Bioethics Discussion Blog

REMINDER: I AM POSTING A NEW TOPIC ABOUT ONCE A WEEK OR PERHAPS TWICE A WEEK. HOWEVER, IF YOU DON'T FIND A NEW TOPIC POSTED, THERE ARE AS OF MARCH 2013 OVER 900 TOPIC THREADS TO WHICH YOU CAN READ AND WRITE COMMENTS. I WILL BE AWARE OF EACH COMMENTARY AND MAY COME BACK WITH A REPLY.

TO FIND A TOPIC OF INTEREST TO YOU ON THIS BLOG, SIMPLY TYPE IN THE NAME OR WORDS RELATED TO THE TOPIC IN THE FIELD IN THE LEFT HAND SIDE AT TOP OF THE PAGE AND THEN CLICK ON “SEARCH BLOG”. WITH WELL OVER 900 TOPICS, MOST ABOUT GENERAL OR SPECIFIC ETHICAL ISSUES BUT NOT NECESSARILY RELATED TO ANY SPECIFIC DATE OR EVENT, YOU SHOULD BE ABLE TO FIND WHAT YOU WANT. IF YOU DON’T PLEASE WRITE TO ME ON THE FEEDBACK THREAD OR BY E-MAIL DoktorMo@aol.com

IMPORTANT REQUEST TO ALL WHO COMMENT ON THIS BLOG: ALL COMMENTERS WHO WISH TO SIGN ON AS ANONYMOUS NEVERTHELESS PLEASE SIGN OFF AT THE END OF YOUR COMMENTS WITH A CONSISTENT PSEUDONYM NAME OR SOME INITIALS TO HELP MAINTAIN CONTINUITY AND NOT REQUIRE RESPONDERS TO LOOK UP THE DATE AND TIME OF THE POSTING TO DEFINE WHICH ANONYMOUS SAID WHAT. Thanks. ..Maurice

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Sunday, November 12, 2017

Medical Advance Directive: An Emphatic "NO!" to Dementia




Norman Cantor, a lawyer and Professor of Law at Rutgers University School of Law wrote a thoughtful article about the medical Advance Directive in the Harvard Law School "Bill of Health" blog


and explaining why he is revising his own medical Advance Directive to instruct his physicians and caretakers to allow him to die if he had developed a dementia "upon reaching a degree of permanent mental dysfunction that I deem to be intolerably demeaning.  For me, this means mental deterioration to a point when I can no longer read and understand written material such as a newspaper or financial records such as a checkbook"

Read his entire presentation at the Harvard Law blog link above and then return to present your views on adding profound mental deterioration to the list of physical illnesses which are irreversible and can be highly distressful to the patient and his family's lives and which he does not want to experience or have his family experience further and if he should face a treatable but serious life threatening condition, he should be allowed to die.

Hopefully, all of my blog readers have their own medical Advance Directive written to designate  a  surrogate to attend to their wishes for treatment of a potentially fatal illness when it occurs. If not, as your physician moderator of this bioethics blog, I would strongly recommend it be created and available for your physicians later to read and observe your directive.

  With Professor Cantor's permission, his Revised Advance Directive is reproduced below. ..Maurice..                                                       
My Revised Advance Directive
     I have witnessed the ravages that Alzheimer's disease and similar progressive dementias produce.  I wish to be allowed to die upon reaching a degree of permanent mental dysfunction that I deem to be intolerably demeaning.  For me, this means mental deterioration to a point when I can no longer read and understand written material such as a newspaper or financial records such as a checkbook.       
     This wish to hasten my post-competence demise is not based on prospective suffering or distress, but rather on my personal vision of intolerable indignity and degradation associated with cognitive dysfunction.  For me, it is critical to shape the post-mortem recollections of my loved ones and to preserve the lifetime image as a vital, critically thinking individual that I have strived to cultivate.  In addition, it is important to me to avoid being an emotional, physical, or financial burden on my family and friends, even if they would willingly assume such burdens. 
    I fully understand that my determination to avoid prolonged, progressive debilitation could prompt my demise even though I might appear content in my debilitated condition.  I am exercising my prerogatives of self-determination and bodily integrity to shape my lifetime narrative, including my dying process, in accord with my strong aversions to mental dysfunction and to dependence on others. 
     My determination not to prolong my life at the described point of debilitation includes rejection of any and all life-sustaining means.  This includes simplistic medical interventions such as antibiotics, blood transfusions, and antiarrythmics, as well as more complex interventions like CPR, mechanical ventilation, dialysis, and artificial nutrition and hydration.  Indeed, if my dementia or any other affliction has produced inability or unwillingness to feed myself – for example, because of swallowing difficulties, or other eating disorders, or just indifference to eating -- I instruct that my caregivers refrain from hand feeding unless I appear receptive to eating and drinking (show signs of enjoyment or positive anticipation).  If I am indifferent or resistant to hand feeding, I do not want to be cajoled, harassed, or in any way impelled to eat or drink.   
     The only limitation on my advance rejection of life-sustaining medical intervention is adherence to humane treatment.  That is, I have no desire to subject my future incompetent persona to a torturous or agonizing dying process.  I presume that palliative steps -- including medication for pain, anxiety, or agitation -- will be taken to ease my dying process. 

