Ethical Issues over DNR Orders

This week, we will have two case studies:

  • Ethical Issues over DNR Orders
  • Emergency Divert Status

These case studies will cover topics in healthcare disparities, cultural competencies, ethics laws, and conflict of interests. You will have the opportunity to discuss a case among your fellow students and perform a written analysis on the case.

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Your Learning Objectives for the Week:

  • Evaluate issues on human behavior in healthcare organizational settings, including issues pertaining to leadership and change interventions to enhance organizational effectiveness.
  • Analyze human resource systems for employment, compensation, training and development, appraisal, and labor/employee relations in health care organizations.
  • Critique healthcare reform process in the US health care system, reviewing major proposals for system reform currently under consideration including governance and accountability models.



Healthcare Ethics (Stem Cell Research)

Technological advances over the past few decades have today created medical possibilities without boundaries and also invoked nightmarish science fiction imagery beyond what was previously imagined.

Even its opponents have not denied the medical benefits of stem cell research. Stem cell research proponents cite the promise it holds for curing what are now incurable diseases such as Alzheimer’s, Parkinson’s, amyotrophic lateral sclerosis (ALS) or Lou Gehrig’s disease, and multiple sclerosis, as well as spinal cord injuries (Pozgar, 2016). Opponents of stem cell research argue that this practice is a slippery slope to reproductive cloning and fundamentally devalues the worth of a human being.

The debate surrounding human embryonic stem cell research plays a crucial role in the culture wars. Those who embrace post-traditional morality see no ethical problem with the destruction of human embryos for research and therapies (Joseph, 2013). There are an estimated hundred million people worldwide who are afflicted by these medical conditions. As personalized medicine and patient stratification come to the fore and therapies are becoming more patient specific, important questions are being raised regarding whether conclusions gained from using a single genomic background in a drug screening assay are globally applicable (Minger, 2013). Stem cells are thought to hold the possibility of creating human organs, which will match the cellular structure of the organ recipient.

Opponents of stem cell research declare the use and destruction of life (or potential life) in the form of embryonic stem cells as unacceptable. Opponents of embryonic stem cell research draw a parallel to the experimentation on human beings in the World War II concentration camps. Because the embryo must be destroyed to obtain embryonic stem cells, and because many opponents of stem cell research equate embryonic stem cells with life, they conclude that such medical breakthroughs cannot ethically be obtained at the expense of human life. On August 9, 2001, President George W. Bush announced his policy on research involving human embryonic stem cells and proclaimed that federal funding would be allocated only to research involving human embryonic stem cell lines produced prior to his announcement (Yaniv, 2008).

Medical Ethics

Ideally, for a medical practice to be considered “ethical,” it must respect all the four of these principles: autonomy, justice, beneficence, and nonmaleficence.

Review each tab to know more.



Requires that the patient have the autonomy of thought, intention, and action when making decisions regarding healthcare procedures.

When Does the Ethic Come into Play: Example

A woman enters the emergency room with stomach pain. She undergoes a CT scan and is diagnosed with an abdominal aortic aneurysm, a weakening in the wall of the aorta, which causes it to stretch and bulge. (This is very similar to what led to John Ritter’s death.) The physicians inform her that the only way to fix the problem is surgically and that the chances of survival are about 50/50. They also inform her that time is of the essence, and should the aneurysm burst, she would be dead in a few short minutes. The woman is an erotic dancer; she worries that the surgery will leave a scar that will negatively affect her work; therefore, she refuses any surgical treatment.

Ideal Actions to be Taken to Observe or Conform to Ethic: As per the Example

The decision-making process must be free of coercion or coaxing. In order for a patient to make a fully informed decision, she or he must understand all risks and benefits of the procedure and the likelihood of success.



The idea that the burdens and benefits of new or experimental treatments must be distributed equally among all groups in society.

