Ethical and Medicolegal Issues

This collection contains Ethical Perspectives and Medicolegal Issues articles published in Continuum. The practice of neurology presents a series of ethical and medicolegal challenges for the clinician. These rarely have simple or straightforward solutions, but require careful consideration by the neurologist. Each article, written by neurologists with particular interest in the area of bioethics, provides a case vignette that raises one or more ethical questions related to the subject area of the issue in which it was published. The discussion that follows is intended to help the reader understand and resolve the dilemma.

Contains: 74 Items
2020 August Volume 26, 1070-1074
Criminal Culpability for Acts Committed During a Possible Episode of REM Sleep Behavior Disorder

Kass, Joseph S.; Rose, Rachel V.

Audio Interview
Rapid eye movement (REM) sleep behavior disorder (RBD) may result in a patient injuring a bed partner while acting out a dream. This article examines the complexities associated with RBD as a criminal defense strategy as well as the legal implications for physicians and their duty to patients and their families to mitigate risks associated with possible injuries related to RBD.
2020 April Volume 26, 499-505
Legal Liability Associated With rtPA Administration and Surrogate Decision Makers

Kass, Joseph S.; Rose, Rachel V.

Audio Interview
Stroke is one of the most common conditions neurologists treat in emergency situations. This article examines the issues of surrogate decision makers and the physician’s potential legal liability in the context of the administration or nonadministration of recombinant tissue plasminogen activator (rtPA) in a common emergency department scenario.
2019 August Volume 25, 1141-1144
Liability and Failure to Warn a Patient

Kass, Joseph S.; Rose, Rachel V.

Audio Interview
This medicolegal article examines a physician’s liability when he or she has knowledge of adverse effects associated with a prescription medication and suggests ways to mitigate that liability risk. The article also discusses the circumstances under which pharmaceutical companies face liability for side effects such as tardive dyskinesia.
2019 April Volume 25, 537-542
Driving and Epilepsy: Ethical, Legal, and Health Care Policy Challenges

Kass, Joseph S.; Rose, Rachel V.

Audio Interview
Although the principle of autonomy allows patients to refuse interventions their physicians recommend, patients are not free to ignore legally mandated restrictions on driving, and physicians are ethically justified in constraining their patients’ driving rights in compliance with state law. Furthermore, the standard of care for treatment of patients with epilepsy includes counseling about lifestyle modifications that promote patient safety and compliance with the law. Neurologists should not only counsel their patients with epilepsy about legally mandated driving restrictions but also document this counseling in the medical record. Failure to counsel and to document may result in legal liability if patients ex...
2019 February Volume 25, 254-259
Prescribing Antipsychotic Medications to Patients With Dementia: Boxed Warnings and Mitigation of Legal Liability

Rose, Rachel V.; Kass, Joseph S.

Audio Interview
Clinicians caring for patients with dementia are often at a loss when trying to manage dementia-related behavioral disturbances pharmacologically because no drugs have been proven effective for this indication. Antipsychotics are commonly prescribed for these patients despite a US Food and Drug Administration (FDA)–mandated boxed warning about the heightened risk of death in patients with dementia treated with antipsychotic drugs. This boxed warning does not prevent clinicians from prescribing antipsychotics to patients with dementia. However, it serves as a heightened warning to prescribers to include the specific risks mentioned in the boxed warning in their discussion of risks and benefits of the proposed th...
2018 December Volume 24, 1789-1793
Ethical Considerations in End-of-life Care in the Face of Clinical Futility

Kass, Joseph S.; Lewis, Ariane; Rubin, Michael A.

Audio Interview
Management of patients with terminal brain disorders can be medically, socially, and ethically complex. Although a growing number of feasible treatment options may exist, there are times when further treatment can no longer meaningfully improve either quality or length of life. Clinicians and patients should discuss goals of care while patients are capable of making their own decisions. However, because such discussions can be challenging, they are often postponed. These discussions are then conducted with patients’ health care proxies after patients lose the capacity to make their own decisions. Disagreements may arise when a patient’s surrogate desires continued aggressive interventions that are either biolog...
2018 October Volume 24, 1535-1539
Legal and Ethical Considerations of Disclosing Human Immunodeficiency Virus Seropositivity to a Surrogate Decision Maker

Rose, Rachel V.; Kass, Joseph S.

