Bioethics of Death and Dying: Sample exam

The following are some sample questions from my course on the bioethics of death and dying. These questions are updated each year based on changing course content, as well as what has already been covered in other assessments, and so is meant only as illustration. I am including the questions themselves and necessary context, and am omitting the rubric, course policies, and notes about suggested sources or which sessions to look at in particular etc.

This exam is conducted as an open-book, take-home, untimed exam, and designed for an accelerated online course. The questions are posted gradually throughout the term, but could be completed within a two week window.

There are three main sections to this exam. For scoring, the first section receives approximately 60% of the weight, the second section 30%, and the final section 10%.

In the first section, students are asked to apply what they learned in this course to a novel topic related to our discussions. They have a choice between questions, and because these are often novel to them, I provide introductory context. Thus, the exam looks longer than it is in practice.

In the second section, students are asked to create their own question related to something they learned or found interesting in the course, and to write an argumentative answer in response.

In the third section, students are asked to critically reflect on their learning and researching strategies. Where the second section asks about the content of their learning, the third asks about the process.

Section one: Prepared questions.

1. Option A. Species specificity in definition(s) of death.

Context: Our primary reading for the definition of death focused on a bio-inclusive account of death for organisms generally. While this course focused most on humans and healthcare, we also discussed in class whether we might have species-specific (or family, genus, etc -specific) definitions of death. Indeed, many species of organisms seem quite different from human organisms. Some examples we discussed: some jellyfish can revert to polyp states; many caterpillars metamorphose into butterflies; cells like amoeba can undergo fission; slime molds can undergo fusion; while some hydra do not appear to undergo senescence. the list stretches on.

Question: Should our definition(s) of death be bio-inclusive for all organisms, or should we develop distinct definitions based on the type of living thing in question? Give an argument for your position.

1. Option B: Resource scarcity and determination of death by neurological criteria

Context: We’ve discussed cases where patients and family members object to determination of death by neurological criteria, whether for personal or other religious reasons. We’ve also observed that many of our course issues are exacerbated if not caused by scarcity. In particular, we mentioned that scarcity is often leveraged in legal cases concerning determination of death and withdrawal from life support, weighing questions of discontinuing support against the costs of that support, scarcity of medical resources and ICU beds, etc. Imagine that there were no resource scarcity issues whatsoever: that we had more than sufficient funding, organs, and more than adequate space, technology, staffing etc. In that context, imagine cases like we’ve discussed in class, where a patient apparently lacks arousal and awareness, and would fail the typical tests for DNC like an apnea test; and where their family is objecting to the determination of death by neurological criteria, arguing that the patient is not dead until their heart and lungs stop, even if their brain is not apparently functioning.

Question: Without scarcity, would there be compelling reasons for a hospital to push for a determination of death according to neurological criteria, rather than cardiopulmonary criteria? Defend your position with an argument.

1. Option C: Postmortem harms

Context: In our readings and in class, we read a few philosophers who discussed whether death (and dying) can be bad for the one who dies. Beyond the harms of death itself, many people seem to believe that our own actions can harm those who are already dead. For example, the belief that desecrating a graving, going against someone’s will, having their cadaver nonconsensually blown up by the military, slandering their name, etc., all can be forms of harm to a decedent. This matters in healthcare for things like research ethics, organ transplantation, medical education using cadavers, etc. These apparent type of harms are called “postmortem harms” (post = after; mortem = death).

Question: Can someone can be harmed even after they have died? Defend your position with an argument, and briefly indicate what that entails for one of the topics we covered in class. For the purpose of this question, assume you are trying to convince someone who does not believe in an afterlife.

2. Option A: Transplant vaccination

Context: In class, we had a research exercise where we discussed mandatory COVID-19 vaccination for solid organ transplant (SOT) eligibility and priority setting. That discussion itself is informed by many of our other questions around valuing lives and deaths, health inequities and stigma, priority setting, responsibility and healthism, etc. This question is an opportunity to build on the course prep and discussions you already completed for that class.

Question: Should solid organ transplant recipients be required to have a COVID-19 vaccination? Why, why not, or under what specific circumstances? Defend your position with an argument. You may pick a particular organ (such as liver, kidney) for the purpose of argument.

