Clitoral Sensitivity Study in Children: A Question of Ethics

The abstract presented for a paper by Yang, Felsen and Poppas “Nerve Sparing Ventral Clitoroplasty: Analysis of Clitoral Sensitivity and Viability” in the October 2007 Journal of Urology sounds rather cut and dry:

“Purpose Enlargement of the clitoris is often a prominent manifestation of virilizing congenital adrenal hyperplasia and other disorders of sexual development. Controversy persists regarding the viability and sensitivity of the clitoris following clitoroplasty. We present 51 consecutive cases of nerve sparing ventral clitoroplasty performed by a single surgeon. Materials and Methods Nerve sparing ventral clitoroplasty was performed in all patients. Postoperative evaluation for clitoral viability included gross examination and capillary perfusion testing. Patients older than 5 years were evaluated for clitoral sensory testing and vibratory sensory testing. Results A total of 51 patients 4 months to 24 years old (mean age ± SD 4.6 ± 6.8 years) with clitorimegaly underwent nerve sparing ventral clitoroplasty. Of the patients 41 had capillary perfusion testing of the clitoris, of whom all had a viable clitoris. Ten of the 41 patients underwent clitoral sensory testing. Patients reported an average degree of sensation of 3.6 ± 0.9 at the labia minora and 4.8 ± 0.4 at the clitoris. Nine of the 10 patients also underwent vibratory sensory testing. Average values for the introitus, clitoris, labia and thigh were 3.56, 1.61, 5.08, and 5.83, respectively. Mean time after surgery for the patients who underwent clitoral sensory testing/vibratory sensory testing was 2.0 ± 0.8 years. No variations in the sensitivity results were reported at followup in 2 patients. Conclusions To our knowledge this is the largest report of followup testing of clitoral viability and sensation after clitoroplasty. Continued long-term followup is ongoing to document long-term sexual function using this nerve sparing ventral approach for clitoroplasty. “

And ends with “study received medical institution review board approval.”

However, ethicists Alice Dreger and Ellen K. Feder writing “Bad Vibrations” 6-16-2010 in the on-line Hastings Center Bioethics Forum consider along with others including surgeons surgery to reduce the size of a large clitoris as medically unnecessary but their main concern with the study was expressed as follows:

“we are writing to express our shock and concern over the follow-up examination techniques described in up exams – which involve Poppas stimulating the girls’ clitorises with vibrators while the girls, aged six and older, are conscious – we were so stunned that we did not believe it until we looked up his publications ourselves. Here more specifically is, apparently, what is happening: At annual visits after the surgery, while a parent watches, Poppas touches the daughter’s surgically shortened clitoris with a cotton-tip applicator and/or with a “vibratory device,” and the girl is asked to report to Poppas how strongly she feels him touching her clitoris. Using the vibrator, he also touches her on her inner thigh, her labia minora, and the introitus of her vagina, asking her to report, on a scale of 0 (no sensation) to 5 (maximum), how strongly she feels the touch. Yang, Felsen, and Poppas also report a “capillary perfusion testing,” which means a physician or nurse pushes a finger nail on the girl’s clitoris to see if the blood goes away and comes back, a sign of healthy tissue. Poppas has indicated in this article and elsewhere that ideally he seeks to conduct annual exams with these girls. He intends to chart the development of their sexual sensation over time.”

The ethicists concerns was not that this genital testing would provide general knowledge about sensory complications of the specific surgical technique but “but it isn’t clear to us how this kind of genital touching post-operatively is in individual patients’ best interests.” So it appears that the view presented is that the surgery is unnecessary in the first place and the repeated post-operative testing is not for the benefit of the patients. What may set this study apart from studies regarding sensation over other parts of the body? Is it because one might look at the testing as a potentially sexual experience for an innocent girl and potentially psychologically harmful? Is such a study ethical? Read the full Bioethics Forum commentary at the link above and let me know if you consider that the authors’ view hold merit. ..Maurice.

Patient Modesty: Volume 35

Continuing on with the Patient Modesty thread, one of the issues that has been implied here recently and in the past is whether the basis for the persistence and lack of resolution of the patient modesty issue is essentially a battle between the sexes. If the issue is valid then it can be expected that there will be no resolution until the mindset of both the male and female society changes toward a more tolerant and supportive relationship between health caregivers and patients of either gender. ..Maurice

Graphic: Illustration of the battle of the sexes from Mirror Company.com

A husband having sex with his now mentally and physically incapacitated wife: Is it ethical and is it even legal?

The 29 year old wife, 5 years ago, suffered a very severe traumatic brain injury from an automobile accident and despite long attempts at rehabilitation now lives at home under the attention and care of her husband who must also attend to the care of their own sons from earlier in their marriage. The wife is apparently alert sufficiently to show some response to visual, auditory and tactile stimulation but is unable to talk or communicate any decisions. She is paralyzed, unable to walk or move on her own, incontinent and unable to attend to her own personal care and has required tube feedings.