Audio Interview
Ethical and legal issues arise when a patient who is human immunodeficiency virus (HIV) positive lacks decision-making capacity and the HIV status must be disclosed to a surrogate decision maker to allow for informed medical decision making. This article discusses the special exceptions to confidentiality built into the Health Insurance Portability and Accountability Act privacy protections, the limitations on claims of common-law marriage, and public health laws that often require informing individuals who are either sex partners or needle-sharing partners of newly diagnosed HIV-infected individuals that they have been exposed to HIV infection.
2018 August Volume 24, 1209-1214
Common Legal Considerations When Moving to a New Medical Practice

Kass, Joseph S.; Rose, Rachel V.

Audio Interview
This article presents a hypothetical case of the legal issues a physician must consider when moving to a new medical practice, such as the enforceability of a noncompete clause, malpractice insurance, communicating this change in practice to existing patients, and custody of medical records.
2018 June Volume 24, 920-925
Assessment of Medical Decision-making Capacity in Patients With Dementia

Rodgers, Joshua J.; Kass, Joseph S.

Audio Interview
Medical decision-making capacity, the patient’s ability to exercise autonomy reasonably, is an essential component of both informed consent and informed refusal. The assessment of medical decision-making capacity is thus fundamental to the ethical practice of medicine. Medical decision-making capacity is not all or nothing but rather exists on a continuum and should be assessed on a decision-by-decision basis. Alzheimer disease and other neurocognitive disorders can affect a patient’s medical decision-making capacity and may pose special challenges to capacity assessment. To illustrate some of these challenges, this article presents a case of a patient with Alzheimer disease who refused a recommended operation ...
2018 April Volume 24, 603-608
Liability for Referrals to Other Physicians

Kass, Joseph S.

Audio Interview
This article presents four hypothetical cases that demonstrate ways in which neurologists may be vulnerable to liability for how they manage patients they refer to other physicians for consultations. This article also discusses the importance of protecting neurologists from claims of negligence through documentation, which includes the rationale for ordering a consultation, deferring a consultation, or disagreeing with a consultant’s recommendations. Lastly, the article discusses the importance of including patients in the decision-making process and detailing these conversations in the medical record.
2017 June Volume 23, 872-876
Response to Medical Errors

Webb, Adam

Despite improvements in patient safety science over the past 15 years since the Institute of Medicine’s publication of To Err Is Human, medical errors remain a major contributor to adverse patient outcomes and mortality. In the aftermath of a harmful medical error, providers often face dilemmas regarding how to best report and disclose errors.
2017 August Volume 23, 1151-1155
Shared Medical Decision Making in Consideration of Opioid Therapy in a Patient With Restless Legs Syndrome

Rubin, Michael

Audio Interview
Treating patients with restless legs syndrome (RLS) may pose a significant challenge to the clinician if those with intractable disease worsen with chronic treatment. Opioids are established as effective treatment for refractory RLS; however, some patients may be reluctant to try opioids because of the risk of dependency. Understanding the physician’s duty to the patient through the framework of a shared decision-making model allows the neurologist to propose opioid therapy despite possible initial reluctance by the patient when the neurologist believes that this therapy is the most medically reasonable approach to optimizing the patient’s well-being.
2017 October Volume 23, 1451-1457
Right-to-Try Investigational Therapies for Incurable Disorders

Simmons, Zachary

Audio Interview
Patients with life-threatening disorders such as amyotrophic lateral sclerosis, for which only minimally effective medical therapies currently exist, often seek treatments not proven to be effective and not approved by regulatory agencies for use outside of experimental treatment trials. The expanded access (compassionate use) provisions of the US Food and Drug Administration (FDA) for access to such therapies are often perceived as being inadequate. In response, states have passed right-to-try laws designed to improve access to experimental therapies for patients willing to assume the risks associated with such treatments. This situation has resulted in conflicts between those who perceive access to such treat...
2017 April Volume 23, 553-556
Mitigating Cybersecurity Risks

Rose, Rachel V.; Kass, Joseph S.

