Problem‐Based Learning in the Patients’ Rights Context
There is an old saying that experience is the best teacher. People seem to remember their
own experiences best. Thus, problem‐based learning is an attempt to provide students with
a learning experience. Students listening to a lecture are like tourists on a tour bus; they sit
back and wait for the lecturer to point out the interesting sights. They click a picture
whenever the lecturer mentions the exam. Students reading a case study may be more
engaged because it is a story about real people; for many people, stories create an image in
their minds that they can remember. Problem‐based learning starts with a case study, a
factual example, but instead of giving an answer, problem‐based learning asks the student
to create an answer by applying a set of norms to the story. Requiring the student to
actively apply a norm or rule to a problem is an experience that a student will not only
remember, but will also internalize. What follows is a partial example. The norms to be
applied are included in the European Charter on Patients’ Rights, attached.
Hypothetical Case, Part I
Nazeli Nazaryan is a 21 year old woman complaining of abdominal pain. Her parents bring
her to State Hospital No. 1 where she is examined by attending physician Aghvanyan. (Day
1). Physician Aghvanyan tells the parents that he has diagnosed Nazeli’s condition as acute
appendicitis and that Nazeli requires immediate surgery. The parents ask about alternatives
to surgery and ask for guarantees about the results of surgery. Dr. Aghvanyan becomes
defensive when they ask how many times he has completed this surgery and with what
results. The parents decide that they don’t like Dr. Aghvanyan and they call an acquaintance
named Dr. Begoian who agrees to do the surgery.
That evening arrangements are made for Dr. Begoian to do the surgery at State Hospital No.
1. Nazeli’s parents pay cash for this service. The appendectomy is successfully performed.
Nazeli is placed in the recovery unit of the hospital.
1.1 Based on the facts stated above, have any patients’ rights been violated? If yes, list
the violations. Who is responsible for each violation?
1.2 Based on the facts stated above, have any violations of Armenian law occurred? If
yes, list each violation and who is responsible for the violation. (Practitioners’ Guide
required for this exercise).
1.3 If you were assigned to evaluate the performance of Dr. Aghvanyan, what additional
information would you like to know? Make a list of persons you would like to speak
to and what questions you would ask each person. Consider question 1.1 above.
1.4 Assume that new techniques for less invasive appendectomies have been developed
in Europe, but that Dr. Begoian used an old technique during the surgery. Does this
constitute a violation of patients’ rights despite the fact that the surgery was
Hypothetical Case, Part II
The next day (Day 2) Dr. Begoian visits Nazeli in the hospital. He reports to her parents that
her condition is good. Because he has a Russian education and because Armenian law
requires that all medical records be kept in Armenian, he does not make any notation in
Nazeli’s medical record. The same events happened the following day (Day 3) and no record
On Day 4 Dr. Begoian visits Nazeli in the hospital. After taking her temperature and
removing her drainage tube, he tells her parents that they can take her home. No record is
made. The parents take Nazeli home but no one informs the hospital administration that
she is has left.
That evening Nazeli had a fever and felt bad. Her father called Dr. Begoian. Dr. Begoian
assured the father that the fever was normal and would pass.
On Day 5 and Day 6 Nazeli’s condition worsens. She has abdominal pain and a fever. Her
parents try to call Dr. Begoian several times but he does not answer his cell phone and no
one answers the calls to his home telephone. In the evening of Day 6 Dr. Begoian finally
answers a call from Nazeli’s father. The father angrily demands that Dr. Begoian visit Nazeli
at home. In approximately 40 minutes Dr. Begoian arrives at the home. After examining
Nazeli he recommends that she be given an enema and that it be performed at the hospital.
Nazeli is transported to the hospital. Dr. Begoian calls ahead to arrange for the enema. An
enema is performed by a nurse. Nazeli’s parents pay the hospital cash for this procedure.
By phone Dr. Begoian assures the parents that Nazeli will be okay and by phone tells the
nurse to send the patient home. No medical record is recorded.
2.1 Based on the facts stated above, list any and all violations of patients’ rights. Who is
responsible for each violation?
2.2 If you were assigned to evaluate the performance of Dr. Begoian, what additional
information would you like to know? Make a list of persons you would like to speak to
and what questions you would ask each person.
