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Monash Bioethics Review Vol. 27 Nos. 1-2

January-April 2008

.ARTICLE
Experiential ethics education: one

successful model of ethics education

.for undergraduate nursing students in

the United States
DAVID PERLMAl'l, PHD

Senior Lecturer
School of Nursing
University of Pennsylvania

ABSTRACT

Lachman, Grace and Gaulord have argued that for bioethics

education for undergraduate nursing students, a preferred
combination of instruction involves a clinically-based nurse with
ethics training and a philosophically-based ethicist with clinical
training. At the University of Pennsylvania School of Nursing,
undergraduate nursing ethics instruction takes this form. The course
director is a philosopher with extensive clinical experience in ethics.
The course utilises four distinct forms of nursing clinical inputs to
educate undergraduate nursing students using a unique
combination of didactic and experiential leaming exercises to
simulate real ethics cases. This paper describes how the course was
developed and refined over the past several years and suggests
several ideas for improvements in nursing ethics education at an
undergraduate level.
.

Introduction
Ethics education in the health professions frequently involves the
use of case studies to elucidate key ethical principles in action and
application. Traditional presentation and discussion of cases allows
retrospective consideration of ethical decision making. The. teaching
methods in the course presented in this paper take a different
approach to ethics cases and learning. Using a form of experiential
learning, called simulation, borrowed from the instructor's experience
in mediation training.P cases are designed for live role-play during class
and involve five distinct activities: 1) two or more students play the role
of ethics consultants;' 2) a number of students play the roles of
patients, surrogates, family members, and clinicians who are either in
ethical conflict or uncertainty; 3) two or more evaluators watch the
evolving role-play and note process;' substance, and interpersonal
qualities for later comment, assessment, and group discussion; 4) the
remaining students in the audience also participate in the evaluation
e Copyright 2008 David Perlman

Monash Bioethics Review Vol. 27 Nos. 1-2

10

January-April 2008

Monash Bioethics RI

and grasp how the ethical principles and substance of a particular

topic work; and 5) instructor-led post hoc evaluation of the case in light
of ethical substance from the readings and ethics literature.
Table One and Table Two, respectively, list the issues covered and
provide the cases used during the semester.

On occs
course to adap

Course evo
The COD
The first is bs
consultation I
consultations
medical cent.
dissertation 1
mediation.v Tl
facilitator for l
in 1998. It VI
introduced to
director, usii
experiences, c
format was f
taking a philo
The course v
School of Nun
remain largely

Ethical framework
The instructor has used the second and third editions of the
textbook Introduction to Clinical Ethics3 since the course's initial
inception and evolution. The course currently uses the third edition of
this textbook, as well as a companion textbook produced exclusively for
nurses." The ethical framework articulated in Introduction to Clinical
Ethics is called clinical pragmatism, and has its philosophical roots in
the pragmatic philosophy of John Dewey and William James. The
instructor supplements the clinical pragmatism framework with the
work of another pragmatist, Henry David Aiken, who argues for four
distinct levels of moral discourse that integrate sophisticated use of
moral reasoning and human feeling. 5
The instructor believes the :clinical pragmatism framework is
optimal for education of health professionals, as the framework utilises
a very familiar method for organising clinical thinking - in terms of
(moral) assessment, (moral) diagnosis, consideration of (moral) options,
and evaluation. Decision makers are required to assess a variety of
ethically relevant contextual factors and, using a method akin to
differential diagnosis, make initial hypotheses of the ethical issues
present and how to resolve them.:

Current

Course description
The instructor is not a licensed nurse or other health
professional. He does have extensive formal clinical experience
(doctoral-level practicum for one full semester at a large academic
medical center and fellowship training for one full year at another large
academic medical center). Given these facts, it was important to
supplement the course with several clinical nursing inputs. Thus far,
the course has utilised four distinct types of clinical nursing inputs:
A permanent and tenure-track member of the standing faculty
and nurse ethicist provides oversight, evaluation and mentorship to the
course director on the development and evolution of the course. Both meet
frequently to discuss the course, its evolution and address any issues.
A teaching assistant [usually a doctoral student with an undergraduate
or advanced practice nursing background) is paired with the course
director to provide in-class clinical information, as needed, and
mentors mock ethics consultants outside of class in a group discussion
format to provide clinical information for the live role-play simulations.
The course is a requirement for all undergraduate nursing students.
A 'real' nurse provides a guest lecture at the end of the semester
to answer questions about ethical and professionalism issues
encountered in practice.
@

Copyright2008 David PaMman

COl

The firs
students with
series of live I
One and the :
has lectures l
context of' th.
pragmatism f
emotion, affec
there is also a
ethics consult:
process and s
for evaluating
and receive fee
. Class is
week; this alle
an evaluation 0:
two hours for tl

Why ethics
Ethics ec
course focuses
that developn
training in a VI
in ethical dis,
,.

_'~L

Copyright2008 David Perlrna

y-April 2008

Monash Bioethics Review Vol. 27 Nos. 1-2

11

January-April 2008

a particular
case in light

On occasion, visiting scholars observe and/or participate in the

course to adapt ethics teaching and learning techniques to other settings.

covered and

Course evolution

itions of the
irse's initial
ird edition of
xclusively for
In to Clinical
tical roots in
James. The
irk with the
~es for four
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work utilises
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,ther health
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g inputs:
iding faculty
orship to the
se. Both meet
y issues.
ndergraduate
the course
reeded, and
p discussion
simulations.
idents.
the semester
lism issues

The course evolved into its current form through several steps.
The first is based on the course director's .clinical experience in ethics
consultation methodology, including training by doing numerous ethics
consultations with experienced ethics consultants at a major academic
medical center as part of his fellowship experience, followed by
dissertation work on ethics consultation methodologies, including
mediation.s The course director also had the opportunity to be a group
facilitator for a required ethics course for second-year medical students
in 1998. It was at this point in time that the course director was
introduced to the textbook, Introduction to Clinical Ethics. The course
director, using these teaching and ethics consultation training
experiences, created several cases to be portrayed live during class. The
format was first introduced to undergraduate liberal arts students
taking a philosophy course in biomedical ethics in the spring of 1999.
The course was also developed .for the University of Pennsylvania
School of Nursing in the autumnof 2005 and the cases and techniques
remain largely the same to this date.

Current course structure

The first part of the course is intended to provide nursing
students with the preparation necessary to successfully conduct a
series of live role-play simulations on the ethical issues listed in Table
One and the specific cases in Table Two. This first part of the course
has lectures and discussions focused on: 1) ethical theories:" 2) the
context of the health care environment; 3) the use of the clinical
pragmatism framework.s and 4) how to integrate reason, theory,
emotion, affect, and interpersonal dynamics in ethical decision making;
there is also a review of videos? or live role-play of a 'mock' or practice
ethics consultation.t? followed by discussion of key points regarding the
process and substance of ethics consultations. In addition, to prepare
for evaluating the simulations, a class session is devoted to how to give
and receive feedback.
. Class is usually three hours long and is conducted once per
week; this allows time for a quiz at the beginning of class, followed by
an evaluation of the previous week's case, which usually leaves approximately
two hours for the live role-play of simulated ethics consultation cases.

Why ethics consultations

Ethics educators reading this paper may wonder why much of the
course focuses on ethics consultations, especially since it is well known
that development of consultation competencies requires advanced
training in a variety of process and interpersonal skills, as well as skills
in ethical discernment, judgment and critical thinking.t ' There are
e Copyright 2008 David Perlman

Monash Bioethics Review Vol. 27 Nos. 1-2

12

January-April 2008

several reasons for this focus. First, John Fletcher, et al. indicate that
health professionals will become the main human resources for ethics
consultation and bedside ethical decision making so it makes sense to
simulate ethics consultations in order to acclimatise students to their
function. Moreover, simulation of ethics consultations may spark
interest in student nurses to serve on ethics committees and
consultation teams when' they begin clinical practice. Second,
simulation of ethics consultations provides a built-in structure to
showcase and safeguard the critical thinking skills necessary for
ethical decision making. Third, simulation of ethics consultations
demonstrates why and how clinical ethics decision making should not
be divorced from, but rather integrated into, clinical decision making.
Such modeling allows students to learn how to anticipate potential
ethical issues and develop the skills to be pro-active in addressing
them. Fourth, presentation of cases seems to be the norm in the
education of health professionals. Fifth, the interactive element in
presenting such ethics consultation cases live, in front of one's peers, .
makes the learning process more enjoyable and less tedious than pure
lecturing and other one-way forms of knowledge delivery. Sixth,
simulation allows nursing students (who are for the most part in their
second, pre-clinical year) the opportunity to understand how complex
the clinical environment can be and prepares them for working in
concert with other health professionals to resolve complicated issues.