A few months ago, the wife became pregnant and the pregnancy was terminated by her physicians in her health interest. Despite the husband arguing that he and his wife were in a loving sexual relationship throughout their marriage, that he never divorced and abandoned her after her accident and that he believed based on his experience with her in the past and her current responses that she wanted the loving sexual relationship to continue despite her handicaps, the wife’s family considered the acts of having sex with the incapacitated wife as rape. They notified the police and started legal guardianship proceedings.

You are the ethicist and you are the judge. Were the husband’s sexual actions ethical? Were they, in fact, legal? What facts and what issues would be important to know and consider in answering these questions?

This scenario, as written here, was adapted from a case study “Sexuality and a Severely Brain-Injured Spouse” in the ethics journal “The Hastings Center Report” May-June 2010.http://www.thehastingscenter.org/Publications/HCR/Detail.aspx?id=4656 There are three separate commentaries by ethicists there but I hope my visitors would answer my question here before looking at their responses. ..Maurice.

Branding Patients: Beneficial or a Violation of Privacy?

Branding is an identification of a subject by applying a marker on that subject which can remain for the time it will be useful. Cattle are branded. Should patients be branded for one reason or another thought to be in the patient’s best interest? For example, a common hospital branding is to have a colored wrist band on a patient to identify the patient who does not wish to have cardio-pulmonary resuscitation in the event the heart stops beating. This branding is to identify those patients with that emergency when a decision has to be made about whether or not to resuscitate particularly if the patient’s chart is not readily available. But there are many other cautions that could be made easily apparent to the hospital staff by affixing some sign to the patient with a visible sticker such as allergy, prone to falling, need for isolation related to infections and others. In recent years there has been developed policies to have symmetrical sided part of the body that is to be operated upon to be branded to avoid mistaken operation on the wrong sided part. And what about privacy? It might not be unusual for others not involved in the patient’s care to become aware of the branding code (perhaps from their own personal experience) and then be able to identify the branding of another patient. For what conditions or issues would you think it would be inappropriate to brand the patient?

If a person has a problem for which others should be aware for the medical benefit of that person or for the safety of others, is it ethical for such a person to be identified? Or because of the way such branding was carried out in the Nazi era on Jews and others, branding is a troublesome consideration for its application to persons? ..Maurice.

Graphic: Photograph of a street sign in Europe branding a neighborhood that the elderly and infirm are present alerting drivers to be aware and cautious.

A True Bioethical Dilemma: Questionable Best Interest for Birds or Known Best Interest for Humans

With the current oil spill in the Gulf of Mexico and the reactive response, there is a true bioethical dilemma that is arising. It has to do with the use of resources to rehabilitate and support those who are injured or will be injured as the oil spill continues or after the spill is stopped.

The issue of the cleaning of the birds contaminated with oil was brought up in a June 14 2010 presentation on National Public Radio. The debated issue is regarding the outcome of those birds rescued and cleaned and whether they are saved from death, can live and reproduce normally into the future. The research evidence seems to be equivocal. A nurse ethicist writing on a bioethics listserv today wrote the following which sets the ethical issue:

“I … heard the NPR piece about the oily gulf birds. And I was perplexed about defining our moral obligation to clean the birds. Being a nurse, I'd start by looking at the scientific research. If I remember correctly, NPR said that the research on cleaning the birds varies widely. The birds may survive being scrubbed of the oil only to die a few days or weeks later because of the oil they ingested. The studies that followed the birds for longer periods also varied widely with some birds surviving for months, but then not reproducing. So the science may not be helpful. I'd have to look into it much more deeply.... and not being a biologist, I might not be a good consumer of the research. However, birds are birds. People will be suffering from this oil spill as well. Should scarce resources be focused on the current bird problem or should we prepare for the future and help the tourist industry or the fishing industry? The financial circumstances for families could be devastating - through no fault of their own. Does our moral obligation change depending upon the funds distributed by BP to various people/industries? Just first thoughts about something that will play out for all of us, especially those near the gulf.”

So the issue is clear: Do the American people and government focus on using all the limited resources available for a known benefit to aid the rehabilitation of humans or continuing to use part of these resources for a scientifically as yet unproven benefit to rehabilitate birds? Any answers? ..Maurice.

Graphic: Widely distributed AP photo modified by me using ArtRage 3

Discarding Praise and Preserving Criticism in Medical Practice

Commenting in the September 6, 2008 “One Big Umbrella” blog, Newfoundland playwright Robert Chafe responded to a question “How do you deal with praise? With criticism? “with “I'd like to be able to ignore both. I've gotten great at discarding praise, but criticism? I can still quote bad reviews and negative feedback for years afterwards. not healthy, that.”

I have a feeling that most playwrights would agree with Mr. Chafe. This led me to wonder whether this might be even a more common response, applicable to all professions including medicine. If so, then what is the difference in the longer term significance between praise and criticism? Could it be that praise is generally given more as just “words” or (perhaps my cynical appraisal) a method for secondary gain by the ones who deliver the praise? But criticism, on the other hand, may contain many fragments of truth and meaning which for the benefit of the receiver and others should be considered and retained. Could it be that praise is generally less constructive than criticism in promoting professional improvement?