Audio Interview
Cybersecurity issues and their impact on compliance with the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act are becoming more of an enforcement focus for a variety of government agencies, including the US Department of Health and Human Services, the Federal Trade Commission, and the Department of Justice. In the case presented in this article, a nurse in a neurology practice opted to speak with a patient about human immunodeficiency virus testing procedures in a manner audible to others in the waiting room. Computer screens with patient information were visible to anyone approaching a desk, the staff had not been tr...
2017 February Volume 23, 254-258
Discussing Life-sustaining Therapy With Surrogate Decision Makers

Hwang, David Y.

Audio Interview
Clinicians caring for patients with severe stroke in intensive care units often grapple with requests from surrogate decision makers for life-prolonging treatment that members of the care team may believe to be futile. An example is a surrogate decision maker’s request to place a tracheostomy and feeding tube in a patient who, in the clinical judgment of the neurocritical care team, is very unlikely to recover interactive capacity. This article presents a case, discusses definitions of medical futility, and summarizes recommended steps for mediating conflict regarding potentially inappropriate treatment.
2016 December Volume 22, 2006-2011
Genetic Testing of Presymptomatic Individuals at Risk for Progressive Myopathy

Simmons, Zachary

Audio Interview
Patients and their family members often ask about genetic testing for asymptomatic individuals who are at risk for developing a genetic disorder. Ordering a genetic test is a complex process involving consideration of many basic ethical principles including autonomy, beneficence, and nonmaleficence, as well as the physician’s duty to act in the patient’s best interest. Physicians have many choices regarding what tests to order, and they must develop the knowledge and skills to best discuss genetic testing with their patients. Integration of core ethical principles into these processes will permit physicians to best serve their patients when obtaining informed consent, considering advantages and harms of potenti...
2016 October Volume 22, 1685-1690
Legal Implications of Physician Investment and Ownership in Health Care Enterprises

Rose, Rachel V.; Kass, Joseph S.

Audio Interview
This article presents a case in which a neurology group practice is considering investing in an imaging center that is owned by nonphysician investors with the aim of referring patients to this imaging center. The article reviews some important legal pitfalls in federal law that physicians must be aware of when considering such an investment and focuses on the general outlines of and exceptions to the Stark Law and the Federal Anti-Kickback Statute.
2016 August Volume 22, 1262-1265
Ethics of Preclinical Dopamine Transporter Imaging

Cochrane, Thomas I.

Audio Interview
While dopamine transporter single-photon emission computed tomography (DAT-SPECT) imaging is sensitive and specific when performed in patients with signs or symptoms of parkinsonism, its predictive value is uncertain in healthy subjects, even with patients who have first-degree relatives affected by Parkinson disease. In deciding whether to honor a patient’s request for a DAT-SPECT, neurologists must balance a patient’s autonomy rights with beneficence and nonmaleficence and also consider the distributive justice implications of ordering the test. Generally speaking, the benefits of a DAT-SPECT will be too small to justify its use in an asymptomatic patient concerned about developing Parkinson disease.
2016 June Volume 22, 943-946
Palliative Care in Multiple Sclerosis

Vanopdenbosch, Ludo J.; Oliver, David J.; Kass, Joseph S.

Audio Interview
Collaboration between the neurologist and palliative care team in the care of patients with severe demyelinating disease can result in improved patient care, and discussion of the complex ethical issues that arise when a patient expresses a wish to die may be rewarding for both patients and caregivers.
2016 April Volume 22, 615-618
Ethical Considerations for the Use of Next-Generation Alzheimer Drugs in Symptomatic and At-Risk Patients

Gauthier, Serge; Rosa-Neto, Pedro; Kass, Joseph S.