Teaching philosophy and learning styles

The specific course requirements are a deliberate attempt to
target four different learning styles: kinaesthetic, reading/writing,
aural, and visual.P Some exercises capture one learning style while
others may capture more than one. Visual learners prefer and retain
information best when' it is presented in the form of charts, graphs,
process flow diagrams, and other visual aids. Aural learners prefer to
hear information, such as lectures, podcasts and speaking with others.
It should come as no surprise that many in academia prefer the written
word (whether in a book, on a projected screen or another medium).
Kinaesthetic learners prefer to rely on experience, examples, simulation
and other forms of practical engagement.
The course uses brief, five-question quizzes, given at the
beginning of class, to test comprehension and ensure adequate out-of
class preparation of the assigned reading material. A recent evolution of
the course features a replacement option for the quizzes: students may
prepare their own outlines of the reading material in lieu of quizzes, or
complete and hand in the information on 'redacted' PowerPoint slides
posted onto the course's online learning management system. This
learning activity focuses on reading/writing.
The live role-play simulations of ethics consultations target the
kinaesthetic and aural learning styles as much as a classroom
environment can. Skills such as thinking on one's feet, argumentation,
and mediation of communication are targeted. There is much out-of
e Copyright

2008 David Perlman

Monash Bioethics Revie

class preparatio
simulations a Sl
weeks before the
playing their chr
The course dire
proceed smoothJ
all have the sa
fullest extent pc
Some actors als
asked to play t
information abc
students who wi
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During th.
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Several select sti
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prepares aggreg
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and the rest of .
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The week j
structured asses
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reached during'
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This activityals
course director :
the course in
reinforcement of
The compr
focuses on upta
skills. One-third
. to two sentence
questions and I
essays and agair.
of the essays. Th
@ Copyright 20DB David Perlman

nary-April 2008

1. indicate that
irces for ethics
nakes sense to
udents to their
.1 S may spark
mmittees and
ctice. Second,
1 structure to
necessary for
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mt evolution of
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: system. This
.ons target the
, a classroom
rrgumentation,
~ much out-of

Monash Bioethics Review Vol. 27 Nos. 1-2

13

January-April 2008

class preparation that students and faculty engage in to make these

simulations a success. First, actors are provided their 'motivations" two
weeks before the simulation and are asked to write out how they will be
playing their character in light of the provided motivations and the case.
The course director meets with the actors so that the simulation will
proceed smoothly, without continuity flaws,' by ensuring that the actors
all have the same basic demographic and clinical information to the
fullest extent possible, without disclosing individual actor motivations.
Some actors also conduct research on their roles, especially if they are
asked to play the part of a clinician who must have certain clinical
. information about the patient.' The teaching assistant meets with
. students who will be playing the ethics consultants to ensure they have
the clinical nursing information necessary for the case and to assist the
consultants in preparing their strategy for the consultation.
During the role-play simulations, students in the audience are
observing the process and substance of the evolving ethics consultation.
Several select students are provided with a detailed evaluation sheet that
matches the clinical pragmatism framework utilised to structure the
consultation. These evaluators complete their sheets and provide verbal
feedback to the consultants and actors immediately following the
consultation (or if time runs short, during the next class period). A
recent evolution of the evaluator role involves the evaluators typing up
their comments and sending them to the teaching assistant, who
prepares aggregate and anonymous comments for the actors and
consultants to gauge their performance from their peers. As
mentioned above, the course director provides a lecture and coaching
session on how to give and receive feedback before the simulations
are scheduled. The evaluators, actors, and consultants in particular,
and the rest of the audience in general, use all of the learning styles
in these simulations.
The week following the simulation, the course director provides a
structured assessment and evaluation of the simulation and provides
the bioethical substance behind the options generated and decisions
reached during the simulation. This activity reinforces the proper use
of the clinical pragmatism framework as well as the substantive
knowledge that the students will need when they take the final exam
and encounter similar issues in their own clinical practice years later.
This activity also utilises all four learning styles. In the future, the
course director hopes to include ethics debriefings with graduates of
the course in their later clinical years to provide additional
reinforcement of the core bioethical concepts in the course.
The comprehensive final exam, given at the end of the semester,
focuses on uptake of key bioethical knowledge and critical thinking
skills. One-third of the exam involves very short answers (usually one
to two sentences) and students have the choice of about fifteen
questions and must complete ten. The other two-thirds are short
essays and again, students have a choice of ten and' must complete five
of the essays. This activity targets the reading/writing learning style.
e Copyright 2008 David Perlman

Monash Bioethics Review Vol. 27 Nos. 1-2

14

January-April 2008

In general, the class is highly interactive, even during the lectures

that form the introduction to the course material and provide
structure, substance and process for the simulations. Class
discussions target all four learning styles as well because the course
director makes a concerted effort to use additional, real-life examples
during lectures and discussions.

Evaluation
In addition to the evaluation of the simulations mentioned above,
there are four other forms of evaluation in the course. The students are
asked to evaluate the course at the end of the semester, using both
closed-ended and open-ended questions. The course director leaves the
room and the teaching assistant collects all evaluations and hand
delivers them to the administration. To preserve the confidentiality and
candour of responses, only after grades are recorded does the course
director have access to the evaluations.
If visiting scholars are present during the course, a separate
evaluation, prepared by the visiting scholar and approved by the course
director, may also be completed by students. The visiting scholars are
usually interested in the educational content and achievement of
objectives for the purposes of replicatingor using the teaching methods
in other settings.
The course director also solicits informal feedback from the
teaching assistant about their teaching. performance, problems
encountered in the meetings outside of class with the mock ethics
consultants, and other feedback. The feedback has been uniformly
positive and the professional development of the teaching assistants
has been enhanced as a result of their unique participation in the
course. Unsolicited, informal feedback from fellow nursing faculty has
also been uniformly positive.

Future directions

Monash Bioethics Re'

consultants at
from evaluato
possible to
PowerPoint sli
variety of pers
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While the course has undergone some 'tweaking' over its ten-year
evolution, the course director has a variety of ideas for future directions
that could further improve undergraduate nursing ethics education.
While the actors in the mock ethics consultations report in their
reflection papers that it is useful to be put in the shoes of patients,
families and clinicians, the course director believes that the use of
standardised patients (SPs) - professional actors who know how to play
the part of patients and are utilised in a variety of health education
settings - might result in better educational outcomes, as students can
concentrate on using the clinical pragmatism framework as ethics
consultants. This is especially the case if the course enrolment remains
at approximately sixty students per semester. This number of students
in one section of the course means that currently some students will
not get to play the role of ethics consultants.
An idea for future courses to increase the level of feedback on
interpersonal and process issues is to videotape the sessions and allow

It would
interactive, ex
Appendix One
ethics teachin]
liberally use
acknowledgem
copyrighted ai
intellectual pre
information s
author directlj
While La
in nursing she
at the universi
would be inte:

e Copyright 2008 David Perlman

@ Copyright 2008 David Perlma

Commental

iary-April 2008

J.g the lectures

and provide
ations. Class
ise the course
l-life examples

ntioned above,
e students are
er, using both
ctor leaves the
lOS and hand
identiality and
ies the course
ie, a separate
. by the course
g scholars are
:::hievement of
ching methods

ack from the

ce, problems
~ mock ethics
een uniformly
ing assistants
ipation in. the
ng faculty has

er its ten-year
:ure directions
ics education.
eport in their
$
of patients,
at the use of
IW how to play
ilth education
i students can
ark as ethics
rnent remains
er of students
students will
f feedback on
ons and allow

