Patient Autonomy: Where Should It Begin and End?

I have published threads here in the past for discussion of the ethical conflict between physician paternalism versus patient autonomy in medical decision-making.

Here is a brief vignette extracted from a book review article “Veatch Hates Hippocrates” by ethicist John D. Lantos in the January-February 2010 issue of the Hastings Center Report that sets the conflict rather clearly. Read it and then give us your view of the “good” and “bad” of this communication between a patient and her doctor. ..Maurice.

Doctor: “I notice that you are coughing, that you are using your intercostal muscles when you breathe and that you are breathing sixty times a minute. I don’t want to impose my values upon you. How do you value that state of being?”


Patient (gasping for air): “…can’t….breathe…”


Doctor: “Can’t breathe? Well for me that would be unpleasant, but I happen to value oxygenation. I wouldn’t want to impose those values on you. I could give you a little oxygen. Or I could give you morphine. Or I could give you a nebulizer treatment. Which would you prefer?”


Patient: “I just…want something that will make me feel …better…”


Doctor: “I want to help. Tell me… what does ‘better’ mean to you?”

Ghostwriting Scientific Medical Articles and the Role of Academic Medical Institutions

If you think that college students turning in their term papers, the text of which was actually written by others and sold on the internet is unethical, consider “respected” physicians associated with well known academic institutions getting paid by pharmaceutical companies to have their name attached to medical research articles which were written by ghostwriters working for the company. I started this topic of ghostwriters on Halloween last year and I would like to continue the topic here stimulated by an open-access article in PLOS Medicine published today titled "Ghostwriting at Elite Academic Medical Centers in the United States" by Jeffrey R. Lacasse and Jonathan Leo.

I am reproducing the Background and the Conclusion (without including references) here but I advise my visitors to read the survey study at the above link, which will include the references. Then return and present your views of the issue and its consequences. ..Maurice.

BACKGROUND-
Medical ghostwriting, the practice of pharmaceutical companies secretly authoring journal articles published under the byline of academic researchers, is a troubling phenomenon because it is dangerous to public health . For example, ghostwritten articles on rofecoxib probably contributed to “…lasting injury and even deaths as a result of prescribers and patients being misinformed about risks”. Study 329, a randomized controlled trial of paroxetine in adolescents, was ghostwritten to claim that paroxetine is “generally well tolerated and effective for major depression in adolescents” although data made available through legal proceedings show that “Study 329 was negative for efficacy on all 8 protocol specified outcomes and positive for harm” . Even beyond frank misrepresentation of data, commercially driven ghostwritten articles shape the medical literature in subtler but important ways, affecting how health conditions and treatments are perceived by clinicians. The ability of industry to exercise clandestine influence over the peer-reviewed medical literature is thus a serious threat to public health In 2009, the Institute of Medicine recommended that US-based academic medical centers enact policies that prohibit ghostwriting by their faculties . However, to date, there has been no systematic assessment of ghostwriting policies at academic medical centers. Since US-based academic medical centers generate biomedical research for a worldwide audience, we chose to conduct the first such investigation on elite US-based academic medical centers. … We sought to describe the current policy situation at US-based academic centers and then to propose an ideal ghostwriting policy.

CONCLUSION-
Medical ghostwriting is a threat to public health which currently takes place only due to the cooperation of researchers employed at academic medical centers. Although there is growing awareness of the danger posed by medical ghostwriting, we find that few academic medical centers have public policies which prohibit this behavior, and many of the existing policies are ambiguous or ill-defined. We have proposed an unambiguous policy which defines participating in medical ghostwriting as academic misconduct akin to plagiarism or falsifying data. By adopting and enforcing this policy, academic medical centers would adhere to the norms of science followed across the rest of the University, and would no longer facilitate clandestine industry influence over the peer-reviewed scientific literature. By prohibiting medical ghostwriting, academic medical centers have a rare opportunity- to significantly reduce a major threat to public health with the stroke of a pen.

The American vs Haitian Homeless: Irony and Injustice?

To start, I want to be clear that I am not against the United States government's humanitarian aid to Haiti and the people of Haiti either now or in the future including reconstruction. However, I am struck by the irony in political behavior where there seems no political will in America to feed, house, educate, get jobs and provide adequate medical care for the millions of homeless, unbefriended and hungry Americans here at home. Yes, there is political concern for support to the "middle class" and Wall street but where is any politician coming out and saying "I intend to allow my government to spend all the money necessary to support the homeless in the United States"? Those on our American streets without home or food are just as helpless and needing of governmental assistance and help as those as those currently living on the streets now in Haiti. If this is political blindness toward one group but not to another, it seems to me that this represents a humanitarian injustice beyond being simply ironic. What do you think? ..Maurice.

Patient Modesty: Volume 31

Patient modesty may cause concern from something as simple as the above graphic or it may be associated with behaviors of medical staff while examining or doing procedures which raise questions regarding unprofessional behavior. We continue here on Volume 31 with followup from the previous volumes regarding approaches to respond to these concerns. ..Maurice.

"Why is my doctor giving me thyroid medication for thyroid nodules?": Who Should Answer?

May I introduce my visitors to Medpedia, a great resource site for medical information and discussion for medical professionals, patients and organizations? There is a section on Questions, the answers provided by professionals. As an example and to start a new topic on my blog, here is the question asked by a visitor to Medpedia and my answer. The question “Why is my doctor giving me thyroid medication for thyroid nodules?” interested me in wondering whether the patient first asked the question to her own physician and if not, why not. Or if she did, was she satisfied with the response or simply wanted to check up on the doctor’s response? Read my response and write here what your own experience has been about being able to ask questions and get understandable answers from your physicians. No names please. ..Maurice.

