 8. What ethical considerations are
Page 51 and 52: 16. Rodwin MA. Srrains in rhe fiduc
Page 53 and 54: II. Case A 25 year-old woman sustai
Page 55 and 56: III. Case Comments (by Michael P. M
Page 57 and 58: some guidance, if they are consiste
Page 59 and 60: On the basis of this analytic appro
Page 61 and 62: 80 years ago by Justice Benjamin Ca
Page 63 and 64: Although physicianshould always act
Page 65 and 66: t(, ;-)- AMERICAN ACADEMY OF NEUROL
Page 67 and 68:
@ Persistent VeSetativeSlate Paticn
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1r= ) AMERICAN ACADEMY OF NEUROLOCY
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PRSISTE\TT }TGETATTVE STAIE ard chi
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PRSISTE{T VEGETATryE STATE PAGE 5 T
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PNSISTEYT ITGETATTVE STATE PAGE 7 5
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PNSISTF{T VEGETATTVE STATE PAGE 9 O
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II. Case Because of progressive dys
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III. Case Comments (by James Bernat
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mother's wishes, some of her guilt
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Special Article n"r.oro*r*,ffi* Eth
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injur5r from improper application o
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,R,, '.=--' AMERICAN ACADEMY OF NEU
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DIAGNOSIS AND EVALUAIION OF D&TBI"I
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DLTGNOSIS AND EVALUAIION OF DE\,I6|
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II. Case The patient (Mrs. M) was a
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III. Case Comments (by Alison Wichm
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usually be identified as her surrog
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with the surrogate and other family
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RAIN DEATH IN ADULTS PAGE 2 3. with
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BRAIN DEATH IN ADIJLTS PAGE 4 E. So
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PHYSICIAN-ASSISTED DYING I. Learnin
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The neurologist writes the prescrip
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Continuation Version Two when the g
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Continuation Version Four The pills
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III. Case Comments (by David Goldbl
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might have benefitted from professi
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from engaging in any acr thar direc
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II. Case @ Neurologi consultation w
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III. Case Comments (by Russell D. S
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C. Dcci.sion Mnkinp and Intplernent
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UNCOOPERATIVE PARENTS @ I. Learning
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The following format is advised for
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even though rhese needs appear to t
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CLINICAL TRIALS I. Learning Objecti
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III, Case Comments (by David Goldbl
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@ ro identify a her to enroll in th
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II. Case A 46-year-old white ntale
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III. Case Comments (by Russell Snyd
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4. The medical community needs to c
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GIFTS FROM INDUSTRY t. Learning Obj
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II. Case Dr. Daniel Barker was rece
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@ B. Identifcation of the Ethical P
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@ specialty medical associations. U
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PROFESSIONAL MISCONDUCT OF A SEXUAL
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The following format is advised for
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one class of nonsexual touching is
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