Interactive Ethics for High School Students
For more than 10 years, the Ethics and the Science Teacher Access to Resources at Southwestern (STARS) programs have invited local high school students to comment on a variety of ethics dilemmas. Students email their comments to firstname.lastname@example.org. Comments are then posted with the students’ initials and school name only. At the end of the comment period, the Program in Ethics in Science and Medicine shares the perspective of an Ethics Program faculty member.
Archived cases are listed in the right-hand column.
Case Closed – Response from Ethics Program Faculty
Mr. Smith is a 54-year-old homeless man admitted to the hospital after he was found unconscious near the Dallas Farmer’s Market. He has been slowly bleeding into his bowel because of complications of his liver cirrhosis, which in turn is due to his lifelong heavy drinking of alcoholic beverages. The bleeding can be stopped temporarily, but cannot be fixed with either medicine or surgery. He has already had 10 blood transfusions, and will need more as long as he survives. The doctors believe that his bleeding has caused serious brain damage which has caused a persistent coma, or state of unconsciousness. While the doctors cannot be sure if he will wake up from coma, they doubt that he will wake up before he dies of other problems. He is likely to die from his liver disease, but the timing of his death is hard to estimate - it could be a few days to a few weeks.
Despite sustained effort, the social worker has been unable to find any family members or even someone who knows him. He has no medical record. He has no advance directive (guidance to doctors about what to do in the case the patient cannot direct his own treatment). He has no insurance, which means that the County’s taxpayers will pay for his treatment.
- Should the patient be allowed to die? Why or why not?
- Why are the multiple transfusions of blood an important consideration in this ethics case?
- Who should decide if, and when, life-sustaining treatment is stopped?
- If Mr. Smith had medical insurance, would that change your responses to the questions above?
The patient should not be allowed to die. As a physician or health care professional, it is your responsibility to do what is in the best interest of the patient. If the patient cannot communicate to you their wishes, then it should be assumed that the patient wants to live as long as he can. Anything can happen in a matter of two weeks, so the patient should be kept alive as long as possible.
Multiple blood transfusions are an important consideration in this case because the many blood transfusions he is using per day could have possibly been used for other patients with a higher possibility of surviving. Another reason blood transfusions should be taken into consideration is because they aren't free. Blood transfusions cost a lot of money, and if he isn't paying for them, the hospital is.
The patient's physician and hospital ethics committee should make a decision of when the treatment is stopped. However, I still believe that they should keep the man alive in case a family member did show up.
If the patient had medical insurance, my above answers would not change and I would more strongly support keeping Mr. Smith alive because money would be less of an issue.
P.P., Senior Clinical Rotation, Plano West Senior High School
Although a doctor should do everything in his or her power to treat the patient, if the bleeding doesn't kill him the cirrhotic liver will, and even if by miracle they don't, he is comatose and sustains brain damage, he will never again have a fulfilling life ahead of him. It is to the best of the blood banks and time of the doctors to painlessly let him pass away.
Blood is not a renewable resource, and having to harvest it from other humans means that there can only be a set amount of blood in one place at any given time. Taking away a massive 10+ blood transfusions to give to this patient means that there are 10+ less blood transfusions that physicians can give if the demand for blood increases anytime soon.
It would be appropriate to hold a meeting of the physicians caring for the patient as well as the Chief at the hospital to assess the situation and make the unanimous decision about whether or not to sustain the life of the patient.
If the patient had medical insurance I would not feel inclined to change my answer. Although he would have a way to pay for his treatments, all the treatments are now moot due to the fact that he can no longer physically recover from his illnesses.
A.T., Senior Clinical Rotation, Plano West Senior High School
Yes, Mr. Smith should be allowed to die because necessary resources are being wasted on a patient who will die of liver disease very soon anyway. He has had 10 blood transfusions and is in need of more, and blood is not a plentiful supply. He also does not have insurance to pay for the care so the money that is used to pay for him could be used to pay for the care of someone else with a better survival rate. The job of a physician is to care for others but if the caring of one impedes upon the caring of everyone else, then there is a problem. A physician must care for as many as possible and not save the life of one single person. Mr. Smith has also had a lot of brain damage so the quality of life will not be there.
Yes, the multiple blood transfusions are a very important factor in this case because valuable resources are being used on a patient that will soon die anyway. This blood could be going out to someone who has a much better chance of survival instead.
