The United States and other countries are experiencing nursing shortages. To help ease the shortage, many resources are spent on recruiting foreign nurses.

What are the reasons for these shortages? If the United States and other industrial nations put their resources into increasing nurse retention, would the need to recruit foreign nurses decrease? Why or why not?
Choose one of the Sustainable Development Goals (SDG) and discuss how a community nurse can work toward achieving that goal.

In order to receive full credit, you will need to clearly respond to both parts of the question using subtitles or bullets AND cite at least one scholarly reference in your response. You are required to participate on at least three (3) days of the week to receive full participation points.

Medical Ethics
Accounts of

Ground-Breaking Cases

Gregory E. Pence
University of Alabama at Birmingham

pen07945_fm_i_xxii.indd 1 09/12/16 8:52 PM


Published by McGraw-Hill Education, 2 Penn Plaza, New York, NY 10121. Copyright © 2017 by
McGraw-Hill Education. All rights reserved. Printed in the United States of America. Previous editions
© 2015, 2011, and 2008. No part of this publication may be reproduced or distributed in any form or
by any means, or stored in a database or retrieval system, without the prior written consent of
McGraw-Hill Education, including, but not limited to, in any network or other electronic storage or
transmission, or broadcast for distance learning.

Some ancillaries, including electronic and print components, may not be available to customers outside
the United States.

This book is printed on acid-free paper.

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ISBN 978-1-259-90794-4
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Library of Congress Cataloging-in-Publication Data

Names: Pence, Gregory E., author.
Title: Medical ethics: accounts of ground-breaking cases / Gregory E. Pence,
 University of Alabama at Birmingham.
Other titles: Classic cases in medical ethics
Description: Eighth edition. | New York, NY: MHE, [2017] | Audience: Age:
 18+ | Editions 1-5 published under: Classis cases in medical ethics. |
 Includes bibliographical references and index.
Identifiers: LCCN 2016026704 | ISBN 9781259907944 (alk. paper)
Subjects: LCSH: Medical ethics–Case studies.
Classification: LCC R724 .P36 2017 | DDC 174/.2–dc23 LC record available at

The Internet addresses listed in the text were accurate at the time of publication. The inclusion of a
website does not indicate an endorsement by the authors or McGraw-Hill Education, and McGraw-Hill
Education does not guarantee the accuracy of the information presented at these sites.

pen07945_fm_i_xxii.indd 2 09/12/16 8:52 PM


This new edition retains in-depth discussion of famous cases, while providing
updated, detailed analysis of the issues those cases raise. Each chapter also focuses
on a key question that could be debated in class.

Unique to this text is a single, authorial voice integrating description of the cases
and their issues with historical overviews. The text is the only one that follows cases
over decades to tell readers what did and, often, what did not, happen. Written by
a professor who helped found bioethics and who has published in the field for 40
years, the text gives students a sense of mastery over this exciting, complex field.
After they have read the book, I hope that students will feel that they have learned
something important and that time studying the material has been well spent.

New to the 8th Edition
New research was added to each chapter, and a new list of topics to debate was
included on the inside cover of the book. Every chapter has been rewritten, tight-
ened, and augmented; issues have been clarified. Highlights of the new edition are
outlined here.

A NEW CHAPTER ON ALCOHOLISM (and addiction): Conflicting views on causes
of alcoholism: Alcoholics Anonymous, neuroscience, Kant, genetics, social sciences,
Fingarette. Focus on the famous case of Ernie Crowfeather.

A MAJOR NEW CASE: The Bucharest Early Intervention Project: Is it the Tuskegee
Study of neuroscience? Research on vulnerable human populations?

A MAJOR NEW SECTON on research on people with schizophrenia, including
cases of patients harmed by such research.

Discussion of Ebola and Zika virus in AIDS chapter: How it has resembled our
responses to AIDS?

Discussion on CRISPR, the revolutionary method of changing genes that almost
any geneticist can use to change a species and its progeny.

Update on the Patient Protection and Affordable Care Act: Why it’s working
and what are its latest problems?


pen07945_fm_i_xxii.indd 3 09/12/16 8:52 PM

iv Preface

Death and Dying: The case of Brittany Maynard; the case of Jahi McMath.

Comas: Update on cases of Terri Schiavo, Belgian coma patient Rom Houben,
and minimally conscious states.

Abortion: Updates on death of Kenneth Edelin, declining numbers of abortion
in America. New topics: Telemedicine and early-stage self-abortions, the Planned
Parenthood video controversy, US Supreme Court decision limiting TRAP (Tar-
geted Regulation of Abortion Providers) laws.