Audio Interview
This article presents a case in which a patient with mild Alzheimer disease requests a prescription for a newly developed Alzheimer disease drug, after which the patient’s daughter inquires about its potential usefulness as a prevention strategy for herself. The article discusses the physician’s responsibility to balance the ethical principles of beneficence, nonmaleficence, and respect for patient autonomy when evaluating requests for medications from patients with neurocognitive disease as well as from asymptomatic but at-risk patients.
2016 February Volume 22, 262-265
Ethical Considerations in Balancing Parental Autonomy With Protecting a Child With Epilepsy From Harm

Miller-Horn, Jill

Neurologists are expected to accommodate parental decisions in the medical care for their child, unless the parental decision places the child at an unnecessary risk of serious harm. Sometimes, respect for parental autonomy is in conflict with the physician’s professional obligation to protect the patient from harm and to optimize treatment for a particular disease or condition. This case illustrates an ethical dilemma created when the neurologist and parent disagree about the most appropriate medical treatment for a child with epilepsy. Viewing the disagreement within an ethical framework, however, provides the parties to the disagreement with an opportunity to understand the beliefs and motivations of everyon...
2015 December Volume 21, 1745-1750
Quarantine, Isolation, and Health Care Workers

Webb, Adam

Although Ebola virus disease and other hemorrhagic fevers are not generally considered infectious diseases of the nervous system, neurologists may be asked to participate in the management of patients with these and other dangerous communicable illnesses, including possible bioterrorism agents. It is essential for all health professionals to understand the public health, legal, and ethical frameworks behind autonomy-limiting interventions such as quarantine and isolation. Health care professionals represent the front line of defense during public health emergencies. They are often disproportionately affected by the illnesses themselves as well as by the public health interventions intended to prevent spread. Th...
2015 October Volume 21, 1445-1450
Ethical Aspects of Organ Donation After Circulatory Death

St. Louis, Erik K.; Sharp, Richard R.

Audio Interview
Neurologists should be familiar with the process and ethical aspects of organ donation. While most neurologists understand the steps involved in organ procurement following brain death, the controversial practice of organ donation after circulatory death (also referred to as non–heart-beating organ donation) is less familiar but increasingly frequent. This article presents a hypothetical case of a patient with a devastating neurologic injury and a poor prognosis for meaningful recovery and discusses the ethical considerations underlying donation after circulatory death, the general procedure of donation after circulatory death, and ethical controversies associated with this practice.
2015 August Volume 21, 1146-1149
The Ethics of Disclosing Another Physician’s Medical Error

Rubin, Michael A.; Friedman, Deborah I.

Audio Interview
The disclosure of medical errors has been shown to improve quality of care and decrease litigation and cost. However, much less attention has been given to how to manage situations in which a patient has been treated less than optimally at another institution or by another physician. The same ethical principles that support disclosing one’s own errors apply to disclosure of other people’s errors. Disclosing errors and encouraging quality improvement at other institutions or by other providers must be performed in a sensitive and judicious manner.
2015 April Volume 21, 476-479
When Religious Beliefs Prohibit a Surgical Patient’s Acceptance of Blood Transfusion

Krishnamurthy, Kaarkuzhali B.

Audio Interview
A 49-year-old man who was a Jehovah’s Witness presented with intractable epilepsy due to a brain tumor. The neurologist wanted to refer him for tumor resection but was concerned about requesting surgery for someone who would not accept blood products. The neurologist must balance his obligation of beneficence and nonmaleficence with respect for the patient’s autonomous decision not to receive blood products. Good communication between patient and doctor is crucial to allow patients to make informed decisions about a choice to refuse transfusion, and doctors must accept the patient’s autonomy, even when it conflicts with the moral imperative to provide treatment if it is available.
2015 February Volume 21, 201-205
Ethical Considerations When Counseling Patients About Stem Cell Tourism

Tsou, Amy

Audio Interview
Worldwide, many clinics market stem-cell based interventions often touted as effective for many diseases including spinal cord injury, multiple sclerosis (MS), and other neurodegenerative diseases. These clinics and their expensive, unproven treatments continue to fuel the practice of stem cell tourism. Given concerns about patient exploitation and safety, how should the physician engage a patient who wants to pursue such treatments? This article presents the case of a patient with neuromyelitis optica interested in pursuing expensive stem cell injections abroad. This article describes stem cell tourism along with some of the ethical issues physicians should consider, while also providing practical resources th...
2014 December Volume 20, 1683-1687
Ethical Implications of an Incidentally Discovered Asymptomatic Chiari Malformation in a Competitive Athlete