If no family can be contacted, then ultimately it is the job of the physician to decide if and when the patient should die. They have the best interest of the patient in mind and know what their chances of survival really are.
If Mr. Smith had medical insurance, that would change the case because he would be willingly paying for everything, so the care cannot be denied to him.S.M., Senior Clinical Rotation, Plano West Senior High School
I believe the patient should be allowed to die. He is a terminal patient, who doesn't have more than a few weeks. And cost is an issue, regardless of what anyone wants to think. The ventilator costs $10,000 a day. He's stays for a week that's $70,000 of the taxpayers money. Also, all the materials being used to keep him alive could be used for someone else.
The transfusions are important because blood is a commodity and all that blood could be used for something else.
The physician should decide if he dies.
No, it wouldn't.
R.G., Senior Clinical Rotation, Plano West Senior High School
The patient should be allowed to die, but done so with dignity and as comfortable as possible. His death is inevitable and terminal. Advanced care will not reverse the ultimate end. As long as drugs that would induce death are not used, allowing the patient to die is no more unethical than caring for a hospice patient. As far as the Hippocratic Oath goes, the oath does not say you have to try to save every life. It says you should not promote death. Perhaps the kindest treatment for the patient would be to allow him to die with dignity and care.
Blood is always in short supply. By using valuable blood units, other patients who do have a great chance of survival may not get the blood they need, especially if this patient has a demanding blood type like O negative.
This case should be brought to the hospital ethics committee that has expertise in handling challenging problems like this.
We would not change our response if he had insurance.
The Clinical Students at Alvin High School
I think he should be allowed to die because of the constant blood transfusions and low chances of recovery. He would have a peaceful death rather than a terrible life.
It is important to consider the blood transfusion because it requires a lot of money and a lot or blood donors. That blood could go to someone who has a higher possibility of life.
The closest family member, or the doctor in charge if family is not available, should decide when life support should cease. Life support should also stop if his treatment impedes another patient's treatment.
No, my position would not change if he had insurance because of his possible low quality of life.
S.R., Senior, Plano West Senior High School
Yes, he should be able to because the injuries he has sustained is too difficult to heal as well as this elderly man having no chance of fully recovering. After 10 transfusions, he is still comatose while his liver continues to fail due to liver cirrhosis. Lastly, this costly treatment is being paid by the government for a man that has slim chances of ever recovering.
No matter how many blood transfusions he receives, he will never recover from his condition or state of being. The ethical controversy, therefore, that is being asked is if these transfusions of blood should be used to treat other patients with greater chances of recovery or to a comatose dying patient with slim chances of ever getting better.
In this scenario, the patient's family cannot be contacted in any way. If after a considerable amount of time has passed where no family can be contacted, then the physician that was first primarily put on the case should be able to decide whether or not to continue treatment.
If the patient indeed had insurance, he would be able to perhaps sustain needed treatment for a longer period of time, however, he would still be eventually be put off treatment due to his deteriorating state of condition. The insurance would only prolong was is inevitable to come.
E.C., Senior, Plano West Senior High School
Should the patient be allowed to die? Why, or why not? I think he should be allowed to die because even if he lived he would die from the liver cirrosis due to his heavy drinking and also the heavy bleeding in the brain would disable him permanently.
Why are the multiple transfusions of blood an important consideration in this ethics case? Because the multiple blood transfusion is costly and there is no unlimited amount of blood to keep him alive. There's a limited amount of blood that he can get since it's not possible to keep him alive for a long time. So it's also disabling doctors to save other lives that can be saved or do surgeries.
Who should decide if, and when, life-sustaining treatment is stopped? It would be the social worker that is in charge of him because they can't find his family so they're also in charge of the patient's welfare as well.
If Mr. Smith had medical insurance, would that change your responses to the questions above? No, it wouldn't change anything
T.H., Senior, Plano West Senior High School
Yes, the patient should be allowed to die because his quality of life if he was to wake up from his coma is horrible; he is homeless with a drinking problem. Not only is his quality of life bad, but he will die within a couple weeks and keeping him alive means using valuable resources that could be used for other patients. Also, because of his drinking problem he does not qualify for a liver transplant so chances of him surviving are very slim so why not let him die now. If he was to wake up from the coma, he would have brain damage and most likely would spend the rest of his time in the hospital bed waiting for nature to take its course so it would just be better to allow him to die. As much as we would like to say that money does not play a role, it does, so since Mr. Smith is practically a lost case and will die within a couple weeks, the tax payers should put their money towards a patient that has chances of surviving.
