Call for Submissions: Essays due to email@example.com by 8:00 a.m. March 12, 2018
Monetary Awards: 1st Place- $1,000; 2nd Place- $300; 3rd Place- $200
This prestigious annual award includes a cash prize recognizing the best essay by a UT Health San Antonio medical student on a bioethics topic. The essay topic will be chosen by the medical student, and all submitted essays will be assessed by a panel of health care ethicists and knowledgeable physicians. All medical students are eligible, and the prompts are provided merely to stimulate ideas. No special preference will be given to essays that follow these prompts as opposed to a completely original topic.
First, a definition is in order: What is Bioethics? Bioethics is a branch of applied ethics that studies the philosophical, social and legal issues arising in medicine and the life sciences. It is chiefly concerned with human life and well-being.
In the course of practicing medicine, physicians often encounter tension between their duties to individual patients and to society (e.g., concern for public health or public/professional norms).
Select one of the following topics and write an essay that identifies and illuminates – through examples, data, case studies, and informed moral reasoning – how physicians should discharge their ethical responsibilities to both the individual patient and to society.
Prompts you may consider:
- The Electronic Medical Record (EMR) emerged in the 1960s to improve physician documentation, communication and billing. In 1991, the Institute of Medicine recommended universal implementation of the EMR as a way to improve health care. Yet, many physicians are concerned that EMR-related responsibilities undermine the care of individual patients. Has the EMR achieved its goals and at what price to patient-doctor relationships?
- The care of patients with serious illness has evolved in recent decades. Palliative care and hospice are increasingly available and integrated into the practice of medicine. These services are recognized as promoting patient well-being and respecting patient rights. One controversial trend at the state level has been the legalization of Physician Assisted Death (PAD), a practice that does not have the united support of palliative care specialists. Proponents argue that PAD is an essential tool for ensuring that comfort and autonomy are available to the most vulnerable members of society. Opponents raise concerns about professionalism and unintended consequences. Should the medical profession embrace PAD as an option for patients with serious illness?
- Maternal mortality is rising in Texas, while the rest of the world is reducing maternal deaths significantly. Recent studies indicate that the poor and minorities are disproportionately affected, and that many of the underlying risk factors are preventable. What is role of the physician in advocating for reduced maternal mortality? And, how can physicians ensure that relevant ethical considerations inform health-related policymaking at the state level?
- Two of the largest immigrant detention centers in the United States are located 75 miles south of San Antonio, in Dilley and Karnes City. Asylum seekers released from these facilities en route to sponsors elsewhere in the country routinely traverse San Antonio, where they may stay in shelters for 3-5 days. Bexar County physicians who are obligated to act as stewards of local resources, including taxpayer dollars, may encounter sick asylum seekers with neither the residency status nor the funding to lay claim to these local resources. What is the nature and what are the limits of moral responsibility for physicians to provide health care to this transient population? Are there ethical or biological hazards associated with disregarding the health needs of these patients? Discuss this question from the perspective of health, human rights and social justice.
The essays will be judged on the following rubric:
Applicability of topic/Educational value to health care professionals
Identification of ethical issues in topic
Shows how topic relates to health care
Quality of writing
Uses proper grammar & spelling
Comprehension of issues
Demonstrates knowledge of chosen topic
Provides evidence to support thesis & arguments
Draws appropriately on external resources
Demonstrates original thought (rather than just restating what others have said)
Clarity of discussion & conclusions
Shows a clear logical flow of argumentation (e.g. thesis; arguments; supporting evidence)
Stays on topic
Makes a logical conclusion for action, thought, or research
Some semesters, though not this one, students may write a paper. Here are 25+ suggested paper topics.
- Legal status of DNR orders in Texas. Are they a treatment decision about withholding or withdrawing life-sustaining treatment for purposes of the Advance Directive Act? Can they be consented to pursuant to Chapter 313 of the Health and Safety Code? Can a DNR order be written unilaterally? Even over the objections of the patient or the patient’s family? And still retain the immunity provided by Chapter 166 of the Health and Safety Code?
