HI 271 | Ethical Case

Jan Michael M. Herber, RN

Studies

CASE STUDY #1
Gwen Thompson lives alone in a remote
rural area. She frequently goes online to
get information, and to obtain goods and
services that are not easily accessible due
to her isolation. She has recently been
diagnosed with hypertension, but finds it
difficult to keep appointments at the
clinic 20 miles away. Ms. Thompson ran
out of one blood pressure medicine
several weeks ago and has been feeling
light-headed. She also noticed that her
blood pressure has been running high. It is
winter, the roads are bad, and she fears
going out, so she begins taking double the
prescribed daily dose of the other blood
pressure medication that she has not run
out of.

CASE STUDY #1
While surfing the net, she finds
CyberDocs.com and discovers that a
virtual house call can be obtained
for a modest fee, so she requests a
house call. That same day a
physician (in a different state)
responds online and Ms. Thompson
describes her symptoms, gives her
recent blood pressure readings, and
mentions that she has run out of
medication. The physician offers to
provide a one-month prescription,
and even arranges for quick mail
delivery of the medication.

CASE STUDY #1
One week later, Ms. Thompson is found unconscious by a neighbor.
At the hospital, she is diagnosed with acute kidney failure, possibly a
result of taking two different prescribed diuretics, one from her
regular physician and the other from CyberDocs. She ultimately
recovers, but the kidney damage is irreversible, and sadly, she will
require chronic dialysis.

CASE STUDY #1
Ms. Thompsons attorney contacts
CyberDocs.com, but the prescribing
physician no longer contracts with
them. CyberDocsclaims that since no
face-to-face contact occurred, no
patient-clinician relationship existed
and,
therefore,
there
was
no
professional duty to do no harm.
CyberDocs also argues that printed
warnings of risk came with the pre
scription when it was delivered.
Arguing that this was a contracted
service with full disclosure of potential
risk, CyberDocs is unwilling to accept
any obligation or responsibility for Ms.
Thompsons situation.

CASE
QUESTIONS

WHAT ARE THE PROS AND

CONS NOTED IN THIS
STUDY?
PROS

CONS

GOES ONLINE to get goods and services

Living ALONE and in a REMOTE area

Diagnosed with HYPERTENSION
Difficulty keeping with APPOINTMENTS
(20 miles away)
RAN OUT of ONE of her medication
Has HIGH BLOOD PRESSURE AND
LIGHT-HEADEDNESS
WINTER SEASON (Road is bad.)
TAKES TWICE of the antiHTN medication
on stock

WHAT ARE THE PROS AND

CONS NOTED IN THIS
STUDY?
PROS

CONS

FINDS CyberDoc.net with virtual house

call with modest fee
Physician RESPONDS and CHECKS on
patient

MENTIONS she has RUN OUT of

medication

Physician PRESCRIBES one-month

prescription and gave quick delivery.
One week: Patient UNCONSCIOUS
DIAGNOSED with Acute Kidney Failure
due to possibly taking two different medications

IRREVERSIBLE KIDNEY DAMAGE

(undergoing chronic dialysis)

Attorney CONTACTS CyberDocs.com

Physician NO LONGER CONTRACTS

with the site

WHAT ARE THE PROS AND

CONS NOTED IN THIS
STUDY?
PROS

CONS
CyberDocs: No face-to-face contact
occurred and no patient-clinician
relationship existed. Therefore, there was
no professional duty to do no harm.

CyberDocs has printed warnings of risk

that came with the prescription.

Arguing that this was a CONTRACTED

SERVICE (sharing of information and
prescription of medication) with FULL
DISCLOSURE of potential risk.
CyberDocs is UNWILLING to accept any
obligation or responsibility for Ms.
Thompsons situation.

WAS THERE A PATIENT-PHYSICIAN

RELATIONSHIP FORMED? WHY/WHY
NOT?
Personally, I
relationship.

believe

that

THERE

IS

patient-physician

There may be arguments that since there is no face-to-face

contact, there is NO PROFESSIONAL DUTY (RESPONSIBILITY).
However, PROFESSIONAL RELATIONSHIP is ESTABLISHED by the
mere fact Gwen Thompson sought consultation and the website
CyberDocs.com agreed to provide that service.
Since Gwen Thompsons search for professional help was honored,
there is PROFESSIONAL PROMISE (OATH) that is characterized the
practice of Medicine.
I will use my power to help the sick to the best of my ability and judgment. I
will abstain from harming or wrong doing any man by it. (Hippocratic Oath).

DO YOU AGREE WITH THE

WEBSITES DEFENSE THAT
SINCE NO FACE-TO-FACE
CONTACT OCCURED, NO
PATIENT-CLINICIAN
RELATIONSHIP EXISTED, AND
THEREFORE, THERE WAS NO
PROFESSIONAL DUTY TO DO
NO HARM?

WHAT ARE THE ETHICAL

CONCERNS ENCOUNTERED IN
THIS CASE?
Beneficence?
Integrity (doing the right thing)?
Fidelity (dedication)?