Blood transfusions are important in this case because Mr. Smith has already had 10 blood transfusions and will require more. Blood is a limited resource, there is always a shortage, so the fact that Mr. Smith is requiring so much blood is an issue. Doctors have already said that Mr. Smith will die in a couple of weeks so using so much blood for this patient means that someone else who needs the blood and could survive will not have it available. So, because Mr. Smith needs blood transfusions to be kept alive, it is important in the case when considering whether he should be kept alive since a family member is unable to be contacted to take that decision.
Ideally a family member should make that decision but in this case since none are available, Mr. Smith's doctors and social worker should make the decision. His doctor will know medically what is the best option for Mr. Smith and whether or not he will eventually recover if kept on life-support. The social worker should also be part of this decision since his/her job is to keep the patient's best interest in mind because Mr. Smith's doctors might have other aspects in mind such as other patients and resources.
No, even if he had insurance my responses wouldn't change because Mr. Smith's quality of life would still be bad, plus he would have brain damage and having insurance doesn't change the fact that he would still die in a couple weeks. Even with insurance he would still be using up valuable resources that could be used for other patients that have a better chance of survival.
S.S., Senior, Plano West Senior High School
The patient should be allowed to die because it is safe to assume that he does not value his life enough or have others that value his life since he has a heavy drinking problem, is homeless, and has no family. The multiple transfusions give more confirmation on why this patient should be allowed to die because the blood used on him can be used on other patients. The resources and money given to him can be used on other patients who can have a more promising future. This patient will be kept alive only to die at a later time. Without family and will, this patient does not give a good reason on why vast resources should be spent on him when the money, blood, and equipment can be used on other patients. The doctor should go to the closest person the patient had, such as a neighbor and find out if the patient would've wanted to live. Then after that, the "closest" people to the patient and the medical team should come to a consensus on what would be a realistic solution for the patient, all emotions aside.
If Mr. Smith had medical insurance, life support may be an option. But insurance companies usually drop patients like that from insurance, so having insurance won't really do anything.
A.H., Plano West Senior High School
No, no person has the right to make the decision except for this man or some one who is aware of his wishes. Since there is currently no way to know his wishes, it must be assumed that he would want to prolong his life for as long as possible.
They are important because they could save other people's lives. But having been to a blood bank I am aware that they throw away lots of blood everyday due to their being expired. So the multiple blood transfusions will help to sustain him instead of being wasted.
No one can decide when it is stopped without having any knowledge of his wishes.
No, insurance does not make one patient a more viable patient than another, so it should be given no weight.
A.K., Senior, Plano West Senior High School
Yes, the man should be allowed to pass away. The costly treatment will only temporarily fix the condition and the quality of life if the man actually does survive will be very poor.
The blood used to treat this man could be used to help a patient who has a higher probability of surviving after receiving the transfusions.
If Mr. Smith does not have an advanced directive and no family members are ever able to be contacted, the head doctor along with the hospital’s ethics team should make the decision about whether to stop life support.
No, my answers would stay the same.
D.N., Senior, Plano West Senior High School
As difficult as it is to say, my belief is that this patient should be allowed to die. Unfortunately, due to the written circumstances, the patient's body is functioning very minimally because Mr. Smith made some unfortunate decisions during his lifetime. His liver is pretty much failed, he has a strong chance of being brain dead, and he is losing a lot of blood due to the bleeding into the bowel. I believe that this is not even close to a decent quality of life and therefore he should be taken off of the ventilator and allowed to pass away.
The multiple transfusions of blood are important because blood is donated and if somebody chooses to save this patient they will be using a lot of blood that others might need. Blood is needed for all transplants and many operations, and if so much blood is used to transfuse Mr. Smith, other people more qualified for serious care could lose out on a chance to live for the next 50 years.
A team of unbiased individuals should decide when to take away life support if no family members are present. There needs to be a few physicians but also some people who are not part of the medical field and can just make an unbiased opinion.