Kirschen, Matthew P.; Illes, Judy

The clinical and ethical implications of an asymptomatic 17-year-old competitive football player incidentally found to have a type 1 Chiari malformation without a syrinx on brain imaging are discussed. Considering that patients with Chiari malformations can sustain irreversible neurologic injury or death after a mild head injury, and given the lack of data describing the risk of catastrophic injury after head trauma, the ethics of clearing this athlete to return to play are reviewed.
2014 October Volume 20, 1426-1429
Medical Marijuana for HIV-Associated Sensory Neuropathy: Legal and Ethical Issues

Larriviere, Daniel G.

The number of states legalizing medical marijuana is increasing. Medical marijuana is possibly effective therapy for HIV-associated sensory neuropathy. Despite legalization at the state level, however, the current and contradictory federal drug enforcement policy creates the risk that physicians who recommend medical marijuana to their patients will lose their ability to prescribe medications. The federal-state tension has legal and ethical implications for neurologists who receive a request for medical marijuana from their patients since neurologists must strive to both relieve suffering and obey relevant laws. Recommendation of medical marijuana by neurologists to their patients is ethically permissible but i...
2014 August Volume 20, 1063-1066
Incidental Visual Field Loss: Ethical Considerations In Assessing and Reporting Ability to Drive

Szewka, Aimee J.; Newman, Nancy

Audio Interview
Driving safety is an issue frequently encountered in the neurology clinic, particularly as it pertains to cognitive decline, vision loss, and motor limitations. This case illustrates the ethical dilemmas associated with determining driving safety, particularly those associated with an incidentally found congenital visual field abnormality. The authors discuss the issues involved with overruling patient autonomy for the principle of beneficence and the ethics of reporting patients with unsafe vision to authorities.
2014 June Volume 20, 681-685
Liver Transplant for Intentional Acetaminophen Overdose and Hepatic Encephalopathy: a Conflict Between Beneficence and Justice

Willey, Joshua Z.; Tolchin, Benjamin David

Audio Interview
In cases of severe acetaminophen-induced acute liver failure and hepatic encephalopathy, liver transplant can be the only real hope for neurologic recovery and indeed survival. In such cases, the bioethical principles of beneficence and justice often come into conflict. This article examines a case in which a neurologist managing an acetaminophen-overdose patient in the neurologic intensive care unit is faced with a conflict between her patient’s need for a liver transplant and the needs of other patients on the transplant list.
2014 April Volume 20, 429-435
Telephone Consultations for Tissue Plasminogen Activator Administration in Acute Stroke

Sattin, Justin A.

Audio Interview
Effective treatment for acute ischemic stroke has been available for 17 years, but wide geographic variability remains in timely access to neurologic expertise and other components of stroke systems of care. Telemedical technology can be used to improve such access, but it is debatable whether neurologists have an ethical obligation to provide consultation regarding tissue plasminogen activator use via the telephone. This article examines whether neurologists are ethically obligated to provide telephone-mediated acute stroke consultation.
2014 February Volume 20, 177-180
Reproductive Issues in Women With Multiple Sclerosis: Ethical Considerations

Morgan-Followell, Bethanie N.; Nicholas, Jacqueline A.; Weisleder, Pedro

Addressing the reproductive concerns of women with multiple sclerosis (MS) is vital for comprehensive care. Contraception, conception, pregnancy, and breast-feeding present many vexing questions to the woman with MS. The risks and benefits of using disease-modifying therapy during the various stages of a woman’s reproductive life are topics that need to be discussed. The physician’s primary duty is to the patient; however, the physician must also consider the fetus and later the child. In helping guide the patient in making medical decisions, the physician must take into account the patient’s motivation for those decisions, including family obligations, cultural norms, and patient values. The physician is instr...
2013 December Volume 19, 1698-1702
The New Frontier of Genetically Targeted Therapies for Muscle Disease

Kang, Peter B.