     The question may arise as to whether I have had a change of mind and revoked my advance directive.  My wish is that no revocation be found unless I do so while still capable of a considered choice, including appreciation of all the major elements involved.  I urge my decision-making agents to avoid the temptation of manipulating my future, incompetent persona to contradict or alter my advance instructions.  And I direct that my original instructions be honored absent an aware, considered change of mind (as opposed to uncomprehending expressions by my demented persona). 

Graphic: Through Google Images. "5th Dementia"PAINTING BY JEFF BOWERING Saatchi Art

Friday, October 20, 2017

Patient Modesty: Volume 82







I think that the above image and words sets the tone of the conversation regarding male physical modesty issues which form most of the conversation currently on the Patient Modesty thread.
Thanks  to Alternative Press via Google Images for the graphic for this Volume.





Continuing on with the Comments, here is the last one as of the time of creating this new Volume and it is by AB who professionally appears to know much of the ins and outs of the medical system. ..Maurice.


At Friday, October 20, 2017 2:41:00 PMAnonymous Anonymous said...
I cannot speak knowledgeably on the distribution of genders in hired medical scribes. It is my impression both male & females are hired to be scribes. At my old medical center, in the emergency department we hired scribes to assist the ED physicians but there was no requirement they only be female. This was the only location where we allowed scribes. Nationwide I don’t know if there is a trend toward one sex or another for scribes, I don’t think there is.

Medical assistants in private practices and clinics is more sinister matter. MAs assisting as a chaperone, for example, always mean the physicians/NP/PA is also present with the chaperone/MA when the patient is naked. As such there should be ZERO reluctance to hire males to perform this duty, if medicine is gender neutral and patients have no preferences (which of course we know is not true for BOTH sexes). The “risk management” issues of a male being alone with an unclothed female are removed in the chaperone situation. Most of the other MA duties in clinics, say a Dermatology clinic, never involve the MA being alone with a naked patient (the physician is always present, at least). (Urology is a special situation which I’m omitting admittedly). So again, no “risk” barrier to hiring male medical assistants in such clinics. But unless others can provide evidence to the contrary it is my personal experience and impression physicians and clinics almost always hire female medical assistants if they will be in attendance with naked patients. Its way more than just happenstance - it is a preference for most physicians. So the question is why is there this preference?

Reasons include 1) the belief men are NOT entitled to the same or any bodily privacy respect as are women (see recent articles above on how its okay for the whole department to view male genitalia), 2) the belief female MAs will not be as great a “risk” as male MAs, 3) physicians can and DO pay females less than they would males, so they can save $ by not hiring males. I think all of these are contributing factors, but they all hinge on #1 being valid and enforceable.

Finally, a comment on the naked Dermatology exam. Standing naked for 10 minutes while the Dermatologist examines every square inch, possibly with a “scribe”/“chaperone” present is a really poor medical practice. There is NO medical reason a patient should be made to remain naked for the entire exam. If that were true every physical exam one got would require being totally naked the whole time. Its absurd. Dermatology needs to modernize and stop their archaic practice that violates basic bodily privacy considerations. All patients need to speak up about practices that make them uncomfortable. And you do NOT have to agree to the presence of an observer/scribe/chaperone. That is your decision. The physician will tell you if she/he feels comfortable performing the exam without their chaperone present. You are paying for this service. —AB

Saturday, August 26, 2017

Patient Modesty: Volume 81






To make the necessary changes in the medical system's duty to provide gender equality to the personal and intimate concerns of all patients, perhaps what is needed is that both genders stand together to achieve that goal. ..Maurice.

Graphic: Google Images and Clipart Panda

AS OF OCTOBER 20 2017, PATIENT MODESTY VOLUME 81 IS CLOSED TO FURTHER COMMENTS.  COMMENTS NOW SHOULD BE WRITTEN TO VOLUME 82.

Sunday, July 02, 2017

Patient Modesty: Volume 80




This Volume's graphic is another example of an attempt to "speak up" when informing the  medical profession of the patient's desires for attention of the system to the patient's modesty and dignity issues. (Thanks to Readers Digest. u.k. via Google Images).  As you may have noticed in the graphic, the patient, while speaking into the stethoscope diaphragm, the ear pieces are not in the doctor's ears.
What I am trying to emphasize is that it is important when telling your concerns to the doctor or the medical system, verify that they are listening!! And, of course, then responding.