My responses would not change because, due to the fact that Mr. Smith has an extremely slim chance of surviving past two weeks, most insurance companies would not pay to continue to keep him on life support. Unfortunately, insurance companies would have to put their money where they know that a patient has a decent chance of pulling through.
H.D., Senior Clinical Rotation, Plano West Senior High School
Most specifically and narrowly in this situation, the patient's rapidly deteriorating condition with near certainty of death in the short run leads me to conclude that he should be allowed to die. This situation presented lends itself to this type of answer but cases can and are often more ambiguous in their possible outcome. It is my opinion that as a healthcare provider it is your job to fiercely advocate for your patient until such action begins to impede the care of others with more serious or treatable conditions. The condition of this specific patient is grave at best and healthcare workers may better be involved in the treatment of others.
The transfusions are important because they are scarce resource. Healthcare is not a magical industry in which everything is available in infinite supply and that everything can be done for every patient. Healthcare is at the will of economics; finite amounts of resources, labor shortage and increasing demand all create costs that do not again, magically disappear. Human life then is not priceless, it is precious. Much should be done for a patient but there comes a point where the cost of inputs greatly exceeds the returns in improvement of the patient condition and quality of life. A hospital is intended to treat sick people and cannot practically be involved in providing palliative care for the dying (such as hospice can).
Lacking in anyone who knows him, the fate of the patient’s further treatment should fully be placed in the hands of a bioethics committee, which are already well established.
No insurance is merely payment. Insurance cannot replace the time that healthcare providers spent on a futile case. Everything has a cost and it is in the best interest of the living and ill that these individuals spend their time on them no matter how much money this patient has at his disposal.
S.S., Senior Clinical Rotation, Plano West Senior High School
Since Mr. Smith already has many problems that have accumulated throughout, it is highly unlikely that if/when he is awake or saved that he will have a wonderful quality of life. Since he has so much damage already in his system, it would be unfortunate to keep him alive and allow him to endure more than he has to. In this case, it would be in the best interest of the patient to let him die. Although the decision is tough, the doctor should take care of the patient to the best of his/her ability, and after absolutely nothing can be done to sustain the patient, only then should Mr. Smith be allowed to perish.
Since Mr. Smith has already used 10+ blood transfusions and will need more, albeit knowing that he will expire anyways, it would be an unfortunate decision to try to save this patient’s life when there are other patients with a higher chance of making it through. It would be logical to provide transfusions to other patients who are in need of it, rather than giving it to a patient who has a slim chance of survival. Again, in the best interest of the patient, this decision should only be made once the doctor has done everything he/she can to prolong Mr. Smith’s life.
Since Mr. Smith has no family members to make decisions for him, the next best person in line would be the doctor. It would be his/her decision to continue to keep Mr. Smith alive, or let him go.
Despite having insurance or not, there is no “cost” to a person’s life. Maybe Mr. Smith is taking up a lot of the medical equipment that can be used for others; yet, he is still a human being and deserves equal treatment. Once again, it’s stressed that the doctor should do everything he/she can for the patient and only when there is no more that can be done, Mr. Smith should be taken off life supporting equipment. Regardless of his situation, even if his medical treatment was covered by insurance, it would still be in his best interest to perish because of the quality of his life. Even if it didn’t cost a penny out of anybody else’s money, letting Mr. Smith go is better than letting him suffer and live a helpless, few weeks.
A.K., Plano West Senior High School
Mr. Smith should be allowed to die naturally. There is no need to consume resources in order to prolong his suffering. The doctors should only make sure that he is comfortable until his passing since his condition is not one that promises any chance of recovery.
The blood transfusions are an important factor in this case, because supplies are limited. The patient in this case is using up a significant amount of blood every day even though it is certain he will die in a short period of time.
Usually, such decisions are made by a completely unbiased ethics team including at least one physician. This is so that the decision is based truly on what is best for the patient and their quality of life.
This would not change my answers above, because I believe that this case is not a conflict involving cost to the hospital as an important factor. Also, even if the patient did have medical insurance, it would most likely not cover his treatment since he is known to be terminal.
D.T., Senior Clinical Rotation, Plano West Senior High School
I believe that the patient should be allowed to die for the following reasons. one, he is using up valuable supplies like blood transfusions and tax payers moneys with no assurance of returning. The next reasons that he should be allowed to die is that he is undaunted unrealistic living conditions which do not seem suitable for human life outside of a hospital.