"Why is my doctor giving me thyroid medication for thyroid nodules?" That is an important question but one that shouldn't and really can't be fully answered on Medpedia. Physician education of the patient with regard to the nature and treatment of their disorder is as important in the practice of medicine as making the diagnosis and beginning treatment. Therefore, the question should really have been asked to and answered by the patient's own physician. The patient's understanding about their disease and their treatment is one major important factor to assure patient ongoing cooperation and compliance. There is no substitute. If the doctor can't explain, as a patient I would be concerned. Paternalism ("I know what is best for you so just do as I say") is no longer the mantra of modern physicians.

Intuition and the Practice of Medicine

"The most decisive actions of our life... are most often unconsidered actions." ~André Gide, The Counterfeiters, 1926


But is what Gide writes intuition? If “unconsidered actions” is really the consequences of intuition, is that what physicians use in making diagnoses and establishing treatment? A dictionary definition of intuition would be the act or faculty of knowing or sensing without the use of rational processes; immediate cognition. Knowledge gained by the use of this faculty; a perceptive insight or a sense of something not evident or deducible; an impression. Other words can also express intuition such as feeling, hunch, idea, impression or suspicion. But, do you think that these words describe what goes on in the mind of a physician when attending to a patient? My answer would be “well..yes, well..no”. First, there is debate as to how to define the word intuition when it is applied to the medical profession. Does it represent a “made-up” theory or assumption without any connection to previously established facts? Or is it a professional way to look at and interpret any facts that are available? Obviously, I can’t tell you what is going throughout the mind of any doctor except myself. To me, however, I find that I use intuition as a method in which I can personally make sense of the facts, both historical including my experience and contemporary. In medicine, simply laying out and evaluating the facts developed in taking a history, performing a physical examination and performing tests or procedures may be clearly insufficient toward coming to a conclusion. The diagnosis or the decision regarding further workup or treatment may still be ambiguous. It takes something more to feel confident to initiate action. That something more, I think, is intuition.


Intuition in medicine has nothing to do with ignoring or setting aside all the facts and proceeding de novo with some innate unexplained but significant mental mechanism which is “all knowing” or spiritual which has powers beyond any rational understanding of mental or physical mechanisms. I do think that intuition is related to the physician’s personal and professional experiences and recollection of the outcomes of those experiences. This recollection is then applied perhaps rightly or wrongly to the contemporary facts and an attempt is made to mold these facts with intuition into a conclusion for action.


Often, physicians must make critical decisions in short time spans during which time other needs for other decisions are appearing. There may not be enough time and the facts may be inadequate to come to a decision based on these facts. Particularly, in such a situation, doctors turn to intuition. This means that the doctor doesn’t simply look at A and B and C and automatically finds a direction toward action D because of established standards of professional practice or because A, B and C have been recognized and D has been rigorously tested in a controlled scientific study and found to be an appropriate action. This is where intuition plays a role. I say to myself "Will what I have learned in the past about this disease or symptom complex, will what I know about the patient, will what has been the standards of practice regarding this condition, and what has been tested and proven valid by scientific studies really apply to this patient and this patient’s condition?" I think it is intuition that then plays a role in getting a decision defined. It may become, as an answer to these questions, “yes, yes, yes, yes” or “yes, yes, yes,yes… but…” and it is the “but” which represents the physician’s use of intuition. My conclusion is that Gides “unconsidered actions” would not represent intuition particularly the way I have used intuition and the way I suspect other doctors have used it in medicine.


As a patient, how to you feel about the physician’s use of intuition, as you define it, and whether you think it is something that doctors should use? Do you have any examples of how your doctor’s intuition played a role in your illness? ..Maurice.

Patient Modesty: Volume 30

The discussion of patient physical modesty concerns continues, particularly related to the genital areas, and its relationship to medical examination and procedures performed or observed by individual healthcare providers of the opposite gender. In Volume 29, an attempt was made to introduce the issue of whether some significant behaviors of mothers toward their sons might contribute to the cross gender modesty concerns raised by male visitors here. Whether or not that possible relationship is continued to be discussed here, the need is to continue to comment about and work out approaches to mitigate the concerns but to the patient's benefit. One of the approaches is to "spread the 'word' (concerns)" directly to the medical system. In this regard, I want to remind my visitors of what I wrote on Volume 29:

CONTRIBUTORS TO THESE PATIENT MODESTY THREADS HAVE AN OPPORTUNITY TO EXPRESS THEIR MODESTY CONCERNS TO A BROADER AND MORE SIGNIFICANT AUDIENCE THAN SIMPLY AND ONLY WRITING COMMENTS HERE. THE ONLINE PUBLICATION HOSPITAL.COM HAS OFFERED TO CONTINUE THIS DISCUSSION ON THEIR PUBLICATION. WITH A GREATER AND MULTI-DISCIPLINE MEDICAL SYSTEM AUDIENCE THEIR PARTICIPATION WILL BE A VALUABLE CONTRIBUTION TO THE BROADCASTING OF THE CONCERNS BEING EXPRESSED HERE.

I have not received word that anyone here has taken advantage of this offer by hospital.com. I strongly suggest that my visitors do participate.
..Maurice.

Graphic: Photograph of painting by Albert Edelfelt, 1877 Ateneum Art Museum, Helsinki Finland and published on Wikipedia in the public domain.
Queen Blanche of Norway and Sweden with Prince (later King) Hacon, a fantasy painting.

NOTICE: AS OF TODAY JANUARY 26, 2010 "PATIENT MODESTY: VOLUME 30 WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 31

Treating the Patient Simply for the Benefit of the Family: Is that Ethical?