For those just joining this blog thread on Patient Modesty, you might want to get introduced to the current discussion by looking at Volume 79 first.. or 78, or 77 or, if you have the time and interest all the way back to 2005 "Naked" which started this blog thread discussion. ..Maurice.

AS OF AUGUST 26 2017, NO FURTHER COMMENTS WILL BE PUBLISHED ON VOLUME 80. COMMENTS ON "PATIENT MODESTY" WILL CONTINUE ON VOLUME 81.

Wednesday, May 31, 2017

Who is the Father?: Sperm Donor Identification


  




The issue is whether the donor of sperm obtained via a sperm bank should be identified even though the donor provided the specimen with the understanding of anonymity?
The following are stories of how through current public accessibility to  DNA identification resources anonymity of the "father" is no longer guaranteed. There is an example of this accessibility in a 2010 issue of Slate and a more current example as presented in the Netherland's Dutch News.

Providing sperm to a sperm bank is of monetary significance to both the donor and finally for the bank itself and the "donation" is still considered a needed action by society. Despite the potential with public-accessible technology and investigations as noted in the two above articles,  should the utilization of the sperm for fertilization continue to permit anonymity of the source?  Well, if the goal is to encourage further donations then a recent study in the journal "Law and the Biosciences" regarding loss of anonymity suggest a problem in procurement as outlined in the Abstract of the article.

Most sperm donation that occurs in the USA proceeds through anonymous donation. While some clinics make the identity of the sperm donor available to a donor-conceived child at age 18 as part of ‘open identification’ or ‘identity release programs,’ no US law requires clinics to do so, and the majority of individuals do not use these programs. By contrast, in many parts of the world, there have been significant legislative initiatives requiring that sperm donor identities be made available to children after a certain age (typically when the child turns 18). One major concern with prohibiting anonymous sperm donation has been that the number of willing sperm donors will decrease leading to shortages, as have been experienced in some of the countries that have prohibited sperm donor anonymity. One possible solution, suggested by prior work, would be to pay current anonymous sperm donors more per donation to continue to donate when their anonymity is removed. Using a unique sample of current anonymous and open identity sperm donors from a large sperm bank in the USA, we test that approach. As far as we know, this is the first attempt to examine what would happen if the USA adopted a prohibition on anonymous sperm donation that used the most ecologically valid population, current sperm donors. We find that 29% of current anonymous sperm donors in the sample would refuse to donate if the law changed such that they were required to put their names in a registry available to donor-conceived children at age 18. When we look at the remaining sperm donors who would be willing to participate, we find that they would demand an additional $60 per donation (using our preferred specification). We also discuss the ramifications for the industry.

    So the question to my visitors is whether the sperm donor should be identified by the sperm bank or attempted, if undisclosed, with current available resources to the public? What is the implication of that decision on the future of the created child, the family, the donor and the whole banking system itself? Is identification what society wants and needs? If lawful will it be ethical? And what role might religion and sociology and medicine play in any decision?  It would be interesting to read what my visitors think.  ..Maurice.

Graphic: From Google Images.

Saturday, April 22, 2017

Patient Modesty: Volume 79



Yes, the current discourse continues to follow the issue of "speaking up" to the medical system regarding patient modesty and patient dignity.  The image above speaking up by way of the bullhorn appears to be a female.  It is this gender which appears to have taken the lead in the past regarding insisting that the system attends to their desires and needs.  It appears from the conversations going on in the previous Volumes of this thread that it is now the requirement of men to take hold of another bullhorn and bellow out their personal desires and needs. Go to it!!  ..Maurice.


Graphic: From Google Images. Courtesy of Pixabay

NOTICE: AS OF JULY 1 2017,  NO FURTHER COMMENTS WILL BE POSTED ON THIS VOLUME 79.  COMMENTS WILL RESUME NOW ON PATIENT MODESTY VOLUME 80

Sunday, April 16, 2017

Visual and Ethical Bias: Same Behavior?































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DON'T LOOK AT THE ABOVE PHOTOGRAPH AGAIN BUT WRITE DOWN WHAT YOU SAW AS YOUR VERY FIRST OBSERVATION.  IN FACT, WRITE IN THE BLOG THREAD COMMENTS BELOW WHAT WAS YOUR DESCRIPTION OF THAT FIRST OBSERVATION.

The point of this demonstration is to test out the scientific visual behavioral experiments which have demonstrated that we all tend to first look at the center of an image and even then come to a final conclusion of what we observed based on that first impression  It has been my concern that this same behavior of making assumptions of appropriate response to a potential ethical issue might be analogous to what has been experimentally documented in visual behavior: looking at the center of the issue and prejudging the ethics seen in the "center pane" of that "window" before evaluating what is to be seen in additional panes, additional windows or going outside, beyond the rooms with windows and their panes and actually entering the external environment where all the essential facts to make ethical judgment and decisions would be more "visibly" available. Jumping to ethics conclusions without knowing all the facts involved, like briefly inspecting this picture I took within a house at the Japanese Garden in Los Angeles, California the other day.  p.s.- there is active animal life readily observed in this photograph. Did you notice that on your first look?   ..Maurice.