Audio Interview
This article presents the case of a 5-year-old boy with Duchenne muscular dystrophy who is eligible to enroll in a clinical trial of gene therapy for this disorder. His parents are grappling with the decision about whether to enroll him. Among the issues under consideration are the potential risks and benefits to him, the costs of participating (because frequent, partially reimbursed travel is involved), and the potential cost savings of receiving this treatment on a research basis rather than as a clinically approved therapy. His parents seek the advice of his pediatric neurologist. After careful consideration of the various factors above, the pediatric neurologist explains to the family that participating in ...
2013 October Volume 19, 1397-1400
The Ethics of Refusing a Request for Off-Label Deep Brain Stimulation Currently in Clinical Trial

Fleming, James K.; Charles, David

Physicians must ensure that patients understand that the principal aim of research is to increase generalizable knowledge. However, patients may hope for individual benefit as a secondary goal of participation. Highly motivated patients may request treatment off label if trial enrollment has ended, leading to ethical dilemmas for clinicians. This case uses early deep brain stimulation (DBS) as an example for exploring the ethically relevant questions related to the off-label use of medical devices.
2007 February Volume 13, 154-157

Williams, Michael A.

2007 April Volume 13, 204-208
2007 June Volume 13, 248-251

Ellenbogen, Jeffrey M.

2007 August Volume 13, 177-181
2007 October Volume 13, 198-201
2007 December Volume 13, 215-219

Cheshire, William P.

2008 February Volume 14, 205-210
2008 April Volume 14, 153-157
2008 June Volume 14, 182-186

Cochrane, Thomas I.

The practice of neurology presents a series of ethical challenges for the clinician. These rarely have simple or straightforward solutions, but require careful consideration by the neurologist. This section of CONTINUUM provides a case vignette that raises one or more ethical questions related to the subject area of this issue. The discussion that follows, written by colleague(s) with particular interest in bioethics, should help the reader understand and resolve the ethical dilemma.
2008 August Volume 14, 208-212

Klein, Eran

The practice of neurology presents a series of ethical challenges for the clinician. These rarely have simple or straightforward solutions, but require careful consideration by the neurologist. This section of CONTINUUM provides a case vignette that raises one or more ethical questions related to the subject area of this issue. The discussion that follows, written by colleague(s) with particular interest in bioethics, should help the reader understand and resolve the ethical dilemma.
2008 October Volume 14, 179-183
2008 December Volume 14, 137-140

Zaidat, Osama O.; Kalia, Junaid; Lynch, John R.

2009 February Volume 15, 159-164

Couillard, Philippe; Brownell, A. Keith W.

2009 April Volume 15, 187-190
2009 June Volume 15, 167-169
2009 August Volume 15, 252-257

Boissy, Adrienne R.

2009 October Volume 15, 170-172
2009 December Volume 15, 203-206

Rodgers-Neame, Nancy T.; Orlowski, James P.

2010 February Volume 16, 166-169

Haberfeld, Elizabeth; Williams, Michael A.

2010 April Volume 16, 224-227

Rabins, Peter V.; Black, Betty S.

2010 June Volume 16, 242-245
2010 August Volume 16, 165-169
2010 October Volume 16, 234-237
2010 December Volume 16, 161-165
2011 February Volume 17, 148-151
A Young Man With Spinal Muscular Atrophy and Impending Respiratory Arrest

Winters, Janine Penfield; Weisleder, Pedro

From a statutory standpoint, the decision-making capacity of adolescents differs significantly from that of adults because adolescents are considered to lack the experience and judgment necessary to make legally binding decisions. Furthermore, in the case of minors, the principle of protection of life tends to outweigh the principle of autonomy. Here we present the hypothetical case of a 16-year-old boy with spinalmuscular atrophy type II who was admitted to the intensive care unit for severe respiratory distress. We focus on the tension that developed among the patient, his parents, and his physicians when the need for emergency mechanical ventilation became apparent. We review the legal and ethical premises u...
2011 April Volume 17, 343-346
Presymptomatic and Early Symptomatic Genetic Testing

Kang, Peter B.