It is not unusual these days for family members to insist that the healthcare providers perform tests and prescribe treatments that may be inappropriate or medically futile but for which the family will feel more comfortable that “everything was done” to improve or preserve the life of their ill loved one. This type of family behavior, if their requests are followed, despite the action may be inappropriate for the patient’s condition or futile, is said to contribute to the unnecessary increased costs of medical care, particularly in end-stage illnesses. And following the requests ends up only benefiting the psychologic uncertainties and anxieties of the family but providing no benefit or occasionally even unnecessary risk or harm to the patient.


Yet, one could also say that physicians should not just be treating the patient but, in fact, are also treating the family and those around the patient who have great emotional and perhaps other interests with the patient. But is this global responsibility really what patient care is all about? Isn’t the responsibility of the bedside physician only for the patient? Well, no. One could argue that physicians do have responsibilities to society and to the community particularly if one considers communicable diseases, hazards to others or (and this might be controversial outside of some disaster) consideration regarding the allocation of scarce resources. Should the physician also have responsibilities to a narrower domain such as the patient’s family? Is there a point, perhaps in the terminally ill and dying patient, where benefit to the family will trump any possible harm or benefit for the patient? And should that attempt to benefit the family be carried out by the physician?


I have tried to put an example of this issue in the form of a scenario and my challenge to my visitors is to answer the question: What is the ethical and most appropriate yet beneficent way the physician in this scenario should respond to the family’s request?

The hospitalized patient is elderly and is in the process of dying from an incurable illness. The patient is now comatose, unresponsive and clearly in no distress. An order has been written by the physician for an intravenous morphine drip administered on a regular basis to keep the patient comfortable. The family, sitting at the bedside, observes a respiratory irregularity that concerns them that the patient is uncomfortable. They request that the nurse provide the patient with additional morphine to what has already been administered. The nurse who has been following and observing the patient finds nothing in the patient’s respiration or responses to warrant additional morphine. She tries to explain to the family the basis of her conclusion. The family disagrees.


The nurse is concerned that to administer the morphine now would not be appropriate care for the patient but would risk that the patient would die prematurely from the morphine dose. The nurse is concerned that she might be causing the patient’s death not for the comfort benefit of the patient but simply for the comfort of the family sitting at the bedside.


The nurse refuses to administer additional morphine and the family calls the doctor.

If you were the doctor receiving the call how would you respond? Again the question “Is it ethical for a physician to treat a patient simply for the benefit of the family?” ..Maurice.

Graphic: Drawing from Washington Irving Rip Van Winkle (Philadelphia: Henry Altemus Company , 1900) 149 modified by me using ArtRage3.

Harvesting Organs for Organ Transplant Without Permission

"Harvesting Organs for Organ Transplant Without Permission" was the title of a topic which I set up on my now inactive "Bioethics Discussion Pages" back in 1996 but the issue is still as fresh today as it was then. There are still many patients on organ transplant waiting lists who are dying because of inadequate numbers of vital organs available for transplant. There is still no established methods to create any or the numbers of vital organs from stem cells to meet the need. There are suggestions for the United States to develop "opt-out" donation programs where all deaths could, if appropriate, be a potential organ donor unless the individual had specifically rejected to be a donor. Below, I copied the responses from my "Pages" visitors. Click on Comments and read and contribute your own views of this ethical and medical issue.
..Maurice.

Here is the question:

In order to obtain enough organs to be transplanted into needy patients, should laws be passed which allow organs to be obtained from persons who have died without the prior permission of the patient or any permission of the family?


Date: Thu, Apr 15, 2004 1:24 PM From: redmc90@yahoo.com To: DoktorMo@aol.com
hello i am a student in 8th grade my name is matt and i was doing a report on harvesting organs when i stumbled upon your accusation. i too beleive in god and christ but do not completely agree with your thinking. if someone is dying and needs an organ than why cant they come from a dead persons body that doesnt need it even if they never gave your permission in the taking of their organs it would still hopefully be in their best interests to save a persons life. again why is this a problem for you and please dont tell me this is just waht you believe.

-matt

Date: Wed, Mar 10, 2004 4:55 PM From: merlin1@velocitus.net To: DoktorMo@aol.com
I'm gonna have to say that even though it seems inhumane, organ harvesting may be necessary. Think about it, if you had a close family member dying because they couldn't get a organ, would you rather let them die or take an organ from a person who was already dead? Obviously you would pick option number two. Because you don't want your family member to die. However, I also think that maybe the family of the donor should have to give some kind of permission, but only if the organ is not neccesary to live. If it is an organ that is required for survival, I think no permission should be required. P.S. IF INHERITANCE IS INVOLVED, I URGE THE FAMILY TO JUST LET THE ORGAN REQUIREE DIE.

Date: Tue, Apr 8, 2003 3:45 PM From: jaliffi@comcast.net To: DoktorMo@aol.com
I do not agree with the idea of harvesting organs from patients without their consent or their family's consent. Who are we as medical professionals if we cannot help respect the rights and spiritual concerns of our patients. I agree that we do need more organ donors however, does the good of many override the good of one? Also I work in an Intensive Care Unit and have seen numerous organ harvestings take place. The person who said "I have read other articles giving grim descriptions on squirming bodies as they are still alive when the harvesting takes place, and find this quite disturbing. " this is wrong. It is my understanding from the Director of Organ Retrieval that they must have a confirmed diagnosis of Brain Death before any organs can be harvested, ( If I am wrong with this interpretation please let me know.) This is not like the Urban legend where the business man meets a women in a bar and wakes up in a tub with ice around him and a grim note stating call 911 before you die because his kidney is gone. We live in a democratic society where we all have the right to decide what happens to us during and after death. I personally am an organ donor and have educated my family and friends to that fact so that there is no misunderstanding about what I want to be done with my body after death. I believe that we should concentrate on educating the masses as to the benefits of organ donation instead of leaving this important decision to be made by one person who does not know what the patient really wants.