When Does the Ethic Come into Play: Example

A woman after a bout with uterine cancer had a hysterectomy (surgical removal of the uterus). Before its removal, however, she had several eggs removed for possible fertilization in the future. Now married, the woman wishes to have a child with her husband. Obviously, she cannot bear the child herself, so the couple utilizes a company to find a surrogate mother for them. The husband’s sperm is used to fertilize one of the wife’s eggs and is implanted in the surrogate mother. The couple pays all of the woman’s pregnancy-related expenses and an extra $18,000 as compensation for her surrogacy. After all expenses are taken into account, the couple pays the woman approximately $31,000 and the agency approximately $5,000. Though the surrogate passed stringent mental testing to ensure she was competent to carry another couple’s child, after carrying the pregnancy to term, the surrogate says that she has become too attached to “her” child to give it up to the couple. A legal battle ensues.

Ideal Actions to be Taken to Observe or Conform to Ethic: As per the Example

Requires that procedures uphold the spirit of existing laws and are fair to all players involved. The healthcare provider must consider four main areas when evaluating justice: fair distribution of scarce resources, competing needs, rights and obligations, and potential conflicts with established legislation. Reproductive technologies create ethical dilemmas because treatment is not equally available to all people.






Requires that the procedure be provided with the intent of doing good for the patient involved.

When Does the Ethic Come into Play: Example

A woman was diagnosed with motor neuron disease (the same disease that Stephen Hawking had) five years ago. This is a condition that destroys the motor nerves, making control of movement impossible, while the mind is virtually unaffected. People with motor neuron disease normally die within four years of diagnosis from suffocation due to the inability of the inspiratory muscles to contract. The woman’s condition has steadily declined. She is not expected to live through the month and is worried about the pain that she will face in her final hours. She asks her doctor to give her diamorphine for pain if she begins to suffocate or choke. This will lessen her pain, but it will also hasten her death. About a week later, she falls very ill and is having trouble breathing.

Ideal Actions to be Taken to Observe or Conform to Ethic: As per the Example

Demands that healthcare providers develop and maintain skills and knowledge, continually update training, consider individual circumstances of all patients, and strive for net benefit.



Requires that a procedure does not harm the patient involved or others in society.

When Does the Ethic Come into Play: Example

A married couple wishes to have a child; however, the thirty-two-year-old mother knows that she is a carrier for Huntington’s disease (HD). HD is a genetic disorder that begins showing signs at anywhere from thirty-five to forty-five years of age. Its symptoms begin with slow loss of muscle control and ends in loss of speech, large muscle spasms, disorientation, and emotional outbursts. After fifteen to twenty years of symptoms, HD ends in death. It is a dominant disorder, which means that her child will have a 50% chance of contracting the disorder. Feeling that risking their baby’s health would be irresponsible, the couple decides to use in vitro fertilization to fertilize several of the wife’s eggs (Cases in Medical Ethics, 2005). Several eggs are harvested, and using special technology, only eggs that do not have the defective gene are kept to be fertilized. The physician then fertilizes a single egg and transfers the embryo to the mother. Approximately nine months later, the couple gives birth to a boy who does not carry the gene of the disorder.

Ideal Actions to be Taken to Observe or Conform to Ethic: As per the Example

Infertility specialists operate under the assumption that they are doing no harm or at least minimizing harm by pursuing the greater good. However, because assistive reproductive technologies have limited success rates, the emotional state of the patient may be impacted negatively. In some cases, it is difficult for doctors to successfully apply the do-no-harm principle.

Reference Cases in Medical Ethics. (2005). Retrieved from

Ethical Issues in Healthcare Research

Ethical norms are so ubiquitous that one might be tempted to regard them as simple commonsense. On the other hand, if morality were nothing more than commonsense, there are so many ethical disputes and issues in our society.

Review each topic to know more.



Adolescent Pregnancy


A fourteen-year-old requests termination of pregnancy.






Placebo Ethics


Doctors are still in disagreement about whether it is ethical to proscribe a placebo without the patient’s consent.