Monash Bioethics Review Vol. 27 Nos. 1-2

15

January-April 2008

consultants and actors to visually assess sessions and match feedback

from evaluators with clips from the simulation. Moreover, it is now
possible to podcast the lecture material, in conjunction with
PowerPoint slides, for student use (either on their computers or on a
variety of personal media players) and therefore maximise class time for
the simulations. This innovation represents yet another future
direction for the course.
The University of Pennsylvania School of Nursing will be
purchasing educational technology that will allow instant polling of
students using wireless handsets tied to specific cues during lectures
using PowerPoint. The course director has established a start-up
educational consulting company (www.e-four.org) to make use of
several of these ideas for future innovations in the course. It would be
possible to combine several of the ideas for the future expressed above
(videotaping and the use of SPs) to stage several scenes and edit them
into PowerPoint and use the polling technology so that students can, as
a group, make certain choices at specific. decision points to chart the
course of the consultation. Knowledge to help the students make the
proper choices can be presented before or immediately after such
choices have been made, thus efficiently combining the didactic part of
the simulations with the experiential component.
One idea for testing this new format would be to evaluate its
effectiveness for the nursing (and other health professional) bioethics
learning environments using a variety of techniques. The easiest is to
compare student evaluations from courses utilising this new format to
those done previously using the more traditional, live role-play
simulations. An ideal test would be a randomised, controlled trial of the
formats. Students, who are required to take the course, would be
randomly selected to participate in one of two sections of the course:
. the traditional, live role-play simulation format; and the pre-recorded,
standardised patient simulation, informed choice format using the
polling technology for navigating one's way through each simulated case.t-'

Commentary
It would be interesting to replicate the course (or at least the
interactive, experiential simulations) in other settings. In this spirit,
Appendix One has the Spring 2008 Syllabus, and others engaged in
ethics teaching, who wish to develop similar courses are encouraged to
liberally use the syllabus materials with appropriate citation and
acknowledgement. Use of the e-four.org educational format is
copyrighted and may be pending patent, so its use is governed by
intellectual property laws. Persons interested in receiving more detailed
information about this educational format should contact the
author directly.
While Lachman, Grace and Gaylord believe that ethics teaching
in nursing should not be 'outsourced'to other departments or schools
at the university (such as philosophy departments or ethics centers), it
would be interesting if a course of the type described in this paper
Copyright 2008 David Perlman

Monash Bioethics Review Vol. 27 Nos. 1-2

16

January-April 2008

could have future nurses and future physicians in the same class.
Since these two groups will need to collaborate in a variety of ways
in their professional careers, modeling. such collaboration during
simulated ethics cases may help to establish the sort of professional
relationship that is necessary for these two separately educated groups
to work together.
Acknowledgements
The author wishes to acknowledge the following individuals for their contributions
to the course:
1. Teaching assistants: Dr Sunhee Park (2005-2007), MinKyoung Song (2007), and
Amy Witkoski (2008).
2. University of Pennsylvania School of Nursing faculty: Dr Terri Weaver, for
allowing the course director a great deal of academic freedom in creating and
teaching the course and Dr Connie Ulrich for oversight, evaluation and mentorship.
3. International health visiting scholar, YukaKawakami, (2007-2008).
4. Kristine Biggie, SS, MSN, RN, CCRN for providing the 'real' nurse guest lectures
(2005-2008).

Monash Bioethics Revi

Table One: i:
nurses court
1. Privacy
2. Comrm
3. Deterrn
4.Informt
5. Treatm
6. Death ~
7. Forgoin
8. Paediat
9. Reprod:

Table Two: c
Notes: Th
such that Case
the cases, the I
patient confider
real-life ethics c

Case One: pi
'Love letter, to
As the etl
centers, you re
MSN, MPH, a
Department. H
retarded thirty-l
been recklessly
was tested for
Richardson fron
through a blood
has been living
wants to warn
home about Jan
partners to su~
promiscuous ra
will be forced to
asking the assis
course of action
The ethics
decided to fad
Nottingham's le
James' social we
of Nellie Reardo:
has called the
e Copyright 2008 David Perlrnan

~ Copyright 2008 David Perlman

iary-April 2008

esame class.
ariety of ways
rration during
of professional
.ucated groups

their contributions
g Song (2007), and
Terri Weaver, for
rrn in creating and

and mentorship.
2008).
urse guest lectures

Monash Bioethics Review Vol. 27 Nos. 1-2

17

January-April 2008

Table One: issues covered in undergraduate ethics for

nurses course
1.
2.
3.
4.
5.
6.
7.
8.
9.

Privacy and confidentiality

Communication, truth telling and disclosure
Determining patients' capacity
Informed consent
Treatment refusals by capacitated patients
Death and dying
Forgoing life-sustaining treatments in patients lacking capacity
Paediatrics
Reproductive issues

Table Two: cases used

. Notes: The cases correspond to the ethical issues in Table One,
such that Case One is about Privacy and Confidentiality, etc. In all of
the cases, the names and features used have been changed to protect
patient confidentiality, as some of the cases are based on features from
real-life ethics consultations.

Case One: privacy and confidentiality

'Love letter to an ethics committee'
As the ethics committee for one of the State's flagship medical
centers, you receive a strange letter from Danielle Richardson, RN,
MSN, MPH, a public health nurse in the Gotham County Health
Department. Her letter explains that James Nottingham, a mildly
retarded thirty-four year-old man who lives in a rural group home, has
been recklessly infecting women in Gotham County with HIV. James
was tested for HN one year ago, after an anonymous tip to Nurse
Richardson from a concerned citizen. He was infected many years ago
through a blood transfusion when he was involved in a car accident. He
has been living in the group home for four years. Nurse Richardson
wants to warn all the women, and their guardians, in James' group
home about James' HIV status as well as contact all known past sexual
partners to suggest they seek HIV testing. If this does not stem James'
promiscuous rampage, Nurse Richardson states in her letter that she
will be forced to seek institutionalisation and/or jail for James. She is
asking the assistance of the ethics committee to determine whether the
course of action she outlines is ethically and legally feasible.
The ethics committee, instead of writing a letter in response, has
decided to facilitate a meeting between Nurse Richardson, James
Nottingham's legal guardian and father, William Nottingham, and
James' social worker, Jessica Duvane. Mrs Angela Reardon, the mother
of Nellie Reardon, one of James' past girlfriends from his group home,
has called the ethics committee several times and vehemently
@ Copyright 2008 David Perlman

Monash Bioethics Review Vol. 27 Nos. 1-2

18

January-April 2008

. demanded to attend the meeting. The ethics committee has selected

several of its members to facilitate this meeting.

Case Two: communication, truth telling and disclosure

'The matching game'

As chair of the ethics committee, one of the transplant clinical

nurse specialists (CNS) calls you with a problem. He has been caring
for a six-year-old little girl with kidney failure. The girl is receiving three
dialysis treatments every week to clean her blood. The girl's type
matching tests revealed that she would be a difficult match. Last week,
her situation became somewhat more dire, prompting the surgical team
to request that the girl's family members be type-matched so that one
of them might donate one of their kidneys. The girl's two brothers were
too young to serve as donors, and her mother did not match. The girl's
father, however, did match. In fact, tests revealed that the father had
anatomically favourable circulation for transplantation.
The transplant CNS met with the father alone after the test and
gave him the results. The CNS told the father that his daughter's
prognosis after the surgery is uncertain, given her extensive kidney
disease. After some thought, the girl's father said that he did not want
to donate a kidney to his daughter. He admitted that he did not have
the courage and that, particularly in view of the uncertain prognosis,
he would rather not donate. The father asked the CNS to tell everyone
else in the family that he was not a match for his daughter. He was
afraid that if they know the truth, they would accuse him of allowing
his daughter to die. He felt that this would 'wreck the family'. The CNS
is asking you for guidance in this matter. You decide to convene an
ethics committee meeting to discuss the options in the case.
Participants: ethics committee members; Robert Sharmer, BSN,
MSW, Transplant Clinical Nurse Specialist; Earl Robinson, the little
girl's father; Mary Robinson, the little girl's mother.
(Note: One of the 'secret motivations' in this case is that the
father has contracted a sexually transmitted disease due to
unprotected sex outside of his marriage and wishes the nurse to lie
both to protect his marriage and his daughter from contracting the
disease should he donate.)

Case Three: determining patients' capacity

'Screw supermanl'

It's 4 am when your pager beeps loudly and interrupts your

slumber. You reach for the phone and return the page. It's one of the
psychiatry night nurses Delia Rosen, RN. She explains that she was
asked to evaluate a patient who had recently been transferred to the
rehabilitation unit. The patient, a Mr Harrington, was involved in car
crash a few weeks ago. He wasn't wearing his seatbelt and he was
catapulted out of the car, landing thirty feet away on his head and
back. Tests revealed a severed spinal cord injury near the base of the
neck, resulting in permanent quadriplegia. Mr Harrington is fully aware
e Copyright 2008 DavidPeriman

Monash Bioethics Review Vc

of the seriousness
probably never regs
While in the intern
conscious state (nc
unit after regaining
Delia explains
Mr Harrington for I
times, and talking'
mentioned how Ch
after his injury. 'SCl
psychiatric team d
making several rei
psychiatrists increa
its maximum level l
but doesn't a pal
treatment?' Delia a
be best handled in
meet and discuss tl

Case Four: info

'Doctors give orde
You receive a
hospital across the
she and her nurses
a patient, Seamu:
Barbara Mendel, R
against his will by .
surgery. He has a
head. The Ear, N08
and determined thr
surgery, but when
Center for surgery
decided not to fore
Morrison, the resic
was very angry. H
sedation for the pI
meeting to talk. abt
good conscience se
against his wishes.
seems 'slow', but t
action the doctors
investigate the cas.