The reason why multiple blood transfusions are vital when analyzing the ethics case is because blood transfusions which are used on this man could be used on other patients. When looking at the patient as an opportunity cost, you find that he is not only a patient who is a large 10 transfusion liability, but he puts other patients and hospital procedures at risk ( for example with no extra blood surgeries can no longer continue).
The decider should be the ethics board that will analyze the situation and given the circumstances they will decide whether the patient has first of all a chance of living and waking up, and secondly a realistic life style after he gets discharged from the hospital.
Even if Mr. Smith did have medical insurance, it would reduce some of the costs that the tax payers have to pay; however the commodities like blood transfusions can not be covered by the insurance and he would still have an unreal life style if he were to awake from his coma.
M.R., Senior Clinical Rotation, Plano West Senior High School
I believe that Mr. Smith should be allowed to die. First of all, he has little to no hope of making a successful recovery, with a predicted couple of weeks to live. The money of the taxpayers is going into his medical care for the entirety of his time in the hospital and many of the resources being used to sustain his life could be used for other patients with higher chances of recovery and survival. Although I do believe that doctors should do everything in their power to keep a patient alive, in this case, due to preexisting conditions – brain damage, liver cirrhosis – and abuse of alcohol which would not be intended to stop, things point to his allowed death.
These blood transfusions are commodities in a hospital setting. As a necessity, the blood should be used in a more hopeful manner, one in which the end result will be positive and will lead to survival and recovery of patients. In his short duration in the hospital, Mr. Smith has already used up so many units of blood, which has not added to his recovery chances. There are many others in the hospital who need the blood more urgently.
The first person who should be able to make the decision would be a family member or relative. But since there is no one present who can vouch for him, I think that a panel of doctors, similar to an ethics board, should discuss the situation, looking at all aspects of the case. The opinion of many needs to be voiced and deliberation must go in to a serious decision of this nature.
If in fact Mr. Smith had medical insurance, some of my answers would change. I think that although he is no longer leaching money out of the taxpayers' pocket to provide support for him, the blood transfusions and hospital equipment and materials used are not as simply replaced as money. All of these items could be needed by others, and although he would have the means to pay for some, or even all, of these aspects of his stay, other could be in need.
C.W., Senior Clinical Rotation, Plano West Senior High School
I believe the patient should be allowed to die. In economics, ideas are measured in terms of marginal benefit and marginal costs. In this case, the marginal cost (blood transfusions & costs of care) are more than the marginal benefits (the patient's life is extended by a couple of weeks). Therefore, it is not beneficial to save the patient. The patient also has a poor prognosis. I feel that resources should not be wasted on a patient that won't live long enough to truly benefit. In triage, patients that have the best chance of survival are treated first. Because of his poor prognosis, I feel that the resources and effort would be better spent on patients with a better outcome. Lastly, I feel like the patient wouldn't want to spend his final weeks as a vegetable. Even if he is kept alive for a few more weeks, his quality of life is extremely poor. I feel that it'd be better for the patient to allow his to pass naturally.
They are an important consideration because the blood transfusions are not curing him. They are simply prolonging the inevitable. The blood could also be used to help other patients. It's important because it supports the idea that providing care for the patient is not beneficial.
I believe that a third party, social worker (whose focus is on the patient and not on the financial costs of treatment) should decide. Someone with the patient's best interest in mind should make the decision. Before a third party makes this call, I believe that every effort should be made to find the patient's next of kin first.
If the patient had medical insurance, it would have a small impact on the decision. Taxpayers no longer have to pay for his treatment, an insurance company will have to instead. Financial costs should not make this decision. He should receive care based on the extent of his injuries/medical issues. The main deciding factor in this case, in my opinion, is the patient's poor prognosis.
E.E., Senior Clinical Rotation, Plano West Senior High School
Yes. He is already suffering enough through him being homeless, an alcoholic, and not having any family. He also is wasting our money.
It is very important because those blood transfusions could be going to someone else who has a better chance of living. It is a waste of valuable resources to treat it to a patient that has no chance of recovery.
Family comes first. If he has no family, then the doctor should decide since he knows the most about the patient.
No. Money is a big factor, but it is not the biggest issue at hand. Insurance or not, he is going to die. So those blood transfusions are still being put to waste.