Presents information about the various healthcare topics and research that may be considered ethically dubious similar to stem cell research (e.g. abortion for young single females, use of placebos, neonatal and pediatric issues, research on placenta, etc.).

Intensive Treatment


The Ethical Acceptability of Limitation of Intensive Treatment: Controversial issue deals with the ethical acceptability of withholding or withdrawing intensive care and/or mechanical ventilation.


Joseph, T. (2013). Human embryonic stem cell research: Its importance in the culture wars. Christian Bioethics19(1), 60–71. doi:10.1093/cb/cbt001

Minger, S. L. (2013). Developing technologies to unlock the therapeutic and research potential of human stem cells [Special issue]. New Biotechnology, 30(4)378–380. doi:10.1016/j.nbt.2012.11.006

Pozgar, G. D. (2016). Legal aspects of health care administration (12th ed.). Burlington, MA: Jones & Bartlett.

Yaniv, H. (2008). On presidents, agencies, and the stem cells between them: A legal analysis of president Bush’s and the federal government’s policy on the funding of research involving human embryonic stem cells. Administrative Law Review60(1), 65–125.



Additional Materials

From your course textbook, Cases in Health Care Management, review the following cases:

· Case 74: Ethical Issues over DNR Orders

· Case 75: How Dare You Bring Your Girlfriend to Visit Mom?

· Case 76: Saline Splash

Universal Healthcare

Healthcare being regarded as a human right and provided to all citizens would require the addition of a large amount of resources. The advantages of universal healthcare for individuals are that everyone would be provided a set standard of preventative and recuperative care. Currently many people are unable to afford preventative check-ups and care causing people to wait until they are extremely sick to reach out for help. This could easily cause whatever the issue is to be way past an easy health solution requiring expensive procedures or possibly being outside of the scope of help (Worstall, 2017). Many people believe that regular access to routine check-ups and education could prevent many negative future health consequences.

The primary disadvantage for some individuals who are now able to afford the costs of their healthcare is that they may no longer be able to purchase better care with their resources. A single payer system would likely eliminate the ability for individuals to pay for their own care, leaving them at the mercy of the national standard of care. Currently many people in other countries with national healthcare systems come to the U.S. because they are able to purchase care that they would not be able to quickly get at home (Belluz, 2017).

A national healthcare system would increase taxes paid by its citizens and like our current tax system, would ride heavily on the taxation of the middle class. While the exact percentages each person would pay, this additional cost could be a burden for many individuals and employers. As an advantage each and every person in the U.S. would be granted some standard of care without seeking out their own complicated health insurance plan. Instead of directly choosing an insurance plan from the established insurance marketplaces, the money for each individual health insurance would be directly pulled from their earnings or fully subsidized by the government and taxpayer money.

The current healthcare system is likely unprepared as is to handle the increase in patients that would be created by the implementation of universal healthcare. Currently many people go to the ER for rudimentary treatment when they deem their health situation to be an emergency or when they are without insurance. This creates an unnecessary burden on the system and inefficiently uses resources. Requiring all citizens to attend scheduled medical appointments would help hospitals better arrange their resources and allow them to develop more efficient standards and practices to best serve those requiring treatment.

Types of Universal Healthcare Adopted across the World

Universal healthcare is a system that provides quality medical services to all citizens. The federal government offers it to everyone regardless of its ability to pay.

Review each year to know more.




The Norwegian healthcare system is organized on three levels, i.e., national, regional, and local levels. The overall responsibility for the healthcare sector rests at the national level, with the Ministry of Health and Care Services.

Benefits and Challenges

This system is very generous, and this program also provides sick pay. The Norwegian system will even pay for “spa treatments” in some cases.

There are significant waiting times for many procedures. Many Norwegians go abroad for medical treatments. The average weight for a hip replacement is more than four months.




Adopted a two-tier system. The government pays two-thirds, and the private sector pays one-third. The public universal system is called Medicare. Everyone receives coverage.

Benefits and Challenges

Those who buy private insurance before they reach thirty receive a lifetime discount. Government regulations protect seniors, the poor, children, and rural residents.




