CASE STUDIES FOR EXAM 1 The following case studies are taken from the Ethics Bowl Fall 2017 Regional Cases

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CASE STUDIES FOR EXAM 1 The following case studies are taken from the Ethics Bowl Fall 2017 Regional Cases (published by Association for Practical and Professional Ethics, and free for use for educational purposes). They were prepared by Susanna Flavia Boxall (Chair), and the Case Writers were Becky Cox-White, Rhiannon D. Funke, Michael B. Funke, and Gretchen A. Myers. I (Brendan) have altered the format and corrected broken links within the references.


A BRIEF GUIDE Case studies are meant to help you practice how to engage in “real life” ethical deliberation: the problems they present are often tricky, and solving them requires that you consider the needs and interests of multiple stakeholders (including patients, staff, the government, various companies, etc.). With this in mind, remember that the goal is NOT just to say what you “think” or “feel.” Instead, you want to find a way to propose a solution that you think you could defend/explain to all those affected by it. (So: put yourself in the shoes of these medical professionals! Do your best to figure out a workable solution). While the details of each case will require a somewhat different response, you generally go through something like the following FIVE steps: Step 1: Identify the Problem(s) and Describe the Morally Relevant Features of the Case. Before starting to say what should be done, it’s important to get clear on what exactly the problem(s) is. With this in mind, take some time to describe the main points of the case study in your own words, and identify what you think are the main ethical issues at stake (i.e., those you’ll be addressing later in the case study response). You should make sure to clearly identify any assumptions about the case you have made. You’ll also want to make clear who the various stakeholders in this case are (these are all the people/organizations who have a stake in the outcome). This will often involve reviewing the sources that are referenced within the case study. This step is often overlooked, but it’s a hugely important one, as many “disagreements” about ethical issues are often a result of different people having wildly different views of what the “facts” are. Taking the time to make this clear ahead of time can save a world of trouble. In general, this should be no more than 15 to 20% of your essay (so, a half page of a three-page paper). You should NOT simply the repeat the case study back to me—the goal in this step is to really narrow in on what is important. Step 2: Identify MULTIPLE Possible Solutions or Approaches. After you are done with step 1, you should have identified one or more specific questions that need to be answered. For example, our question might be “What is the morally right thing for X to do?” or “What should the law/policy about Y be?” Now, we need to identify more than one possible answers to this question. In some cases, we’ll already know what X did (and we’re trying to figure out whether it was the right thing to do); in other cases, we’ll be starting from scratch. You should make sure to include both (1) obvious solutions (the ones you know people will bring up) and (2) “creative” solutions (ones that occur to you as you work through the problem). Make sure you describe each of these solutions/approaches in enough detail so that a reader can understand what each would entail. Step 3: Determine Which Ethical Principles or Ideas Might Be Relevant, and Explain Why. As you start trying to solve the problem, you’ll want to think about what ideas might be most relevant. These might be general ideas (e.g., the idea of autonomy, or beneficence), specific policies (e.g., regarding things like abortion, euthanasia, etc.), or even a different case study with which you see similarities. Now, clearly and succinctly explain why these ideas are relevant. Don’t assume your audience will automatically know what you are talking about—take your time to explain, even if it seems obvious to you. This is a great place to bring in class material (from the notes, textbook, etc.), or from outside resources (though be sure to cite this). Step 4: Argue for Your Chosen Solution. Now, go to work! Use the ethical ideas/concepts you’ve identified in step 3 to argue for ONE of the solutions in step 2. This is the “heart” of your response (and it may take up 50% or more of your essay), but you shouldn’t start on this step until you’ve worked through steps 1 through 3. While this doesn’t occur until relatively late in the process, you’ll want to make sure your thesis statement (that is, a statement about what your conclusion is re: this case) comes early in the essay. Step 5: Consider Objections to Your Solution. To close, try to think about possible objections to your solution. These might include (1) potential misunderstandings (which you can answer by clarifying) or (2) genuinely bad things about your solution (here, you’ll have to argue that your solution is still better than the alternatives, despite these problems). When doing this, you’ll be trying to take the point of the view of someone who favors one of the other solutions to the case study. When it comes to the exams, a failure to adequately deal with objections is often the difference between an A-level response and a B- or C-level response.