Monday, December 26, 2016

Order vs Chaos in Medical Practice






As patients look at their experiences within the medical system and profession, do you think they find a system that is well thought out and is practiced in an orderly fashion to facilitate the basic premise of medicine to care appropriately for those who are ill?  On the other hand, there is always the potential for chaotic disorder when dealing with uncertainties of disease and humans on both sides of the medical relationship. Is there evidence of chaos characterized by unsystematic medical practice which can lead to serious medical errors, higher cost of medical care and inattention to humanistic aspects of patient care?  If patients find significant chaos imbedded within the medical system, what might the patients' opinions be regarding the cause of chaos and what might be the remedy to establish order?  Do you think that something is missing in student medical education or the medical system itself to properly deal with the aspects of diagnosis, treatment and general patient  care which, if attended to might diminish the effects of such lack of order? 


On the other hand, does the medical system seem quite properly functioning with signs of disorder either absent or properly managed to the benefit of the patient?  What is a patient's view?  ..Maurice.

Graphic: Order and Chaos painted by me 2916 with ArtRage

Tuesday, December 20, 2016

What Makes a "Good Doctor": Patients' Viewpoint





As I teach first and second year medical students. Is there one quality in the performance of being a physician that I should stress to the students is the most important in being a good doctor? I mean, one quality which sets the definition of a good doctor. In answering my question, I look to the perspective of the patient interacting with their physician and what the patient is really looking for to give the doctor the title "good".. However, which would also be most interesting would be to read opinions of those visitors to my blog who are or were patients themselves who have interacted with doctors as to what single quality they are looking for which makes that doctor "good" and should be part of the education of my medical students to attain. What should I teach them?
..Maurice.. 

Tuesday, December 13, 2016

Physician's Political View: Does It Matter? It Might.



Did you suspect that your physician's political views may affect your doctor's medical advice and attention to you as his or her patient?  If you suspect that they do, this is supported by a study published this year in the Proceedings of the National Academy of Sciences of the U.S.A. by Eitan D. Hersh and Matthew N. Goldenberg and summarized by this Abstract:


Physicians frequently interact with patients about politically salient health issues, such as drug use, firearm safety, and sexual behavior. We investigate whether physicians’ own political views affect their treatment decisions on these issues. We linked the records of over 20,000 primary care physicians in 29 US states to a voter registration database, obtaining the physicians’ political party affiliations. We then surveyed a sample of Democratic and Republican primary care physicians. Respondents evaluated nine patient vignettes, three of which addressed especially politicized health issues (marijuana, abortion, and firearm storage). Physicians rated the seriousness of the issue presented in each vignette and their likelihood of engaging in specific management options. On the politicized health issues—and only on such issues—Democratic and Republican physicians differed substantially in their expressed concern and their recommended treatment plan. We control for physician demographics (like age, gender, and religiosity), patient population, and geography. Physician partisan bias can lead to unwarranted variation in patient care. Awareness of how a physician’s political attitudes might affect patient care is important to physicians and patients alike.

For those visitors here who have no access to the Proceedings, you can read the details of the findings in an  October 3 2016 Atlantic article.

Read the article and return and express your opinions about your experiences, if any, regarding the politicalization of how your doctor advises or treats you.  That's assuming that you even asked your doctor or the doctor actually told you about his or her political view.  Did that ever happen?  




Sunday, December 11, 2016

All Pain: Treat It or Accept It?

The issue is whether it is ethical and spiritually worthy to treat all pain.  Yes, some  pain is a signal of illness which if the illness is properly diagnosed it can be cured and the pain is relived.  But, there is pain which ends up without an illness to cure to relieve the pain. And now, the medical profession is faced with an epidemic of pain being treated with narcotics, narcotics leading to habituation fostered by physician prescriptions.  And this epidemic is causing concern and challenges to physicians but also should be a concern for the public, the pharmaceutical companies and the government.

Maybe, physicians and patients should look at some pain as an intrinsic and spiritual part of life and that, well, those experiencing pain should understand that and live with it.  An example of this view was written by the Lebonese poet Khalil Gibran in a poem titled


                                         "ON PAIN"

Your pain is the breaking of the shell that encloses
your understanding.
 Even as the stone of the fruit must break, that its
heart may stand in the sun, so must you know pain.

And could you keep your heart in wonder at the
daily miracles of your life, your pain would not seem
less wondrous than your joy;
And you would accept the seasons of your heart,
even as you have always accepted the seasons that
pass over your fields.
 
And you would watch with serenity through the
winters of your grief.
 Much of your pain is self-chosen.
 It is the bitter potion by which the physician within
you heals your sick self.
 