Has a single-payer system. The government pays for services provided by a private delivery system. The government pays for 70 percent of care. Private supplemental insurance pays for vision, dental care, and prescription drugs. Hospitals are publicly funded. They provide free care to all residents regardless of the ability to pay.

Benefits and Challenges

Canada has high survival rates for cancer and low hospital admission rates for asthma and diabetes. A whopping 56.3 percent of patients waited more than four weeks to see a specialist. As a result, many patients who can afford it go to the United States for care.



Castro, E. M., Van Regenmortel, T., Vanhaecht, K., Sermeus, W., & Van Hecke, A. (2016). Patient empowerment, patient participation and patient-centeredness in hospital care: A concept analysis based on a literature review. Patient Education And Counseling99(12), 1923-1939. doi:10.1016/j.pec.2016.07.026

Kayler DeBrew, J. (2015). Can being ageist harm your older adult patients?. Nursing45(10), 66-67. doi:10.1097/01.NURSE.0000471428.31828.50

McDonough, J. E. (2017). Prospects for Health Care Reform in the U.S. Senate. New England Journal Of Medicine376(26), 2501-2503. doi:10.1056/NEJMp1706433



Additional Materials

From your course textbook, Cases in Health Care Management, review the following cases:

· Case 77: The Gift Catalog

· Case 78: Unapproved Treatments: Honey on the Wound

· Case 79: When Lunch Is More Than a Meal


The Emergency Medical Treatment and Active Labor Act (EMTALA)

The purpose of the Emergency Medical Treatment and Active Labor Act (EMTALA) is to ensure that any individual who comes to a hospital, through the ER, is cared for, even if he or she does not have insurance. The ability to give this care may be threatened by insufficient capacity, inadequate community resources, and the uninsured and underinsured who have no other resource. Now, some patients, who do not have insurance, have taken to use the ER as their primary care physician (The Ethics Committee, 2005). This is one of the things the Affordable Care Act addressed by expanding the coverage for patients under the Medicaid program.

The Act stops hospitals from financially screening patients, but there is still the practice of “triaging out” patients and treating patients with true emergencies first (Moffat, 2017). So it’s difficult for an ER physician to resolve the conflicting obligations of the patient, the hospital, and the payments that will be incurred by treating someone without insurance, which is commonly filtered into the bad debt budget for the hospital. Those costs can filter out among the rest of the hospital with increased cost to those who do have insurance (The Ethics Committee, 2005).

Another ethical question is how financing medical care should influence individual medical decision making (The Ethics Committee, 2005). This is when the third parties get involved. Many times, a physician will want a specific scan done, e.g., computed tomography (CT) scan and magnetic resonance imaging (MRI). Many times, the insurance company won’t allow it until other steps or scans have been done (The Ethics Committee, 2005) even if the Doctor has documented that the MRI with contrast will show the possible sign of a liver lesion while the CT scan will show only an unclear view. Though many times, the insurance will state that the CT scan should be done, even though it’s inadequate, before they will approve the MRI. It’s a difficult issue for the ER physicians as they are ethically bound to help everyone that comes through the ER doors, but the cost can sometimes be overwhelming for the institution.








Limitations of the EMTALA Law

Review each tab to know more.

· Ant-Dumping

Presents few points of limitations of the EMTALA law along with some examples.


Designed to prevent private hospitals from transferring uninsured or underinsured patients to public hospitals, enforcement and fines seem to come in waves. In 2000, Congress made EMTALA enforcement a priority with nearly as much in penalties in that year as in the previous ten years. EMTALA made national headlines again in 2013 when a Nevada psychiatric hospital was accused of sending patients to California by bus without making arrangements for their care.


















· EMTALA Law Misinterpretation

Presents few points of limitations of the EMTALA law along with some examples.


Some groups are proactive and require all of their physicians to undergo an annual EMTALA continuing medical education (CME) course. On the other end of the spectrum, some emergency room (ER) groups have no written policy about EMTALA and leave it to the medical director to educate their staff.