- Resolving fetal-maternal conflicts. Pregnant women sometimes refuse medical interventions that would benefit themselves, their fetus, or both. These interventions might be major surgery (e.g., a C-section), antibiotic therapy for a Strep infection (easy to treat, not good if left untreated), or a fetal monitor (to name just a few). Some of the interventions are quite invasive, others not so much. Some are inherently quite risky, but not others. Sometimes the risk (of either treatment or nontreatment) falls entirely on the fetus; sometimes they fall on the pregnant woman, too. How should these types of conflicts be resolved?
- Pregnant women and permanent vegetative state (PVS) or brain death. Suppose a pregnant woman is injured in a car crash and is eventually declared to be in a PVS or to be dead according to neurological criteria. May her surrogate decision maker choose to support her organs, and the life of the fetus, until the child can be delivered? Must the surrogate decision maker continue life-support? Does it matter if at the time of decision the fetus is not yet viable?
- Children as human research subjects. The Maryland Court of Appeals handed down two opinions in a case involving Johns Hopkins' Kennedy Krieger Institute in Baltimore. The opinions have been widely criticized on the ground that if the court’s decision is followed elsewhere, it will be the end of so-called “non-therapeutic” pediatric research. What is the federal government’s position on such research? Where do other states stand?
- Human tissue. Who owns bone, sinew, corneas, and other saleable body parts? Who can consent to its post-mortem removal? What do state statutes say about the nonconsensual removal of human tissue? Why does federal law prohibit the sale of solid organs but permit the sale of other human tissue (and blood, sperm, and ova)? Do the rules that govern these activities sufficiently protect the interests that need to be protected? Or do they go too far and discourage an efficient market?
- Physician-assisted suicide (PAS). Oregon is the only state to have legalized the practice. The Supreme Court has ruled that considerations of neither due process nor equal protection compel states to allow the practice and that the Department of Justice may not prosecute Oregon physicians who participate in PAS. Your paper can go in lots of different directions. Should other states follow Oregon’s lead? Is there an equal-protection argument that once a state has legalized PAS, it must also legalize active euthanasia? What can we learn from the practices of other countries?
- Patentatibility of genetic code. Should genetic researchers be able to obtain patents on "raw" genetic code? What should the Patent and Trademark Office's policy be on demonstrating "utility" in order to obtain a patent for a snippet of DNA?
- Is "brain dead" really dead? All 50 states and the District of Columbia have rules that define death in terms of the irreversible cessation of all neurological functioning. This notion of “brain death” has been around since 1968, when the Harvard Medical School Report on “irreversible coma” (now regarded as something of a misnomer) was issued. Yet, just as soon as we as a nation seem to have become comfortable (more or less) with the concept, it is coming under increasing scrutiny and criticism. Is it internally inconsistent? Is it a snow job by the transplant community? Are the NY and NJ variations the way of the future? Is neocortical death preferable to whole-brain criteria for determining when death occurs?
- Out-of-Hospital DNR Orders (OOH-DNR) and children. Not many states authorize OOH-DNR orders. Even fewer authorize them for minors, but Texas does. Should OOH-DNRs for children be limited to those who are certified to have a terminal or irreversible condition? What happens when a child with an OOH-DNR order suffers cardiac or respiratory arrest in school? On a commercial airline flight? In a restaurant? How the should rights and obligations of the various affected parties be balanced? What should a regulation from the Texas Department of Health, Texas Department of Education, or FAA look like?
- Organ donation after cardiac death ("DCD," or non-heartbeating donor ("NHBD") protocols).) Usually, cadaveric organs are harvested from donors who have been declared “brain dead.” Sometimes, however, the donor, the donor’s family, or the transplant team don’t want to wait that long for the organs. Some transplant centers have reverted back to the old cardio-pulmonary criteria for determining death. Of course, they provide a certain amount of medical assistance along the way, ostensibly to help ensure the viability of the organs. In so doing, are these centers actually killing patients for their organs? Taking organs from patients who do not satisfy the criteria for determining death in this country? What would a good NHBD protocol look like? Absent the sorts of safeguards contained in such a protocol, should local DA’s be considering homicide charges of some kind? What are the relative advantages and disadvantages of "controlled" vs. "uncontrolled" DCD?