Case Five: trea

'Jamar Jackson'
Jamar, a fift
when an eightee
Boulevard. Jamar
IC) Copyright

2008 David Perlman

January-April 2008

ittee has selected

I!,;
;

lld disclosure
ransplant clinical
~ has been caring
l is receiving three
. The girl's type
match. Last week,
the surgical team
tched so that one
two brothers were
: match. The girl's
rat the father had
:1.

after the test and

at his daughter's
extensive kidney
.t he did not want
t he did not have
certain prognosis,
rs to tell everyone
:laughter. He was
,e him of allowing
: family'. The CNS
de to convene an
~ case.
rt Sharmer, BSN,
ibinson, the little
case is that the
disease due to
i the nurse to lie
a contracting the

I interrupts your
ge. It's one of the
ins that she was
ransferred to the
lS involved in car
tbelt and he was
on his head and
rr the base of the
rton is fully aware

,j

Monash Bioethics Review Vol. 27 Nos. 1-2

19

January-April 2008

of the seriousness of his injuries and realises that he will most

probably never regain physical sensation or function below his neck.
While in the intensive care unit, Mr Harrington was in a minimally
conscious state (not quite a coma). He was transferred to the rehab
unit after regaining consciousness.
Delia explains that her team was consulted last week to evaluate
Mr Harrington for depression. They found him to have a flat affect at
times, and talking to him only angers him. One time the psychiatrists
mentioned how Christopher Reeve had survived and even flourished
after his injury. 'Screw Superman', was all Mr Harrington had said. The
psychiatric team decided to prescribe him an anti-depressant. After
making several requests to have his' feeding tube withdrawn, the
psychiatrists increased the dosage of Mr Harrington's antidepressant to
its maximum level and added an antipsychotic agent. 'I know it's 4 am,
but doesn't a patient have a right to refuse life-saving medical
treatment?' Delia asks you. You suggest that perhaps this case would
be best handled in the morning, when all of the people involved can
meet and discuss the issue.

Case Four: informed consent

'Doctors give orders and nurses follow them'

You receive a phone call from the head nurse at the community
hospital across the street from the medical centre. She tells you that
she and her nurses have just met and' decided that they will not sedate
a patient, Seamus Sullivan, who' is refusing surgery. The nurse,
Barbara Mendel, RN, describes the case. Mr Sullivan was transported
against his will by the sheriff of a rural county to the medical centre for
surgery. He has a very large and very messy mass on the side of his
head. The Ear, Nose, and Throat (ENT) surgeons evaluated Mr Sullivan
and determined that they could remove the growth. They scheduled the
surgery, but when transport came to bring Mr Sullivan over to Medical
Center for surgery, he refused to get on the stretcher. The nurses
decided not to force him to go. When ENT heard what happened, Dr
Morrison, the resident in charge of Mr Sullivan's care, came over and
was very angry. He yelled at one of the nurses that he would order
sedation for the patient if he refused again. The nurses called a staff
meeting to talk about the issue. They all agreed that they could not in
good conscience sedate a patient just so he could be taken to surgery
against h-is wishes. The surgery is in his best interests and Mr Sullivan
seems 'slow', but the nurses have a moral problem with the course of
action the doctors are proposing. You agree to talk to the surgeons and
investigate the case.

Case Five: treatment refusals by capacitated patients

'Jamar Jackson'
'
Jamar, a fifteen year old black boy, was involved in an accident
when an eighteen-wheeler sideswiped his bicycle on Roosevelt
Boulevard. Jamar has a serious closed head wound. The swelling
@

Copyrighl20OSDavid Perlman

Monash Bioethics Review Vol. 27 Nos. 1-2

20

January-April 2008

inside his skull is killing his brain. He has a tremendous wound on his
back. His back is a huge flap of skin and tissue that reveals ribs. He is
receiving powerful antibiotics to stave off infection and extensive wound
care - scrubbing and cleansing the wound to keep it clean. Neurology
has evaluated Jamar and determined that he probably will never regain
consciousness and his scans reveal diffuse and permanent brain
damage. The surgeons have met and determined that, based on
Jamar's grim prognosis, surgery to close his wound is not indicated.
They want to stop the antibiotics as well. Jamar will surely die. The
surgeons, knowing the general distrust some black families feel
towards the medical system, feel that Jamar's family might perceive
their wish to withdraw and withhold treatment as an instance of
discrimination. They have asked for the involvement of the ethics
consultants to facilitate the meeting where they will disclose Jamar's
condition and inform his family of their desire to withdraw and
withhold treatment. The family knows Jamar is in a serious condition,
but not that the surgeons are refusing to operate on his back and want
to withdraw the antibiotics. (Note to ethics committee members: this
must be a group meeting at some point, although you may choose to
meet with the doctors first just to make sure you have all the facts and
to prepare the doctors for what you will do. Your job is to help the
family understand the doctors' wishes and help to generate options
that will satisfy the interests of all parties.)
Parts: Ester Jackson, Jamar's mother; Dr Richard Gunderson, chief
of paediatric surgery; Delmar Morris, Jamar's cousin; ethics consultants.

Case Six: death and dying

'I won't kill himl'
Herbert Solomon was diagnosed with end-stage colon cancer ten
months ago. A veteran of Vietnam, Herb sought surgery and
chemotherapy treatment. at the Veteran's Hospital. The surgery
successfully removed the primary tumour in the colon, but the
surgeons discovered advanced metastases to the liver. Herb has been
taking increasing amounts of oral morphine for pain control - in .a
sense self-medicating, since the VA pharmacy dispensed the morphine
elixir in a 250 cc container. Despite his morphine intake, Herb is still
not fully relieved of his pain. Two days ago, Herb found that he could
not keep food down and started vomiting dark red blood, an indication
that his entire digestive system has shut down. Herb was admitted to
the VA hospital, a tube inserted into his stomach to suction off his
undigested stomach contents and blood. Herb lost consciousness
yesterday, but he is often agitated. The physicians explained to the
family that his agitation is probably due to toxins building up in his
brain from hepatic encephalopathy, the inability of the liver to convert
toxins and excrete them. The son, a college educated biology major
who has studied medical ethics, asked the bedside nurse if she is
providing adequate doses of morphine to control his pain. The nurse
emphatically tells the son that she will not give more morphine for fear
@ Copyright 2008 David PaMman

Monash Bioethics Review ,

of hastening his d
frustrated with the
Parts: Diego
nurse; Dr Wahid HE

Case Seven: fo:

patients lackill
'Proxy paradox'
Janet Busch
arrives in the en
suburban road, WI
her. On the scene
resuscitated. She
injuries other than
of her head, the trs
wound. The CT re
bowel', profuse SWI
motor vehicle crasl
for tests, she is tr
resident on the tra
organ donor' durin,
Larry Busch,
the car, is brought
scared. After a ful
concussion, no br
blood is drawn fa
neurology floor.
Janet began
care unit. Her pul
was rising - clinic
unsurvivable brain
blood tests had co
wife had a blood
(Pennsylvania's legr
After several
changes, for bette
another CT scan of
the previous scar.
nonsurvivable hea
ventilator support.
full necrotic bowel,
she arrested on th
multi-organ systerr
antibiotics given 1
provided. Janet's d
while Larry was inc
Larry has recoveree
decisions for his wi
Copyrighl2008 David PaMman

21

lanuary-April 2008

Monash Bioethics Review Vol. 27 Nos. 1-2

us wound on his
eveals ribs. He is
extensive wound
clean. Neurology
will never regain
iermanent brain
that, based on
is not indicated.
I surely die. The
ck families feel
y might perceive
an instance of
nt of the ethics
disclose Jamar's
D withdraw and
erious condition,
is back and want
:e members: this
u may choose to
. all the facts and
ib is to help the
generate options

of hastening his death by respiratory depression. The son, angry and

frustrated with the nurse, decides to contact the ethics committee.
Parts: Diego Rivera, the patient's son; Felicia Cohen, oncology
nurse; Dr Wahid Hassan, oncology attending physician; ethics consultants.