Respect for Patients Rights and Dignity?

Non-Maleficence?
Justice?
Responsibility?

WHO HAS MORAL

RESPONSIBILITY FOR WHAT
HAPPENED TO THE PATIENT?
WHY?

THE PRIMARY CARE PHYSICIAN?

THE PATIENT HERSELF?
THE PHYSICIAN WHO EXAMINED HER
THROUGH CYBERDOCS?
THE CYBERDOCS WEBSITE?

DO YOU THINK THAT

CYBERDOCS.COM HAS THE
MORAL RESPONSIBILITY? WHY
OR WHY NOT?

Yes.

All interactions made between the client and the physician were
created through Cyberdocs.com.
Their design may ask the client only little information of her case.
Therefore, risks and complications may not be made aware to the
physician.
The site allows one-month prescription which could provide the
patient irreparable damage.
Even when CyberDocs claims that no duty exits because there
was no face-to-face contact, there were:

Shared trust
Awareness of weakness
Accountability should exist between them (CyberDocs.com and the
patient).

DO YOU THINK THAT THERE

WAS NEGLECT ON THE
PATIENTS PART? WHY OR WHY
NOT?
Yes.

She has run out of ONE high blood pressure medication.

Not securing her stock of this medication in anticipation of winter

season.

She TOOK TWICE THE DOSE of the anti-HTN medication that

she still has.

Form of self-medication
Under-dosage may not cure the symptom. Over-dosage can produce
collateral damage to heart, kidneys or other organs (Alhassan, 2012).

She verbalized that she has run of high blood pressure medication
(NOT TELLING SHE HAS ANOTHER MEDICATION).

Misleading information, which possibly led the physician to prescribe

more than what is needed.

DO YOU THINK THAT THERE WAS

NEGLECT ON THE DOCTORS
(CYBERDOCS) PART? WHY OR WHY
NOT?
Yes.
I believe that there was negligence on the part of the physician
who checked on her online. This is mainly because the physician
shouldthe
have
been done
to prevent
was not able What
to assess
patient
thoroughly,
particularly missing
this
scenario?
the part wherein:
What are her current medications?
If he was able to determine the blood pressure medications, which of
those medications were not available?
If he was also able to determine that she was taking a diuretic
medication, he might have chosen a different drug choice for her.

WHAT SHOULD HAVE BEEN

DONE TO PREVENT THIS
SCENARIO?

Gwen Thompson

Being proactive about medical care (Cheeks, 2013)

Be more alert with drug stocks

CyberDocs.com
Delineate scope
and
limitation
?7. What
What
should
should
havehave
been
been
done
done
to prevent
to
Outright telling
risks
this scenario?
prevent
this scenario?
Create a better workflow wherein such event would be prevented (e.g.
Different modules for each type of consultation and have required
information).
Show how long the physician is contracted in the site.

CyberDocs.com Physician
Be more investigative when assessing the patient.
Be more wary with prescribing medications.
Have a sense of responsibility and professionalism even when patient
is checked online.

CASE STUDY #2
Gina Conti is 75 years old, with multiple
chronic medical conditions including severe
rheumatoid arthritis. She lives in a rural
chronic-care nursing facility, and requires a
wheelchair to get around. Mrs. Conti was
recently seen by her family physician for a
persistent rash. Following several failed
diagnoses and treatments, her physician
recommended referral to a dermatologist
at a university hospital 60 miles away.
Neither Mrs. Conti nor her physician feels
that she can make a trip of this kind due to
her fragile condition, but since the local
hospital is part of the universitys
telehealth network, Mrs. Conti agrees to
have the dermatology consultation done
remotely.

CASE STUDY #2
Mrs. Conti is not sure what to expect, and has only been informed that
she will, be seeing a skin doctor on the TV screen. Upon arrival at
the local hospital, Mrs. Conti is taken to a room near the emergency
room waiting area where the dermatologist appears on a
videoconferencing screen. Mrs. Conti feels a little uneasy while talking to
the dermatologist on the screen, especially when the dermatologist asks
the nurse to disrobe Mrs. Conti so her rash can be examined.

CASE STUDY #2
The nurse is instructed to use a special camera for a closer examination of
the rash on Mrs. Contis buttocks, and scrapings are taken and sent to the
lab. Mrs. Conti notices that the dermatologist seems to be talking to
someone else, but it isnt until the session is almost over that she realizes
that a student and resident have been present off-camera, without her
knowledge or permission having been requested. When Mrs. Conti is wheeled
out of the telehealth room, she feels as though people in the ER waiting
room are staring. She is grateful to
have seen a skin specialist without
having to travel far, but wonders why
her physician didnt give her more
advance warning about what to
expect in the video consultation.

CASE
QUESTIONS

WHAT ARE THE PROS AND

CONS NOTED IN THIS
STUDY?
PROS

CONS

Lives in a rural CHRONIC-CARE

NURSING FACILITY

75 YEARS OLD with multiple chronic

medical conditions (severe rheumatoid arthritis)
Requires WHEELCHAIR
Persistent rash with failed
diagnoses and treatments

Physician recommended a referral (60

miles away).