Therefore trust the physician, and drink his remedy
in silence and tranquillity:
For his hand, though heavy and hard, is guided by
the tender hand of the Unseen,

And the cup he brings, though it burn your lips, has
been fashioned of the clay which the Potter has
moistened with His own sacred tears.



Do my visitors look upon pain or their own pains in the same way as Gibran.  And if accepted as simply part of life, much pain can be accepted without involving the narcotic prescription written by that licenced physician "outside" of you?  ..Maurice.

Saturday, December 10, 2016

Patient Modesty: Volume 78





HERE WE ARE AGAIN!  This graphic was published in Patient Modesty, Volume 4, June 26, 2008.  And the following is from Avram on that date:

MER is absolutely correct. As 
I've been posting here for over a year, nothing is going to change until the issue of a double-standard in modesty considerations for males ends up in court as a
class action test of DISCRIMINATION Law-- unequal treatment by gender. We have had BFOQ provisions in law which manditate that health insitutions use them to protect the patient modesty(read privacy) of ALL patients, regardless of gender.

The right to privacy and modesty were linked in BFOQ legislation to include what would be viewed as intimate pelvic care. 

Everything that is currently status quo is outside the law and it will change if it is challenged because it can not be upheld within the existing law. 
Female nurses, male doctors, HMOs 
all have a vested interest in 
maintain high levels of female 
staff. They will stonewall to
their advantage at every turn
until a judge rules in class-action that males must be treated equally with females or BFOQ be
removed from law. If that were to happen, then all female patient modesty requests would also be
ignored and male staff could rushed into OB/GYN and L&D, etc. What's good for the goose is 
good for the gander.

I'm not a lawyer but I know you 
can not discriminate against
either sex in a straight forward
manner. To respond "you are 
not a woman" is all an American
Civil Liberties attorney would need to make something out of this. Have any of those posting here, who are being denied equal rights to medical privacy/modesty, attempted to do this? MER, have you sent highlights of your extensive and well organized research to any legal body for an evaluation?


So my question is: ARE WE ANY FURTHER ALONG IN THE DISCUSSION AND SOLUTION?? 
Hate to be pessimistic..
 ..Maurice.

AS OF TODAY APRIL 22 2017, PATIENT MODESTY: VOLUME 78 WILL NO LONGER
BE ACCEPTING NEW COMMENTS.  YOU MAY CONTINUE THE DISCUSSION WITH COMMENTS ON PATIENT MODESTY:VOLUME 79

Tuesday, September 13, 2016

Patient Modesty: Volume 77











Interestingly, the conversation is back to this blog thread #24 begun September 2009. and here is the link to zoom back in time and visitors to compare.  I do think that this direct communication with the medical provider is the best way for the individual patient to make his or her standards known.  It may be that there is no way to change the medical profession through political or legislative action. Isn't that what the consensus of my visitors are here?  ..Maurice.


AS OF DECEMBER 10, 2016 THIS THREAD WILL BE CLOSED FOR ALL COMMENTS. DO NOT ATTEMPT TO WRITE ANY FURTHER COMMENTS HERE. PLEASE GO TO "PATIENT MODESTY: VOLUME 78" TO CONTINUE COMMENTS

Sunday, May 29, 2016

Patient Modesty: Volume 76







The narrative currently going on in the previous Volume 75 reminded me of what was being discussed back in November 2011 in Volume 45.  For my newer visitors, you might be interested to go back to that Volume or the ones previously to see that this issue of medical staff intentionally violating patient modesty was and still has been a "thorn" or more in the list of complaints about medical practice. ..Maurice.

Graphic: From Google Images


NOTICE: THIS "PATIENT MODESTY: VOLUME 76 IS NOW CLOSED FOR FURTHER
COMMENTS.  GO TO "PATIENT MODESTY: VOLUME 77" FOR FURTHER COMMENTS


Monday, March 14, 2016

Patient Modesty: Volume 75






HOW ABOUT PATIENTS SETTING A LIMIT?  Analogous to this posted sign by merchants, it is interesting to read (Volume 74) discussion about  possible, potential patient reactions or responses to the behavior of the medical system itself with regard to issues of patient dignity and modesty.

Perhaps, either through regulatory agencies or simply by individual patient actions, the patients' requests will be met.  If you were designing a  simple sign to be displayed by every patient to "set the limits", how would you design the text or graphics?   ..Maurice.

Graphic:  From Google Images.


NOTICE: AS OF TODAY MAY 29, 2016 "PATIENT MODESTY: VOLUME 75" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 76

Sunday, December 13, 2015

"Pimping": Not About Sex-- About Medical Education"




This cartoon below is certainly a good example of "pimping" which has been for years, really generations a technique of medical education. I recently wrote the following to a professional medical educator's listserv:


The December 8 2015 issue of JAMA (Volume 314 No. 22) presents a Viewpoint article which I believe challenges us medical school teachers to find evidence of educational value in a practice carried out by medical school teachers and attendings  which is apparently not rarely applied to their students.  The practice is "pimping"  and is defined in the article by referring to an 1989 JAMA article by Brancati: "a series of difficult and often intentionally unanswerable questions posed to a medical student or house staff in quick succession.  The objective of pimping is to teach, motivate, and involve the learner in clinical rounds while maintaining a dominant hierarchy and cultivating humility by ridding the learner of egotism."

