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Case summary

The case Surgery: Iturralde v. Hilo Medical Center, USA describes a situation where Decedent Arturo Iturralde was admitted to Hilo Medical Center (HMC), a health facility owned and operated by the
state in Hilo, following a problem with her legs that were continually becoming weak. This was in January 2001 when Arturo was examined by Dr. Ricketson, a credentialized orthopedic surgeon after
which the patient was diagnosed with degenerative spondylolisthesis L4–5 with stenosis. The condition required a spinal fusion surgery to be performed by implanting two rods into the patient’s
spine which was available at the hospital.
Feeling that waiting for that long would be risky for the patient, he improvised the two rods by cutting a steel screwdriver into two pieces which implanted into Arturo’s spine. During the next
day, Arturo fell once or twice, leading to shattering of the screw shafts. On February 5, 2001, he returned for three additional surgeries in order to replace the screwdriver with the expected
titanium rods. After he was discharged from the hospital, Arturo died on June 18, 2003, as a result of urosepsis complications. Consequently, the family was awarded $5.6 million following a jury
that accused both the Hilo medical center and Dr. Ricketson of being negligent.
Medical malpractice component
In the case of Iturralde v. Hilo Medical Center, USA, Dr. Ricketson had a legal duty to operate Arturo in a professional manner and in a way that may not cause any harm to his health. He never
first confirmed whether the surgery equipment was available before commencing the surgery, which in one or another was in contrary to the legal duties of surgeons. In addition, Dr. Ricketson’s
conduct reveals negligence upon the patient by acting in a manner that “deviates from the standards of care in the medical community” (Calisi, 2017; par 2). The surgeon resolved to use of
improvised screwdriver strands rather than the recommended titanium rods. It is believed that the negligence of Dr. Ricketson is responsible for the death of his patient three years after the
surgery. In addition to Dr. Ricketson’s negligence, the non-Party Hawaii Orthopaedics, Inc was also accused of negligence because of hiring Dr. Ricketson who they knew was not fit for the job
having been chased in two health facilities.
Such a case could not have occurred if Feldmeyer had alerted the hospital administration about Dr. Ricketson’s code of conduct. This is in accordance with one of the various malpractice policies
that second-opinion physicians possess an ethical obligation to whistle blow if he/she feels that the standard of treatment has been breached by a medical practitioner (Moore, 2017). Despite the
fact that Feldmeyer was present during the start of the initial surgery, she just decided to keep quiet only to speak out when things had already gone bad. In addition, it is a requirement before
any health care facility employing a surgeon to take him/her through a credentialing process, document his professional competence and ensure he is physically and mentally healthy to offer services
to patients. Nevertheless, did not Hilo Medical Center put this into consideration and it could have saved the situation by not having unqualified surgeons in the facility.
When Dr. Ricketson agreed to operate Arturo, a legal duty was established between him and the patient, and in the provision of services, a physician possesses a duty of professional care to the
patient. In this respect, Dr. Ricketson was expected to use the right titanium rods rather than the improvised screwdriver rods that were not recommendable for human implantation. By implanting
screwdriver rods into Arturo’s spine, Dr. Ricketson breached the professional duty to provide care to his patient since he never delivered the standard of care which although can be defined
differently in various jurisdictions is what any other surgeon would have executed his/her duties in performing the surgery to Arturo (Bal, 2009). Therefore, implanting screwdriver rods rather than
titanium rods is an obvious breach of duty that is self-spoken.
Dr. Ricketson’s case of negligence would lead to health care consumers associating state’s facilities with inefficiency and in-capabilities to an extent to making a patient’s condition worse rather
than helping them recover. This is in line with the notion that state-run institutions are poorly run and inefficient in their operations. While people from different cultures may have a different
translation of the case above, some other people would even resolve traditional treatment methods which they believe could be more careful and true in their service. An incidence such as the one
discussed in Iturralde v. Hilo Medical Center, USA can result in the public losing trust in state-run health care facilities which they believe can be a source of problems rather than healing.
Although HMC was to some extent accountable of the surgery gone bad, it was Dr. Ricketson’s big mistake not to adhere what was to be done in the practice. That could the reason why the jury
allocated 65% of the fault to Dr. Ricketson and 35% proportion to HMC (FindLaw.com, 2012).
Ethical component
According to Torjuul, Nordam & Sorlie (2005), physicians are never sure of what is deemed as correct and right actions to be taken upon patients in different situations. While surgeons are expected
to look for patients’ welfare and minimize pain and suffering as much as possible (Pandit & Pandit, 2009), they are faced with difficult ethical dilemmas as well as decision making because they
have to choose between two or more options Torjuul, Nordam & Sorlie (2005). In the case at hand, Dr. Ricketson thought waiting for the titanium rods for one and half hours was risky for the
patient. Much concerned to alleviate suffering and fighting to save Arturo life, Dr. Ricketson resolved to improvise a screwdriver to come up with the rods to be implanted into Arturo’s spine,
which is believed to have worsened the patient’s condition and subsequent death three years down the line.
In order to prevent liability issues in the future, HMC could change its employment policies to ensure that physicians and health care providers employed in the facility are competent and skilled
enough to handle all cases involving treatment. Although it is believed that health care providers and staff are well trained to the standard of care and also ethical guidelines, it would be good
to conduct continuous training on the expected code of conduct and state clearly in the code of conduct that every practitioner is held wholly liable for all malpractice litigations. Employing
eligible employees would ensure that people employed in the health care facility are competent enough and skilled to handle patient cases. In addition, with the practitioners being aware that they
are responsible for their own actions, they will be much more careful in their practice and ensure that they provide a safe, quality healthcare experience to their patients.


