Chapter  10: Care of the Dying

Section 5. Decision Scenarios 

Summary of Methodology for Analyzing and resolving Cases involving moral dilemmas in Health Care:


Paradigm for the Method:

Sample Case Analysis:

Introduction to Clinical Ethics, 4th edition using the case of Dax Cowart.:



For each of the scenarios you should consider how a person would reach a decision if that person were using the basic principles from EACH of the following traditions:








1. Pneumonia and 92 year old male

2. Brain hemorrhage and 81 year old male

3. Five (5) Fatal Diseases in 70 year old male with a Living Will

4. Four deaths of elderly without higher brain functions

5. Shot dead

6.Netherlands Law 1993

7. Female 45 years old with leukemia and an overdose of prescribed medication

8. Flash Fire Victim and surrogate decision making

From:  Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000  . Page 242 Scenario #1

 “This gentleman is Ethan Zinker,” Dr. Clara Woods said. She bent over the bed and put her stethoscope to the chest of the elderly man. He stirred but showed no sign of waking. “He’s got pneumonia,” Dr. Woods said, straightening up. “But aside for being ninety-two years old, and having lost a few of his marbles, nothing else is wrong with him. If we treated him aggressively with antibiotics, he might live for another six or eight years. Maybe more.” She shrugged. “But we’re only controlling his fever and keeping him comfortable.”

                “How come you’re not giving him antibiotics?” Dr. Robert Elias was shocked. He was Morningside Hospital’s new bioethicist and it was his first morning of making rounds with Dr. Woods. “I mean, he has a life-threatening disease that usually responds well to therapy.”

                “Right,” Dr. Woods said, nodding. “But he’s also got an advanced directive that tells us in no uncertain terms not to intervene.” She flipped through the chart until she located the social worker’s report. “He was the Powell professor of physics at Columbia. A very smart guy, he couldn’t stand the idea of not being mentally sharp and active.”

                “So he said if he began to fail mentally, then if he needed treatment to keep him alive, he didn’t want to have it.” Dr.Elias was beginning to understand.

                “Exactly,” Dr. Woods said. “But the funny thing is, when he started to get senile and moved into the nursing home, he quite liked it.” She smiled. “He couldn’t recognize his daughter most of the time, but he knows the people he lives with and sees everyday. He’s made a couple of friends, and according to these notes, he like watching reruns of X-Files.”

                “He should be treated,” Dr. Elias said flatly. “The idea of not treating someone who is evidently enjoying life struck him as very wrong.”

                “I think so, too,” Dr. Woods said. “The only right course of action is to ignore the advance directive and treat him. Let’s face it, Professor Zinker didn’t know what his life would be like now when he gave his directive. It wouldn’t be a good life for him the way he used to be, but that’s not the way he is now.” His expression turned grim. “He needs to be treated, before it’s too late to help him.”


From:  Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000  . Page 243 Scenario #2


Jeffry Box was eighty-one years old when he was brought to Doctor’s Hospital. His right side was paralyzed, he spoke in a garbled way, and he had trouble understanding even the simplest matters. His only known relative was his sister four years younger, and she lived half a continent away. When a hospital social worker called to tell her about her brother’s condition, she was quite uninterested. “I haven’t seen him in fifteen years,” she said. “I thought he might already be dead. Just do whatever you think best for him. I’m too old to worry about him.”

                Neurological tests and X-ray studies showed that Mr. Box was suffering from a brain hemorrhage caused by a ruptured brain vessel.

                “You can fix it?” asked Dr. Hollins. She was the resident responsible for Mr. Box’s primary care. The man she addressed was Dr. Carl Oceana, the staff’s only neuro surgeon.

                “Sure,” said Dr. Oceana. “I can repair the vessel and clean out the mess. But it won’t do much good, you know?”

                “You mean he’ll still be paralyzed?”

                “And he’ll still be mentally incoherent. After the operation he’ll have to be placed in a chronic care place, because he won’t be able to see to his own needs.”

                “And if you don’t operate?” Dr. Hollins asked.

                Dr. Oceana shrugged. “He’ll be dead by tomorrow. Maybe sooner, depending on how long it takes for the pressure in his skull to build up.”