Gunderson, chief
cs consultants.

colon cancer ten

ht surgery and
al. The surgery
colon, but the
r. Herb has been
in control - in a
sed the morphine
take, Herb is still
lnd that he could
iod, an indication
I was admitted to
:0 suction off his
st consciousness
explained to the
uilding up in his
ie liver to convert
ed biology major
~ nurse if she is
. pain. The nurse
morphine for fear

January-April 2008

Case Seven: forgoing life-sustaining treatments in

patients lacking capacity
'Proxy paradox'
Janet Busch, a fifty-year-old female motor vehicle crash victim,
arrives in the emergency room (ER). The car veered off a small
suburban road, went down an embankment, and rolled over, pinning
her. On the scene, she arrested briefly and had to be intubated and
resuscitated. She arrived in the ER unconscious. She had no visible
injuries other than a minor scalp laceration. By examining the CT scan
of her head, the trauma team discovered she had a serious closed head
wound. TheCT reveals no other internal injuries other than 'shock
bowel', profuse swelling of the bowels consistent with an unrestrained
motor vehicle crash victim being thrashed around. After blood is drawn
for tests, she is transferred to the neurological intensive care unit. A
resident on the trauma team summarises her poor prognosis as 'a good
organ donor' during rounds later that day.
Larry Busch, Janet's forty-seven-year-old husband, and driver of
the car, is brought into the ER a few minutes later, alert but obviously
scared. After a full trauma team work-up, a CT scan finds a minor
concussion, no broken bones, and no other internal injuries. After
blood is drawn for tests, the patient is transferred to the general
neurology floor.
.
Janet began to seize after transfer to the neurological intensive
care unit. Her pulse was fast and irregular and her blood pressure
was rising - clinical signs of significant brain swelling and possible
unsurvivable brain injury from lack of oxygen. One hour later, the
blood tests had come back from the lab. Test results reveal that the
wife had a blood alcohol level of 0.235 and the husband 0.199
(Pennsylvania's legal limit is 0.08).
After several days in the neurological unit without any clinical
changes, for better or worse, the neurosurgeons decide to perform
another CT scan of Janet's head, and the results were even worse than
the previous scan. The neurosurgeons conclude that she has a
nonsurvivable head injury and will probably die if removed from
ventilator support. In addition, Janet's 'shock bowel' has progressed to
full necrotic bowel, due to the lack of oxygen to her vital organs when
she arrested on the crash scene. She will die in several weeks from
multi-organ system failure unless dialysis is performed on her blood,
antibiotics given to prevent infection, and complete IV nutrition
provided. Janet's daughter, Joan, had been the proxy decision maker
while Larry was incapacitated by his own minor head injury. Now that
Larry has recovered somewhat, he is legally entitled to make treatment
decisions for his wife. The neurosurgeons meet at Larry's bedside, with
Cl Copyright 2008 David POI1man

Monash Bioethics Review Vol. 27 Nos. 1-2

22

January-April 2008

Joan present, to inform Larry of his wife's grave condition. With tears
in his eyes, Larry vehemently refuses to discontinue Janet's life
sustaining treatments. The neurosurgeons, concerned about the futility
of continuing to provide life-sustaining treatments for Janet, decide to
involve a group of ethics consultants to mediate the case.
.
Players: ethics consultants; Dr Malik Jones, neurosurgeon; Joan
Busch, Janet's daughter; Larry Busch.

Case Eight: paediatrics

'Got milk'

Virginia Patterson is a twenty-eight-year-old new mother with an

extensive psychiatric history. She is bipolar (manic-depressive) and is
currently taking a drug called zolpidem used to de-escalate extreme
manic ('I'm superwoman; I can do anything!') or depressive episodes.
She is breastfeeding and wants to contiriue to do so because she feels
.that it promotes bonding and is healthier for her baby. The
neonatologist, Dr Hernandez, presented the benefits and burdens of
breastfeeding to her before discharge: breastfeeding is best for the baby
because the baby receives love, attention and the mother's antibodies;
it is good for the mother because it encourages bonding; and research
shows that breastfeeding is the first step to encourage other positive
child rearing duties. However, the zolpidem that Virginia takes
represents an unknown risk to the child (and Virginia says she is
allergic to lithium). The drug is present in the breast milk and can act
as a powerful sedative on the child. Cases of respiratory depression in
newborns have been reported in the literature from mothers who take
the drug and breastfeed.
Kathleen Henderson, RN is a home health nurse charged with
providing newborn weight checks for Virginia's baby. During one visit,
she notices that Virginia has not refilled her bottle of zolpidem from two
weeks ago. She might have discontinued the zolpidem in order to safely
breastfeed. However, without zolpidem, she might represent a danger to
her child during one of her manic or depressive mood swings. Kathleen
has a legal obligation to report this fact to Child Protective Services.
She phones Virginia's psychiatrist, Dr Martin, to discuss the issue.
Kathleen phrases her dilemma with several questions: 'who is my"
patient?'; 'can we force her to take her drugs so she will be a good
mother even though that represents a potential harm to her baby if she
continues to breastfeed?'; and 'can we force her not to breastfeed?' The
question of reporting is moot, Kathleen says, but the psychiatrist urges
her to wait until all parties can meet to discuss the issue. Afraid for her
license should she not report and concerned about the numerous
ethical issues, Kathleen tells the psychiatrist that she wants her ethics
committee involved in facilitating such a meeting.
Parts: Virginia Patterson, the twenty-eight-year-old mother;
Patricia Delgado, Virginia's case manager from the Mental Health
Department; Simon Loeb, Virginia's case worker from Child Protective
Services; Dr Juan Hernandez, Virginia's neonatologist (the newborn
e

Copyright 2008 David Perlman

Monash Bioethics Review .

baby doctor); Dr
Henderson, the pa

Case Nine: rep

.'Womb for rent'
Jeff and Sal:
year, when they d
they learned that
unable to conceive
The couple, with t
investigated all of
(IVF) of a. surrogat
other forms of fer
would prefer to h.
them. That was
naturally, and usi
their gametes wou.
Jeff and Sa
organisations anc
mothers. After ms
young, healthy wo
and what sold the
and study financ
Accountant. As pl:
pay for Rebecca's I
The fertility
Rebecca to ensure
transpire. It was u
and Sabrina's garr
the hopes that at
addition, .Dr Roger
try IVF again. It IT.
many implanted,
explained. Everyon
As it turned
Rebecca's uterus i
as could be. How
which Dr Rogers c
the fetus, she disc
and would be bon
left heart syndrom:
surgeon, who expl
condition after th
of operations nee
benefit analysis, ..:
for them if Rebec
. tried again with tt
such an occasion.
co Copyright 2008

David Perlman

anuary-April 2008

Monash Bioethics Review Vol. 27 Nos. 1-2

ltion. With tears

ue Janet's life
ibout the futility
Janet, decide to
e.
rosurgeon; Joan

baby doctor); Dr Josephine Martin, Virginia's psychiatrist; Kathleen

Henderson, the paediatric home health nurse; ethics consultants.

mother with an
.pressive] and is
-scalate extreme
'essive episodes.
ecause she feels .
her baby. The
and burdens of
Jest for the baby
her's antibodies;
ig; and research
~e other positive
Virginia takes
nia says she is
nilk and can act
ry depression in
others who take
se charged with
)uring one visit,
ilpidem from two
.n order to safely
.sent a danger to
swings. Kathleen
rtective Services.
scuss the issue.
.ns: 'who is my
~ will be a good
o her baby if she
breastfeed?' The
sychiatrist urges
re, Afraid for her
t the numerous
wants her ethics
ear-old mother;
Mental Health
Child Protective
st (the newborn

