Case example

Metropolitan Medical Center (MMC) is a private, not-for-profit 500-bed acute care hospital. MMC clinicians and administrators are wrestling with a serious problem. Over the past year, MMC has admitted eight different patients who presented to the MMC Emergency Department with severely damaged heart valves that have required valve replacement surgery. In each of these patients, the damaged valve was the result of endocarditis, a bacterial infection of the inner surface of the heart, including the heart valves. All of the patients report intravenous (IV) injection of a homemade liquid preparation of Opana® (oxymorphone hydrochloride), a potent narcotic pain medication designed for oral ingestion. All of the patients are from the same nearby town, all are indigent, and none have health insurance. Despite strong warnings from their physicians that continued IV drug use would likely cause reinfection of the implanted heart valves, four of the patients have returned to MMC with recurrence of endocarditis requiring repeat valve replacement.

MMC medical staff members have sharply divided opinions about how to respond to these patients. Several cardiovascular surgeons have argued that these patients should be warned that they will not be offered repeat surgery if they continue IV drug use and present to the hospital a second or third time with damaged heart valves due to endocarditis. Several infectious disease specialists have argued that these patients are suffering from an addictive disease and that they are therefore not responsible for their condition and should receive life-prolonging surgery. A psychiatric consultant reports that these patients meet statutory criteria for involuntary commitment and treatment for their substance abuse, but that no substance abuse treatment facilities are currently willing to accept them for the extended treatment they require.

The president of MMC has charged the chief medical officer (CMO) to develop and implement a consistent approach to caring for these patients. What approach should MMC adopt?

As mentioned in the Preface, the aim of this book is to provide a concise introduction to fundamental concepts, methods, topics, and arguments in health care ethics. Each chapter begins with a case example in which health care professionals, patients, or others confront a specific moral problem or question in a health care setting, and each chapter ends with an analysis of that case.