I wonder what my blog visitors think about how physicians should manage, if they could, the discard vs retention as applied to praise vs criticism issue. Unfortunately, criticism is rarely directly delivered by the physician’s patients or even from the physician’s own colleagues and, from my own experience; the criticism is mostly delivered by one’s self. That self-criticism is, fortunately or unfortunately, rarely easily discarded. ..Maurice.

Graphic: Discarded awards, photographed by me 6-8-2010 in a neighborhood yard.

Empathy for All in the Bioethics Universe

Bioethics represents the ethics involved with all living things. Empathy means understanding and concern for others. Shouldn't those of us, people, animals and all living together on this single planet have empathy for all? You may find the video presentation of Jeremy Rifkin on YouTube regarding his concept of an empathetic civilization interesting. After all, this is what bioethics, in its fullest sense, is all about. After you have watched the graphic presentation, return and write about what you think of the concept. ..Maurice.

Are Physicians to Serve as Moral Gatekeepers?

Are physicians to serve as moral gatekeepers? This question is nicely dissected, particularly in reference to the actions of cosmetic surgeons, in an article in the May 2010 issue of the Virtual Mentor by Jordan Amadio who by now has received his Doctor of Medicine degree from Harvard Medical School.   Go to the link and read the article.

Beyond the individual patient for whom the patient’s physician has the fiduciary responsibility to attend and provide the patient the best and most beneficent advice and skills, there looms society. Society is the medium in which the physician must live and flourish along with his or her patient and which can have profound effects on both.  And the question arises, when a physician attends the patient should the physician also consider the impact of what he or she is advising or doing upon society both in moral, practical and financial impacts?  The latter two has recently been of concern because of the limits of resources and funding.

The moral aspect of what the physician decides and does has also  important social implications.  The matter of cosmetic surgery is considered in the article as, in many cases, a way the physician is reshaping societal views of what is considered normal, unpleasant, beautiful in personal appearance.  And, perhaps, to make the ethical issue worse, physicians have become complicit (and being paid by the patient to be complicit) in resetting the societal views.  Other areas of moral impact on society involves contraception, abortion, assisted reproduction, homosexuality, sexual identification as well as other non-reproductive or sexual areas such as gun control, death penalty, relations between physicians and suspected terrorists,  end-of-life issues, physician-assisted suicide and organ transplantation, genetic screening and genetic mutation of plants, animals and perhaps humans.  The question arises, as to how energetic or activistic should physicians become in their moral views and through their actions.

Moral and political views may merge.  A recent example, written up in the national news, of a physician becoming almost a literal gatekeeper was that of a Florida urologist, Jack Cassell, who posted a sign on his office door allegedly reading, "If you voted for Obama ... seek urologic care elsewhere. Changes to your health care begin right now, not in four years."

What are your thoughts about personal gatekeeper roles of physicians in their position as professionals and by their voices and actions regarding moral issues and altering the way society looks at itself and behaves? Or should, ideally, physicians  simply attend to the personal needs of their patients, suppressing moral concerns and dismiss worries regarding the effect on society in general?  ..Maurice.

Futility of Treatments: Should an Ethics Committee Decide?

On  May 14 2010 the Practical Bioethics Blog had an issue posted by Rosemary  Flannigan asking the question “Ethics Committee as Decision Makers?”  She wrote: 

In New Jersey we have the case of the 73 year old man in a persistent vegetative state for nearly a year, hooked up to a ventilator, dialysis machine and feeding tube because the patient’s daughter did not agree to the futility conclusion reached by the medical staff and who sued—and won—when the hospital placed a “do not resuscitate” sign on his bed and halted dialysis. Oh, we are getting good at endorsing family’s determination about “extraordinary” means—but we are not so good when family won’t agree to our clinical conclusions. So a group of physicians and “bioethics experts” in New Jersey are advocating “for an independent ethics committee to help resolve end-of-life disputes between families and hospitals.”WHOA!! Aren’t we jumping the gun here? Aren’t ethics committees designed to help OTHERS make good decisions? Haven’t we long held the conviction that “ethics committees are not decision-makers”? I see the need for help here, but let’s call it BY ANOTHER NAME.Agree? Disagree? I’m all ears!!! Link: New Jersey needs independent panel to resolve disputes over end-of-life care,Editorial, New Jersey Star-Ledger, May 12, 2010”

I wrote back the following response:

It's all a matter of who's "futility". What is the definition of futility which is being used by the various parties who are alive and contemplating? From the context of physiologic futility, if that is the basis for the physician's and hospital's definition they are fully mistaken. The ventilator, dialysis and feeding tube was, in fact, keeping the patient alive and with that definition the treatments were certainly not futile. Ah! but if the physicians and hospital were basing their decision on quality of life, the conclusion of futility of the treatments could be appropriate---but only if this was the quality of life that the patient DIDN'T want or to be maintained. But who would know what the patient really wanted? Why, of course, it might be the daughter..if she had engaged her father in a discussion of his desires about life if he was ever incapacitated. He may have told her that he didn't want to be kept alive but forever unconscious and not able to participate in life. The daughter says that the treatment is not futile but does that represent her own view or the view of the father? If it is her own personal conclusion it is not what should be considered since if she is acting as a surrogate for her father. It must be her father's view of what he wanted as a quality of life that she should be disclosing. Even if he never talked to her about quality of life, if he was a robust and active man as she might describe him, one might assume that he would want to return to some reasonable degree of awareness and participation in life. Based on the length of debility and the systemic chronic complications this will likely not happen. Would he have wanted his body functions, color, temperature and heart beat to be maintained indefinitely for the benefit of his family? If the daughter knows that this would be what her father wanted, then she was speaking for her father by denying futility. But I would doubt it. The role of the ethics committee in all this? Well, it would be simply to explain everything I wrote above to all the stakeholders: family, physicians and hospital. Unfortunately, the patient would be one stakeholder which will not be informed. Once this is done, it is up to the stakeholders to come to a decision. At that point, the ethics committee in their classic role, can either agree or disagree with the parties and make their view known. The ethics committee will make no final decision, should not make any final decision that will be acted upon. The decision is up to the stakeholders with the daughter speaking for her father. No other named or unnamed committee is necessary.

So there it is: In this case what was important was to understand how the word “futile or futility” was used.  Then to be sure that the word was used appropriately. If futility deals with the ineffectiveness of a treatment to sustain a life and the treatment is ineffective then it is futile. If futility deals with quality of life of the patient, it is essential to remember that it is up to the patient to have expressed what quality of life the patient would have wanted.  If the patient never confided with anyone, someone who has lived with the patient and knows the patients likes and dislikes may help all come to a conclusion about the patient’s definition of “quality”.  If that quality will be absent despite the treatment then the treatment is futile.  And then what one does with a prognosis of futility..well, that should be the decision of the doctors with the patient or patient’s surrogate. But not one of an ethics committee.   ..Maurice.

Patient Modesty: Volume 34

This thread has been continuing since August 2005..approaching now 5 years. With the literally thousands of commentaries written to this topic of patient modesty on this blog, I challenge our visitors here to go beyond simply expressing their concerns here, much of which I do consider valid, and now progress to the necessary chore of broadcasting the concerns to the general public, the medical system, the politicians and the government. I would like to see evidence of such action since I am sure that this will be the only route to real change, real change that I now realize (which I hadn't prior to 5 years ago) is necessary. So "go to it!"..Maurice.

ADDENDUM 5-15-2010: Those who wish to participate in advocating to the public and the medical system your views regarding the need for more attention to patient modesty and gender selection of healthcare providers, a long time visitor to this thread, swf, has set up an advocacy blog to begin this advocacy challenge. Go there and start the process.

Graphic: from various Google sources. Thanks.

NOTICE: AS OF TODAY JULY 2, 2010 "PATIENT MODESTY: VOLUME 34" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON Volume 35.
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Female Circumcision:Nicking or Cutting: Is Either Ethical?

There is some current controversy about an April 26, 2010 statement of policy by the American Academy of Pediatrics (AAP) and published in Pediatrics which suggests to pediatricians that though ritual female circumcision should be continued to be illegal in the United States, the federal government ought to allow physicians to perform simple "nicking" of the female child's genitalia as a nominal  acceptance of the family's request for full ritual circumcision and along with education of the family regarding the immediate and long term harms of full circumcision. These actions may reduce the probability that the family will take the child overseas for full circumcision.  Read the pdf file from Pediatrics to learn all about female circumcision and the suggestions and recommendations made by the AAP. For a description of the controversy read the article in the New York Times May 6 2010 edition.

Irrespective of the United States current law against any form of a non-medical procedure on a female child's genitalia, is it ethical to disregard the request of the parents for a long established and performed ritual procedure on their daughter, particularly if the ritual circumcision is also performed on the male child? Would simple nicking of the skin be a reasonable substitute for full circumcision if permitted by the parents and  be an ethical alternative for the physician to perform?

What are the limits to acceptance of norms from other cultures when requested to be performed in the multi-cultural United States?  ..Maurice.

Is Ethical Consensus Always Ethical?

Ethical consensus often sets guidelines to society as to what approach or act is a "good" and yet should that be the way ethical decisions should be made? Yesterday, on vacation in Morro Bay on the central coast of California, I found the group of seagulls which I photographed and it struck me at the time that they were making a graphic point regarding an issue that I brought up with the discussion of ethical consensus as written in the thread “Good People Doing Bad Things for Good Reasons". The black and white birds were headed and looking one way. The single colored bird was headed and looking the other way. Could one say that the black and white birds were part of a consensus and the colored bird was not? And if so, were the black and white birds looking the "right" way and the colored bird was not?  It is just this dilemma regarding the product of a consensus particularly when the way a person or society itself is guided to either the "right" or "wrong" way based on that consensus.  Or should we consider instead the direction set by the colored bird? ..Maurice.