2. Option B: Global partiality

Context: Imagine the following case. The year is 2027. The world is experiencing a novel orthopoxvirus pandemic nicknamed squirrelpox (Spox). The symptoms of Spox are similar to smallpox, with painful sores and high death rates; the new Spox spreads faster. A vaccine is quickly synthesized using a live virus. Recall that this means that the vaccine is actually infecting you with a different virus, where that virus is milder than Spox but builds immunity to Spox. Canada currently has a first-dose vaccination rate of only 70%, and a full-dose (with boosters) rate of just 10%. Meanwhile, the whole population of Yemen has a first-dose rate under 4%, and a full-dose (with boosters) rate under 1%. A representative from Yemen has called on Canada for aid, including donating some of their stockpiled vaccine doses. At a Canadian parliamentary debate, they are deciding whether there is a moral imperative to donate some of their doses to Yemen. Some representatives argue that we have a duty to aid those in crisis, and that a global pandemic cannot be treated only locally. Other representatives argue that there is a duty to care for those in Canada first, and that even if this responsibility were not legally mandated, it would be morally mandated. They argue we should keep doses locally until we have better first-dose rates, ideally much higher full-dose rates, especially since we do not know the demographics of those who are not yet vaccinated. Assume that the number of doses Canada is considering donating is enough to provide one dose to every person in Yemen, or one dose to every person in Canada, but not both.

Question: In the above case, should Canada redistribute its stockpiled Spox vaccine doses to Yemen? Why, why not, or under what conditions? Support your answer with an argument. You are not expected to do more research than was already covered in class.

2. Option C: Houselessness and cause of death

Context: In June 2023, over 250 people each day who called for shelter intake were unable to be matched with shelter space in Toronto (and this only includes phone intake for individuals). This is more than twice the rate from June 2022. Those without shelter access, we’ve argued in class, are at increased vulnerability for death and dying. Meanwhile, we’ve emphasized how access to data is important for better bioethics, how the ways we fill out cause of death certificates impacts our available data, and how determining cause of death can be subject to value judgments. Similarly, we’ve also emphasized social and upstream determinants of health and of dying. This question pulls some of these discussions together from across the whole course, asking us to reflect on what should count as relevant causes of deaths. For example, some might think that houselessness and lack of shelter beds plays a role in heat deaths of unhoused people.

Question: Under what circumstances, if any, should “houselessness” or “inadequate social housing” be formally listed as one of the causes of death in Ontario death records? Defend your position with an argument. You are allowed but not required to make reference to the Medical Certificate of Death form and documentation we covered in class.

3. Option A: Decedent death data and deferred consent

Context: Typically, we expect that people explicitly consent prior to being registered as a participant in research studies. In emergency medicine, deferred consent is used in cases where explicit prior consent cannot be given prior to registration (consider my icepack bath example from lecture). One problem is that participants may die before they can consent to the use of collected data, and that a patient-chosen substitute decision maker (SDM) may be unavailable to consent on their behalf. We briefly discussed some moral, policy, research, and affective issues related to these cases in class.

Question: Should we allow deferred consent research studies to keep decedent data, even if the participant was unable to provide consent before dying, and no patient-chosen substitute decision maker is available on their behalf? Why, why not, or under what conditions? Defend your position with an argument.

3. Option B: Advance requests for MAID

Context: The CCA Expert Panel Working Group on Advance Requests for MAID published their State of Knowledge report in 2018 (one of the assigned options for session nine; click here for the pdf). The report identified three main scenarios in which Advance Requests for MAID may occur: (1) After a patient is deemed eligible for MAID; (2) After a patient is diagnosed, but before they are deemed eligible for MAID; and (3) Before a patient is diagnosed. We reviewed some of these options in class, when discussing the relationship between advance requests and waivers of final consent. This question focuses just on the three scenarios described in the report.

Question: In which of the above three scenarios, if any, do you think Advance Requests for MAID should be permitted? Defend your position with an argument. If you do not think MAID should be permitted at all, your answer should still be focused on advance requests specifically.