In this project, you will analyze a court case involving medical malpractice (Please see attachment for case). You will use the facts from the original case to identify an ethics issue, determine
an ethical theory that would help provide a safe and quality healthcare experience for the patient, and apply a clinician–patient shared decision-making model.

Ethical Component: In this section, you will evaluate the case to identify the specific ethical issues and determine ethical theories and shared decisionmaking models that would help resolve the
issue and provide a safe, quality healthcare experience. Then, you will propose and defend ethical guidelines for healthcare providers to follow in order to avoid future incidents.

A.Describe the ethical issues that led to the malpractice case and explain why the issues are credited with causing the incident. Support your response with research and relevant examples from the
B. Describe an ethical theory that would help resolve the issue and provide a safe, quality healthcare experience for the patient. Support your response with research and relevant examples from the
C. Select a physician–patient shared decision-making model and explain how it would provide a safe, quality healthcare experience for the patient
D. Propose ethical guidelines that would have helped prevent the incident and would help the organization prevent future incidents.
E. Defend how your proposed ethical guidelines will hold healthcare providers accountable to themselves, their profession, their patients, and the public.


Ethics Case Study

Ethical Issues

Healthcare ethics are moral principles, values, and beliefs which guide caregivers in their service delivery (Vermont Ethics Network, 2011). Ethical issues depend on the nature of the choice to be made, and the role played by the practitioner and the care receiver. Healthcare ethics is based on four principles which are autonomy, beneficence, non-maleficence, and justice (Wall, Angelos, Brown, Kodner, & Keune, 2013). In the case of Iturralde versus Hilo Medical Center, USA, Dr. Ricketson did not follow all the four principles he did not give the patient autonomy over his own body. In addition, although he practiced beneficence, he did harm to the patient by implanting screwdrivers instead of the recommended titanium rods hence breaking the principle of Non-Maleficence.

According to Moore (2000), there are three aspects which make a surgical procedure ethically acceptable: institutional stability, laboratory background, and field strength. It was, therefore, wrong for Dr. Ricketson to use a procedure which is not ethically acceptable, thus causing the death of the patient. Another ethical issue in the case is the reluctance of the second-opinion physician, Dr. Feldmeyer, to alert the hospital administration about the malpractice. It is the obligation of the second opinion physician to blow the whistle if she or he observes a bleach in the standard of treatment by the main practitioner.

Ethical Theory

In the case at hand, the patient died because the physician did not conform to the rules, duties, and obligations crucial to the delicate procedure he was undertaking. It is for this reason that deontology is proposed as the best ethical theory to resolve similar issues in future, ensuring that patients are provided with a safe and quality care. According to Hynes (2013), deontology theory holds that a practitioner should strictly adhere to pre-set rules which are unbreakable and do not vary depending on the situation. Using this theory, the actions of Dr. Ricketson are found to be unethical, especially his use of screwdrivers instead of the recommended titanium rods. It is clear that the doctor did not follow the set rules and guidelines.

In deontology, morality is based on the action and not the outcome. A harmful action, such as unapproved procedure, is not acceptable regardless of the outcome. The actions of Dr. Ricketson are, therefore, viewed as unethical even if the patient would have healed from the procedure. According to Mandal, Ponnambath, and Parija (2016), medical negligence results from a deviation from the guidelines and set standards. Using deontological principles, it can be argued that both doctor Dr. Ricketson and Feldmeyer were negligent; the former for using a harmful procedure, and the latter for failing to report to the hospital administration.
Decision- Making Model

Shared decision making is an approach to medical practice in which the decision is arrived at through consultations between clinicians and patients by considering all options and using available evidence to make informed preferences (Elwy et al, 2012). Decisions should not only be guided by scientific evidence but also preferences of patients and families in a shared decision making (SDM) model that is practical for each situation. In the current case, a three-talk model is proposed. The model presents SDM as a transition between three types of talks which are the team talk, the option talk, and the decision talk (Elwy et al, 2012).

In the model, clinicians work with patients to determine treatments, tests, and management options using available evidence and considering informed preferences.  The model is characterized by active listening, deliberation, consultation, and working together. There is a logical sequence between the different kinds of talks, although the model is not linear but rather cyclic. The three-talk model is based on the principle that patients’ ideas are important in healthcare consultation including their attitude to risk and uncertainty. The model will be useful in giving a conceptual framework for shared decision making in cases similar to the one of Iturralde and Dr. Ricketson.