Jenny Aliffi JAliffi@comcast.net

Date: Mon, Apr 7, 2003 2:55 PM From: bdscott36@netscape.net To: DoktorMo@aol.com
After losing my best friend because there was no compatible liver early enough available, my opinion on this matter changed. I believe that many people are to afraid to make the right decision in favor for organ donation because they think doctors would let them die earlier than people without organ donation permission. Education on this matter is essential, so that there is no doubt about the correctness of the proper procedure. if more organs could be harvest early enough, many lives could be saved. Having the permission prior to organ harvesting is probably the only correct and legal way right now, but I think that taking those organs without this permission should be taken into consideration. At the end it is our body that rises to heaven. Our body will stay behind, and this body could still save many lives.

Date: Thu, Nov 7, 2002 10:05 AM From: JUICY JKB@aol.com To: DoktorMo@aol.com
I think its wrong harvesting organs without permission. If the person who died said they could have an organ then that will be convenient. But harvesting organs without permission its wrong. For one it isnt your organ and it is not up to you to do that. You should ask permission. I would donate an organ to anyone in my family and if somebody who i didnt know needs it badly, but they would have to have permission. Why would you not want to ask permission? This is a very serious case and to think that there are people out there who will not ask permission is unfair.

Date: Wed, Oct 16, 2002 9:26 PM From: s_lel@hotmail.com To: DoktorMo@aol.com
I wanted to reply to the organ harvesting debate, as a college composition paper has sparked my interest in this subject. I believe that organ harvesting is a wonderful gift for someone to give. If the possible donor has not determined if they either want to donate or be kept whole, I think it should be completely up to the overseeing doctor to decide whether the organs are valuable enough to donate, and whether or not to donate them. I have read other articles giving grim descriptions on squirming bodies as they are still alive when the harvesting takes place, and find this quite disturbing. However, if it is not possible to save this possible donor from certain death, I think it should be mandatory to donate, AS LONG as it is not otherwise stated in a living will. I also believe everyone should be required to have a will after the age of 18, even if it is just a living will.

This is a very touchy subject, but by allowing people's grieving families to make this decision for someone when they are completely consumed by the death of the possible donor, the deceaseds wishes are many times not carried out. People should keep in mind that if they want to donate, SIGN your driver's license and make it very clear to your family of your wishes...Keep an updated living will and make certain all family memebers have agreed to carry out your wishes!!

Thank you for your time, Steph

Date: Wed, Sep 25, 2002 10:42 AM From: crti@voyager.net To: DoktorMo@aol.com
My main concern is not about whether an organ "donor" or next of kin gives consent, but whether or not the "donor" is really dead. As one responder said, her son's organs could not be used because he was dead already! Is it the removal of organs that changes a living person into a dead body? Anyone familiar with the moment of death knows that a dead person does not grimace or squirm. Yet, this is what happens when the surgeon makes the incision to remove a so-called "brain dead" donor's organs. The donor's body reacts by moving, grimacing and squirming, unless given a paralyzing drug. Due to the protests and strong reactions of medical personnel (who are upset to see the supposed "corpse" move), transplant surgeons have come to rely on such drugs to suppress signs of life. Even then, there is an increase in blood pressure and heart rate. The heart continues beating until the surgeon stops it a few moments before cutting it out. Informed consent is the real issue. Shouldn't people being asked to sign donor cards and potential donors' relatives be told the whole truth about the organ transplant process BEFORE making a decision?

Sincerely, Julie Grimstad, Director Center for the Rights of the Terminally Ill

Date: Fri, Sep 6, 2002 6:31 AM From: n.long@centralservices.co.uk To: DoktorMo@aol.com
I don't believe in the validity of harvesting organs for transplant without permission. My reasoning for this is that as far as I can tell (and no one seems to have addressed this issue here) organs are only viable for harvesting if the body from which they are being harvested is only clinically or brain dead and not completely dead. Is it not true that once the heart ceases to beat the function of the organs rapidly deteriorates? In this case if the patient is on life support does the hospital not require permission from the relative to withdraw the life support? If they require permission to withdraw life support and they need to harvest the organs before removing the life support they would have to ask the relatives' permission to harvest the organs before life support was removed.

I think it should be up to the individual to decide whether they wish to donate their organs or not. The needs of society as a whole cannot override the rights of the individual as societal ideals are based on the ideals of the individuals that go to make up that society. If the needs of society override the rights of the individual, the ideals on which the society is based are rendered null and void.

We would all like to see disease and hurting stop all over the world, but to legislate that organs can be removed without the consent of the "donor" or the knowledge of the relatives of the "donor" denies the intrinsic rights that people have over their own bodies. If we can decide in wills how our bodies are disposed of after our deaths, then we must be able to decide for ourselves whether or not we wish to donate parts of our bodies to others.

Thank you for letting me share my views with you.

Date: Thu, May 2, 2002 8:27 PM From: ally_121@hotmail.com To: DoktorMo@aol.com
Dear Dr. Mo, My name is Valerie Budahl. I am a student of Mrs. Lundberg's Advanced Biology class. We have discussed bioethical topics and chose topics to which we were interested in doing filementality projects on. My topic is illegal organ trafficking. I did research to find out the ethical debates of taking organs illegally. I weighed the advantages and disadvantages related to this type of organ transplants. This procedure may save a life or two, but I find it very unethical to kill convicts or infants just to save a life or two. I found some pretty gruesome information about grandparents selling grandchildren to the highest bidders in order for those children to be killed and used as organ donars. In my filementality I have added several links to help others discover the true origins of organs obtained illegally. Thank you for allowing me to share my opinion, I hope people will have more knowledge to go on after visiting my filementality page when making decisions about organ transplants.