The Choice for Your Professional Career: Nurse vs Doctor

My introduction to this thread is very simple. It's a question: If you were or are looking for a professional career, which profession would you select of these two options, either to become a nurse or to become a doctor? And then, why would you select one over the other? ..Maurice.

Obama: Hospital Patient: New Visitation and Decision Rights

It has finally come. Yesterday U.S. President Barack Obama wrote a Memorandum requesting that the Secretary of Health and Human Services create a regulation to federal law which requires that all hospitals who receive money from the government for Medicare and Medicaid must allow all hospital patients to have the visitors whom they request regardless of "race, color, national origin, religion, sex, sexual orientation, gender identity, or disability." In addition, "to guarantee
that all patients' advance directives, such as durable powers of attorney and health care proxies, are respected, and that patients' representatives otherwise have the right to make informed decisions regarding patients' care." This means that no longer will a same-sex partner be prevented from visiting their ill hospital mate by a hospital regulation or decision. That means that no same-sex partner who was directed in a patient's legal advance medical directive to make medical decisions for the patient will be denied that power and the decisions accepted by the hospital from a family member.

Why did this order take so long to arrive? And what ethical or humanistic argument can one make to counter this Memorandum? ..Maurice.

THE WHITE HOUSE
Office of the Press Secretary
For Immediate Release April 15, 2010
April 15, 2010
MEMORANDUM FOR THE SECRETARY OF HEALTH AND HUMAN SERVICES
SUBJECT: Respecting the Rights of Hospital Patients to
Receive Visitors and to Designate Surrogate
Decision Makers for Medical Emergencies
There are few moments in our lives that call for greater
compassion and companionship than when a loved one is admitted
to the hospital. In these hours of need and moments of pain and
anxiety, all of us would hope to have a hand to hold, a shoulder
on which to lean -- a loved one to be there for us, as we would
be there for them.
Yet every day, all across America, patients are denied the
kindnesses and caring of a loved one at their sides -- whether
in a sudden medical emergency or a prolonged hospital stay.
Often, a widow or widower with no children is denied the support
and comfort of a good friend. Members of religious orders are
sometimes unable to choose someone other than an immediate
family member to visit them and make medical decisions on their
behalf. Also uniquely affected are gay and lesbian Americans
who are often barred from the bedsides of the partners with whom
they may have spent decades of their lives -- unable to be there
for the person they love, and unable to act as a legal surrogate
if their partner is incapacitated.
For all of these Americans, the failure to have their wishes
respected concerning who may visit them or make medical
decisions on their behalf has real consequences. It means that
doctors and nurses do not always have the best information about
patients' medications and medical histories and that friends and
certain family members are unable to serve as intermediaries
to help communicate patients' needs. It means that a stressful
and at times terrifying experience for patients is senselessly
compounded by indignity and unfairness. And it means that all
too often, people are made to suffer or even to pass away alone,
denied the comfort of companionship in their final moments while
a loved one is left worrying and pacing down the hall.
Many States have taken steps to try to put an end to these
problems. North Carolina recently amended its Patients' Bill of
Rights to give each patient "the right to designate visitors who
shall receive the same visitation privileges as the patient's
immediate family members, regardless of whether the visitors are
legally related to the patient" -- a right that applies in every
hospital in the State. Delaware, Nebraska, and Minnesota have
adopted similar laws.

My Administration can expand on these important steps to ensure
that patients can receive compassionate care and equal treatment
during their hospital stays. By this memorandum, I request that
you take the following steps:
1. Initiate appropriate rulemaking, pursuant to your
authority under 42 U.S.C. 1395x and other relevant provisions
of law, to ensure that hospitals that participate in Medicare
or Medicaid respect the rights of patients to designate
visitors. It should be made clear that designated visitors,
including individuals designated by legally valid advance
directives (such as durable powers of attorney and health care
proxies), should enjoy visitation privileges that are no more
restrictive than those that immediate family members enjoy.
You should also provide that participating hospitals may not
deny visitation privileges on the basis of race, color, national
origin, religion, sex, sexual orientation, gender identity, or
disability. The rulemaking should take into account the need
for hospitals to restrict visitation in medically appropriate
circumstances as well as the clinical decisions that medical
professionals make about a patient's care or treatment.
2. Ensure that all hospitals participating in Medicare or
Medicaid are in full compliance with regulations, codified at
42 CFR 482.13 and 42 CFR 489.102(a), promulgated to guarantee
that all patients' advance directives, such as durable powers
of attorney and health care proxies, are respected, and that
patients' representatives otherwise have the right to make
informed decisions regarding patients' care. Additionally,
I request that you issue new guidelines, pursuant to your
authority under 42 U.S.C. 1395cc and other relevant provisions
of law, and provide technical assistance on how hospitals
participating in Medicare or Medicaid can best comply with the
regulations and take any additional appropriate measures to
fully enforce the regulations.
3. Provide additional recommendations to me, within
180 days of the date of this memorandum, on actions the
Department of Health and Human Services can take to address
hospital visitation, medical decisionmaking, or other health
care issues that affect LGBT patients and their families.
This memorandum is not intended to, and does not, create any
right or benefit, substantive or procedural, enforceable at
law or in equity by any party against the United States, its
departments, agencies, or entities, its officers, employees,
or agents, or any other person.
You are hereby authorized and directed to publish this
memorandum in the Federal Register.
BARACK OBAMA
# # #