She cannot make a trip of this kind due to

her fragile condition.

Hospital is part of the universitys

telehealth network.
Patient agrees to have the consultation
done remotely.

Patient is not sure what to expect.

Informed that she will, be seeing a skin
doctor on the TV screen.

WHAT ARE THE PROS AND

CONS NOTED IN THIS
STUDY?
PROS

CONS

Grateful to have seen a skin specialist

without having to travel far

Mrs. Conti feels uneasy while talking to the

dermatologist on the screen especially
when disrobing and examining the
buttocks.
Mrs. Conti notices that the dermatologist
talks to a student and resident who have
been present off-camera, without her
knowledge or permission having been
requested.
She feels as though people in the ER
waiting room are staring.
Wonders why her physician didnt give her
more advance warning about what to
expect in the video consultation.

WAS THERE A VIOLATION OF THE

PATIENTS
RIGHTS
DURING
THE
CONSULTATION? WHAT ARE THE ETHICAL
CONCERNS
ENCOUNTERED
IN
THIS
CASE?
YES.
Informed Consent and Concise Information:
The patient was only informed that she will, be seeing a skin
doctor on the TV screen., not fully informing the patient on
what would happen during the procedure.
What really happened:
Disrobed in front of the doctor on the TV screen.
Buttocks were examined.
Knew later on that there were other people.
Privacy and Confidentiality:
The patient disrobed in front of the TV without knowing that there
were other people who saw her during the consultation.
Self-Determination
Gina Conti was not able to have a choice whether if she would let
other people examine her or not.

WAS THE CONSENT GIVEN BY

GINA CONTI ENOUGH TO
ENCOMPASS THE OTHER
POSSIBLE VIOLATION(S) TO
HER PRIVACY AND
CONFIDENTIALITY?
WHY OR WHY NOT?

WHO IS MORALLY RESPONSIBLE

FOR WHAT WOULD HAPPEN TO
THE PATIENT?
THE PATIENT HERSELF?
THE DOCTOR WHO PERFORMED THE
TELEMEDICINE CONSULTATION?
THE OTHER MEMBERS OF THE HEALTHCARE
TEAM (NURSES, MEDICAL STUDENTS, PEOPLE
RESPONSIBLE FOR CONSENTING THIS
PROCEDURE?

WHY?

WHAT SHOULD HAVE BEEN

DONE TO PREVENT THIS
SCENARIO?

CREATE an improved Informed Consent for consultation through

Teleconferencing.

?7. What
What
should
should
havehave
been
been
done
done
to prevent
to
this scenario?
prevent
this scenario?

Source: templehealth.orgs A Practice Guide to Informed Consent

WHAT SHOULD HAVE BEEN

DONE TO PREVENT THIS
SCENARIO?
CREATE an improved Informed Consent for consultation through
Teleconferencing.

?7. What
What
should
should
havehave
been
been
done
done
to prevent
to
this scenario?
prevent
this scenario?

Source: templehealth.orgs A Practice Guide to Informed Consent

REFERENCES:
Nelson, W. (2009). Handbook for Rural Health Care Ethics A
Practical Guide for Professionals. Hanover, NH: Dartmouth
College Press.

Case Study #1
Alhassan, B. (2012). The Dangers Of Self Medication. Retrieved October
18, 2014 from http://connectnigeria.com/articles/2012/ 11/07/thedangers-of-self-medication/
Philippine Medical Association : Hippocratic Oath (n.d). Retrieved October
18,
2014
from
https://www.philippinemedicalassociation.org/
downloads/pma-codes/HIPPOCRATIC-OATH.pdf
American Nurses Association : Short Definitions of Ethical Principles and
Theories Familiar words, what do they mean? (n.d). Retrieved October
18,
2014
from
http://www.nursingworld.org/MainMenu
Categories/EthicsStandards/Resources/Ethics-Definitions.pdf
Josephson, M. (2010). 12 Ethical Principles for Business Executives by
Michael
Josephson.
Retrieved
October
18,
2014
from
http://josephsoninstitute.org/business/blog/2010/12/12-ethicalprinciples-for-business-executives/

REFERENCES:
Case Study #1
Cheeks, D. (2013). 10 Things You Want To Know About Medical
Malpractice. Retrieved October 18, 2014 from http://www.forbes.com/
sites/learnvest/2013/05/16/10-things-you-want-to-know-aboutmedical-malpractice/

Case Study #2
National Health Council : Principles of Patients Rights and
Responsibilities. (1995). Retrieved October 18, 2014 from
http://www.nationalhealthcouncil.org/pages/page-content.php?
pageid=66
Temple Health : A Practical Guide to Informed Consent. (n.d.)
Retrieved October 18, 2014 from http://www.templehealth.org/
ICTOOLKIT/ html /ictoolkitpage5.html

THANK
YOU!!!