S.T., Senior Clinical Rotations, Plano West Senior High School
The patient should be allowed to die. Either way, most likely, the patient will die very soon due to his condition, so why waste expensive resources, that could be used for patients that are more in need, and have a better chance of survival. On top of that, he most likely is in pain and he has serious brain damage so he shouldn't suffer any longer and if he does survive, his quality of life won't be good.
Other patients that may be the same blood type as Mr. Smith are losing "good blood" that they could potentially use to get better and continue to live, whereas Mr. Smith, unless by some miraculous miracle, has no chance of survival and will continue to need transfusions until he dies. Also, blood transfusions are expensive, as well as limited based on blood donors and are not worth using on Mr. Smith.
The ethics team along with the Doctor should decide on whether or not the treatment should be stopped or continued. Without an advanced directive or any family, the decision should be made based on the patients health at this point, as well as his current and future quality of life, and unfortunately the cost the hospital/tax payers are spending (this includes Doctors time and effort as well as supplies).
No, even if he has medical insurance it doesn't mean that everything he is receiving is paid for, and all of the equipment is still very expensive, and some harder to get than others, as well as the Doctors time and effort. Again, you also have to take into account the quality of life and whether it is really helping him or making him suffer more.
D.B., Senior Clinical Rotation, Plano West Senior High School
Yes, I believe the patient should be allowed to die because he has a limited time of life as it is and prolonging a vegetative state is not improving his quality of life in any way, it is only prolonging his death. The fact of the matter is that he is costing the hospital time and care that could be devoted to a patient with a better prognosis. This man will not be able to be cured of the disease and furthermore will not qualify for a liver transplant due to history of alcoholism, furthering the point of his inability to recover.
It isn't that multiple transfusions of blood to this patient would be a waste, because he is in need, but it is an unwise use of resources that could be treating a patient that needs the same level of care that maybe has insurance, family present, or even a better outcome.
It is tough to say who should be able to decide for the patient in the event that there is no family present, but there should be ethics board involved as well as the overseeing doctor and a social worker, but the inclusion of the doctor falls into the category of drawing away from the care of other patients.
If Mr. Smith had medical insurance then the situation may unfold a little differently. In that case he may have someone to contact through the insurance company to make decisions for him or even a living will/ advanced directive placed through the insurance.
G.L., Senior Clinical Rotation, Plano West Senior High School
Mr. Smith should be allowed to live. Even, if his quality of life will be bad if he regains consciousness and does not have a family or advance directive, we need to assume that he wants to live as long as possible. However, if no family shows up, then Mr. Smith should be allowed live for a week to see if his condition has improved. If not, then life-support should be discontinued. This way there is a compromise between those want Mr. Smith to be taken off life support and those that want to keep him on it.
The transfusions are considered in this ethics case because that is what is keeping Mr. Smith alive. Also the matter of the cost of the transfusions come in the case; is it wise to use the taxpayer's money to pay for the transfusions when that money could be used for another patient in need?
If they find anyone that is connected with Mr. Smith then they should decide what happens to him. However, if no family shows up, then the ethics team should deliberate and weigh the options of Mr. Smith and take a vote.
My responses would not change even if Mr. Smith had insurance.
S.J., Senior, Plano West Senior High School
The patient should be allowed to die because the patient would die soon anyway. It is also the patient’s fault that he had been drinking alcoholic beverages, which has caused this state. If this event was caused by an outsider, the authorities should pay for the patient to live because the patient did not do anything wrong. However, since the patient drank alcoholic beverages on his own accord, he is responsible.
The multiple transfusion of blood is an important consideration because the patient already had 10 blood transfusions, and will need a constant supply to survive. It also caused the patient to be in a coma, not letting the patient talk to investigators. The world cannot give away thousands of blood transfusion for free to any stranger. The world needs to save its supply in order to supply the people that will pay the money.
The county taxpayers should decide when the life-sustaining treatment is stopped. The county taxpayers are the people who pay for the patient, so they have the right to decide if and when the life-sustaining treatment to stop.
If Mr. Smith had medical insurance, I would change my response to the questions above. Since the county taxpayers do not have to pay for Mr. Smith’s treatment because he has medical insurance, the medical insurance is responsible to maintain Mr. Smith’s life.