                “What would you do?”

                “I know what I would want done to me if I were the patient,” said Dr. Oceana. “I’d want people to keep their knives out of my head and let me die a nice, peaceful death.”

                “But we don’t know what he would want.” Dr. Hollins said.

                “He’s never been our patient before, and the social worker hasn’t been able to find any friends who might tell us what he would want done.”

                “Let’s just put ourselves in his place,” said Dr. Oceana. “Let’s do unto others what we would want done unto us.”

                “That means letting Mr. Box die.”



From:  Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000  . Page 243 Scenario #3

On April 8th, 1984, William Bartling was admitted to the Glendale Adventist Medical Center in Los Angeles. He was twenty-seven years old and suffered from five ordinarily fatal diseases: emphysema, diffuse arteriosclerosis, coronary arteriosclerosis, an abdominal aneurysm, and inoperable lung cancer. During the performance of a biopsy to diagnose the lung cancer, Mr. Bartling’s left lung collapsed. He was placed in ICU, and a chest tube and mechanical respirator were used to assist his breathing.

                Mr. Bartling complained about the pain the respirator caused him, and he repeatedly asked to have it removed. When his physician refused, he pulled out the chest tube himself. This happened so often that eventually Mr. Bartling’s hands were tied to the bed to keep him from doing it. He had signed a living will in attempt to avoid such a situation.

                Although after discussions with Richard Scott, Mr. Bartling’s attorney, Mr. Bartling’s physician in the hospital administration agreed to disconnect the respirator, the hospital’s attorney refused to permit it.  He argued that, since Mr. Bartling was not terminally ill, brain dead, or in a persistent vegetative state, the hospital might be open to legal action.

                Mr. Scott took the case to Los Angeles Superior Court. He argued that Mr. Bartling was legally competent to make a decision about his welfare and that, although he did not want to die, he understood that disconnecting the respirator might lead to his death. The hospital’s attorney took the position that Mr. Bartling was ambivalent on the question of his death. His statements “I don’t want to die” and “I don’t want to live on the respirator” were taken as inconsistent and so as evidence of ambivalence. Removing the respirator, the attorney argued, would be tantamount to aiding suicide or even committing homicide.

                The court refused to either allow the respirator to be removed or to order that Mr. Bartling’s hands be freed.  To do so,  the court ruled, would be to take a positive step to end treatment, and the only precedents for doing os were in cases in which the patients were comatose, brain dead, or in a chronic state of vegetative state.

                The case was then taken to the California court of Appeal, which ruled:  “If the right of a patient to self-determination as to his own medical treatment is to have any meaning at all, it must be paramount to the right of a competent adult patient to refuse medical treatment is a constitutionally guaranteed right which must not be abridged.”

                The rule came too late for Mr. Bartling.  He died twenty-three hours before the court heard his appeal.


From:  Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000  ., Page 244, Scenario #4


When two plainclothes detectives arrived at Virginia Crawford’s suburban apartment at 6:30 on a Sunday morning to arrest her for murder, she was not surprised to see them.

                She cried when they insisted on putting her in handcuffs before transporting her to the jail in the county court building.  Yet she had more or less expected to be arrested eventually.  For almost a month, a police investigation had been conducted at Mercy Hospital, where Ms. Crawford worked as a nurse in the intensive-care unit (ICU).  The entire hospital staff knew about the investigation, and Ms. Crawford herself had been questioned on three occasions by officers conducting the inquiry.  At the time, her answers had seemed to be satisfactory to the police, and there was no hint that she was under suspicion.  Still, she always believed that eventually they would catch up with her.

                The investigation centered on the deaths of four elderly patients during the period from February 1979 to March 1980.  All of the patient were in ICU the times of their deaths.  Each had been diagnosed as suffering from a terminal illness, and the chart notation on each case indicated that they had all suffered irreversible brain damage and were totally without higher-brain functions.

                The three women and one man were all unmarried and had no immediate family to take an interest in their welfare.  All of them were being kept alive by respirators, and their deaths were caused directly by their respirators being turned off.  In each instance of death, Ms. Crawford had been the person in charge of the ICU.