3. Option C: Pre-mortem vital organ donation

Context: In class, we discussed some issues with pre-mortem cryonic preservation: of seeking to undergo lethal procedures before one dies, to increase the chances at future resuscitation. In our recent guest lecture, case three offered a similar request for fatal care, concerning an apparently permanently unconscious patint’s advance request for vital organ donation. Let’s call this patient Joan for convenience. Assume that we know Joan’s request was well documented, witnessed, written recently and competently, and there is no reason to think Joan was coerced or would have changed her mind since writing the request. Assume further that Joan’s documentation shows a strong understanding of the risks involved in the surgery, and of the prognoses with disorders of consciousness. Finally, assume that Joan, though apparently permanently unconscious, retains enough residual neurological function in her brain stem that no physician would yet determine her dead by standard “whole-brain” criteria (e.g., she breathes spontaneously, even if there is no evidence of awareness, and no or limited evidence of arousal). Removing Joan’s vital organs would certainly lead to her death, and would render standard life sustaining technologies like artificial ventilators useless.

Question: Should we allow Joan and patients like her to donate their vital organs, even if the surgery for that donation would be the proximate cause of those patients’ deaths? Why, why not, or under what conditions?

4. Option A: The scope of suicide

Context: Consider three cases. (1) A patient is deemed eligible for MAID under track one (RFND). On the scheduled date, they provide final consent, and receive active euthanasia a minute later. (2) A person trapped inside a collapsing high-rise building appears to step deliberately through a broken window and falls to their death. (3) A human rights activist posts online that the oppressive political situation in their home country is being ignored. Two months later, they die by self-immolation outside that country’s government building. The different definitions and approaches to suicide we discussed in class would appraise these cases differently. This question asks you to defend a position with regard to each.

Question: Which of the above three cases, if any, could not be considered a death by suicide? Support your position with an argument.

4. Option B: Determining suicide deaths

Context: In your readings and in class, we discussed how the operating understanding of suicide as an intentional, self-caused death is both philosophically and clinically contested, including by those working in coroners’ offices. In particular, there are concerns about the requirement that a suicide death is “intentional,” and how this could be determined in practice. We talked about “psychiatric autopsies” in particular, as well as the inconclusiveness of physical markers, and the often absence of reliable witness testimony. In light of these discussions, this question asks you to take a position on the determination of suicide deaths.

Question: Should we continue to determine suicide as a manner of death, even if we cannot directly assess the intentions of a decedent? Why, why not, or under what conditions? Provide an argument for your position.

4. Option C: Diagnosing grief

Context: Early in the course, we discussed some complexities of grief and trauma as responses to loss. Now at the end of the course, you’ve seen these issues applied and expanded across other debates. You’ve also developed a better understanding the landscape of loss in contemporary medical contexts, as well as the social and structural contexts impacting our apparent choices, experiences, options, and health outcomes. This question asks you to reflect through these later discussions, back onto the beginning of the course.

Question: Under what conditions, if any, should we diagnose grief as an illness or disorder? Provide an argument for your position.

4. Option D: Patient beliefs in an afterlife

Context: This course has regularly encouraged us to reflect on how our moral questions and choices are often constrained by what we do know, and what we can know. One big issue around the ethics and epistemology of death and dying is a genuine uncertainty about what happens after death. Many different cultures, spiritualities, religions, and individuals have different and even competing ideas about what happens after death, whether there is something like an “afterlife,” and what those afterlives might involve, and we’ve surveyed several of these throughout the term. Still, no groups have presented sufficient arguments or evidence to generate a more global consensus on the existence or nature of an afterlife. This lack of a global consensus has led most medical decisions at the end of life to discount personal beliefs in an afterlife when considering how to provide appropriate healthcare for their patients. For example, the fact that someone believes that they are going to heaven when they die is not usually taken to mean a health care practitioner can reduce the quality or amount of healthcare being provided to that patient at the end of life compared to individuals who think there is no after life and that this life is all they have. But throughout the course, we’ve also discussed different ways in which personal beliefs about death can and do impact individuals’ attitudes toward issues in healthcare and deathcare more broadly. This, coupled with more patient-oriented focuses in most Western bioethics literature, might lead us to reappraise the role of personal beliefs in an afterlife.

Question: Should a patient’s belief in an afterlife affect the kinds of healthcare they are offered or receive? Why, why not, or under what conditions? Your answer should focus on one of the following debates: (1) The dead donor rule for vital organ transplant; (2) Determination of death by neurological criteria; (3) MAID; (4) Suicide prevention; (5) Emergency triage.