- Charity care. Texas requires its not-for-profit hospitals to provide charity care as a quid pro quo for tax-exempt status. A dozen or more states do the same, and more states are jumping on the charity-care bandwagon every month. The federal government used to require charity care as a prerequisite for tax-exempt status, but it dropped that requirement in 1968. Should it resurrect the charity-care requirement? If so, what should it look like? What are the pitfalls illustrated by various state experiments in this field? Is there a better way to deal with the problems of providing health care for the indigent and uninsured?
- Anencephalic newborns. Medical texts usually refer to anencephaly as a condition that is “incompatible with life” or to anencephalic newborns as “born dying.” Despite this, a few years ago, the Florida Supreme Court said the organs of a baby born with no neo-cortical hemispheres could not be donated because the baby was still alive under Florida law. (The AMA once opined that anencephalics should be regarded as an exception to the requirement that organ donors be dead and then turned around at its next session and revoked its own ruling.) A few years later, the 4th Circuit Court of Appeals said that a Virginia emergency room had an obligation under federal Medicare law to treat the respiratory distress of an anencephalic infant who was brought to the ER from a local nursing home. Do we need to rethink the law’s response to anencephaly? Or are anencephalic newborns entitled to the same level of protection as any other member of society?
- What are 5 things the next Texas Legislature needs to fix in the Advance Directives Act? Even after the 1999 overhaul, the 2003 tweaking, and the 2007 proposed overhaul of the Advance Directives Act, this law seems incomplete in some ways and flawed in others. You could study the various states’ approaches to advance directives law in a reliable treatise such as THE RIGHT TO DIE by Alan Meisel and Kathy Cerminara (in Underwood Law Library), talk to ethics committee chairs in the community, read the Uniform Health-Care Decisions Act, compare provisions to the Texas law, and argue for the changes you think our law most needs to have.
- Should DNR orders be respected during surgery and in recovery? Patients with DNR orders sometimes get surgery, and that surgery may involve general anesthesia. Customarily, DNR orders are suspended during surgery and patients who experience cardiac arrest are given CPR and full life support. Although they have taken somewhat different positions on this, surgeons’ and anesthesiologists’ groups have come out in favor of a more nuanced approach to DNR orders during and immediately after surgery. What would a hospital policy look like? Is it a good idea?
- Demands for futile treatment. Surrogate decision makers often ask that “everything be done” for a patient. Sometimes they are more specific. Occasionally this request is for treatment deemed by the medical team to be “futile.” Should physicians be able to withhold or withdraw nonbeneficial interventions? If so, under what circumstances? What process values should be respected?
- Should the U.S. Congress ban all human cloning ("reproductive" and “therapeutic” cloning)? The distinction between types of cloning activity is driven by the desire of many to create new sources of embryonic stem cells by creating new embryos. What are the arguments for and against both types of cloning? Which do you find persuasive and why? Note: the President's Commission on Bioethics has weighed in on this topic with its first report.
- Federal funding for stem cell research. President Bush’s policy, announced August 2001 and fleshed out by the NIH since that time, superseded an earlier funding policy put out by Pres. Clinton’s NIH chief, Dr. Harold Varmus. There are a couple of ways (at least) to proceed on this topic, e.g.: Which funding policy got it right (if either did)? On the merits, how did Bush do? Is this a funding policy that is doomed? Internally inconsistent? Based upon unsustainable premises or distinctions? Or is it a principled compromise that will stand the test of time?
- Ethics of third-world drug research. Drug companies have been accused of running drug-testing protocols in third-world countries that would be unethical and impossible to run in the U.S. Other times, they have been criticized for testing drugs that will eventually be marketed at a price the third-world countries won't be able to afford. What should the rules be for such research?
- The federal "Baby Doe" rule. Two Dallas Morning News articles in 2002 highlighted some problems with the Baby Doe rule. The Texas Supreme Court has decided a case that raised some of these issues (even though the Court of Appeals refused to discuss Baby Doe). Should the Baby Doe rule be abandoned? Modified? Or kept just the way it is?