Assisted Reproduction: Updates on the Gosselins, McCaughey septuplets, IVF
clinics, mistaken swaps of embryos, outsourced surrogates, and foreigners using
American surrogates; a sperm donor meets eight of his children, right-to-life
groups file in court to protect frozen embryos; state surrogacy laws, Snowflake
(embryo adoption and its high costs), brighter chances for infertile women aged
30–40 of having IVF baby on late tries.

Stem Cells, Cloning, and Embyros: Updates on stem cells, battles over embryos
among divorced couples and right-to-life friends, mitochondria-swapping to
cure genetic disease (“a child with three parents”); hucksterism in selling stem-
cell therapies; continuing problems in cloning primates.

Impaired Babies and Americans with Disabilities Act: Update on “Baby Jane Doe”
Keri-Lynn, Marlise Munoz case; UAB’s controversial SUPPORT study on
preemies, relevance to babies born with microcephaly from Zika virus.

Ethics of Research on Animals: Updates on the Great Ape Project, Edward Taub’s
work, legal protection for chimpanzees in research.

Transplants and Organ Allocation: Updates on numbers, costs, and outcomes,
especially for tracking bad outcomes of adult organ donors.

Genetics chapter: The pitfalls and promises of: personalized genetic testing and
Big Data, CRISPR, and testing for diseases with no treatments.

Chapter on Enhancement: New emphasis on relation of enhancements to people
with disabilities.

If you have suggestions for improvement, please email me at: [email protected]

pen07945_fm_i_xxii.indd 4 09/12/16 8:52 PM



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tion’s integrated assignment and assessment platform. Connect also offers SmartBook for
the new edition, which is the first adaptive reading experience proven to improve grades
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ideas in each chapter;

• An Instructor’s Manual for each chapter with full chapter outlines, sample test
questions, and discussion topics; and

• Lecture Slides for instructor use in class.

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pen07945_fm_i_xxii.indd 6 09/12/16 8:52 PM




Gregory E. Pence is professor and chair of the Department of Philosophy at the
University of Alabama at Birmingham. Between 1977 and 2011, he taught medical
ethics at the University of Alabama Medical School. He still directs its Early Medi-
cal School Acceptance Program.

In 2006, and for achievement in medical ethics, Samford University awarded
him a Pellegrino Medal. He testified about human cloning before committees of the
U.S. Congress in 2001 and the California Senate in 2003.

He graduated cum laude in Philosophy with a B.A. from the College of William and
Mary in 1970 and earned a Ph.D. from New York University in 1974, working mainly
under the visiting professor, Peter Singer.

In 2010, his UAB team was national champion of the Intercollegiate Ethics Bowl.
His teams won national championships of the Bioethics Bowl at Duke University in 2011
and Florida State University in 2015. At UAB, he has won both the Ingalls and President’s
Awards for excellence in teaching.

• He has written six trade books, including Who’s Afraid of Human Cloning?
(1998), Re-Creating Medicine: Ethical Issues at the Frontiers of Medicine (2000),
Designer Food: Mutant Harvest or Breadbasket of the World? (2002), Cloning
after Dolly: Who’s Still Afraid? (2004), How to Build a Better Human: An Eth-
ical Blueprint (2012), and What We Talk about When We Talk about Clone
Club: Bioethics and Philosophy in Orphan Black (2016).

• He has edited four books of general essays, Classic Works in Medical Ethics
(1995), Flesh of My Flesh: The Ethics of Cloning Humans (1998), The Ethics of
Food: A Reader for the Twenty-First Century (2002), and Brave New Bioethics

• He has published over 60 op-ed essays in national publications: two each
in the New York Times, Los Angeles Times, Newsweek, and Chronicle of Higher
Education; one each in the Los Angeles Times, Atlanta Journal-Constitution,
and Philadelphia Inquirer; and 35 in the Sunday Birmingham News. His reader,
Brave New Bioethics, collects these essays from 1974 to 2002.

• A full list of books by Gregory Pence is available through Connect.

About the Author

pen07945_fm_i_xxii.indd 7 09/12/16 8:52 PM


Several people helped in preparing the 8th edition of this text.
Users of this text also improved the new edition with their suggestions and

corrections. In particular, Charles Cardwell, Pellissippi State Community College in
Tennessee, and Jason Gray, who taught bioethics at UAB for two years, spotted
many errors and made many helpful suggestions, as did my colleagues Josh May
and Matt King. My research assistant Karan Jani wrote helpful summaries of the
Bucharest Early Intervention Project and CRISPR. Lillian Chien provided amazing
proofing at the last stage.