Sincerely, Valerie Budahl

Date: Wed, Apr 3, 2002 10:58 AM From: CCROEL@webtv.net To: DoktorMo@aol.com
In response to Susan Melton-Piper, Davis, CA, I'd like to point out a few things:

As of today, there are simply not enough medical services (including medicine) to meet the desires of the society. In the USA, distribution of the available supply goes to those who a willing to pay the most money for those services. Because emergency rooms are required by law to treat everyone who comes in the door, emergency rooms are in crisis.

In England, Government provides funding and triage is made by government officials; waiting in line is the principle method, but many needy patients must do without proper care; the system is in crisis and the supply of services is falling far behind even minimal standards.

Someone must pay for medical services, and when the suppliers are permitted to make a (what many perceive to be an "unconscionable") profit, the supply (barring monopolistic and other illegal manipulation of the "market") tends to increase. So far, while the "distribution" of medical care seems to be terribly inequitable on occasion, over all, there is more and better care available here than anywhere else (or so I have been told).

The inequitable distribution can be largely corrected by government providing of money to the needy and by charitable contributions. HMO's do not, and probably cannot, fund all "needed' care (especially organ transplants). But in any event, it seems likely there will always be people who need services which will not be given to them. When Medicare was first enacted, if all the care persons over 65 WANTED were given to them, there would have been no care available for anyone under 65.

------------------------

There would be no shortage of organs if: the deceased were presumed to have consented to the donation, and only specific objection by "loved ones" prevents the use of organs. This is the system used in Belgium, where they have a surplus of organs. Since the only "pain" suffered by 'loved ones" comes from LEARNING of the salvaging, I would permit salvaging in all cases, while keeping the actual donations confidential.

What seems to be missed in many cases, is the fact the emotions of "loved ones" takes so much precedence over the feelings of patients who are dying and who desperately want to live.

Date: Wed, Mar 27, 2002 4:30 PM From: DustiLLucas@cs.com To: DoktorMo@aol.com
My answer is NO. You should have permission to obtain the organs legally. I do not believe there will be any law that will pass making it legal to take organs with out permission.

Date: Mon, Mar 25, 2002 6:56 AM From: roberts.j@insightma.com To: DoktorMo@aol.com
I am currently writing a Argument Paper FOR organ harvesting. My son had a liver transplant. Through our 5 years of many hospitalizations, I saw many kids die because an organ couldn't be procured in time. This is my experience with one pediatric transplant center, but this is happening all over the United States - NEEDLESSLY.

There are currently 88,000 people listed for organs. The US annual mortality in the year 2000 was 2,404,598. Even disqualifying 50% of those for transplant and then another 20% to accomodate people who will not donate due to religious beliefs, that still leaves 721,379 possible donors. My math may be off as far as reasons possible donors would be unacceptable, but there are more than enough possible donors available to help the 88,000 people listed.

Jennifer L. Roberts

Date: Sat, Mar 16, 2002 9:24 AM From: smelton@davis.com To: DoktorMo@aol.com
Although a scientist, I totally disagree with organ/tissue harvesting without consent of the next of kin. My primary reason for disagreeing is the price we put on the process. I am not an organ donor at this time due to the political nature and the "price tags" placed on human life. The current system does not allow for the most needy patient to receive the organ, it is whether or not the patient has money to pay for the services, adequate insurance or any insurance at all. Unless we develop a system that allows everyone fair access based on medical and scientific reasoning rather than ability to pay, I and my family will refuse to be organ donors despite the fact that I believe in the life-saving measures of it.

Susan Melton-Piper, Davis, CA

Date: Mon, Jan 7, 2002 12:59 PM From: AnG da Angel623@aol.com To: DoktorMo@aol.com
I think there should be a law that says if you DO NOT sign anything than your organs can be donated, but if you choose not to donate you have to sign that on your lisence. I think donating organs is a good thing because it can save lives. If you take organs from a dead person, I don't see a problem at all.

Angela

Date: Sun, Oct 21, 2001 8:02 PM From: lttyates@bellsouth.net To: DoktorMo@aol.com
It would not be respectful to just take a persons organs without their permission. It would of course be offensive to the family, if they did not agree to have their loved ones organs donated. I could not imagine someone taking my organs. I do believe in organ donation, I just haven't made that kind of committment for myself yet.

Date: Thu, Jun 28, 2001 9:20 PM From: TulsaBaby1@aol.com To: DoktorMo@aol.com
I think if there is a relative or responsible to make the decision of donation then they should make that decision. However, if the physican ameks the determination that there is irreversible brain death and there is not anyone available to make that decision, it would seem that that patient could become a ward of the state and give the doc the right to decide the issue. There needs to be more education the the average consumer about this issue so that it can be addressed in their medical records.

R.Cobb, RN

Date: Tue, May 1, 2001 8:59 PM From: ren_gibb@hotmail.com To: DoktorMo@aol.com
Hi! I am a Nursing student from Tasmania, Australia. I am Currently doing an assignment on wether or not a person actually owns their organs. Or if Doctors should be allowed to remove a persons organs after death for any reason with out the permission of the decesed person. One question that has been raised is, does it actually mater the person is dead? Also, If the person who has died no longer needs those organs then wouldn't it be better to then use them for the furtherance of another persons life or for research to find cures and preventions of diseases.

It is a question with no clear answers. I believe that it is a persons choice to decide wether or not to donate their organs and that the government should not be able to force a person to give up their organs. There a number of reasons that a person may refuse, and doctors need to be sensative to a persons religious and/or personal beliefs.

There is definatly a need for better education on the issuses surrounding death and organ donation, with better education may be more people that are willing to donate their organs.