So what we must decide is whether this "pimping" is an effective and benign form of Socratic teaching or in most cases really a form of medical student "mistreatment"
To learn more about "pimping" in medical education, read this outline of the practice in eTalk.




The cartoon also brings up another issue as to whether "pimping" medical students, interns and medical residents not only may intimidate and emotionally "harm" them but could this behavior eventually harm the patient.  A second year medical student writing in the Pulse website describes not only her own "pimping" but also witnessing her teacher "pimping" a clinic patient. 

However, a surgical resident who read the Pulse story wrote me the following:
I may be in the minority when I say, I'm "pro"-pimping/Socratic method. I didn't think it was a fair analogy for the student to compare herself to the patient--the patient is not a medical professional. Making decisions with incomplete information is part of all of our jobs.  I say this from the perspective of someone that still has to take written and oral boards as part of my board certification process.  Practicing for oral boards is serial escalation of difficult questions.

Pimping exposes the things that "I don't know that I don't know".  It is normal to feel defensive when you don't know the answer to a question and pimping teaches you to repress the "fight or flight" response, to acknowledge gaps in understanding, to maintain humility and to remain poised in the face of uncertainty.  I consider pimping the surgical love language. How else does the attending quickly assess where deficiencies lie? How do you otherwise also motivate the student that gets great scores on standardized exams to keep studying?  You don't take the time to pimp people when you're not invested in their education.You just ignore them. 

My favorite attendings can always find me in a crowd of residents and call me out--it's how I know they still care. 

So, what do you think about this form of "pimping"?  Have you experienced such questioning as part of your own occupation or experience?  If you are or were a medical educator would you use this technique to educate your students or could this really be only a form of self-interest on the part of the physician educator and intimidation of the student of any sort should not be part of the education process.  Let's hear from you on this behavior. ..Maurice.

Graphic: From Google Images. Referred source: https://euuuh.com/






Tuesday, December 08, 2015

Patient Modesty: Volume 74











Throughout the entire discussion about the issue of patient modesty there is one issue that still hasn't been resolved.  That issue is: within the "doctor-patient relationship" is there really any balance existing or required between the "needs" of the patient and the "needs" of the physician?  Yes, there is imbalance in favor of the physician with regard to medical education and medical/surgical skills and the need to apply this knowledge and skills effectively for the patient. However, since it is the patient who has the illness and who is about to be diagnosed and treated should the balance with regard to "needs" be loaded on the patient's side because it is the patient who is ill and because  the patient should have the primary interest and concern which then includes all matters of modesty? The physician's "needs", such as facilitation of time spent with the patient, assistance by others (which might include gender other than that of the patient) during interaction with the patient or other physician professional but self-interest demands, should bear far less weight on balance than the patient's modesty needs. On the other hand, shouldn't the goal be an attempt to balance the "needs" to provide a safe and effective outcome of any doctor-patient relationship?  And, yes, in that balance some matters of patient modesty might be affected.  I speak as the blog moderator and not as a physician as I present this issue of balance for discussion.  ..Maurice.


Graphic: Balance--from Google Images


NOTICE: As of  March 14 2016, Volume 74 is now CLOSED to further Comments. Go to "Patient Modesty: Volume 75" to continue posting.

Friday, October 30, 2015

Right Way and Wrong Way: Making an Immediate Ethical/Legal Medical Decision






This thread is about what is the ethical and legal "right way" and what is 
the "wrong way"  for doctors and nurses in an emergency room to respond when they are in the act of attempting to save a patient's life and then after resuscitation, started earlier by the paramedics, and was in progress was told by the patient's surrogate to stop at once and let the patient die, not allowing the opportunity to taper off the resuscitation and observe possible recovery.  Here is the scenario as written as the Case Study in the September-October 2015 issue ofthe "Hastings Center Report" for which I have received permission to reproduce here. 


Robert F. is an eighty-five-year-old who suffered a heart attack at home in a rural location some thirty minutes from any major hospital. By the time the paramedics arrived, he was unconscious and nonresponsive. After spontaneous return of circulation, they began their standard procedure of therapeutic hypothermia. Robert's core temperature was lowered using ice packs, and cold intravenous fluids were initiated. Soon afterward, Robert started to shiver when his body temperature reached 35.6° Celsius. He was then given a bolus of vecuronium as a neuromuscular blockade, sedated, and intubated. He was also given a low-dose vasopressin for blood-pressure control. Shortly after Robert arrived in the emergency room, his daughter, his medical decision-maker, produced an advance directive documenting that her father has a do-not-resuscitate (DNR) order, and she demanded that the breathing tube and any other life-sustaining treatments be withdrawn immediately.

