Ethics Case Studies

1. Ethics Case Studies VSIAS: July 21, 2010

2. How Argument Works

3. An Example of Method In Ethics James Rachels- Active and Passive Euthanasia

4. Smith Greedy Rich Nephew Plots Murder Accidental Appearance Waits for Bath Sneaks In Presses Head Under Water Holds Hand over Head Splashing Thrashing Nephew Drowns Plan Successful Good Guy or Bad Guy?

5.  Jones Greedy Rich Nephew Plots Murder Accidental Appearance Waits for Bath Sneaks In Nephew Slips [Presses Head Under Water] Holds Hand over Head Splashing Thrashing Nephew Drowns Plan Successful Good Guy or Bad Guy?

6. Method In EthicsJames Rachels- Active and Passive Euthanasia The Bare Difference Between Act and Omission Does Not Make A Moral Difference

7. A Practical Methodin Ethics

10. Immigration Ethics�If It Isn�t Documented�� Mr. S is a 24-year-old client who receives substance abuse counseling through the CSB. Mr. S has several significant stressors in his life that have become the focus of counseling. One major issue surrounds Mr. S�s illegal immigration status. Mr. S�s counselor is reticent to document this issue in detail because the records could be subpoenaed. Should the SA counselor keep complete records?

11. Immigration Ethics�We Need the Complete Picture� Ms. F is a 15-year-old woman who was brought in for intake by non-custodial family members. Ms. F reports suicidal ideation and at least one attempted overdose. She also reports a history of sexual abuse by family members. She explains that she never went to the authorities for help because her family is in the country illegally. The CSB staff person suspects child abuse and neglect and makes the requisite call to CPS. The CPS investigator inquires about immigration status. How should the staff person respond?

12. Immigration Ethics�The Law Is The Law� Ms. H is a 25-year-old woman who was brought in for intake by non-custodial family members. Ms. H reports suicidal ideation and at least one attempted overdose. She also reports a history of spousal abuse but explains that she never went to the authorities for help because she and her husband are in the country illegally. How should the CSB counselor respond? What if Ms. H has a physical disability and her only support/care provider is her husband?

13. Discharge Issues Ms. L is a 27-year-old patient at a State Mental Health Facility who was admitted from jail after making suicidal statements. Ms. L carries a diagnosis of depression with suicidal history. She suffers from Post Traumatic Stress Disorder and has a long history of poly-drug substance abuse. Ms. L is pregnant, at thirty weeks approximate gestational age. Obstetrical exam reveals no apparent damage to Ms. L's fetus. Although Ms. L is presently receiving therapy, treatment with anti-depressants is contraindicated because of her pregnancy. Question has developed surrounding discharge plans for this patient. Ms. L has indicated that she is likely to engage in drug abusing behavior if she returns to jail or if she is bonded out to the community. This drug use may cause significant problems for Ms. L's fetus. Although Ms. L meets discharge criteria, all other things being equal, staff are concerned that continued hospitalization might be necessary to protect the fetus. Is it ethically problematic to keep Ms. L in the hospital longer than usual because she is pregnant?

14. Substance Abuse Cases Mr. B is a 53-year-old client who carries a diagnosis of chronic schizophrenia, paranoid type with severe delusions who experienced his first psychotic break in his early twenties. Mr. B has a history of ETOH and poly-substance abuse and has very poor insight into his own condition. Clozaril was initiated two years ago but was discontinued after it triggered polydypsia that resulted in dangerously low sodium levels. Mr. B has had suicidal ideations and engaged in at least two serious suicide attempts while living in an assisted living facility. The most recent suicide attempt resulted in admission to a State MH facility. Hospital personnel have now determined that Mr. B has capacity to make his own healthcare decisions and that he is discharge ready. They believe that the patient should be discharged to an ALF but CSB staff are concerned that given his history, Mr. B would be at risk in such a setting. This ethics consult was requested to determine whether or not there are any ethical issues associated with supporting Mr. B�s discharge into various possible settings.