The ansrsource developmental editing, lead by Anne Sheroff and Reshmi
Rajeesh were the perfect editors and helped me take this text to a higher level. I
also appreciate the following reviewers for the eighth edition:

Brendan Shea, Rochester Community and Technical College, Minnesota
Sarah Schrader, University of California, Santa Cruz, California


pen07945_fm_i_xxii.indd 8 09/12/16 8:52 PM


Chapter 1 Good and Bad Ethical Reasoning; Moral Theories and Principles  1

Chapter 2 Requests to Die: Terminal and Nonterminal Patients  19

Chapter 3 Comas: Karen Quinlan, Nancy Cruzan, and Terri Schiavo  57

Chapter 4 Abortion: The Trial of Kenneth Edelin  84

Chapter 5 Assisted Reproduction, Multiple Gestations, Surrogacy, and Elderly
Parents  109

Chapter 6 Embryos, Stem Cells, and Reproductive Cloning  132

Chapter 7 Impaired Babies and the Americans with Disabilities Act  157

Chapter 8 Medical Research on Animals  179

Chapter 9 Medical Research on Vulnerable Populations  196

Chapter 10 Ethical Issues in First-Time Organ Surgeries  221

Chapter 11 The God Committee  243

Chapter 12 Using One Baby for Another  264

Chapter 13 Ethical Issues in the Treatment of Intersex and Transgender
Persons  284

Chapter 14 Involuntary Psychiatric Commitment and Research on People with
Schizophrenia  299

Chapter 15 Ethical Issues in Pre-Symptomatic Testing for Genetic Disease: Nancy
Wexler, Angelina Jolie, Diabetes and Alzheimer’s  325

Chapter 16 Ethical Issues in Stopping the Global Spread of Infectious Diseases:
AIDS, Ebola, and Zika  346

Chapter 17 Ethical Issues of the Patient Protection and Affordable Care Act  367

Chapter 18 Ethical Issues in Medical Enhancement (and their effect on people with
Disabilities)  392

Chapter 19 Ethical Issues in Treating Alcoholism  405

Brief Contents

pen07945_fm_i_xxii.indd 9 09/12/16 8:52 PM



1. Good and Bad Ethical Reasoning; Moral Theories and Principles  1
Good Reasoning in Bioethics  1

Giving Reasons  1
Universalization  2
Impartiality  3
Reasonableness  3
Civility  4

Mistakes in Ethical Reasoning  4
Slippery Slope  4
Ad Hominem (“To the Man”)  5
Tu Quoque (Pronounced “Tew-kwoh-kway”)  5
Straw Man/Red Herring  5
Post Hoc, Ergo Propter Hoc (“After This, Therefore, Because of This”)  6
Appeal to Authority  6
Appeals to Feelings and Upbringing  7
Ad Populum  7
False Dichotomy (“Either-Or” Fallacy)  7
Equivocation  7
Begging the Question  8

Ethical Theories, Principles, and Bioethics  8
Moral Relativism  8
Utilitarianism  9
Problems of Utilitarianism  10
Kantian Ethics  11
Problems of Kantian Ethics  12
The Ethics of Care  12
Virtue Ethics  13
Natural Law  13


pen07945_fm_i_xxii.indd 10 09/12/16 8:52 PM

Contents xi

Theories of Justice  15
Libertarianism  15
Rawls’s Theory of Justice  15
Marxism  16
Four Principles of Bioethics  16
Final Comment  18

Discussion Questions  18
Notes  18

2. Requests to Die: Terminal and Nonterminal Patients  19
The Case of Elizabeth Bouvia (1983–Present)  19

The Legal Battle: Refusing Sustenance  20
The Case of Larry McAfee (1985–1995)  24
The Case of Brittany Maynard (2013–2014)  26
Background: Perspectives on Dying Well  27

Greece and Rome  27
The Bible and Religious Views  28
Philosophers on Voluntary Death  28
The Nazis and “Euthanasia”  30
Hospice and Palliative Care  32
Dying in Holland  32
Jack Kevorkian  33

Dr. Anna Pou  34
Recent Legal Decisions  37

Oregon, 1994  37
Ancient Greece and the Hippocratic Oath  38
Ethical Issues  39

The Concept of Assisted Suicide  39
Misconceptions about Suicide  39
Rationality and Competence  40
Autonomy  41
Inadequate Resources and Poor Treatment  42
Social Prejudice and Physical Disabilities  43
Is Killing Always Wrong?  45
Killing versus Letting Die  46
Relief of Suffering  47
Slippery Slopes  48
Physicians’ Roles, Cries for Help, and Compassion  50
Mistakes and Abuses  50
Cries for Help  51