The medical staff is very reluctant to comply with this demand for immediate action. Until the neuromuscular blockade wears off, removing the ventilator will prevent Robert from breathing. Furthermore, it may take some time to reverse the therapeutic hypothermia procedure to the point that the patient is at normal temperature. In addition, therapeutic hypothermia itself often causes arrest, so the patient may need to be resuscitated again.


Should the staff wait until the patient is warm or honor the decision of his daughter, who holds his medical power of attorney?

To stop all resuscitation at once will cause the patient to die while being professionally treated and the patient's status for surviving without injury would remain unestablished. This obviously was a moral "no no" by the doctors and nurses since this act at this time might represent to them as unprofessional "killing" of the patient.   On the other hand, to not follow the request of the patient through an advance directive for medical care and the demand of the surrogate daughter, would mean that the doctors and nurses were ignoring the legal and ethical autonomy  of the patient.

So tell me, which is the "right way" and which is the "wrong way" for those medical professionals to act.  ...Maurice.

Graphic: From Google Images


Monday, August 24, 2015

The "Dark Side" of Medical Education?












It is rare that a medical journal would publish an essay by a physician anonymously which describes the "dark side of medicine" and perhaps including the "dark side" of medical education.  The article is in the August 18 2015 issue of the Annals of Internal Medicine 
and in an editorial  in the same issue, the following:

We hope that medical educators and others will use this essay as a jumping-off point for discussions that explore the reasons why physicians sometimes behave badly and brainstorm strategies for handling these ugly situations in real time. By shining a light on this dark side of the profession, we emphasize to physicians young and old that this behavior is unacceptable—we should not only refrain from personally acting in such a manner but also call out our colleagues who do. We all need the strength to act like the anesthesiologist in this story and call our colleagues “assholes” when that label is appropriate. We owe it to ourselves, to our profession, and especially to our patients. 

So this "dark side" can be said to also involves those of us in involved medical education such as myself.. Perhaps  medical educators are inadequately inspecting and controlling the content of the "hidden curriculum" being presented to medical students  and  not facilitating advice and support for those students and doctors who witness "dark behavior" to "speak up"  to the perpetrators but also to superiors in administration. 

By the way, if you want more, read the article in Better Health
an immediate response to the Annals essay.   ..Maurice.

Graphic: From Google Images and modified by me with ArtRage and Picasa3.


Sunday, August 09, 2015

Patent Modesty: Volume 72: NOTICE





                                                         NOTICE


    "PATIENT MODESTY VOLUME 72" HAS BEEN CLOSED TO NEW COMMENTS  SINCE AUGUST 5 2015 AND IS NO LONGER ACCEPTING COMMENTS.

YOUR COMMENTS ARE STILL WELCOME.  PLEASE GO TO "PATIENT MODESTY: VOLUME 73"   ..Maurice.

Wednesday, August 05, 2015

Patient Modesty: Volume 73








So the issue now with regard to patient modesty and patient dignity issues in the care of patients is whether there is "broken" trust in the doctor-patient relationship, particularly with regard to the patient not trusting their physician or nurses.  Or, one might argue, was there any trust from the very beginning of the relationship? If so, was the absence of trust because the physician or nurse did not offer evidence which would support trust by the patient or that patients enter or put into the relationship with the mindset that "all professionals in medicine are considered untrustworthy"? 
Whatever the origin, it is clear from the comments on the previous Volumes that trust is a missing element in medical care and is clearly a part of any discussion of patient modesty or dignity. ..Maurice.


Graphic: From Google Images.

AS OF DECEMBER 8 2015, NO FURTHER COMMENTS WILL BE PUBLISHED ON VOLUME 73 BUT COMMENTS WILL CONTINUE ON VOLUME 74.

Saturday, May 23, 2015

"Commercial Surrogacy": Women'$ Bodie$ as Container$










The title of this blog thread " 'Commercial Surrogacy': Women's Bodies as Containers" with the plural expressed with dollar signs may be a bit over descriptive but yet it emphasizes a commerce present today which is utilizing local women or bringing foreigners into the United States and elsewhere to directly participate in the pregnancy and delivery another family's genetic child.  The question is whether this is a fair utilization and commercialization of a woman and her body and whether, after delivery and she is no longer a container for the pregnancy, she should be allowed to maintain some relationship to the child and the child's family.

This topic is, I think, very nicely described, in a paper by a PhD student Hannah Giunta on the Michigan State University Bioethics website. The ethical and humanistic point which is stressed by Ms Giunta is "Commercial surrogacy arrangements where prospective parents possibly supply the raw ingredients, sign a contract, and return for pick-up with the intention never to see the surrogate again require women to do fundamentally relational work without relational support or respect. Effectively, couples are saying,'You’re good enough to carry our child but not welcome as part of our family.' It’s this attitude that is unacceptable." 