23

January-April 2008

Case Nine: reproductive issues

.Womb for rent'
Jeff and Sabrina Tyler had been trying to conceive a child for a
year, when they decided to see a fertility specialist. As it turned out,
they learned that Sabrina had a condition that. had rendered her
unable to conceive and bear a child. Both of them had healthy gametes.
The couple, with the assistance of their fertility doctor, Mabel Rogers,
investigated all of the various options - adoption, in vitro fertilisation
(NF) of a surrogate mother using gametes from Jeff and Sabrina, and
other forms of fertility assistance. Jeff and Sabrina decided that they
would prefer to have a child that is the biological product of both of
them. That was the goal they had tried to achieve in conceiving
naturally, and using in vitro fertilization of a surrogate mother from
their gametes would provide them with the result they wanted.
Jeff and Sabrina spent six months researching the various
organisations and agencies that matched couples with surrogate
mothers. After many interviews, they settled on Rebecca Stevens, a
young, healthy woman. Jeff and Sabrina were successful accountants
and what sold them on Rebecca Stevens was her goal to go to college
and study finance in the hopes of becoming a Certified Public
Accountant. As part of the legal contract, Jeff and Sabrina agreed to
pay for Rebecca's living expenses in an apartment near their house.
The fertility doctor described the process for Jeff, Sabrina, and
Rebecca to ensure that everyone understood the risks and what would
transpire. It was usually necessary to create several embryos from Jeff
and Sabrina's gametes, analyse them, and implant several embryos in
the hopes that at least one would implant in Rebecca's uterus. In
addition,Dr Rogers freezes ten additional embryos in case they need to
try IVF again. It may be necessary to selectively reduce embryos if too
many implanted, as that might endanger Rebecca, Dr Rogers
explained. Everyone was comfortable with that process.
As it turned out, only one of the four embryos injected into
Rebecca's uterus implanted successfully. Everyone seemed as pleased
as could be. However, at her twenty-four-week obstetrician visit, at
which Dr Rogers conducted an ultrasound to check on the progress of
the fetus, she discovered that the fetus had a developmental anomaly
and would be born with a devastating heart defect called hypoplastic
left heart syndrome. Dr Rogers refers the couple toapaediatric cardiac
surgeon, who explains the risks and benefits of trying to correct this
condition after the baby is born. Rather than go through the series
of operations necessary to treat their future child, using a cost
benefit analysis, Jeff and Sabrina determine that it would be better
for them if Rebecca terminated this particular pregnancy and they
tried again with the other embryos that Dr Rogers had frozen for just
such an occasion.
Cl Copyrighl 2008 David Perlman

Monash Bioethics Review Vol. 27 Nos. 1-2

24

January-April 2008

Jeff and Sabrina asked Rebecca to come over to their house for
dinner and they discussed the situation. Rebecca's jaw dropped when
she learned what Jeff and Sabrina wanted her to do. While she
understood that it might be necessary to selectively reduce implanted
embryos, she had never agreed to terminate the pregnancy unless there
was a severe defect that was incompatible with life. She explained to
Jeff and Sabrina that the operations to correct the heart defect could
save their baby and she was opposed to terminating the pregnancy on
those grounds.
Upon hearing what happened, and hoping to prevent positions
from becoming entrenched, Dr Rogers called Jeff, Sabrina, and Rebecca
to ask if they might seek the counsel of the hospital's ethics committee.
Wishing to avoid the costliness of involving lawyers at this stage, they
consented to appear before the ethics committee to learn what options
might be explored in their case.
Parts: . Jeff Tyler; Sabrina Tyler; Rebecca Stevens; Dr Rogers;
ethics consultants.

Monash Bioethics Review V<

11

American Societj

12

Fleming ND and 1

Health Care Ethic

Improve the Acad
13

Of course, there,
the latter type of
Lipman AJ, Sac
incremental valui
Academy of Aft
http://www.mus
20internet-based

ENDNOTES

10

Lachman YD, Grace PJ and Gaylord N, 'Bioethics education: an inadequate

foundation for ethical nursing practice?', American Society for Bioethics and

Humanities Annual Meeting, Denver, Colorado, October 26, 2006.

While the instructor borrows simulation techniques from mediation training, it

should be noted that simulation is a well-documented and tried-and-true method
for ethically teaching clinical skills to health professionals. See, Ziv A, Wolpe PR,
Small SD and Glick S, 'Simulation-based medical education: an ethical
imperative', Academic Medicine, vol. 78, 2003, pp. 783-788.
Fletcher JC, Lombardo PA, Marshall MF and Miller FG, Introduction to Clinical
Ethics, 2nd edition, Frederick, MD: University Publishing Group, 1997; Fletcher
JC, Spencer EM and Lombardo PA, Fletcher's Introduction to Clinical Ethics, 3rd
edition, Frederick, MD: University Publishing Group, 2005.
Schroeter K, Derse A, Junkerman C and Schiedermayer D, Practical Ethics for
Nurses and Nursing Students: a short reference manual, Frederick, MD: University
Publishing Group, 2002.
Aiken HD, Reason and Conduct: new bearings in moral philosophy, New York:
Alfred A.Knopf, 1962; Perlman DJ, 'Putting the "ethics" back into research ethics:
a process for ethical reflection for human research protection', Journal of Research
Administration, vol. 36, no. 1, 2006, pp. 13-23.
Perlman DJ, Transformatiue Ethics Consultation: a supplement for ethics facilitation
for emotionally charged conflicts, PhD Dissertation, University of Tennessee,
Knoxville, 2000; Perlman DJ, 'Mediation and ethics consultation: towards a new
understanding of impartiality', American Bar Association James Boskey Memorial
Essay Contest, 2001, available at http://www.abanet.org/dispute/perlman2001.
pdf and http://www.mediate.com/artic1es/perlman.cfm [accessed March 3, 2008].
Solomon WD, 'Normative ethical theories', in Reich WT [ed.), Encyclopedia of
Bioethics, vol. 2, New York: Simon and Schuster MacMillan, 1995, pp. 736-748.
Fletcher, Spencer and Lombardo, Fletcher's Introduction to Clinical Ethics,
Appendix 2, pp. 339-347.
.
Loyola University maintains several Apple QuickTime videos of mock ethics

consultations available at: http://bioethics.lumc.edu/online_masters/ECE_skill.html

Fletcher, Spencer and Lombardo, Fletcher's Introduction to Clinical Ethics,

Appendix 3, Case 1, pp. 349-352.

CoPyright2008 David Portman

ClCopyright 2008 David Portman

anuary-April 2008

their house for

dropped when
do. While she
educe implanted
ncy unless there
She explained to
eart defect could
he pregnancy on

Monash Bioethics Review Vol. 27 Nos. 1-2

25

January-April 2008

IV

irevent positions
ina, and Rebecca
-thics committee.
t this stage, they
am what options

11

12
13

American Society for Bioethics and Humanities (ASBH),. Core Competencies for
Health Care Ethics Consultation, Washington, DC: ASBH, 1998.
Fleming ND and Mills C, 'Not another inventory, rather a catalyst for reflection', To
Improve the Academy, vol. 11, 1992, pp. 137-155.
Of course, there are a variety of ethical and regulatory issues to be considered in
the latter type of test, but these are beyond the scope of the present paper. See,
Lipman AJ, Sade RM,' Glotzbach AL, Lancaster CJ and Marshall MF, 'The
incremental value of internet-based instruction: a prospective randomized study',
Academy of Medicine, vol, 76, no. 10, 2001, pp. 72-76, available at
http://www.musc.edu/humanvalues/manuscripts/lncremental%20value%20of%
20internet-based%20instruction.pdf [accessed February 19,2008].

-ens; Dr Rogers;

ation: an inadequate
:ty for Bioethics and
2006.
mediation training, it
ried-and-true method
See, Ziv A, Wolpe PR,
Iucation: an ethical

'ntroduction to Clinical
}roup, 1997; Fletcher
to Clinical Ethics, 3rd
D, Practical Ethics for
derick, MD: University

ohilosophu, New York:

k into research ethics:
n', Journal of Research
ini for ethics facilitation

iversity of Tennessee,
Itation: towards a new
ames Boskey Memorial
dispute/perlman200 1.
sed March 3,2008].
[ed.], Encyclopedia of
,1995,pp.736-748.
on to Clinical Ethics,
rideos of mock ethics
rs/ECE_skill.html
on to Clinical Ethics,

Cl Copyright 2008 DavidPer1man

Monash Bioethics Review Vol. 27 Nos, 1-2

26

January-April 2008

Appendix One
Spring 2008 Syllabus (Note: certain private information
has been redacted.)
NURS 330, Section 001, Spring 2008, Healthcare Ethics
Meeting Times: 5.00-7.50 pm, Mondays
Meeting Place: Claire M Fagin Hall (formerly the Nursing
Education Building) Room 110
Instructor: David Perlman, PhD, Senior Lecturer, Penn SON and
Associate, Penn Centre for Bioethics (bio available here)
Email: perlmand@nursing.upen.edu
Office and Office Hours: By appointment
Department Mailbox: Claire M Fagin Hall, Campus Code 6096
TA Office and Office Hours: By Appointment

Course Texts:
1.