R. Gibb, Tasmania, Australia

Date: Thu, Jan 11, 2001 8:11 AM From: sandy@isaacs.mv.com To: DoktorMo@aol.com
1. We are losing confidence in our doctors' unbiased ability to make decisions based primarily on the patient's best interests. 2. Higher technology medicine such as neonatal and transplants seem to me to be primarily for the benefit of the medical intellect and research interests, not for the society as the costs in my mind outweigh the societal benefits. As Mass General trustees decided decades ago when they refused authorizing heart transplants as consuming too much hospital resources for the benefit of too few.

Date: Mon, Oct 30, 2000 3:36 PM From: sk4711@gmx.de To: DoktorMo@aol.com
I think let dead people automatically become organ donors is not right. I think MUCH MORE education on organ donation is needed. I, myself, as a recipient (cornea, both eyes) had problems to find the needed information. Well my doctor told me, but to find information which is official there for everybody is very rare. The major problem is that most people don't know what exactly is meant when talking about translantation, oh, I mean they don't know about the laws, privacy policy e.t.c.... I know from people around me, that there is only very rare knowledge about organ donation, some of them even believe in the bad myths, such as that one saying " if you go to hospital and there is a need for organs they would let you die". Such myths need to be eliminated! I conclude that people should say on their own if they want to become donors or not, BUT they should be better educated on all the issues.

Sandy K.

Date: Fri, Oct 6, 2000 7:47 PM From: nwilliams@GLENOIT.COM To: DoktorMo@aol.com
I believe that the harvesting of organs in order to save lives is a good thing. However, I don't believe that the government should get involved in making these decisions for us. The individual has the right to determine the fate of his or her own body and organs. I believe this concept is as basic as breathing and sleeping. And too, when has money ever been spent to educate and inform a society on the benefits of any wise health care choice that actually had any real substance? I believe that money should be poured into these "technological wonders" that shows real promise today - the creation of organs from cell tissue. If you can clone a functioning, healthy organ which a dying person could use, why not do it? Is this playing God? Not any more than taking an organ out of a dead body and putting it into a living one to extend that life. In this manner you could still make organs available to all and paid for through medical insurance. The selling of organs to the highest bidder does not become an issue and once again the rich would not benefit through the neglect and suffering of the poorer segments of society. If someone is willing to make a sacrifice to give the gift of life, that gift should not be diminished by making it available only for those who can afford to pay the price. When you take such a benefit away from an entire segment of the population, you actually say that these people don't matter, that they are disposable and of no consequence. When a society does this to the most vunerable of all, its decline has already started. Our lofty ideals and perceived sacrifices don't mean anything if we, as human beings and citizens of this Earth, do not consider everyone of equal value with equal rights to health care and well being.

N. Williams, North Carolina

Date: Fri, Oct 6, 2000 5:48 PM From: Rustyp37@aol.com To DoktorMo@aol.com
I am a Registered Nurse, a wife, daughter and mother of two. I agree there is a definite need for organs for transplant. I do not agree that organs should be taked without consent. Many people believe that the body needs to remain intact or the persons spirit life will be interfered with. I see it as an invasion of privacy if we take organs without consent. I'm not sure how we can reach people before their time of grieving to get them to become donors but I think that is where our focus should be. I have informed my family that I wish to be a donor when I die and I hope they will follow my wishes.

Date: Wed, Jul 26, 2000 9:08 AM From: dfentres@memphis.edu To: DoktorMo@aol.com
I'm chairman of Citizens for Organ Procurement Rights, a Memphis TN based group which feels we could solve the organ shortage if people who are not willing to donate would be given the option of signing a futures contract to permit sale of their organs to the highest bidder in the U.S. when the brain dead condition occurs. Though this is prohibited by the 1984 Organ Transplant law presently, we believe this is an unconstitutional taking of private property (since we are not allowed to dispose of our organs as we wish), and we anticipate challenging that part of the law. Allowing such organs to be sold would increase the supply hugely and would only provide payment to the harvestee's estate, and only if the organs are useable. No coercion is involved, and next of kin would sign on to the contract in advance, thus disposing of the question of their consent after the death. Since the pact would be agreed to typically years before the death occurs, a record of the harvestee's health could be maintained, resulting in an even better quality of organs than may currently be the case.

My name David F. Diamond, my email (dfentres@memphis.edu) and snailmail address (4976 Kimball Ave, Memphis TN 38117) and phone #: 901 761-5577

Date: Thu, May 4, 2000 11:08 AM From: smyrnami@pathwaynet.com To: DoktorMo@aol.com
My son died while very young, and we wished for his organs to be donated. We were told it wasn't medically possible to harvest organs from a dead person, the person had to be alive, at immanent death, brain dead, or etc....... While we wanted something good to come of our loss, our understanding was he wasn't a candidate because he was already gone. In answer to your question, no, I don't believe anyone should have the right to harvest organs without consent. I do believe we need to better educate the public regarding the needs of organs and the circumstances in which a person is a candidate for organ donation. Personally, I believe when we have finished with our bodies, they are of no use to us, and could be of great use to those we leave behind. But, I do not believe any government should dictate a decision such as this. There are many religious and personal beliefs that would contradict organ donation, we have a right to make that decision for ourselves. In my opinion, the best course of action to further the cause of organ donation would be to educate the public: make information available, provide an information center for questions and comments, discuss history of organ donation, and personal stories from people who have been involved in organ donation.