 What I would like to see discussed here on this blog thread is both the ethical good or bad of this form of commerce but also Ms Giunta's concern that if such use of women and their bodies is socially and legally acceptable whether something more should be offered to these women: acceptance into the newly born child's family as a family member.  ..Maurice.

Graphic: From Google Images modified with ArtRage and Picasa3..



  

Wednesday, February 25, 2015

Patient Modesty: Volume 72







What has been written throughout all these now 72 Volumes of Patient Modesty has been descriptions after descriptions of the "bad", thoughtless behavior of the medical system with regard to the dignity of the patients under the system's care.  I have repeatedly voiced on this thread the need for my visitors now, beyond simply writing here about the problem, to make an effort to change the way the medical system "thinks" and "works".  

I have found today evidence that the system is looking for ways to make changes in teaching, practice and behavior. The Association of American Medical Colleges (AAMC) has now publicized its attempt to make such changes.  It is guided by a statement  by the AAMC Board of Directors who in 2014"affirmed the value of fostering a positive learning environment with a formal statement that reads in part: 'We believe that the learning environment for medical education shapes the patient care environment. The highest quality of safe and effective care for patients and the highest quality of effective and appropriate education are rooted in human dignity.'"

So, to my visitor, there you are: this major medical system organization involved in medical school education and the teaching of medical practice to the residents and fellows in this profession is looking for change.  It is now your opportunity to write to the AAMC and express your concerns of the current system and your advice for the future.  This will be your opportunity to "plant a good" which has a chance to flower. ..Maurice.

Graphic: From Google Images and modified by me with Picasa3.



Friday, January 23, 2015

Patient Modesty: Volume 71










I would like to start out this Volume 71 with a basic question to help define what is understood as physical modesty and how it applies to this issue as experienced by patients within the medical system. Is modesty of an individual only related to how the individual feels about their own personal exposure to others or does it also includes how the individual reacts to the exposure or "immodesty" of others? For example, is a patient expressing modesty when they see and react to a woman breast feeding her baby in public? or finding someone on the beach with a "bikini"?  Does every patient who finds challenges to their modesty within their experience with doctors and nurses also are emotionally upset upon viewing, experiencing what is felt to be immodest behavior by others?  In other words, does patient physical modesty concerns actually  involve an individual's general philosophy regarding attention to modesty of self but, in addition, also of others?  This distinction, I think, is important.  ..Maurice.

Graphic: "Bathing Suits" from Google Images

NOTICE: AS OF TODAY  FEBRUARY 25, 2015 "PATIENT MODESTY: VOLUME 71 WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 72.








Thursday, January 22, 2015

WOMAN'S BREAST MILK: SHOULD IT BE UP FOR SALE?





In case you didn't know, a woman's breast milk is a commercially but also a nutritionally valuable commodity at least as an example supported by Medolac Labs and Mother's Milk Cooperative.  This milk is said to be needed by hospitalized pre-term infants whose mothers are not yet lactating.  I read about it in an article in the  Michigan State University Bioethics website  on lactation and  the laws and actions which have been taken including commodification of the woman's milk.

A scholarly article on the subject of the sale of mother's milk was written in the Winter 2009 issue of the Nevada Law Journal 

The sale of organs for transplant is not approved in the United States, only donation.  The question arises as to whether it is ethical to have lactating women provide their breast milk for sale. Is breast milk analogous to a solid organ?

Can or should the same arguments regarding the value, availability and ethics of "selling" apply to both breast milk and kidney?   (You can read more on the issue of the selling of solid organs for transplant in my blog thread "Organ Donation: Who, How, Why and also What are the Ethics (5))"

How about comparing selling the mother's milk to the legal commodification of eggs and sperm or blood elements?

A physician ethicist has reassured me on this topic:

"Maurice, ...
There are American markets for buying and selling human body parts, including blood, plasma, platelets, breast milk, hair, sperm, and unfertilized eggs. The National Organ Transplant Act bans compensation for organs, including livers, kidneys, and bone marrow. Flynn v. Holder adds the acquisition of hematopoietic stem cells from circulating blood to the list of acceptable activities.

An ethical analysis suggests that the key characteristics of these acceptable market-based donations of human body products are:
– The donated stuff can with time be regenerated.
– The injury to the donor is minimal and commensurate with the sale price.
– The risks to the donor of more serious morbidity and mortality are minimal."

And then, of course, there is the long history of "wet nursing" when other women took on the task of nursing a child if the mother was unable to do so.

To my visitors: Do you find any arguments against the selling of the milk obtained from a  lactating mother and, if you do, what are they?  ..Maurice.

Graphic: Migrant Mother, Dorothea Lange, Library of Congress / Public Domain / Wikimedia Commons