Looking Back at Terri Schiavo 5 Years Later

It’s now 5 years since the death of Terri Schiavo and one wonders whether it is of value to remember another “Terri Schiavo Day Anniversary”. Though the political attention to Terri has faded and the legal battle of the case has been resolved , the name and the moral and ethical conflict still lingers on, particularly refueled by the recent publicity regarding the United States bishops and their revision of the Catholic Religious Directive #58 regarding hydration and nutrition and, of course, the health reform law recently passed and signed. I found three articles which give different perspectives as one looks back at the Terri Schiavo story.

Kathi Ruse writing in the Washington Times still feels that the America public were misguided if they really concluded, as indicated by the polls, that Terri should be allowed to die.

Reverend Jason Poling writing in the Baltimore Sun writes about being surprised that the same people who felt that the wishes of the Terri’s parents trumped the decision of the husband regarding Terri’s medical care were the ones who “ordinarily defend the traditional understanding of marriage--- people who in the course of pastoral ministry and teaching emphasize to couples (and their parents) the importance of 'leaving and cleaving,' , who encourage couples to work out their problems rather than running to their parents, who really do believe that the two become one.”

Finally, Matt Sedensky writing for the Associated Press comments that while the Terri Schiavo case brought to attention of the American public the necessity for people to write out their wishes for end of life care in an Advance Disrective, there was little change in the numbers of people filling out these forms (20-30%) comparing before and after her death.

..Maurice.

When Should Doctors Retire?

OK, here is the question I would like to put to my visitors: when should doctors retire from practice and the treating of patients? The matter of when to retire is becoming a more important issue in the United States where healthcare reform associated with increasing medical coverage for previously uncovered public is going to require more physicians available for their care. Of course, most decisions to retire are made by physicians themselves based on health issues or emotional or physical burn-out or their desire to spend more time with their family or other life pleasures. However, should this be a judgment only made by the doctor or should rules be set by patients, politicians, courts (that is by society) and directed to medical regulatory boards for enforcement?

If there is no age set by law, should there be? At what age? If compulsory retirement is set by society and there is no specific age set, what other criteria should society use to say to the doctor “it’s time for you to begin another life”? If the doctor is not frankly demented then should retirement be triggered by the number of malpractice suits or the number of complaints to medical boards by patients, serious professional ethical or legal issues or failure to pass some tests of proficiency and knowledge periodically required to be taken? If a doctor does not fully meet the minimal test scores, would that automatically mean “you’re out” or could doctors still participate in medical care but with lesser degrees of responsibility? Should all such triggers be considered final or should doctors always be considered able to be rehabilitated?


And finally, is a “retired doctor” of any value to society?

Any answers? ..Maurice.

Patient Modesty: Volume 33

Here we go into Volume 33. From what is being written it seems that though the women have much greater access to the healthcare providers of the gender they desire than the men, there are still are many upsetting modesty issues that the women face. So, despite this inequality, both genders have unresolved patient modesty issues. There is the suggestion that the lives in the medical environment of both genders could be improved by both genders working on the problems..together! Perhaps we can read here more about this and how this joint advocacy can best be carried out. ..Maurice.

GRAPHIC: "Walking Together" from webshots.com and modified by me with Picasa3.

NOTICE: AS OF TODAY MAY 11, 2010 "PATIENT MODESTY: VOLUME 33" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 34.

Which is Best for the Patient?: A Patient Patient vs An Impatient Patient

If the title of this thread started with "Which is best for the Doctor", my general opinion would be easily answered with "a patient with patience." Doctors know that diagnoses are not made easily and treatments do not always give instantaneous cures. So patient patience is the most comfortable patient behavior looked for by the doctor. However, answering the question from the viewpoint of what is best for the patient, the one who is ill and symptomatic, ah! there probably are different responses. And it is from that viewpoint that I would like my visitors to respond. First, though, let's look at a list of what writers and philosophers had to say about patience and impatience and which I culled from the Thinkexist.com website.

First, patience:

"All human wisdom is summed up in two words - wait and hope” ...Alexandre Dumas Père (French Writer, one of the most prolific and most popular authors of the 19th century, 1802-1870)

“Patience is the companion of wisdom.”...Saint Augustine (Ancient Roman Christian Theologian and Bishop of Hippo from 396 to 430. One of the Latin Fathers of the Church.354-430)

“The two most powerful warriors are patience and time.”...Leo Nikolaevich Tolstoy (Russian moral Thinker, Novelist and Philosopher, notable for his influence on Russian literature and politics.1828-1910)


“Patience and fortitude conquer all things”...Ralph Waldo Emerson (American Poet, Lecturer and Essayist, 1803-1882)

And now, impatience:

“In all evils which admit a remedy, impatience should be avoided, because it wastes that time and attention in complaints which, if properly applied, might remove the cause”...Samuel Johnson (English Poet, Critic and Writer. 1709-1784)

“Perhaps there is only one cardinal sin: impatience. Because of impatience we were driven out of Paradise, because of impatiencewe cannot return.”...(English born American Poet, Dramatist and Editor who achieved early fame in the 1930s as a hero of the left during the Great Depression. 1907-1973)


“Patience is the support of weakness; impatience the ruin of strength”...Charles Caleb Colton (English sportsman and writer, 1780-1832)


“All human errors are impatience, a premature breaking off of methodical procedure, an apparent fencing-in of what is apparently at issue.”...Franz Kafka (German Writer of visionary fiction, 1883-1924)

“Experience has taught me this, that we undo ourselves by impatience. Misfortunes have their life and their limits, their sickness and their health.”...Michel de Montaigne (French Philosopher and Writer. 1533-1592)


“Impatience is the mark of independence, not of bondage”...Marianne Moore (American Poet, 1887-1972)

So now considering the uncertainties and burdens of a patient who is ill and in this age of patient autonomy where the patient has become more responsible for their own decisions and treatment, which behavior, patience or impatience, would be the most productive for a better outcome? Which behavior would you classify yourself as demonstrating? ..Maurice.

Physician's Mantra?: "If You Can't Cure It, Your Job is Over"

The issue is simple: Should the doctor's job in interacting with a patient be to make a diagnosis, establish treatment and then cure the patient? Do all patients come to their physicians with the view that it is the doctor's duty to continue all medical management to a cure and if that is not at all times the physician's goal then their preoccupation with the patient's illness is over? This view seems consistent with what is happening in practice. When an illness appears terminal, there often seems to be a conflict between the physician's prognosis and advice that further treatment or procedures will be futile and to institute simply comfort care vs the patient or family's demands for continuing a program directed at attaining a cure or if not in their mind statistically possible at least go for a "miracle cure". Does the physician's duty toward the patient then stop if he or she cannot expect or provide a cure? Of course, I think not. But is that really what most patients and families expect of a physician? I must say, however, that when cure is not possible there may be a tendency by some physicians to forget that their professional and humanistic duty is to actively participate in a palliative role toward the patient. Their excuse to themselves might be "if you can't cure it, your job is over." ..Maurice.

Uncertainty in the Diagnosis: How Do You Want That Told to You?

The patient comes to me

Sick with symptoms and uncertainty

Is it bad; is it fatal, can I be cured?

She sits in front of me with that look

That look asks me to tell her the answers

“Sure” I think to myself

No uncertainty on my part to myself

And I guess no uncertainty is on my face

I say to her “Tell me how you feel”

Then comes the stream of symptoms and complaints

I try to keep the stream from flooding my understanding

In my mind the diagnoses start their own stream

It could be this, it could be that, but it couldn’t be the other
Or could it?

I reassure myself. The physical exam will sort it all out

But does it? I thought it would but it doesn’t

Maybe this or that seems now unlikely but yet on the other hand…

The history and physical is over and the patient sits in front of me

She awaits my diagnosis

But, in fact, I, myself await the diagnosis

Is uncertainty now seen on my face?

I have no decision since, in fact, I am undecided.

How do I respond to her and her look for me to tell her the answers? I would like your help. Should the words “I don’t know yet” come from my mouth? Will that be therapeutic for her symptoms and her concerns? Should I say “Well, it could be this, it could be that, it could be…It could be”?
Should I say “I know it could be this, I know it could be that, I know it could be… it could be”? Should I just say “I am just uncertain as to what is wrong with you so let’s wait until the tests are back”? What is wrong for the doctor telling the patient “I just don’t know at present”? Or is it wrong for the doctor to be expressing uncertainty to a patient who has symptoms and herself uncertainty? Help me understand how you would expect the doctor to express the doctor’s uncertainty about your symptoms and concerns. ..Maurice.

Hospital Romances: What to Do About Them?

The ethical and professional goal in a doctor-patient relationship is directed toward attaining the benefit for the patient. The goal of a hospital attending to the care of patients should be the same. There are many factors that can interfere with meeting that goal. One interesting issue is one related to the interaction between two professionals who work in the hospital but who develop a romantic relationship with each other. If you watch the TV dramas about hospital life, it seems that such romantic relationships appear frequently and almost as frequently as those dramatic critical medical emergencies.

But as with other employment environments, such relationships between two individuals who are working together particularly under stressful conditions is not unpredictable. The question is whether a hospital should tolerate the development of such relationships which may lead to progression along with distractions to patient care or if the relationship ends with one of the parties hurting, similar distraction might be expected. In addition issues of sexual abuse can occur along with discrimination in the workplace, particularly if one of the couples is an administrative or professional superior to the other or to other professionals in the hospital.

How should hospitals ethically and legally handle the issue of romance, particularly between professionals within the hospital workplace? Is it practical and realistic for a hospital administration set a zero-tolerance policy to such romantic relationships? What should be the hospital’s response to such relationships?

