The Legal Framework of Medical Ethics in the United States

Abstract

The legal framework of medical ethics in the United States is important to an understanding of the application of medical ethical principles in everyday practice. This chapter reviews the legal background of issues including decision-making by competent patients and incompetent patients, the ethics of reproductive health, issues around hastening the end of life, the ethics of psychiatric treatment, and confidentiality. Important legal cases discussed include, among others, Schloendorff v. Society of New York Hospital, In re Quinlan, Superintendent of Belchertown State School and Another v. Joseph Saikewicz, Roe v. Wade, and Vitaly Tarasoff et al. v. The Regents of the University of California. Other important legal principles discussed include those raised in the Baby Doe Rules, the Oregon Death with Dignity Act, and the Health Insurance Portability and Accountability Act of 1996. The chapter includes an explanation of sources of law and sets the stage for a more detailed exploration of ethical issues in the question and answer section of the book.

Review and Reflect: Ask Yourself and Talk with Colleagues

For each of the following scenarios, ask yourself and talk with colleagues about the following questions: What ethical tensions exist in this situation? What legal obligations, if any, are present? What are the clinician’s next steps?

Scenario 1

A family practice physician provides prenatal care for a woman until her 36th week of pregnancy, at which time she transfers to the obstetrician who will facilitate her delivery. The woman returns to the family physician’s office 2 weeks later, stating that she has not felt the baby move for 2 days. She told the obstetrician her concerns the day before, and he assured her once he auscultated fetal heart tones with the Doppler. The woman still felt worried, however. Upon further investigation, the family physician notes that she has suffered an intrauterine fetal demise. The physician is troubled, because the standard practice is to obtain a nonstress test in a patient with a 38-week gestation who complains of decreased fetal movement, and wonders why the obstetrician did not do this test. The test may have indicated fetal distress, at which time delivery or a Cesarean section could have been performed.

Scenario 2

A psychiatrist member of a medical school’s committee on rank and tenure is reviewing materials from applicants for promotion in various departments of the school in advance of a committee meeting. He reads the promotion packet for a seemingly well-qualified assistant professor of dermatology who is applying for promotion to the rank of associate professor. The psychiatrist has treated the dermatologist for cannabis abuse and depression but believes that he is doing well currently.

Scenario 3

The sister-in-law of a physician’s friend has severe fibromyalgia, which was previously treated very successfully with a novel medication. Unfortunately, she has lost her job, no longer has insurance, and cannot afford the medication. The physician’s friend has a job with great benefits and asks the physician if he would prescribe the medication in the friend’s name so that he might obtain it under his prescription plan and then give it to his wife.

Scenario 4

A primary care provider treats a 26-year-old man who uses crystal methamphetamine on the weekends and has unprotected sexual intercourse. He is planning a trip to a gay resort and has already obtained methamphetamine for his stay there. The physician worries about how to provide optimal care to this patient.

Scenario 5

A nursing home sends an elderly, wheelchair-bound man who has had a stroke to the hospital because he continually calls the police, saying that Jesus has told him the nursing staff are abusing him. In the hospital, the patient shares a room with a high-functioning man recovering from an orthopedic injury. The following day the elderly patient tells the attending physician that the hospital nursing staff ignore his requests for help to use the bathroom and so he has soiled himself. His roommate confirms his story and adds that he has been helping the patient use the bathroom as a result. The roommate, who is being discharged, is concerned for the elderly man’s safety.

Scenario 6

A very helpful colleague asks a physician to write a letter supporting his application for clinical privileges that the physician feels are beyond the scope of his training.

Scenario 7

A 45-year-old diabetic man obtains medical care in a multidisciplinary clinic. He sees one doctor for primary care issues and another for psychiatric issues. He has been living with diabetes for 20 years and has struggled with diabetic neuropathy in the past. As a result, he takes high doses of pain medications, prescribed by the primary care physician. He is on permanent disability but manages to live a more-than-humble lifestyle. He has developed a trusting relationship with the psychiatrist and finally admits that he sells his pain medications in order to pay his rent and car loan. He takes just enough of the prescribed pain medications to test positive on monthly toxicology screens that the primary care physician has instituted.

Scenario 8

A health promotion nurse and family medicine physician are conducting a smoking cessation class. The attendees begin to talk about their increased irritability and that they find themselves becoming easily frustrated. A single mother reports that her major stressor is her children, especially her 9-year-old son. She notes that he is upsetting her frequently with his behavior and that she is having urges to either smoke or choke the child to death. The urges have become so strong that she has twice had dreams about following through, and on one occasion she put her hands on his neck but did not squeeze.

Scenario 9

A physician treats a man and his wife separately in a general medicine clinic. The man discloses that he is having an affair with a same-sex partner and asks to be tested for sexually transmitted diseases. He reports that he “dabbles” in drug use, specifically methamphetamine, which his male partner supplies. Because of the high rate of unprotected sex and HIV among men who have sex with men using methamphetamine, the physician suspects that the man is at risk for HIV, hepatitis B, syphilis, and other sexually transmitted diseases. The physician believes that the man’s wife is also at risk, because the couple continues to be sexually active and has not used condoms in many years. At the wife’s next appointment, she asks the physician why her husband suddenly has decided to undergo “a bunch of medical tests” and asks if she should be aware of anything regarding her husband.

Acknowledgments

The following authors contributed to the scenarios in this chapter: Laura Weiss Roberts, M.D., M.A., Daryn Reicherter, M.D., Jodi K. Casados, M.D., Joseph B. Layde, M.D., J.D., Celeste Lopez, M.D., Peter Marcus, M.S., M.A., Lawrence M. McGlynn, M.D., Richard Shaw, M.D., Christopher Warner, M.D., LTC, Mark Wright, M.D.