CASE 1: EUTHANASIA FOR ALCOHOLISM On July 14, 2016, a Dutch general practitioner euthanized Mark Langedijk by giving him a lethal injection. Langedijk’s death had been approved by a physician from Support and Consultation on Euthanasia (SCEN), the Netherlands’ medical body that examines requests from persons wishing to avail themselves of state-assisted dying. “Enough is enough,” stated the 41-year-old alcoholic, who had unsuccessfully undergone twenty-one attempts at rehabilitation for his addiction. His marriage destroyed, Langedijk said he “could not continue to live as an alcoholic.”i Physician-performed-euthanasia (“mercy killing”) has been permissible in the Netherlands since 2002; although still officially illegal, it is not prosecuted when 1) the patient’s request is voluntary and well-considered, 2) the patient’s suffering is unbearable, and 3) there is no prospect of improvement. A SCEN physician must agree that these criteria are met. Contrary to popular belief and usual practice, the act does not state that euthanasia may only be performed in the ‘terminal stage’ of a condition.ii Initially, 90+% of requests came from terminally ill cancer patients. However, over the last decade requests have come from persons with a greater variety of diagnoses. More than one person has requested and been granted euthanasia for “social isolation and loneliness,”iii and pediatricians have recommended that euthanasia be available to patients as young as 10-years-old. The number of euthanasia deaths has nearly tripled since 2002.iv As with any controversial action, worries arise. First, procedural questions arise about the clarity and quantifiability of the criteria generally, and about the distinction (if any) between physical and psychological pain particularly. Second, debates are ongoing about who is the appropriate judge of “enough”; proponents of broader criteria appeal to patient autonomy, while opponents worry about potential abuse. Finally, the moral obligations of physicians to patients with refractory suffering is unclear.

CASE 2: WHY SUICIDE? In March 2017 Netflix released an episodic web series based on a novel by Jay Asher called Thirteen Reasons Why. The series follows the lives of high school students living in the wake of a classmate’s suicide. The narrative concept is that before Hannah Baker’s suicide, she recorded a series of thirteen audiotapes outlining the reasons why she kills herself. Hannah leaves these tapes in the custody of a friend, Tony, who delivers them to a cast of characters—each of whom Hannah believes contributed to her ending her own life. Soon after the show was released, critics began to publicly complain. One criticism common to many parents, mental health professionals, and teachers is that the show glamorizes suicide. The National Association of School Psychologists cautions that the show’s “powerful storytelling may lead impressionable viewers to romanticize the choices made by the characters and/or develop revenge fantasies.”v This concern has been echoed by some parents who claim that the suicides of their teenage children were triggered by the The series now begins each episode with a trigger warning, but originally the show contained trigger warnings for only three episodes—the 9th, which graphically depicts Hannah’s rape, and the 12th and 13th, which feature suicide scenes. Hannah Baker’s suicide at the end of the first season is graphic and violent. Nic Sheff, a writer on the series, describes the portrayal as “an instant reminder that suicide is never peaceful and painless, but instead an excruciating, violent end to all hopes and dreams and possibilities for the future.”vii The show’s production team anticipated a controversial discussion about the show, given the prevalence of suicide, suicide attempts, and suicide ideation among teens. As producer Selena Gomez puts it, “this is happening every day…Whether or not you wanted to see it, that’s what’s happening. The content is complicated.” According to the CDC “17.0% of students (grades 9-12) seriously considered attempting suicide in the previous 12 months (22.4% of females and 11.6% of males).”viii Though this data precedes the release of the show, the correlative evidence in a recent study has shown that “13 Reasons Why, in its present form, has both increased suicide awareness while unintentionally increasing suicidal ideation.”ix