15. Forced Withholding (Review) Ms. M is a client in her early thirties who has two children, ages six and seven. Ms. M is not married but she has had a boyfriend who is reported to be abusive. The belief that the boyfriend is abusive derives from behavioral cues from the children, bruising of Ms. M and known illegal drug activity that has resulted in the boyfriend not only spending some time in custody but also being subject to a court order restricting him from the apartment property. Since the boyfriend has been unable to visit, Ms. M has done rather well but she now wants to move to another apartment. Staff members are concerned that if she moves to a place where the boyfriend can gain access, both she and the children will be at risk and that Ms. M might re-engage in substance abuse. This ethics case consultation was requested to determine the degree to which the CSB has a moral obligation to assist Ms. M in finding alternative housing when staff does not believe that it is in her interest to move.

16. Substance Abuse Cases The Ethics Committee was recently asked to comment on a complicated scenario presented by one of our therapists. The therapist has been providing services to one client for over a year. That individual indicated that his sister had been expressing suicidal ideation and that she might need services. The therapist then spoke to the sister who confirmed suicidal ideation but denied a plan or intent to kill herself. The sister did state that her suicidal thoughts increase when she drinks alcohol. The therapist then spoke to SA staff about setting up a priority intake and the SA supervisor requested that the therapist do the sister�s intake. Both the initial client and his sister signed releases of information so the therapist could talk to both siblings about relevant issues, and the sister was assigned to an SA therapist. The brother has now withdrawn his consent for release of information but also indicates that his sister is drinking again. The therapist has reason to believe, based on interactions with her own client, that the sister is lying to her therapist about drinking. The ethical question that has been posed concerns the role of the brother�s therapist in discussing the sister�s drinking with the sister�s therapist, thus breaching the brother�s confidentiality.

17. Prevention Ethics Is it ethical to use funding that comes from alcohol/medication/abusable substance businesses or organizations to pay for prevention education/marketing/youth leadership? For instance, is it ethical to generate a website linked to the prevention coalition that educates the public about potential Rx abuse risks, leads viewers through a self diagnosis by symptom, and then advocates that viewers ask their physicians about specific medications to address the symptoms?

18. Prevention Ethics Is it ethical to use contributions from local alcohol distributors to pay for youth leadership events sponsored by prevention specialists? Should those companies be listed as event sponsors?

19. Ethics and Dual Diagnosis:Does Categorization Matter? VSIAS: July 21, 2010

20. Dealing With Dual Diagnosis Expertise The Hockey Puck Prioritization of Need

21. Ethics in Long-Term Care�Psychiatric Instability� Mr. C is a resident in assisted living who has requested to return to independent living. Staff indicate that Mr. C was admitted to assisted living based on concern surrounding his documented suicidal ideation and a desire to closely monitor his medication management, even though he did not meet UAI criteria for assisted living. It is unclear how Mr. C scores on the UAI currently but his physical function has not deteriorated since admission. However, Mr. C does have a history of depression and there is some concern that we will be less able to monitor his mental health status in independent living. The primary ethical issue is based, therefore, on whether or not depression, without associated losses of physical function, creates a legitimate basis for ruling out an individual for living independently.

22. �The Social Responsibility ofBusiness is to Increase Profits�Milton Friedman �The whole justification for permitting the corporate executive to be selected by the stockholders is that the executive is an agent serving the interests of his principal. This justification disappears when the corporate executive imposes taxes and spends the proceeds for �social� purposes�.