Medical Screening Exams



Under EMTALA, everyone who comes to the emergency department (ED) and requests medical care has a right to a medical screening exam. This screening examination should be reasonably calculated to uncover any emergency medical condition. The screening examination must also be nondiscriminatory, meaning that all patients with similar complaints must receive similar screening exams and/or testing (Silverman, 2015).


Reference Silverman, M. (2015). Keeping up with EMTALA—It’s the law, and it’s good for your patients. Retrieved from


Who Pays the Cost for EMTALA?

EMTALA is, indeed, the central factor in the “free-rider” phenomenon. The government forces hospitals to care for these individuals, without financially compensating hospitals for the cost of doing so.

Hospitals in areas with a high indigent population must shift more of the cost of unreimbursed care than those in areas of low unreimbursed care. It’s like increasing the taxes in poor areas and lowering taxes in affluent areas. Furthermore, since the bills are different with each patient, some will receive a higher proportion of shift than others. It’s like raising taxes on the sickest patients just because they have the ability to pay.

Recent bills that offer to reform the Affordable Care Act have included provisions for a partial tax credit to emergency physicians who provide unreimbursed EMTALA mandated care. The important feature of this provision is that these are tax credits, not reductions to income such as those received for charitable giving. Why? Again it goes to treating everyone equally. If a wealthy tax payer who pays a higher proportion of this income gives to charity, his or her benefit from charitable donation is proportionally higher (Plaster, 2015). Thus, lower income or even taxpayers who already lower their taxable income through charity will feel a smaller effect from the reduction of income.

Reference Plaster, M. L. (2015). Who pays the tab for unfunded care? Retrieved from



The Ethics Committee. (2005). After the medical screening exam: Non-emergent care and the ethics of access in the emergency department. Retrieved from American College of Emergency Physicians website:–legal/ethics/after-the-medical-screening-exam-non-emergent-care-and-the-ethics-of-access-in-the-emergency-department/#sm.001mlw54q13oeeaaw0w1a9ljewtf9

Moffat, J. C. (2017). Appendix A: The Emergency Medical Treatment and Active Labor Act (EMTALA). In The EMTALA answer book (1–6). Retrieved from EBSCOhost Business Source Complete research database.



Additional Materials

From your course textbook, Cases in Health Care Management, review the following cases:

· Case 80: No Good Deed Goes Unpunished

· Case 81: Saint or Fake?

· Case 82: When “Yes” Means “No”







Week 5 Discussion


Supporting Lectures:

Review the following lecture:

· Healthcare Ethics (Stem Cell Research)

Discussion Questions

Before beginning work on this discussion forum, please review the link “ Doing Discussion Questions Right ” and any specific instructions for this topic.

Before the end of the week, begin commenting on at least two of your classmates’ responses. You can ask technical questions or respond generally to the overall experience. Be objective, clear, and concise. Always use constructive language, even in criticism, to work toward the goal of positive progress. Submit your responses in the Discussion Area.


Case Study Seventy-Four: Ethical Issues over DNR Orders

Mr. Warden, a 93-year-old white male, is admitted to Centerville Community Hospital from Centerville Estates Nursing Home. Mr. Warden has had multiple strokes and is only partially responsive to painful stimuli. He does not recognize or respond to nursing staff, physicians, or family members. In addition, he has flexion contractures and a large infected decubitus ulcer over his left sacral area. Further evaluation shows Mr. Warden has extremely poor heart function and is in congestive heart failure. The notes from Centerville Estates Nursing Home indicate Mr. Warden has had one visitor in the past six months; that visitor was not a family member.


Discussion Questions

· What are the facts in this situation?

· Autonomy, nonmaleficence, beneficence, and justice are the cornerstones of ethical decision making. What ethical dilemmas does this case illustrate?

· Have any principles of ethical decision making been violated in this case? What ones have been supported? How might our cultural upbringing, personal assumptions, and opinions influence our decisions as health care managers? Provide rationales for your responses.

