This writing assignment will be an application of John C. Moskop's simple method for case analysis. Rather than adopting a traditional essay structure (introduction, body, conclusion), please structure the assignment as follows: Include a very brief introduction announcing what the assignment plans then perform each of the six steps, in order, and explicitly marked by the relevant number. There is no need for a conclusion. The case raises a number of our course topics: autonomy, surrogate decision-making, beginning-of-life treatment choices, and end-oflife treatment choices. refer to Moskop's description and application of the entire six-step method in Chapter 3. Here is some additional guidance concerning certain steps in the method and the way I'd like you to approach them.

Instep 1, keep in mind that there is more than one way of formulating the problem and sometimes there is more than one problem that could be formulated. The way you do step 1 guides and constrains what you will do in the further steps. It is very likely that, in working on steps 2-4, you will want to go back and revise (alter, narrow, widen) your statement of the problem in step 1 to capture your deeper understanding of the case.

Instep 2, please assume that the information in my description of the case is already understood; simply state what further information you think is needed to make the decision.

Forstep 4, you might wonder: what sorts of argument, principles, etc. should I include for each option identified in step 3? Let your case be your guide! If one or more of Beauchamp and Childress' four principles is relevant, definitely explain how. But it's likely that other kinds of considerations will seem relevant for defending certain optionsperhaps a similar case where the decision seemed sound; perhaps an argument based on the sanctity of human life; etc. Look back at Moskop, Chapter 3, for a variety of options for reasoning in medical ethics (virtue ethics, the rule-based approach, etc.). Think broadly and do your best to give the strongest possible version of any reason or argument that you give.

For step 6, since you won't be carrying out any action, simply explain which consequences it would be relevant to assess (if this were a real decision playing out) and why the assessment would be useful.

CASE 1: Pregnancy and Advance Directives

Twenty-nine-year-old Janet and her husband, Tom, were driving home from her ob-gyn appointment when tragedy struck. Another driver, elderly and distracted by an incoming text message, ran a red light and T-boned Janet and Tom's Mini-Cooper. Both young people sustained severe injuries. Tom died on the way to the hospital. Janet survived, having escaped injury except to her head; but that was unfortunately massive. Her physicians now say, a week after the accident, that the prognosis is grim. The best one could hope for is continued life in a persistent vegetative state. Just before leaving the doctor's office, Janet had sent a jubilant text message to her parents. "Guess what?! We're pregnant!!! " So Janet was pregnantand prescient. Unlike most young adults, Janet had thought about mortality in advance of this accident. She is, or was, a nurse. She had gone to continuing education workshops about end-of-life care and advance care planning. Janet then had completed her own advance directives some months ago, naming Tom as her primary agent and durable power of attorney for healthcare decisions. She named her parents as secondary agents. Janet also had completed, with notarized signature, a healthcare treatment directive. Among her directives was a clear, handwritten statement about life prolongation if she were, somehow, "to end up in anything like PVS, from which I am not apt to recover." Janet had written that, in such a condition, "I do NOT want my life to be extended by means of medically assisted nutrition and hydration, ventilator, or other life support." And then it happened. With Tom gone, treatment decisions are left up to Janet's parents. They both are thoughtful people, healthcare professionals also, who take very seriously their difficult responsibility of acting as surrogates on Janet's behalf. Janet's parents had received a copy of their daughter's advance directives. After consulting her physicians and other family members, they conclude that Janet had very likely not considered the possibility of being pregnant while being in a persistent vegetative state. If she had, they think, she would have made an exception in her advance directive. With this reasoning in mind, they ask her physicians to maintain life-sustaining treatment and attempt to bring the pregnancy to term. After the pregnancy is brought to term, Janet's parents intend to follow her healthcare treatment directive and ask the physicians to discontinue life-sustaining treatment. Would it be possible to bring Janet's pregnancy to term? Yes. The pregnancy was 14 weeks along and the fetus sustained no injury. The Proceedings of the Mayo Clinic documents a case in which a woman entered a persistent vegetative state at 14 weeks of pregnancy and her healthy baby was delivered by cesarean section at 34 weeks. As the authors explain, "if a patient is in a chronic vegetative state, in which cerebral function is lost but specific vital functions such as respiration and blood pressure regulation are retained, somatic survival can be maintained for a prolonged period." What is a persistent vegetative state (PVS)? Also known as unresponsive wakefulness syndrome, "chronic vegetative state is defined as the subacute or chronic condition that sometimes emerges after severe brain injury and consists of a return of wakefulness accompanied by an apparent total lack of cognitive function." To be clear, "wakefulness," here, does not mean consciousness. Janet has no subjective awareness. By definition, patients in PVS do not experience pain. That said, since there is some evidence that the brains of such patients register pain to some extent, Janet's physicians operate on the assumption that she can feel pain, providing analgesics where appropriate, etc., as they would with a fully conscious patient. For the purpose of this assignment, please assume that there is no legal obligation to maintain Janet's life in order to maintain the life of the fetus. It would be legally permissible to withdraw Janet's life-sustaining treatment. Prepare a case analysis that would help her physicians handle this situation. This case is heavily adapted from the Center for Practical Bioethics website