                After securing the services of an attorney, Ms. Crawford was released on bail, and a time was set for her appearance in court.  Through her attorney, Marvin Washington, she made a statement to the media. 

                “My client has asked me to announce that she fully and freely admits that she was the one who turned off the respirators of the four patients in question at Mercy Hospital.  She acted alone and without the knowledge of any other individual.  She is prepared to take full responsibility for her actions.”

                Mr. Washington went on to say that he would request a jury trial for his client.  “I am sure,” he said, “that no jury will convict Ms. Crawford of murder merely for turning off the life-support systems of people who were already dead.”

                When asked what he meant by that, Mr. Washing ton explained.  “These patients were no longer people,” he said.  “Sometime during the course of the treatment, their brains simply stopped functioning in a way that we associate with human life.”

                Ms. Crawford was present during the reading of her statement, and after a whispered conversation with her attorney, she spoke once for herself.  “I consider what I did an act of compassion and humanity,”  she said.  “I feel no guilt about it.  I did for four people what they would have wanted done, if they had only been in a condition to know.”


From:  Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000  ., Page245, Scenario #5

Consider the following four cases.

Harvey Shick of Tyler, Texas, on June 1, 1983, shot his wife in the head twice with a .22-caliber pistol.  Marie Shick had suffered from severe arteriosclerosis since the late 1970s and suffered extreme pain in her lower legs.  The couple had been happily married for forty-five years.  Although Mr. Shick was charged with murder, the charges were dismissed by the state district court judge.  “I found nothing would be gained in this case by further punishing this man,” Judge Donald Carroll said.  “This was an act motivated by love,” Mr. Shick’s attorney said.  “He was distressed at the sickness, and additional treatment would have brought only a precarious and burdensome prolonging of life.”  Mrs. Shick’s family supported the action.

On September 14, 1984, Thomas Engel, a registered nurse, removed the respirator from Joesph Dohr, a seventy-eight-year-old stroke patient at St. Michael hospital in Milwaukee.  Mr. Engel said Mr. Dohr’s family asked that treatment be stopped.  His physician said he had refused the request because he believed Mr. Dohr’s death was imminent.

Mr. Engel described the bedside scene with Mr. Dohr’s daughter that had let him to act:  She was standing there by her father’s bed, stroking his arm and cheek and crying and talking to him.  He was in a coma, in a steady decline.  The only thing keeping him alive was the ventilator breathing for him. “This isn’t right,” she said.  Then she looked across the bed at me, right in my eyes, and she said “If I could do this thing I would.”  Now, what would you do?

Mr. Engel was charged with practicing medicine without a license.  He pleaded guilty and received a twenty-month suspended sentence.  His nursing license was revoked for one year.

On August 8, 1985, seventy-nine-year-old Abel Montigny walked into the intensive-care unit of Worchester Memorial Hospital in Worcester, Massachusetts, and shot his wife in the head.  He then shot himself.  Both died from the injuries.  Mrs. Leona Montigny, seventy-six, had been in the hospital  months.  She suffered from serious stomach and blood disorders and was recovering from surgery.  Her illnesses were considered treatable, and she was in no immediate danger of death from them.

Roswell Gilbert, a seventy-five-year-old retired engineer, was convicted in Ft. Lauderdale, Florida, on  May 9, 1985, for killing his incurably ill seventy-three-year old wife.  The couple had been married fifty-one years.  Emily Gilbert had a debilitating bone disease and Alzheimer’s disease; as a consequence, she suffered both severe pain and mental disorientation.  According to a witness, on the day of the killing Mrs. Gilbert had said to her husband “I’m in pain.  I want to die.”  Mr. Gilbert said later, “Who’s that somebody but me?  I guess I got cold as ice.  I took the gun off the shelf, put a bullet in it and shot her.  Then I felt her pulse.  I thought, ‘Oh, my God, I loused it up.’  I put in another bullet and shot her again.”  Mr. Gilbert was sentenced to twenty-five years in prison with no chance of parole.  As he left the courtroom, his daughter cried out, sobbing, “Daddy, Daddy, I don’t  want to see my daddy in jail—he’ll die in jail.”