Further Reading and Resources  51
Discussion Questions  52
Notes  52

3. Comas: Karen Quinlan, Nancy Cruzan, and Terri Schiavo  57
The Quinlan Case  57

Pulling the Plug or Weaning from a Ventilator?  60
Substituted Judgment and Kinds of Cases  61

pen07945_fm_i_xxii.indd 11 09/12/16 8:52 PM

xii Contents

The Cruzan Case  61
The Terri Schiavo Case  64

Enter Lawyers and Politicians  65
What Schiavo’s Autopsy Showed  68

Ethical Issues  69
Standards of Brain Death  69
Chances of Regaining Consciousness from Coma and PVS  70
Terri’s Chances of Re-awakening  72
Compassion and Its Interpretation  73
Religious Issues  74
Nagging Questions  74
Disability Issues  75
Some Distinctions  75
Advance Directives  77
The Schiavo Case, Bioethics and Politics  78

Further Reading and Resources  78
Discussion Questions  79
Notes  80

4. Abortion: The Trial of Kenneth Edelin  84
Kenneth Edelin’s Controversial Abortion  84
Background: Perspectives on Abortion  88

The Language of Abortion  88
Abortion and the Bible  88
The Experience of Illegal Abortions  90
1962: Sherri Finkbine  90
1968: Humanae Vitae  91
1973: Roe v. Wade  91
Abortion Statistics  92

Ethical Issues  92
Edelin’s Actions  92
Personhood  92
Personhood as a Gradient  93
The Deprivation Argument: Marquis and Quinn on Potentiality  94
Viability  95
The Argument from Marginal Cases  96
Thomson: A Limited Pro-Choice View  96
Feminist Views  97
Genetic Defects  97
God Must Want Me to Be Pregnant, or Else I Wouldn’t Be  98
A Culture of Life or a Culture of Death?  98
Abortion and Gender Selection  99
Abortion as a Three-Sided Issue  99
Antiabortion Protests and Violence  100
Live Birth Abortions and How Abortions Are Done  100
Fetal Tissue Research  101
Emergency Contraception  101
Maternal versus Fetal Rights  102

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Contents xiii

Viability  103
The Supreme Court Fine-Tunes Roe v. Wade  103
Partial Birth Abortions  104
States Restrict Abortion Clinics  104
Self-Administered Abortion by Telemedicine  105

Further Reading  106
Discussion Questions  106
Notes  106

5. Assisted Reproduction, Multiple Gestations, Surrogacy, and Elderly
Parents  109

The Octomom and the Gosselins  109
Louise Brown, the First Test Tube Baby  110

Harm to Research from Alarmist Media  112
Later Developments in Assisted Reproduction  112
Sperm and Egg Transfer  113
Freezing Gamete Material  114

Ethical Issues  115
Payment for Assisted Reproduction: Egg Donors  115
Payment for Assisted Reproduction: Adoption  115
Paid Surrogacy: The Baby M and Jaycee Cases  116
Multiple Births: Before the Octomom and Gosselins  117
Older Parents  118
Gender Selection  119
Unnatural  119
Physical Harm to Babies Created in New Ways  121
Psychological Harm to Babies Created in New Ways  122
Paradoxes about Harm and Reproduction  122
Wronging versus Harming  123
Harm by Not Knowing One’s Biological Parents?  124
Is Commercialization of Assisted Reproduction Wrong?  124
Screening for Genetic Disease: A New Eugenics?  125
Designer Babies?  126
Assisted Reproduction Worldwide  126
Time to Regulate Fertility Clinics?  127
Conclusion  128

Further Reading  128
Discussion Questions  128
Notes  129

6. Embryos, Stem Cells, and Reproductive Cloning  132
Background on Embryonic Research, Cloning, and Stem Cells  132
Ethical Issues about Reproductive Cloning  140

Valuable from Conception  140
Potential for Personhood  140
Slippery Slopes  141
Reductio ad Absurdum  141

pen07945_fm_i_xxii.indd 13 09/12/16 8:52 PM

xiv Contents

The Interest View  142
Embryos and Respect  142
The Opportunity Cost of Missed Research  143
My Tissue  144
Moot?  144

Reproductive Cloning  144
Reproductive Cloning: Myths about Cloned Persons  144
Against the Will of God?  145
The Right to a Unique Genetic Identity  145
Unnatural and Perverse  146
The Right to an Open Future  146