· Based on what you know from this short case; why do you think Mr. Warden’s daughter is so insistent on wanting “everything” done for her father?

· What if Mr. Warden was wealthy and had a large estate? Would that change your opinion of the son and his responses? Provide a rationale for your response.

· If the son had no power of attorney, how could this issue be resolved? Can a physician decide to withdraw care without the consent of the family? Who has the final say in the care of a patient in this condition? Provide your reflections and personal opinions as well as your recommendations and rationale for your responses.

Submission Details:

To support your work, use your course and textbook readings and also use the  South University Online Library . As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Your initial posting should be addressed at 500–1000 words as noted in the attached PDF. Submit your document to this Discussion Area by the due date assigned. Be sure to cite your sources using APA format.




This final project assignment is associated with the NCF (non-completion failure) grade. Failure to complete this assignment will result in the issuance of a grade of NCF if the course average would result in a failing grade in the course. Students should contact their Academic Counselor or Program Director if they have any questions regarding the NCF grade and its implications.

Supporting Lectures:

Review the following lecture:

· The Emergency Medical Treatment Active Labor Act (EMTALA)


The project assignment provides a forum for analyzing and evaluating relevant topics of this week on the basis of the course competencies covered.


Robert and Roy, emergency medical technician paramedics (EMT-P), were back on the streets after a slow afternoon of handling administrative tasks in the office. Neither paramedic had checked the divert status board before heading out, so they were unaware that numerous hospitals in the city were on emergency department (ED) divert.






Case Study Eighty-Three: Emergency Divert Status

Read the above case study; your task would be to evaluate this case study utilizing the format below. Make sure to include at least two scholarly/peer-reviewed articles to help support your evaluation.

Case Study Evaluation

· Prepare a written report of the case using the following format:

· Background Statement: What is going on in this case as it relates to the identified major problem?

· What are (only) the key points the reader needs to know in order to understand how you will “solve” the case?

· Summarize the scenario in your own words—do not simply regurgitate the case. Briefly describe the organization, setting, situation, who is involved, who decides what, etc. Specifically identify the major problems and secondary issues.

· What are the real issues? What are the differences? Can secondary issues become major problems?

· Present an analysis of the causes and effects.

· Fully explain your reasoning. Declare your role in a sentence or a short paragraph explaining from which role you will address the major problem and whether you are the chief administrator in the case or an outside consultant called in to advise.

· Regardless of your choice, you must justify in writing as to why you chose that role. What are the advantages and disadvantages of your selected role? Be specific.

· Recognize the strengths and weaknesses of the organization.

· Identify the strengths and weaknesses that exist in relation to the major problem. Again, your focus here should be in describing what the organization is capable of doing (and not capable of doing) with respect to addressing the major problem. Thus, the identified strengths and weaknesses should include those at the managerial level of the problem. For example, if you have chosen to address the problem from the departmental perspective and the department is understaffed, that is a weakness worthy of mentioning. Be sure to remember to include any strengths/weaknesses that may be related to diversity issues.

· Find out alternatives and recommend a solution.

· Describe the two to three alternative solutions you came up with. What feasible strategies would you recommend? What are the pros and cons? State what should be done—why, how, and by whom. Be specific. Evaluate how you would know when you’ve gotten there. There must be measurable goals put in place with the recommendations. Money is easiest to measure; what else can be measured? What evaluation plan would you put in place to assess whether you are reaching your goals?

· TIP: Write this section as if you are trying to “sell” your proposed solution to the organization. Convince the reader that your proposed solution is the best available and that it will work as planned. Make sure that the goals you identify are worth the effort required to achieve them!

To support your work, use your course and text readings and also use the  South University Online Library . As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Submission Details:

· Name your file as SU_MHA6999_W5_Project_LastName_FirstName.

· Your assignment should be addressed in a 4- to 6-page document.

· By the due date assigned, submit it to the Submissions Area.

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