2.3 If you were assigned to evaluate the management procedures of State Hospital No. 1,
what additional information do you need? How would you discover which norms must
be applied? Who would you like to speak to and what questions would you ask?
Hypothetical Case, Part III
On Day 7 Nazeli continues to suffer abdominal pain and a fever. Her parents take her to
Hospital No. 1 where she is examined by Dr. Begoian. Nazeli has a fever of 38.5 C. Dr.
Begoian requests an ultrasound examination, the results of which show free floating liquid
in Nazeli’s abdomen. Dr. Begoian does not tell Nazeli’s parents about the free floating liquid
in her abdomen. Instead, he gives Nazeli an antibiotic injection. He assures Nazeli’s parents
that additional surgery is not necessary. Nazeli asks for “something to take away the pain.”
Dr. Begoian tells her that she must be brave, and sends Nazeli home. No record is made.
On Day 8 at 4:00 in the morning Nazeli vomited and is in a severely weakened condition.
The parents call Dr. Begoian who advises that Nazeli be examined by an infectious disease
specialist. Later that morning, Nazeli’s parents take her to the HIV / AIDS clinic for
examination. The blood tests reveal no infectious disease and the doctor there, Dr.
Dalakyan, advises the parents that it is more probable that there is a surgical problem.
Nazeli asks for “something to take away the pain,” but Dr. Dalakyan states that he is not her
primary physician and does not want to prescribe something which might conflict with
health care regimen. Dr. Dalakyan recommends to the parents that they take Nazeli back to
Nazeli’s parents immediately transport her to Hospital No. 1. While she is being examined
by Dr. Enokyan, head of surgery, Nazeli goes unconscious. Dr. Enokyan tells the parents that
he must conduct exploratory surgery to discover what is wrong. No alternative treatment is
considered or discussed. The parents, desperate, agree to the exploratory surgery without
truly understanding what the term means. Due to the urgency, there is no written record of
During surgery Dr. Enokyan discovers that Nazeli has developed a purulent peritonitis which
requires the removal of her ovaries and cervix. He removes these body parts and tries to
clean the infected area.
After surgery Dr. Enokyan explains to Nazeli’s parents what work he had to do. The parents
are in complete shock that body parts have been removed. Later that evening, Nazeli dies in
the recovery room.
One month later the hospital contacts the parents and requires that they pay for the
exploratory surgery because it does not fall within the provisions of the state budget for free
3.1 Based on the information above, list any and all violations of patients’ rights and the
corresponding person responsible.
3.2 Can the hospital, a state entity, also be responsible for a violation of patients’ rights?
What procedures should the hospital establish considering patients’ rights numbers 8 &
9? Should the hospital bear responsibility for any violations by individual doctors?
3.3 Assume that new techniques for less invasive appendectomies have been developed in
Europe, but that Dr. Begoian used an old technique during the surgery. Does this
constitute a violation of patients’ rights despite the fact that the surgery was originally
considered successful? What additional information might you need in order to decide
this issue? What are the possible sources for this information?
3.4 You are an employee of the state Ministry of Healthcare. Nazeli’s parents come to you
and ask that the Ministry intercede so that they do not have to pay for the exploratory
3.4.1 What procedures must be followed to process this request?
3.4.2 If you fail to inform the parents that they may also have a right to compensation
against the hospital or 1 or more doctors under Armenian law, have you violated
patients’ rights numbers 13 and 14? What norms or code might you research in
order to decide this question?
3.5 You are an attorney at the Office of the Human Rights Defenders. You receive a written
complaint from Nazeli’s parents. The complaint fails to specify what recourse or relief
the parents want and who they blame for their situation.
3.5.1 Does this complaint come within the jurisdiction of the Human Rights Defender? If
yes, why? If no, why?
3.5.2 Are you obligated to help the parents formulate a better complaint? Why or why
not? If you are not obligated, can you volunteer to help them formulate a better
3.6 You are an attorney in private practice. Nazeli’s parents have come to you for help.
3.6.1 What are their options under Armenian law?
3.6.2 Devise a strategy to obtain compensation for the parents. Considering that they do
not have much money, they want to avoid litigation, but if required, they will borrow
money to finance litigation in the court.
3.6.3 What additional evidence do you need in order to pursue litigation? How would you
obtain expert testimony?
3.6.4 The parents want to know what possibility there is that they could obtain
compensation. How would you assess the risks of litigation? What additional
information do you need?