2.
3.

Fletcher JC, Spencer, EM and Lombardo PA (eds), Fletcher's

Introduction to Clinical Ethics, 3rd edition, Frederick, MD:
University Publishing Group, 2005, ISBN: 1-55572-027-7
(Required Text - Note: the 2nd edition will not correlate to the
syllabus, readings, or quizzes).
Articles on Blackboard (https:/ /courseweb.library.upenn.edu)
Schroeter K, Derse A, Junkerman C and Schiedermayer D,
Practical Ethics for Nurses and Nursing Students: A Short
Reference Manual, Frederick, MD: University Publishing Group,
2002, ISBN: 1-55572-066-8 (Optional Text).

Introduction and course objectives

This is a survey course in biomedical ethics, with a focus on
ethical issues in the practice and delivery of professional nursing care.
There are two objectives for this course. The first is to instill a basic
understanding of what biomedical ethics is. We will accomplish this by
briefly studying some classical approaches to ethical theories, followed
by more detailed exploration of how ethical issues arise in health care.
The second objective is to improve your critical thinking and
communication skills in relation to potential ethical issues you will
encounter. To accomplish this you will write essays for examinations,
participate in highly interactive mock ethics consultations, and collaborate
on group presentations.

Quizzes or outlines (150 points, 150/0 of total grade)

Quizzes to test your understanding of the reading material will be
given for the first five minutes of each class session (except the first,
e Copyright 2008 David Perlman

Monash Bioethics Revie

third, and last)

whether the abs
on time. As an f
of the reading
completing the ]
Finally, student
quiz grade by su

Final exam (:
.
The final e
into two parts: I
grade) and (2) a
study guide is a'
exam, including

Class partici]
This class
attendance, pal
lectures, talking
hours or via e
consultations a
determined subje
your fellow studei
One third
frequency, quali
thirds of your
attendance, pre]
ethics consultat:

Mock ethics
400/0 of total
Let's face
some instructor
time. Thus, I ha
also to be fun, j
allow. The succ
and enthusiasm
will be circulate:
To playa:
patient, family n
To serve a:
Your moel
total grade for t
member or an
opportunity to s
ethics consultal

specialty, you rr
ill> Copyright 2008 David Perlman

nuary-April 2008

information
hcare Ethics
ly the Nursing

Monash Bioethics Review Vol. 27 Nos. 1-2

27

January-April 2008

third, and last}. There will be no make-up quizzes (regardless of

whether the absence is excused or not), so make sure you get to class
on time. As an alternative to quizzes, students may prepare an outline
of the reading material either by creating their own outlines or
completing the redacted slides posted on Blackboard for each reading.
Finally, students unhappy with particular quiz grades can replace a
quiz grade by submitting an outline within one week of the quiz.

Final exam (300 points, 30% of total grade)

, Penn SON and

here}

The final exam for this course will be comprehensive and divided
into two parts: (I) A very short answer section (worth 1/3 of the total
grade) and (2) a short essay section (worth 2/3 of the total grade). A
study guide is available on Blackboard to help students prepare for the
exam, including sample questions.

us Code 6096

Class participation (150 points, 15% of total grade)

(eds), Fletcher's
Frederick, MD:
1-55572-027-7
correlate to the

ary. upenn.edu)
:hiedermayer D,
idenis: A

Short

iblishing Group,

This class requires active and frequent participation. Consistent

attendance, participation in discussions, asking questions during
lectures, talking to the instructor and teaching assistant during office
hours or via email, and, of course, discussing the mock ethics
consultations are all forms of class participation. This grade is
determined subjectively, depending on your attitude towards the material,
your fellow students, and the instructor and teaching assistant.
One third of your participation grade will be based on the
frequency, quality, and relevance of comments made during class. Two
thirds of your participation grade will be based on your class
attendance, preparation of the reading material, and serving as a mock
ethics consultation evaluator.

Mock ethics consultation presentations (400 points,

40% of total grade)
with a focus on
aal nursing care.
to instill a basic
complish this by
heories, followed
ie in health care.
1 thinking and
issues you will
or examinations,
is, and collaborate

:al grade)
g material will be
(except the first,

Let's face it. Sitting in class for 3 hours every week listening to
some instructor drone on and on about ethics is not your idea of a good
time. Thus, I have tried to structure the class to optimize learning, but
also to be fun, interactive, and as realistic as a classroom setting will
allow. The success of each class will depend on the amount of effort
and enthusiasm you put into it. Early in the semester, a sign-up sheet
will be circulated. You will sign up two times:
To play an ethics committee member or to play an 'actor' (ie,
patient, family member, or clinician)
To serve as an evaluator of the ethics committee
Your mock ethics consultation grade will be worth 40% of your
total grade for the class or 400 points. Portraying an ethics committee
member or an actor will be worth 400 points You will have the
opportunity to select the date on which you will participate in the mock
ethics consultations, so if you have a particular clinical interest or
specialty, you may wish to correlate the dates and topics listed in this
@

Copyright 2008 David Periman

Monash Bioethics Review Vol. 27 Nos. 1-2

28

Monash Bioethics Revie

January-April 2008

consultation t,
questions. The i
the committee I
actors. In antic
role motivation
how they plan tr
For the ac
authentic portr
points). In addi
consultation tal
double-spaced e
of the essay a:
reflecting on th.
essay will compr
actor. Essays w
receive a check'
a check t..J) and'
minus (-..j-) and c

syllabus and sign up for that date. Or, if you have other exams or
commitments, you may wish to avoid certain dates. Please bring your
up-to-date calendars to class, because switching will not be
possible in a class of this size.

Details on being an ethics committee member

As an ethics committee member, you and a number of other
students will help the actors reach a resolution to their case. You will
use the clinical pragmatism framework, your knowledge of the chapter
of the text for which you are scheduled, and your interpersonal skills to
help the family members and clinicians who are either in conflict or
uncertain about what ethical options exist to reach a resolution.
Thus, it will be necessary for the ethics committee members to
meet outside of class to build a strategy and research the problem and
medical condition(s) at the crux of the consultation. The only
information you will have regarding the case are the participants'
names and a brief summary of the case as it would appear on a
consultation request in the patient's chart. To provide time for the
ethics committee members to meet outside of class, you will receive
your case materials two class sessions before your mock consultation
is scheduled. To assist in preparing the clinical information for each
case; the Teaching Assistant will meet with the committee members
before the consultation.
Your grade as an ethics consultant will depend on your level of
preparation, participation, and use of the clinical pragmatism framework
and other materials in the textbook. Because of the amount of out-of
class preparation required to successfully be an ethics committee
member, your grade will start at a B- and will be adjusted up or down
depending on how successful you are as a member of the committee.

Details on be

Details on being an actor

As an 'actor', you might play one of a number of roles - a
bereaved mother, a physician, a nurse, a social worker, a son who
must make a hard choice for his dying father. To make such
enactments realistic, you will be given guidelines on how to 'play' this
character - not a script, but your motivation (for good examples, see
the cases in Appendix 3 of our book). In addition to this motivation,
you should think about the values, beliefs, biases, and knowledge
that your character would hold so that you can authentically role
play that character. You must not discuss your role or
motivation with others in the class unless directed to do so
by the instructor - this must be kept secret in order for the
mock consultation to succeed. Actors in the past have found it
invaluable and necessary to research their role, especially if called
on to play clinicians, who must be knowledgeable about the various
conditions, treatments, options, and pathophysiology in the case.
To assist in preparing for the consultation and to ensure a smooth
experience, the instructor will meet with all actors before the
C Copyrighl2008 David Periman

