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On The Other Hand...

"It seems the illegality is what concerns you," put in Bernat.

"So what did you tell her?" someone finally asked.

"We recommended she not smoke marijuana," Edwards said, and "we recommended she breast-feed."

A few weeks later, Edwards reflects on that committee meeting. It does not surprise him that there was no clear opinion from the committee. "Almost by definition," he says, "an ethical dilemma is a situation where there is not a clear answer."

"That's the nature of the beast," agrees Bernat. "Our goal is to provide a forum for discussion, [to] help people understand the issues. We don't have decision-making authority."

What did surprise Edwards, however, was that "there was very little concern . . . about the illicit drug use," he says. "They were quite happy to go with breast-feeding and its known benefit, [despite the mother's] continued participation in an illegal activity with undefined but probably low risk medically."

The committee deals with many other kinds of cases, all of them heartrending for everyone involved. "There's never an ethics consult that isn't upsetting," says one committee member. The decisions can be tough, painful, overwhelming, emotionally charged, and even nightmarish at times. Here are a few more examples:

Betty, now in her seventies, has suffered from bipolar illness since she was a young adult. Many years ago, she had

Patrick McCoy: The committee's leaders "help the whole story unfold"

Reporters from prominent media outlets—from the New York Times to People magazine—interview DMS's Bernat on major ethics cases. He was quoted widely, for example, about the suit involving Terri Schaivo.

The ethics instruction that today's medical students receive—including at Dartmouth—"is done piecemeal" says Bernat. There is just too much that needs to be incorporated into the curriculum. "If I had my druthers," he adds, "we would have a required course."

signed what's known as a Ulysses contract—named for the Roman hero who instructed his crew to bind him to the mast of his ship and not release him, even if he begged to be set free, while the ship sailed past the Sirens, whose beautiful singing lured sailors to their death on the rocks (his crew, meanwhile, plugged their ears with beeswax to keep from hearing the enchanting songs).

Someone with a mental illness that occurs in predictable phases may sign such a contract during a healthy phase; it authorizes doctors to deliver the treatments they think best and gives them permission to disregard what the patient says when the mental illness is uncontrolled. So, for instance, since Betty's kidneys are failing, she is getting dialysis, even though she insists she doesn't want it. The problem before the ethicists is that Betty is now very sick—both physically and mentally. In addition to her kidney problem, she has been diagnosed with cancer. And she is not well mentally for long enough to revoke the Ulysses contract. (In addition, there is concern that the contract she signed didn't include a provision allowing her to change her mind even if she genuinely, rationally decided to do so.) At this point, neither Betty's caregivers nor her sister are sure what the right course of action is.

An ethics consult helped everyone understand that continuing aggressive treatment no longer made any sense. Betty was placed in hospice care and died peacefully.

David, a 35-year-old man, dies in a car accident. His wife wants to have his sperm harvested so she can use it to have a child. That would require nearly immediate harvesting, before the sperm

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