Problems with Primate Cloning  147
The Spindle Problem   148
Inequality  149
Good of the Child  150
Only Way to Have One’s Own Baby  151
Stronger Genetic Connection  152
Liberty  152
A Rawlsian Argument for Cloning and Choice  153
Links between Embryonic and Reproductive Cloning  153

Further Readings  154
Discussion Questions  154
Notes  154

7. Impaired Babies and the Americans with Disabilities Act  157
1971: The Johns Hopkins Cases  157

1970s: Pediatric Intensivists Go Public  158
Ancient History  159

1981: The Mueller Case: Conjoined Twins  159
1982: The Infant Doe Case  160

1982–1986: The Baby Doe Rules  161
1983–1984: The Baby Jane Doe Case  162

1983–1986: Baby Jane’s Case in the Courts  163
Follow-up on Baby Jane Doe  164
Media Ethics and Bias  165

Ethical Issues  166
Selfishness  166
Personal versus Public Cases  167
Abortion versus Infanticide  168
Killing versus Letting Die with Newborns  169
Personhood of Impaired Neonates  169
Kinds of Euthanasia  170
Degrees of Defect  170
Wrongful Birth versus Wrongful Life  171
1984: Legislation  172
1992: The Americans with Disabilities Act (ADA)  173

pen07945_fm_i_xxii.indd 14 09/12/16 8:52 PM

Contents xv

The Strength of Disability Advocates  174
Conceptual Dilemma: Supporting Both Choice and Respect  174
UAB’s Support Study on Premies  175

Further Reading  175
Discussion Questions  176
Notes  176

8. Medical Research on Animals  179
The Animal Research Front and Gennarelli’s Research  179

Evaluating the Philadelphia Study  181
PETA and Edward Taub’s Research on Monkeys  181

The Law and Animal Research  183
Numbers and Kinds of Animals in Research  184
Descartes on Animal Pain  184
C. S. Lewis on Animal Pain  185
Philosophy of Mind and Ethics  186
Peter Singer on Speciesism  186
Tom Regan on Animal Rights  188
Why We Need Animals in Research: The Official View  189
Critiquing the Official View  190
Chimpanzees and Research  192

Further Reading  192
Discussion Questions  193
Notes  193

9. Medical Research on Vulnerable Populations  196
Infamous Medical Experiments  196

William Beaumont  196
Nazi Medical Research  196
Josef Mengele  197
The Nuremberg Code  198
Questionable American Research  198

The Tuskegee Study (or “Study”)  200
Nature and History of Syphilis  200
The Racial Environment  201
Development of the Tuskegee Study  202

Ethical Issues in the Tuskegee Study  205
Informed Consent and Deception  205
Racism  206
Media Coverage  206
Harm to Subjects  207
Effects on Subjects’ Families  208
Kant and Motives of Researchers  208

Other Studies Like the Tuskegee Study  209
HIV Prevention in Africa: Another Tuskegee Study?  209
The Krieger Lead Paint Study  210
1946–1948: The Guatemalan Syphilis Study  211

pen07945_fm_i_xxii.indd 15 09/12/16 8:52 PM

xvi Contents

Financial Conflicts and Twenty-First-Century Research  212
Toward International Standards of Research Ethics  213
The Collaborative Model  214
The Death of Jesse Gelsinger  215

The Bucharest Early Intervention Project (BEIP)  216
Further Reading  217
Discussion Questions  217
Notes  217

10. Ethical Issues in First-Time Organ Surgeries  221
The First Heart Transplant  221

Fame Cometh  224
The Post-Transplant Era: “Surgery Went Nuts”  224

Barney Clark’s Artificial Heart  225
The Implant  226
Post-Clark Implants  228

Limb and Face Transplants  229
Ethical Issues in First-Time Surgeries  232

The Desire to Be First and Famous  232
Concerns about Criteria of Death  234
Quality of Life  235
Defending Surgery  236
Cosmetic versus Therapeutic Surgery  237
Expensive Rescue versus Cheap Prevention  237
Real Informed Consent?  238
Conclusion  239

Further Reading  239
Discussion Questions  239
Notes  240

11. The God Committee  243
The God Committee and Artificial Kidneys  243

Shana Alexander Publicizes the God Committee; Starts Bioethics  245
The End Stage Renal Disease Act (ESRDA)  246
The Birth of Bioethics  247
Supply and Demand of Donated Organs  247

Ethical Issues in Allocating Scarce Medical Resources  248
Social Worth  248
Personal Responsibility …

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