23. �A Stakeholder Theory of the Modern Corporation: Kantian Capitalism�Evan and Freeman �The corporation should be managed for the benefit of its stakeholders: its customers, suppliers, owners, employees and local communities. The rights of these groups must be ensured, and, further, the groups must participate, in some sense, in the decisions that substantially affect their welfare.�

25. Dealing With Dual Diagnosis The Arete of the Provider

26. Moral Management�Being Nice Vs. Being Ethical� Supererogation

27. Moral Management�Identify the Default Assumptions� Background Obligations

28. Moral Management�The Source of Obligation� What Is Your Role?

29. Moral Management�The Source of Obligation II� What Are Your Relationships?

30. Moral Management�How Relationships Work� Tacit Expectations Explicit Promises

31. Moral Management�What Ethical Leaders Do� Identify Default Obligations Recognize Distinct Obligations Across Individuals, Disciplines and Departments Prioritize Conflicting Obligations Support Valid Processes

32. Aristotelian Virtue Theory Remember Your Ar�te

33. SAS Dual Relationships�I Thought You Were My Sponsor� Staff person S has agreed to be Staff person T�s sponsor. They have known each other for a long time, and the relationship seems to work well. On one occasion however, Staff person T confides in his sponsor and tells him that he recently relapsed. Staff person T is confident that he can overcome this setback, and he is asking Staff person S for support. After discussing the experience fully, Staff person S is concerned that Staff person T might have been high while at work. Worse yet, Staff person S is worried that Staff person T might be tempted to divert medications from some consumers for his own benefit. Although Staff person T does not have any evidence of medication diversion or dangerous work habits, he feels that he is in a moral dilemma. Does the duty of confidentiality as a sponsor outweigh the duty to maintain a safe work environment? Should Staff person S be more loyal to Staff person T, or to the facility in which he works?

34. The Ethics of Disclosure The CSB has been contracted to provide therapeutic supports for non-violent juvenile offenders, and as part of that work, two sets of charts are kept; An Alcohol and Drug Services chart that is kept under the strictest of confidence, and a second chart to which probation officers have access. During a recent meeting, a consumer�s probation officer wanted to know if the therapist had information to suggest that any rules are being infringed by adolescents in their program. The parole officer had a clear expectation that information revealed in the therapeutic relationship would be shared with the parole officer. Should the parole officer have access to information relevant to the operation of the program?

35. Substance Abuse Cases Mr. A is a 51-year-old client who has been diagnosed with Bipolar Affective Disorder and Poly-Substance Abuse. Mr. A has been receiving services from the CSB for several years and is currently receiving Welbutrin, Depakote and Seroquel. This ethics consult was requested because Mr. A also reports a history of marijuana, valium and benzodiazepine abuse and describes current heavy alcohol use. Furthermore, Mr. A indicates that he has been doubling his Seroquel dose but he is unwilling to accept SA treatment or to undergo regular drug and alcohol screenings. The ID team, including the attending physician, has become concerned that continued provision of Seroquel is dangerous. The team offered to continue to provide Seroquel only if Mr. A agreed to a 30 day Inpatient SA treatment program, an aftercare program, and drug/alcohol screenings. Mr. A has not agreed to this plan and continues to demand that his Seroquel prescription be renewed. This ethics consult was requested to determine whether or not CSB staff may ethically refuse to provide Seroquel in these circumstances.

36. Substance Abuse Cases Mr. J is a 28-year-old individual who was TDO�ed after demonstrating psychotic symptoms. The assigned therapist believes that Mr. J suffers from mental illness, but he also believes that many of the symptoms are triggered by substance abuse. The therapist does not believe that meaningful progress can be made unless Mr. J�s SA issues are handled first. SA staff believe that Mr. J�s current psychosis obscures insight and eliminates any likelihood for progress with SA issues. The MH professional believes that SA is the primary diagnosis and only wants to deal with MH issues after substance abuse has been eliminated. The SA professional believes that MI is the primary diagnosis and only wants to deal with SA issues once Mr. J�s mental health has been stabilized. How should staff proceed?

37. Substance Abuse Cases Mr. K has requested mental health counseling and indicates a history of bipolar affective disorder. He also admits to chronic marijuana use. When the psychologist assigned to Mr. K suggests that drug use could exacerbate his mood disorder, Mr. K states that he has no drug problem, that that is not why he has accessed services, and that he does not want to access any services that target drug use. Mr. K hints at the fact that he considers the marijuana to be efficacious in dealing with his symptoms.