Section two: Your own further learning outcomes (content)

5. Further learning outcome

Context: Refer to our recorded class discussion from session one and session ten for a comprehensive explanation and Q&A (starting with the example of the exam where I studied all the wrong things). In brief, this question asks you to report on your own further learning outcomes: stuff that you learned, engaged with, and valued that you have not already had an opportunity to demonstrate in course assessments. We have covered a lot of topics and issues in the past month (see our final review in session twelve), while you’ve also been conducting your own research and learning. While you’ve been presented many questions and paper topics relating to dominant course themes, these hardly cover all that we’ve been learning. For example, we spent a lot of class time discussing QALYs, MAID and disability, environmental health injustices, the construction of patient choices, structural versus local sites of intervention, the limitations of harm reduction, the roles of theory and evidence in policy development, and even what bioethics is or should be. Importantly, we’ve also challenged the authority of bioethics educators and traditions, and the risks of assuming that “we” know best what matters to and for different people. This question allows you to reflect and report on what you found valuable or interesting, and to demonstrate critical engagement with that content. As mentioned in class, if you’re unsure whether your topics counts as sufficiently different from previous assignment prompts, you are encouraged to discuss using instructor office hours or the discussion board online. I’d be glad to help!

Question: What is one further issue that you have learned about while taking this course that you were not given an opportunity to demonstrate through the course assessments so far? Briefly explain that issue, then defend a position regarding that issue with an argument. You may choose any issue that we have covered in required materials, optional materials, office hours, course lectures, or even things that you found on your own during the last month, as long as they are clearly related to the bioethics of death and dying. The only limitation is that you cannot pick an issue that you’ve already been given a chance to write on in course assessments.

6. Another further learning outcome

Context: See the context for question five.

Section three: Further learning outcomes (strategies)

7. Learning and researching strategies

Context: You have been studying in an accelerated, synchronous, online course about difficult topics, during an ongoing pandemic and several heat emergencies. This is a very non-ideal learning context, and we have encouraged students to be attentive to their learning and research practices, supporting them with in-class workshops and discussions. For this question, you may reflect on any of the study skills you’ve been using to prepare for class, learn during class, or write your assignments, etc. If this question feels too open-ended for you, you might reflect on the following further prompts (these are for your consideration, and not things you are necessarily required to answer): What learning or research strategies have you tried using in this course so far, for your assignments or lecture preparation and notetaking? What about those strategies was successful or unsuccessful? What was your experience reading, watching, or listening to different sources throughout the course? What things prevented you from meeting your own research or learning goals, whether they are self-imposed or external circumstances, and how might you have better addressed them? What was your experience like conducting research during our live lectures (like with organ transplantation), or doing your own self guided research in preparation for our later sessions? What was the hardest part of writing your blog post or research paper, and how did you work to make it less hard? If you haven’t tried anything that feels new, or haven’t changed your practices, this doesn’t prevent you from reflecting on what you have been doing so far in terms of the above questions: What seems to be working for you, why do you think it’s working well, and how might it be even better improved upon in the future? See the recorded content from the final class for examples of some of the skills you’ve been developing by engaging in lectures.

Question: What have you tested or changed about the ways you engage with learning and research in this course? Select one or two strategies only. Explain those strategies and how you used them in practice, your motivations for choosing them, and plans for building from them in your ongoing studies. Stronger answers will provide concrete examples. Note: this answer should focus on how you have been learning (strategies), not what you have been learning (content).

Bonus questions:

BONUS: Taking this course

Context: Refer to our discussion in sessions one and two about the value or limitations of learning bioethics in a philosophy classroom, issues of interdisciplinarity, moral authority, and why we’re investing this time and money into an academic credit rather than using the same resources on community development or volunteer experience in clinical settings, etc. Now that the course is at its end, it is worth revisiting our earlier discussions.

Question: Are you morally justified in taking this course? Why, why not, or to what degree? Support your answer with an argument.

BONUS: “Less bad”

Context: We spent much of session twelve discussing what comes next after this course, as well as how our learning in this course can translate (or not) into meaningful changes or actions in our lives and the lives of those around us. We’ve also spent a lot of time throughout the course discussing different levels of intervention, the limitations of local interventions on structural problems, and the urgency of many bioethical problems.

Question: What is one step you personally can take to make death (or dying) less bad for yourself and your own communities? Why and how would that make death less bad? Consider and respond to at least one objection to your position based on our course discussions.