                Gilbert lost a chance for clemency when two of thee members of the Florida Cabinet rejected the governor’s recommendation that he be freed while the case was appealed.  “the laws does not give one person the right to kill another because of illness or age,” said Gerald Lewis, one who voted against clemency.  But in August 1990, in failing health, Gilbert was finally freed on probation.  He died on September4, 1994.


From:  Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000  ., Page. 246, Decision Scenario #6

In 1993 the Netherlands passed a law permitting physicians to assist in the suicide of terminally ill patients.  The law requires that the patient’s decision to die be informed and irrevocable, and that there be no other solution acceptable to the patient that would improve the situation.  (See “The Dutch Experience” in the “Introduction” for details.)


From:  Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000  ., Page 247, Decision Scenario #7

In March 1991 Dr. Timothy Quill published an article in the  new England Journal of medicine in which he described how he had prescribed barbiturates for Patricia Diane Trumbull, a forty-five-year-old woman suffering from leukemia.  In prescribing the medication, Dr. Quill also informed Ms. Trumbull, who had been his patient for a long time, how much of the drug constitute a lethal dose.

                Ms. Trumbull later killed herself by taking an overdose of the barbiturate, and Dr. Quill was investigated by a Rochester, New York, Grand jury.  Although it is illegal in New York to assist someone in  committing suicide, the grand jury decided not to indict Dr. Quill on the charge.

                Dr. Quill’s actions were later reviewed by the three-member New York State Board for Professional Medical Conduct to consider whether he should be charged with professional misconduct.  The board arrived at the unanimous decision that “no charge of misconduct was warranted.”

                The board, in its report, distinguished between Dr. Quill’s actions and those of Dr. Jack Kevorkian. The board pointed to Dr. Quill’s long-term involvement in caring for Ms. Trumbull and contrasted it in Dr. Kevorkian’s lack of any prior involvement with those whom he assisted in killing themselves.

                Moreover, the board pointed out that Dr. Quill “did not directly participate in any taking of life” and this too made his actions different from those of Dr. Kevorkian.  “One is legal and ethically appropriate, and the other, as reported, is not”  the board concluded.


From:  Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000  , Page 247, Scenario #8

“Apparently, he was inside the take with an oxygen hose to provide ventilation,” Dr. Mangel said.  “There was some oil residue on the walls.  When Mr. Golenga struck an arc to weld the seam, there was a flash fire.”

                Mrs. Golenga gripped the hand of her nineteen-year-old son, Cervando.  Both had been crying, but now listening was so important that they forced back their tears.

                “How badly hurt is he?”  Mrs. Golenga asked. 

                “Very badly,” Dr. Mangel said.  “Most of his body is covered with severe burns, and his lungs are damaged form breathing in the fire and smoke.”

                “Will he live?” Cervando asked.

                “I have to be honest with you and say that I don’t think he will,” Dr. Mangel said.  “We are giving him plasma and saline solutions to rehydrate him and antibiotics to try to stop infections.  But he hasn’t got much of a chance.”

                “The pain, what about the pain?” asked Mrs. Golenga.

                “There’s only so much we can do.”

                “There’s really no hope?” Cervando asked.

                “I wouldn’t  say that,” Dr. Mangel said.  “There is always hope.  But in this case it is very limited.  He might die in a few hours, or he might die tomorrow or the next day.”

                “Please,” Mrs. Golenga said.  “Can you help him die?  I know he doesn’t want to suffer if he has no real hope.  He told me often ‘If something happens to me, don’t let them stick me full of needles and keep me alive.  Tell them to put me out of my misery.’  Can you do that, Doctor?”

                Are you sure that’s what he would want?” Dr. Mangel asked.

                “My mother is right,” Cervando said.  “I’ve heard my father say that many times.  He said he never wanted to just lie around and suffer, being a burden to himself and everyone.  We want to do as he wanted us to.”

                 “We could stop treating hom,” Dr. Mangel said.  “then let nature take its course.”

                “That sounds terrible,” Mrs. Golenga said.  “To make a man fight for his life when he has no hope and ho help.  It is cold and cruel.”

                “I’m sorry,” said Dr. Mangel.  “It’s all that the law permits me to do.”

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