This article presents a hypothetical case of a boy with early symptoms of Becker muscular dystrophy whose family wishes to defer genetic testing because of concerns about genetic discrimination. The possibility of genetic discrimination in this case is discussed, especially in the context of the Genetic Information Nondiscrimination Act (GINA) that took effect in 2009. GINA protects individuals who are asymptomatic, not those who have "manifested disease." The patient under discussion has symptoms, albeit subtle, of Becker muscular dystrophy, and thus would be regarded by most observers as having "manifested disease." Thus, there appears to be no disadvantage for a patient under these circumstances to have gene...
2011 June Volume 17, 641-643
The Limits of Parental Authority to Accept or Refuse Medical Treatment

Miller, Geoffrey

The legal and ethical right of parents to refuse medical treatment for their children differs from the authority possessed by competent adults with decisional capacity. Parents have a duty to act in the best interests of their children from the children's perspective and not to inflict harm. Best interests are determined by weighing benefits and burdens, which includes using evidence-based outcomes and value judgments. The result is placed along a risk/benefit spectrum. If the result is close to low risk/high benefit, the parents have a strong obligation to accept a health care team recommendation. Otherwise, parents may choose between reasonable medical options without threat or coercion.
2011 August Volume 17, 872-876
Spinal Cord Injury and a Request to Stop Treatment

Gordon, James

When a person who is not terminally ill requests that life-prolonging treatment be stopped, the treating physician must systematically consider all relevant diagnostic, prognostic, and psychosocial elements of that request. First, the patient's decision-making capacity must be confirmed. Next, medical facts, patient preferences, quality of life, and contextual matters surrounding the request must be evaluated and interpreted. Finally, to respect the patient fully, the treating physician must engage all clinical and paraclinical resources needed to ensure that the request is truly informed and autonomous.
2011 October Volume 17, 1119-1123
When Physicians Disagree: A Case of Nonconvulsive Status Epilepticus

Hixson, John David

Differences of opinion among attending physicians, resident trainees, and nurses are not uncommon in hospital situations. When such cases arise, ethical dilemmas must be approached with mindfulness of basic ethics principles and communication. This article presents a case of nonconvulsive status epilepticus to highlight these considerations.
2011 December Volume 17, 1335-1339
Emergency Management of Acute Ischemic Stroke in Incapacitated Patients Who Have No Surrogate Decision Makers

Rincon, Fred

When hospitalized patients with acute ischemic stroke are unable to make their own medical decisions, clinicians usually turn to advance directives and the patient's close family members and friends to define the patient's wishes and expectations regarding treatment and prognosis. In many jurisdictions, if there is no surrogate for an incapacitated patient, an emergency ethics or risk management consultation is advisable and is usually done with a representative of the hospital's law office. The ethics team can represent the patient's interests by hearing the recommendations of the treating physicians and then deciding whether their recommended treatment plan is ethically permissible and in the patient's intere...
2012 February Volume 18, 176-180
Opioid Administration for Severe Neuropathic Pain in a Patient With Depression and Prior Heroin Use

Elliott, Kathryn J.

The treatment of pain can raise ethical dilemmas. This article presents a case of a young woman with a pain crisis from severe neuropathic pain that is complicated by comorbidities of depression and prior (but not active) heroin use. Medical and ethical justifications for either withholding or providing opioids for her pain are examined. State and federal laws governing opioid prescriptions by physicians for pain management are reviewed.
2012 April Volume 18, 416-420
Should the Cost of Care For Patients With Glioblastoma Influence Treatment Decisions?

Dropcho, Edward J.

This article presents the case of a patient with recurrent glioblastoma who questions whether he can or should pay for treatment with bevacizumab. There are differing views on the physician’s role in dealing with cost and cost-effectiveness issues for patients, but it is becoming increasingly unrealistic for physicians to disregard the cost of cancer care when making treatment recommendations. Physicians need to be able to address cost issues in order to allow individual patients to make the best informed decision about what treatment option is the most beneficial and the “best value” for them.
2012 June Volume 18, 655-658
Surrogate Decision Making in Neurocritical Care

Adelman, Eric E.; Zahuranec, Darin B.