K. Pennock

Date: Thu, Apr 27, 2000 12:22 PM From: tde_smith@yahoo.com To: DoktorMo@ aol.com
With the shortage of organs in this country, you would think that perhaps someone would suggest implementing a presumed consent program. What presumed consent does is make everyone an automatic organ donor, unless they state otherwise. Presently, Belgium has this program implemented, and their need for organs has been reduced significantly since the progam began 10 years ago. One of the major advantages of this program would be the immediate access to organs once someone has died. There would be no need to gain prior consent, because it would already been assumed that consent was given. There are too many people in this country who die everyday due to the unavailability of organs. This program would significantly reduce that number. Just something to get people thinking about the importance of organ donation. No hassel, no paper work to fill out, because the assumption has already been made that a person is an organ donor. I personally think it is an excellent idea. It's too bad we probably won't see a program like that implemented in this country.

T. Smith, (RN student)

Date: Tue, Apr 4, 2000 7:49 PM From: Logfencepost@cs.com To: DoktorMo@aol.com
I am writting to you from Colorado. I am a BSN student and I am doing a debate on harvesting of organs. I am very sure that no one else but the patient should make the decission to donate their organs after death. I think that every doctor and nurse should encourage a individual to make the decission about donation before a situation occurs. I think this is something that we could add as a standard of care during physicals. Just like we ask about allergies and current medication, we would ask them how they feel or if they have ever considered donating their organs when they pass on. This would in hopes eliminate some of this turmoil over families, doctors etc... making the decission when truely it is the patients choice. I do think that in some situations, where the patient has not voiced their opinions and the family chooses to donate, then I think that they are acting as the loved ones advocate and are doing what they think is best for that patient and are doing what the patient would have wanted done.I do not think that it is by any means the medical staffs place to decide if the patient donates after death. If you have any information or good sources to help me along in my debate, feel free to write me at: logfencepost@hotmail.com

Thanks, Dena Banta

Date: Sun, Apr 2, 2000 1:04 PM From: bbergero@mesastate.edu To: DoktorMo@aol.com
Hello. I am a student in nursing school and we are studying different ethical issues. I am responding to the article on "Harvesting Organs for Organ Transplant Without Permission." I think people have a right to be in charge of what happends to their body after they die, therefore I do not agree with harvesting organs of the dead without their permission even though the country is in need. What health care workers could do instead would be to educate the population more on organ donation. With more incentive such as knowing how much one may help someone in need may change the minds of some before they die. Telling loved ones of the decision is a big part of the problem too. Without anyone else knowing what a person wants is not helping anyone.

Sincerely, Becky

Date: Wed, Mar 29, 2000 7:31 PM From: IbarraAE@aol.com To: DoktorMo@aool.com
HELLO, I 'AM A NURSING STUDENT AND I 'AM WORKING IN PROJECT RELATED TO THIS TOPIC. MY ANSWER IS NO, I DON'T BELIEVE ORGANS SHOULD BE HARVESTED WITH PRIOR CONSENT EITHER FORM THE DISEASED PERSON OR BY THE FAMILY. I HAVE ANOTHER ISSUES. WHAT HAPPEN IF A PERSON WHO HAS LEGALLY AUTHORIZED THE HARVESTING OF HER/HIS ORGANS AND AT THE TIME OF DEATH THE FAMILY DOES NOT WHAT TO ALLOW THE HARVESTING? WHO'S DECISION IS HONORED? THE FAMILY? THEN THE RIGHT OF AUTONOMY OF THE PERSON DEAD ID VIOLATED. THE DECISION OF THE DISEASED? THEN THE FAMILY MAY SUE... WHICH IS THE MORE ETHICAL APPROACH?

Date: Thu, Feb 24, 2000 6:00 PM From: Dixon_18439@email.msn.com To: DoktorMo@aol.com
To me a person is dead when he or she can no longer take can of themselves.when a person brain can on longer tell his or her body to what to do without the assistance of machines then this person is already dead. He cannot speak or do any of the thing he once did but may at that point he or she can give the last gift they have, their heart, kidney,liver or what ever is health and need. that what I think.

Date: Mon, Feb 21, 2000 4:17 PM From: MRobcor@cs.com To: DoktorMo@aol.com
I believe that once a person is pronounced brain dead that they are truly dead. I believe at that time the client's organs should be utilized to help someone in great need of them and that the brain dead person be able to die a peaceful dignified death. I work with a population where many of my clients are basically brain dead with no quality of life and it saddens me that they can't pass on and provide someone else with their good organs.

Mrobcor@cs.com

Date: Wed, Feb 16, 2000 3:53 PM From: Tarin@goplay.com To: DoktorMo@aol.com
Dear Dr. Mo, My name is Tarin Broksieck, and I am writing you from Deuel High School in South Dakota. I have researched the topic "harvesting of organs". I have found a lot of information, which helps me to agree with organ harvesting in some circumstances. I believe that doctors and even relatives should not be allowed to decide if a person should donate their organs or receive donated organs. I think that the decision should be left up to the individual. Doctors do not have the right to take anyone's organs without that individual's permission. This is all true, but also, individuals should be encouraged to donate their organs. It is an opportunity to save someone's life or even a few lives. Therefore, I believe that organ harvesting and donating is a positive thing, because it gives people the chance at life. Sincerely,

Tarin Broksieck

Date: Mon, Feb 14, 2000 11:26 PM From: TLageman@aol.com To: DoktorMo@aol.com
Presumed consent, legalized organ harvesting, bottom line is a vehicle for the liberal guardians of society to legalize his or her agendas. There is no medical atheists, healthcare provider, bureaucrat or other modern hodo going to tell me what my obligation to society or my fellow man is or will be. I will make this decision. No, there should not be any law. For the benefit of our liberal readers, I carry a living will which speaks for me when and if I am not able to. It specifically forbids harvesting of any of my body parts, this cannot be overridden by my family or medical institution.

T. Lageman

Date: Sat, Jan 22, 2000 6:11 PM From: Phlsburydoughboy@aol.com To: DoktorMo@aol.com
I think that that it would be ok to harvest patients organs ONLY if there is permission, or if no one is left that could say no...like if the patient was the only one left in his family and he had no friends.