,
i

.!.
~

The abilitj
leadership skill
provide feedbacJ
training on how
sessions and pr
evaluate the c
attention to the
interaction. YOl
discussion of t
towards the em
terms of the eli:
following the cal
framework, you
evaluation for di
for this small ~
participation gra
Evaluators
their name to
should prepare i
name for the ins
to the ethics con

iC> Copyright 2008 David Perlman

29

January-April 2008

Monash Bioethics Review Vol. 27 Nos. 1-2

: other exams or
.ease bring your
lng will not be

consultation to work out certain common details and answer

questions. The instructor will then communicate certain information to
the committee members based on the results of the meeting with the
actors. In anticipation of this meeting, all actors should, using their
role motivation handed out to them, prepare a paragraph or two on
how they plan to play their roles.
For the actor part grade, 75% will be based on your realistic and
authentic portrayal of your character during the consultation (300
points). In addition, within two weeks of the class after which your
consultation takes place, you will also submit a two-page minimum,
double-spaced essay reflecting on your role in the consultation. Think
of the essay as a journal entry that your character would make,
reflecting on the experience of being a part of the consultation. This
essay will comprise the remaining 25% (100 points) of your grade as an
actor. Essays will be graded as follows: Good to excellent essays will
receive a check plus ("+) and 100 points; fair to good essays will receive
a check (,,) and 80 points; and poor to fair essays will receive a check
minus (,,-) and 60 points.

iber
number of other
.eir case. You will
Ige of the chapter
rpersonal skills to
her in conflict or
.eeclution.
dttee members to
l the problem and
tation. The only
the participants'
ruld appear on a
vide time for the
, you will receive
nock consultation
ormation for each
mmittee members
d on your level of
matism framework
amount of out-of
ethics committee
justed up or down
he committee. '

nber of roles - a
orker, a son who
. To make such
how to 'play' this
Dod examples, see
:0 this motivation,
S, and knowledge
uthentically role
s your role or
lrected to do so
in order for the
ast have found it '
.specially if called
about the various
ilogy in the case.
ensure a smooth
actors before the

January-April 2008

Details on being an evaluator

The ability to give and receive constructive feedback is a good
leadership skill for anyone to have. As an evaluator, your job is to
provide feedback to the ethics committee and actors. After providing
training on how to give and receive feedback during one of our class
sessions and providing you with an evaluation sheet, your job is to
evaluate the committee. During the consultation, pay particular
attention to the substance, process, and interpersonal elements of the
interaction. You will use your evaluation to jump-start group
discussion of the process and options reached by the committee
towards the end of class and during my presentation of the case in
terms of the clinical pragmatism framework in the class immediately
following the case. For the evaluation phase of the clinical pragmatism
framework, you will need to work outside of class and bring in your
evaluation for discussion at the beginning of the next class. Your grade
for this small group work will comprise a large part of your class
participation grade.
Evaluators will be asked to type up their evaluations and place
their name to receive credit for evaluating. In addition, evaluators
should prepare another version of their typed evaluation without their
name for the instructor and/ or teaching assistant to provide feedback
to the ethics consultants and actors in an anonymous fashion.

Cl Copyright 2008 David Perlman

Monash Bioethics Review Vol. 27 Nos. 1-2

30

January-April 2008

Monash Bioethics Reviev

Syllabus
Role

Points Possible
out of 400

400 points

Ethics
committee
member

OR
Actor

Evaluator

OR
.400 points (300
points, actor
portrayal; 100
points, reflection
essay)
o points (grade will
be built into class
participation grade)

Workload
Advance, out-of-class

preparation required

Mastery of material required

No additional work after the

consultation
Some advance preparation
Creativity, enthusiasm, and
realistic role-playing required
Essay required two weeks
after case
No advance preparation
Honesty in appraising the
committee's performance and
asking thoughtful questions
Preparation of two typed
evaluation forms

Honor statement, plagiarism, and. policy on grades incomplete

Students will be held to the highest academic standards as
outlined by the Code of Academic Integrity (http://www.vpul.upenn.
eduyosl Zacadint.html]. Plagiarism is the intentional use of the words or
ideas of an author as one's own without proper credit. In ethics, since
ideas build on a shared intellectual history, you must acknowledge the
words and ideas of others. If you use direct quotes from sources,
quotation marks should be used and page numbers, titles, and authors
given in a citation. If you summarize the ideas and words, the latter
three elements should be cited. Plagiarism or any other form of
academic dishonesty will result in a failing course or assignment grade
and referral to appropriate disciplinary action. I will consider giving
grades of Incomplete (I) on a case by case basis, but only in the most
extraordinary circumstances and with appropriate documentation.

Grading Scale
Final grades: A+=100-97 (1000-965 points); A=96-93 (964-925
points); A-=92-90 (924-895 points); B+=89-87 (894-865 points); B=86
84 (864-835 points); B-=83-80 (834-795 points); C+=79-77 {794-765
points); C=76-74 (764-735 points); C-=73-70 (734-695 points); D=69
60 (694-595 points); and F=59 or lower (594 or fewer points).

e Copyright 2008 David PoMman

Date
Mon Jan 28
Mon Feb 4
Mon Feb 11

Mon Feb 18
Mon Feb 25

Mon Mar 3
Mon Mar 17
Mon Mar 24
Mon Mar 31
MonApr 7

Mon Apr 14
MonApr 21
MonApr28
TBD

Note: Th
and you will r
installed in orde
Java Platl
www.java.com)
Apple's Qu

Copyright 2008 David Perlman

January-April 2008

Monash Bioethics Review Vol. 27 Nos. 1-2

31

January-April 2008

Syllabus
of-class
uired
rterial required
work after the

Date
MonJan 28
Mon Feb 4
Mon Feb 11

e preparation
thusiasm, and
lying required
d two weeks

Mon Feb 18

reparation
ipraising the
rformance and
ful questions
f two typed

Mon Feb 25

lS

Mon Mar 3

les incomplete
aic standards as
www.vpul.upenn.
se of the words or
.t. In ethics, since
t acknowledge the
:es from sources,
itles, and authors
words, the latter
1Y other form of
assignment grade
11 consider giving
: only in the most
cumentation.

Mon Mar 17
Mon Mar 24
Mon Mar 31.
Mon Apr 7

MonApr 14
MonApr 21
Mon Apr 28
TBD

\=96-93 (964-925
:65 points); B=86
+=79-77 {794-765
95 points); D=69
points).

Topic, Assipments, and Readin2s

Introduction: Overview of the Course and
Sociology of the Hospital
Quiz 1, Lecture and Discussion (Article or:
Blackboard)
Skill Building in Ethics Consultation: Discussior:
and Evaluation of Mock Ethics Consultations
(http:/ /bioethics.lumc.edu/online_masters/ECE_
skill.html) (see below) Appendix 2 Introduction tc
Clinical Ethics (ICE)
Quiz 2, Lecture and Discussion
Chapters 1, 2, and 4 ICE
Quiz 3, Quiz 4, and Mock Ethics Consultation
Case 1
Chapter 7 ICE Privacy and Confidentiality
Chapter 8 ICE - Communication, Truth-Telling,
and Disclosure
Quiz 5 and Mock Ethics Consultation Case 2
Chapter 9 ICE Determining Patients' Caoacitv
Quiz 6 and Mock Ethics Consultation Case 3
Chapter 10 ICE Informed Consent
Quiz 7 and Mock Ethics Consultation Case 4
Chapter 11 ICE Treatment Refusals
Quiz 8 and Mock Ethics Consultation Case 5
Chapter 12 ICE Death and Dying
Quiz 9 and Mock Ethics Consultation Case 6
Chapter 13 ICE - Forgoing Life-Sustaining
Treatments
Quiz 10 and Mock Ethics Consultation Case 7
Chapter 14 ICE Pediatrics
Quiz 11 and Mock Ethics Consultation Case 8
Chapter 15 ICE - Reoroductive Issues
Evaluation of Case 8 followed by guest speakei
and pizza party
Final Exam

Note: This website seems to take a long time to completely load

and you will need to make sure you. have the following software
installed in order to view the videos and slides for the third class: .
Java Platform 2, version 1.50 (available as a free download at
www.java.com)
Apple's QuickTime (available as a free download at www.apple.com)

@ Copyright 2008 David Perlman

Monash Bioethics Review Vol. 27 Nos. 1-2

32

January-April 2008

Monash Bioethics Revie

Using th
methode
focus on

Class Structure
Each class (except the first, third, and last) will usually start with
a brief quiz (so be on time!).
The first couple of classes will be lecture and discussions. The
classes with mock ethics consultations scheduled will proceed as follows:
Quiz andanswers
Brief lecture and discussion on moral diagnosis, options, and
evaluation of the previous consultation presentation
Next, live-enactment of the mock ethics consultation
For example, for the second mock ethics consultation, there will be a
quiz on the chapter for that day, a lecture and discussion on the first
mock ethics consultation, followed by the live enactment of the second
mock ethics consultation.

DAVID L HUNTER

School of Bioethic(
School of Biomedic
University of Ulatel

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@ Copyright 2008 David Perlman

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