This subject is discussed in an interesting clinical cases discussion in the January 2010 issue of the American Medical Association’s Virtual Mentor titled “Zero Tolerance for Hospital Romance”. Go to the link, read the discussion and return here with your view of a fair and realistic response for a hospital to make. ..Maurice.

Should Doctors Examine, Diagnose and Treat Their Family Members?

In a 1991 study of physicians published in the New England Journal of Medicine:99% of 465 physicians surveyed had requests from family members for medical advice, diagnosis and treatment.

Family members included spouses, children, parents, siblings, nieces, nephews, in-laws, aunts, uncles and cousins. Eighty-three percent of physicians had prescribed medication for a family member, 80% had diagnosed medical illnesses, 72% had performed physical examinations, 15% had acted as a family member's primary doctor, and 9% had performed surgery on a family member.In addition, 152 (33 percent) reported that they had observed another physician "inappropriately involved" in a family member's care, and 103 (22 percent) had acceded to a specific request about which they felt uncomfortable.

The American Medical Association Medical Code of Ethics Opinion 8.91 (1993)"Self-Treatment or Treatment of Immediate Family Members" states the following:

Opinion 8.19 - Self-Treatment or Treatment of Immediate Family Members

Physicians generally should not treat themselves or members of their immediate families. Professional objectivity may be compromised when an immediate family member or the physician is the patient; the physician’s personal feelings may unduly influence his or her professional medical judgment, thereby interfering with the care being delivered. Physicians may fail to probe sensitive areas when taking the medical history or may fail to perform intimate parts of the physical examination. Similarly, patients may feel uncomfortable disclosing sensitive information or undergoing an intimate examination when the physician is an immediate family member. This discomfort is particularly the case when the patient is a minor child, and sensitive or intimate care should especially be avoided for such patients. When treating themselves or immediate family members, physicians may be inclined to treat problems that are beyond their expertise or training. If tensions develop in a physician’s professional relationship with a family member, perhaps as a result of a negative medical outcome, such difficulties may be carried over into the family member’s personal relationship with the physician.

Concerns regarding patient autonomy and informed consent are also relevant when physicians attempt to treat members of their immediate family. Family members may be reluctant to state their preference for another physician or decline a recommendation for fear of offending the physician. In particular, minor children will generally not feel free to refuse care from their parents. Likewise, physicians may feel obligated to provide care to immediate family members even if they feel uncomfortable providing care.

It would not always be inappropriate to undertake self-treatment or treatment of immediate family members. In emergency settings or isolated settings where there is no other qualified physician available, physicians should not hesitate to treat themselves or family members until another physician becomes available. In addition, while physicians should not serve as a primary or regular care provider for immediate family members, there are situations in which routine care is acceptable for short-term, minor problems. Except in emergencies, it is not appropriate for physicians to write prescriptions for controlled substances for themselves or immediate family members.



All of the above was written from the aspect of the physician but what I would like to know is whether if you are or if you might be the family member of a physician, to what extent, if at all, would you want the "doctor in the family" participating in the diagnosis, advice or treatment of your illness? ..Maurice.

Patient Modesty: Volume 32

We continue on with a multi-faceted discussion regarding patient modesty. Is there any one facet in these previous 31 volumes which hasn't as yet been covered? It seems to me that virtually everything has been discussed except perhaps the role of the government, both state and federal and politics in the distresses expressed here by my visitors. Particularly interesting would be whether anyone who is involved in the United States healthcare reform is considering patient modesty and gender selection issues as part of that reform. Any thoughts on that? ..Maurice.

Graphic: The Donkey and Elephant political cartoon by Thomas Nast (1840-1902) American editorial cartoonist with text applied by me using Picasa3.


NOTICE: AS OF TODAY MARCH 24, 2010 "PATIENT MODESTY: VOLUME 32" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 33

Teaching the Painting the Human Body: The Use of Cadavers

Should students who are learning to create paintings of the human body be allowed to have the opportunity to look at and then paint human cadavers? Shouldn't art students have the same opportunity to inspect and draw the human body from the dead as medical students have such an opportunity to learn human anatomy? Should such use be publicized and people asked to donate themselves after death to be a model for an art student? Should unclaimed cadavers be used for this purpose? What is the difference between the use by an art student and that use by a medical student? Is there an ethical difference? Are there certain limits which should be set for the use of the dead by others? If so, what should they be? Many questions..can anyone write an answer? ..Maurice.

Doctors

"Doctors" by Rudyard Kipling (1865-1936)



Man dies too soon, beside his works half-planned.
His days are counted and reprieve is vain:
Who shall entreat with Death to stay his hand;
Or cloke the shameful nakedness of pain?

Send here the bold, the seekers of the way--
The passionless, the unshakeable of soul,
Who serve the inmost mysteries of man's clay,
And ask no more than leave to make them whole.

I am a physician! And as a physician, I feel emotionally strengthened by reading this classic poem by this famous poet from India. I feel encouraged and proud that I am in the right profession and doing the right thing. Shouldn't I? ..Maurice.