Audio Interview
Patients with critical neurologic illness typically have impaired capacity to make their own medical decisions. In these cases, neurologists need to make medical decisions based on advance directives (such as a living will) or the decisions of a surrogate. A hypothetical case of a 60-year-old man with an intracerebral hemorrhage is used to highlight some of the difficulties that can occur when attempting to apply general statements made in a living will to a specific medical treatment decision. The ethical and legal issues surrounding surrogate decision making as they apply to acute critical neurologic disease are discussed, along with suggestions for how to resolve potential disagreements.
2012 August Volume 18, 896-899
Treatment of Refractory Headache: Potential Conflicts of Interest in Coding

Kornbluth, Joshua A.; Russell, James A.

Audio Interview
Issues directly or indirectly related to the increasing costs of health care services have the potential to adversely affect physicians’ fiduciary responsibilities to their patients. Coding deception in response to perceived unfairness in reimbursement practices represents one of these potential adverse influences. This case discussion addresses the potential motivations underlying coding deception and the reasons it cannot be supported from either a legal or ethical perspective.
2012 October Volume 18, 1158-1162
Grounded for an Ethical Dilemma: Disequilibrium in a Commercial Airline Pilot

Kirschen, Matthew P.; Friedlander, Joel A.

Audio Interview
This article presents the case of a 41-year-old airline pilot with benign paroxysmal positional vertigo who requests that his diagnosis not be disclosed to his commercial airline employer or his aviation medical examiner because it may result in the suspension of medical certification. The legal and ethical requirements for physicians reporting impaired pilots are discussed as well as practical recommendations for handling such situations. The argument is made that a physician’s obligation to honor patient confidentiality should not take precedence over his or her duty to protect the safety and well-being of the airplane passengers and the general public. If the patient chooses not to self-report, a physician h...
2013 April Volume 19, 470-474
“Will I Get Alzheimer Disease?” When Cognitively Normal Patients Ask to be Tested for Alzheimer Disease

Snider, B. Joy; Buckles, Virginia D.

Audio Interview
This article presents the case of a cognitively normal patient who is requesting a procedure (amyloid imaging) recently approved for the diagnosis of Alzheimer disease (AD) in patients with cognitive impairment. The predictive value of this test in unaffected people is not clearly established. Knowing the results of the test will have no effect on therapeutic options, although the patient may make lifestyle decisions based on the results. There is potential risk to the patient in terms of insurability, employability, and psychological consequences. Physicians will face this situation with increasing frequency as the AD biomarker field progresses.
2012 December Volume 18, 1469-1473
2013 February Volume 19, 199-203
Ethical Considerations in REM Sleep Behavior Disorder

Vertrees, Stephanie; Greenough, Glen P.

A patient diagnosed with REM behavior sleep disorder (RBD) has as much as a 65% risk of developing an α-synucleinopathy. Currently, it is not possible to predict whether an individual will develop a disease, or, if so, which disease.The neurologist treating the patient must consider (1) the difference between disclosing a diagnosis and disclosing the risk of a diagnosis; (2) whether to disclose this risk to patients; and (3) if deciding to disclose the risk, the appropriate timing of such a conversation.
2013 June Volume 19, 795-800
Genetic Testing in Children With Epilepsy

Wusthoff, Courtney J.; Olson, Donald M.

Audio Interview
Genetic testing is now available clinically for several epilepsies. Neurologists increasingly face decisions about diagnostic testing in affected patients and should carefully deliberate the ethical considerations associated with genetic testing. The merits of ordering a genetic test are largely based on the utility for guiding clinical care, providing a prognosis, estimating recurrence risk, and identifying comorbidities. At the same time, a decision to pursue any genetic testing also requires evaluation of associated ethical concerns. This case illustrates ethical challenges that arise when considering genetic testing for a pediatric patient with epilepsy.
2013 August Volume 19, 1087-1091
Disclosing a Misdiagnosis of Multiple Sclerosis: Do No Harm?

Solomon, Andrew J.; Klein, Eran

Audio Interview
The difficulty of diagnosing multiple sclerosis (MS) has been well documented. However, recent data also suggests that neurologists frequently encounter the clinical challenge of having to undo a misdiagnosis of MS. Undiagnosing MS has important clinical, psychosocial, and economic consequences for the patient, the treating neurologist, and the healthcare system at large. This article presents a case of misdiagnosed MS and discusses ethical challenges and obligations for the neurologist.