Dr. Ricketson made a unilateral decision about using screwdrivers instead of titanium rods without consulting the patient or even other caregivers. Had he applied the three-talk model of SDM, the patient would have given his opinion and preferences, and thus the doctor could not have been found to be negligent as it was in the particular case. SDM helps to achieve a safe, quality healthcare experience for patients by utilizing different categories of expertise both in medicine and in personal life. As Elwyn et al. (2012) noted, patients need to be informed about options without necessarily carrying the responsibility of making decisions.

The three-step model for SDM has psychological, emotional, and social factors which influence the dialogue between the physician and the patient. The team talk helps to ensure the patient understand the options available. The option talk is used to five more detailed information while the decision talk considers the preferences and settles on the best choice. Elwyn et al. (2012) used the term deliberation to mean the consideration of pros and cons of options, assessing their implications, and a foresight of possible futures in both the best and worst-case scenarios.

Ethical Guidelines

To prevent incidences similar to the discussed case, ethical guidelines, recommended by the American College of Surgeons (2016), have been proposed to help the healthcare organization improve its services. First, there is a need for practitioners to provide the highest quality care by abiding by rules and regulations as well as maintaining competence throughout their careers. A responsible healthcare giver should provide effective treatment appropriately and compassionately through the application of knowledge, skills, and experience. A surgeon ought to study and evaluate a new procedure or innovation so that he or she becomes proficient with its application. To improve care and treatment outcomes, surgeons must inform patients about their state of health and the proposed treatment procedure so that they can make informed consent.

Also, healthcare practitioners should work competently and impartially, by advocating for transparent, fair, and consistent practices. Regardless of the setting, they should always try to achieve quality and safety and support models which promote the best intervention. Additionally, healthcare givers should recognize that there is freedom of choice and that a patient chooses his or her physician except during emergencies. The patient can terminate his or her relationship with the physician. In such a situation, the physician should transfer the medical records to the new physician without prejudice. Further, the practitioner should keep medical records confidential and ensure that information is only shared with authorized persons.

Apart from the relationship between physician and patient, relationship with colleagues is crucial for proper care. This is because no practitioner is an expert in all areas, and hence there is a need for teamwork. Ethical practice holds that all individuals involved in patient care be treated with respect. There should be no case of discrimination or harassment based on gender, age, race, religion, disease, or even ideology.

Lewis (2018) asserts that healthcare organizations need to follow given standards in their services to patients and that they are responsible for maintaining the guidelines. Therefore, healthcare organizations, such as the Hilo Medical Center, need to set internal ethical standards modeling government and state standards. The administration should ensure that employees follow the standards and that rules and regulations should be used in all decision making. It is by following rules that incidences like the one where Dr. Ricketson made a wrong and unethical decision will be prevented in future.

Moreover, Hilo Medical Center and other healthcare organizations need to provide their employees with continuous professional development and education. Continuous education helps practitioners to give high-quality care to patients by acquiring new skills and learning about new procedures and innovations. All new innovations should be incorporated into formal protocols. Before a new technique is tested in humans, animal studies should be carried out to determine the efficacy and suitability. Finally, it is proposed that when an incompetent practitioner is identified, such as Dr. Ricketson, the organization should take proper disciplinary action to prevent future incidences.

In conclusion, the ethical guidelines proposed above will hold healthcare providers accountable to themselves, their profession, patients, and the public since they will eliminate cases in which practitioners act on their own. Thus, ethical standards lead to better healthcare by ensuring practitioners act within a set of guidelines thereby eliminating individual errors. Public support for a medical organization increases with the promotion of ethical standards according to Lewis (2018). When the community has faith in a healthcare organization, donations will be given to projects such as medical research leading to advancements in health science and innovation.




American College of Surgeons. (2016, April 2016). Statement on principles. American College of Surgeons. Retrieved from www.facs.org/about-acs/statements/stonprin

Elwyn, G., Frosch, D., & Thomson, R. (2012). Shared decision making: A model for clinical practice. Journal of General Internal Medicine, 27(10), 1361-1367.

Hynes, J. (2013). A brief sketch of the ethical theories used in medical practice. Catholic Medical Quarterly, 63(4), Retrieved from www.cmq.org.uk/CMQ/2013/Nov/ethical_theories_used_in_medicin.html.

Lewis, J. (2018). What is the importance of good ethical standards in health organizations? Chron, Retrieved from www.smallbusiness.chron.com/importance-good-ethical-standards-health-organizations-15449.html

Mandal, J., Ponnambath, D. K., & Parija, S. C. (2016). Utilitarian and deontological ethics in medicine. Tropical Parasitology, 6(1), 5-7.

Moore, F. D. (2000). Ethical problems special to surgery. Archives of Surgery, 135(1), 14-16.

Vermont Ethics Network. (2011). Health care ethics: Overview of the Basics. Vermont Ethics Network, Retrieved from www.vtethicsnetwork.org/ethics.html

Wall, A., Angelos, P., Brown, d., Kodner, I., & Keune, J. (2013). Ethics in surgery. Current Problems in Surgery, 50(3), 99-134.


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