CASE 3: QUARANTINES On January 19, 2017, the Centers for Disease Control (CDC) enacted a new rule, effective February 21, 2017, to expand its powers to screen, test, and quarantine people traveling into or within the United States, in the presence of a sudden epidemic of an infectious disease (e.g., Ebola), when quick and decisive action is necessary to contain the threat.x The new rule aims at preserving public health, but some epidemiologists, lawyers, and health organizations say it poses a serious threat to civil liberties, because it allows authorities to detain and examine people without ensuring due process, and completely eliminates the requirement for informed consent.xi Indeed, a similar attempt proposed in 2005 was scrapped in 2010 after a wave of critical comments.xii Moreover, in the past broad quarantine powers have been abused and used to harm minorities—such as a quarantine of San Francisco’s Chinatown in 1900.xiii In an op-ed for The New York Times, Kyle Edwards, Wendy Parmet, and Scott Burris argue that the present regulations do not have strict enough medical guidelines or sufficient protections for when errors in the decision to quarantine occur: “[T]he new rules give the C.D.C. significant in-house oversight of the decision to quarantine, with up to three layers of internal agency review. This internal review has no explicit time limit and could easily stretch on for weeks while a healthy person languishes in quarantine.”xiv To be clear, while the internal review might stretch on for an indeterminate amount of time, the law only expressly allows for an individual to be quarantined for 72 hours before they are entitled to review. The law also includes provisions in which an individual can obtain a second medical opinion, and challenge the detainment in court.xv Nevertheless, some scientists and lawyers argue that the CDC’s expression of its powers is heavy-handed, and that they do not spell out that they will only use their broad powers when absolutely necessary…For instance, the CDC used its powers at point-of-entry places to monitor travelers’ temperatures during the latest Ebola outbreak, and maintained a list of 10,000 travelers who ended up being monitored for 21 days because of potential exposure. None were infected.xvi On the other hand, as explained by public health expert Lawrence Gostin, the CDC needs broad powers, because “quarantines can be key to stopping people from spreading deadly bugs…[T]he United States is vulnerable to a whole range of infectious diseases that are circulating around the world, but we don’t know which one will be next. And so when something sweeps upon our shores, we don’t want to have a delay.”xvii Moreover, given global warming’s unpredictable impacts on the environment that may increase mosquito-born infectious diseases, xviii as well as the genesis of other non-environmental-related infectious diseases, the CDC likely needs authority to contain such threats for public health and safety

CASE 4: GOLDWATER TAKING ON WATER Earlier this year [in 2017], a small group of psychiatrists held a town-hall meeting at Yale Medical School to discuss President Donald Trump’s mental health. Dr. Bandy X. Lee, a psychiatry professor at Yale University, organized the meeting. She believes that psychiatrists have a “Duty to Warn” that Trump is not only unfit to serve as president, but also dangerous to the health and security of the citizens of this country.xix And though Dr. Lee’s position is controversial, she is far from the only one who subscribes to it. Dr. John Gartner, a psychiatrist and former John Hopkins Medical School professor, has stated that “from a psychiatric point of view [Trump is] the absolute worst-case scenario,” as if someone had tried “to create a Frankenstein’s monster of the most dangerous and destructive leader and had freedom to create any combination of diagnosis and symptoms” found in the Diagnostic and Statistical Manual of Mental Disorders (DSM).xx Dr. Gartner has created the following petition on We, the undersigned mental health professionals (please state your degree), believe in our professional judgment that Donald Trump manifests a serious mental illness that renders him psychologically incapable of competently discharging the duties of President of the United States. And we respectfully request he be removed from office, according to [A]rticle 4 of the 25th [A]mendment to the Constitution, which states that the president will be replaced if he is “unable to discharge the powers and duties of his office.” The petition is public and asks only for mental health professionals to sign. The category “mental health professional” is not limited to psychiatrists, but rather includes nurses, psychologists, and other community service providers. Indeed, because the petition is public, at least some of its 59,261 signatures may be from people without a mental-health background.xxi Dr. Gartner’s position is controversial because the American Psychiatric Association’s code of professional conduct forbids psychiatrists from publically commenting on the mental health of living public figures without first personally examining them. This rule is informally known as “the Goldwater rule,” after the man who led to its creation. In 1964, over 1000 psychiatrists signed a petition opining that the Republican presidential nominee, Barry Goldwater, was psychologically unfit for the office of president. The petition was published in Fact magazine, which Goldwater later sued for libel and won.xxii So it is no wonder that psychiatrists today are hesitant to publically declare President Trump mentally unfit, even if they might personally believe he is. Indeed, as a group of mental health professionals express in a letter to the editor of the New York Times, the silence imposed by the Goldwater rule “has resulted in the failure [of the psychiatric profession] to lend our expertise to worried journalists and members of Congress at this critical time.”xxiii Dr. Jerrold Post, founder of the CIA’s Center for the Analysis of Personality and Political Behavior, has similar concerns: “You have all kinds of amateurs out there giving diagnoses of what they think is wrong with President Trump’s psychological makeup. But they don’t really know what they’re talking about. Meanwhile, the psychiatrists are not allowed to weigh in.”xxiv Amid this controversy, it is important to remember that mental illness does not automatically render a person unfit to lead—in fact, certain types of mental illness may help a person be a good leader. According to Dr. Nassir Ghaemi, quite a few famously great leaders like Abraham Lincoln and Martin Luther King Jr. “had some form of mental illness.”xxv And as to Trump, it is unclear whether the traits that have so many people so worried are the symptoms of mental illness or simply his personality. Dr. Frances Allen, the chairman of the task force that wrote the DSM-IV, believes that characterizing Trump’s behavior as mental illness not only excuses his bad behavior

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