- Living related organ donors and paternity information. When an adult child decides to donate an organ to a parent on the donor waiting list, blood samples are analyzed to determine whether the offspring is a match. This information provides information that is also conclusive (or nearly so) on the question whether the recipient is the donor’s biological parent. Are potential donors entitled to genetic parentage information? How do genetic counselors handle the analogous situation (if an analogous situation exists)? Should the transplant surgeon provide this information? What are the implications of your answer for the informed consent process?
- The "Ashley Treatment." Ashley is a brain-damaged girl whose parents feared that as she got bigger, it would be much harder to care for her; so they set out to keep her small. Through high dose estrogen treatment over the past two years, her growth plates were closed and her prospective height reduced by about 13 inches, to 4'5". The doctors also removed her uterus to prevent potential discomfort from menstrual cramps or pregnancy in the event of rape; and also her breast tissue, because of a family history of cancer and fibrocystic disease. Not having breasts would also make the harness straps that hold her upright more comfortable. "Ashley has no need for developed breasts since she will not breast feed," her parents argue, "and their presence would only be a source of discomfort to her." How far should parents and doctors be able to go in modifying their child through drugs and surgery? Has Ashley been disfigured? Abused? Or lovingly cared for?
- Medical decision making for minors. What should the standards be for reviewing and overruling parental medical choices? You might focus on one set of such decisions (end-of-life decisions, decisions by Christian Scientists, etc.) for your analysis.
- Health law and ethics. Various regulations and statutory prohibitions have their roots, and their continued justification, in ethics. Illegal remuneration, fee-splitting, self-referral, corporate practice of medicine doctrine, patient abandonment . . . these and many more represent not only legal norms, but ethical norms as well. Is the ethical thinking about these doctrines outmoded or still valid? Are there newer and better ways to deal with the harms these doctrines try to address?
- Sex selection (and other genetic manipulations). What limits, if any, should be placed on the ability of prospective parents to guide or alter the genetic makeup of their offspring?
- Bioethics and literature. The President's Commission on Bioethics has posted five sets of readings on various bioethics themes. Pick one or more themes and evaluate the readings. Are they biased or balanced? Are essential points of view missing? What do you make of the readings that are listed? Do they speak to policy issues in any useful or unique way?
- Medicine and capital punishment. Should physicians be allowed to medicate prisoners to make them competent for trial? For execution? The AMA has opinions on this; are they correct? Are they even coherent? And are they on a collision course with the Eighth Amendment's prohibition of cruel and unusual punishment?
- Conjoined twins. What should the rules be for the separation of conjoined twins? What if separation is necessary to save one twin but will inevitably lead to the death of the other?
- Physical restraints in emergency medicine. What are the limits? Should they be changed?
- "Boutique medicine." Now there's a national society for doctors who want to charge upfront fees to patients who want preferential treatment. What should the law say, if anything, about "concierge" or "boutique" medicine? Is this a development hospitals might want to emulate?
- Veterinary ethics. This is an overlooked area, except perhaps with respect to the use of animals in research for human products, but practicing veterinarians have ethical issues, too. For example, do veterinarians have an obligation to provide charity care? Can they refuse to return a pet to its owner until the owner pays the bill for services rendered? What are the limits on an owner's right to insist that an animal be euthanized (i.e., is it ethical to euthanize a cat that sprays? a treatable horse for the insurance proceeds? a sick animal without the owner's permission?)? Should veterinarians be required to report animal abuse? What should be the limits on a veterinarian's ability to sell nonprofessional goods and services?
- Access to experimental drugs. Do terminally ill patients have a constitutional right to get access to experimental drugs without enrolling in a clinical trial? A divided panel of the DC Circuit said yes in a May 2, 2006, opinion. In fact, they concluded that the constitutional right is fundamental and that the appropriate test of any rule limiting access is strict scrutiny. This is an opinion of potentially far-reaching consequences for patients, health care providers, payors, and the future of clinical drug trials in this country.
Note: Many, many useful web sites exist to help get you started with your research. My own Bioethics Web Resources page collects links to a lot of these resources.