Date: Tue, Oct 5, 1999 6:40 PM From: PaganDenMa@aol.com To: DoktorMo@aol.com
I do not believe in harvesting of organs without permission of the family or without evidence of the deceased being an organ donor (i.e. by driver registration or in their living will, etc.) I work in Transplant Surgery and am well aware of the severe shortages of viable organs for transplant, but I believe that education of potential donors (especially where living donors are a possibility) is vital. Also, I think that providing incentive in the form of death/funeral benefits for an organ donor after harvest is a wonderful idea (I believe Pennsylvania is offering this). I work at the University of Maryland, and we have a highly developed living donor kidney program that is helping to take some of the edge off - but that's only for one organ. And living donor liver transplants are more dangerous - both patients end up in the ICU after the operation. Living donor pancreas transplants (islet cells) are still coming out of the experimental stages. And as for heart and lung - well that's another story. But no, I definitely think the concept of informed consent applies here. No harvesting without consent!

Date: Thu, Sep 9, 1999 4:36 AM From: jmarty@netspace.net.au To: DoktorMo@aol.com
I believe that once you are dead, that you may as well try to help someone else live. What harm is this going to do to the family or to the dead person? You can't tell me that the family are actually going to 'do' something with the person once they are dead?

Regards, Allison

Date: Fri, Jul 9, 1999 8:34 AM From: lifeadvo@spiritone.com To: DoktorMo@aol.com
Presumed Consent, taking organs without the express permission of a person or his family members is a barbarity that society ought to reject. Why do I call it a "barbarity"? Is it because I am anti-organ or tissue donation? That would be too simplistic. I call it barbarism simply because such legislation has the effect of making human persons merely a product or resource of the state's will. The state manages water, forest, and other "resources," and so human beings are just another product to be controlled.

Date: Mon, Jun 21, 1999 9:16 PM From: WAnde10258@aol.com To: DoktorMo@aol.com
I do not believe that the organs should be taken from a dead body without prior permission from the person or their family. I think the key here is education and getting the word out about being a donor. There are many ethical issues that are faced when this issue is brought up. What if that person's religous beliefs conflict with using body parts, etc. Although I would gladly give my organs now (the ones I could spare) or when I am dead, it does not mean that the government should impose on already hurting families, delay barriel and then take organs without permission. This is very wrong. There has got to be another way!!! I also believe that forcing organ donation would create huge problems. What about organs on "the black market", can you imagine what kinds of things would be happening if you needed an organ, found a match and accidently on purpose made it that you would get that organ. Or maybe a family member of yours did that in a desperate attempt to save your life. Things would just get out of hand. It needs to be a choice. Also, I think that if I were awaiting an organ donor, I would want them to be willing to help and not forced.

Date: Wed, Dec 2, 1998 7:41 PM From: Cutie 6852@aol.com To: DoktorMo@aol.com
I think that the if the family or if the deceased person doesn't want them to have their organs they shouldn't touch them. If this new biotechnology that I heard about in the newspaper works(creating whole organs by using one cell) we won't have to worry about this issue hopefully.

morgan

Date: Fri, Nov 20, 1998 1:12 PM From: bogie@anv.net To: DoktorMo@aol.com
While I do believe that organ donation is the most generous sacrifice an individual can make, it just is not working. Look at the numbers-the WAITING list grows but the DONOR list does not increase at the same pace. Educating people is not the answer. We must be realistic and look at the best solution--the SALE of organs! I know it defies all morals and ethics, but it is realistic- ex: John is dying and is offered $--- for his liver. This is money his family could use. Two matching recipients are notified-one has money for the liver and the other does not. The one with the money get the transplant. My point is that John is not a donor and without the sale, both would still be waiting. Now one is saved, the other does not have to compete when a matching donation shows up, and Johns' family receives some funds they would not have otherwise. And no one knows the financial status of Johns' family. Perhaps his death put a tremondous financial hardship on them.

Date: Tue, Jun 30, 1998 7:25 PM From: follisj_98@yahoo.com To: DoktorMo@aol.com
I am a student at the University of Missouri. Regarding your question as to whether or not to retrieve organs from deceased patients without consent, it is my belief that retrieving organs without consent violates the ethical principle of autonomy. People have the right to make choices regarding their own health care. Should we assume that since they are dead that they have given up that right? I think a better alternative is to focus on educating the living to make their wishes known before they die. Don't get me wrong, I am all for donation of tissue and organs, i just believe that informed consent should be obtained first.

Date: Tue, Jun 2, 1998 1:44 PM From: DTRF@aol.com To: DoktorMo@aol.com
Hello. I am a nurse from Florida and hold several certifications and am also a paramedic. I have read the organ donation senerio and personally feel, after harvesting several patients, that one must need permission. I had gotten into some "trouble" after caring for a head injuried victum, young male whom had become brain dead. He was listed as a John Doe and three law enforcment agencies where (so they say) trying to find family. I finally found family on the 11th hour. The patient would have become an organ donor due in fact that in Florida, the organ donation agency can petition the court for organs after three days if the patient's family is not found and the patient remains a "Doe". I am pro organ donation, but not in this matter. If one can choose to abort a fetus, one can certainly choose to donate organs. If the person can not verbalize or otherwise make an informed consent (or family member) then the patient should be left as is. Thank you for your time and have a nice day. Pardon any typing errors sir. I do like your web site and plan on reading it frequently, thank you

Date: Fri, May 15, 1998 9:22 AM From: sheilac@kalama.doe.Hawaii.Edu To: DoktorMo@aol.com
I think it's alright for dead persons organs to be obtained because their dead already. Why not give somebody a better life if your not going to use what they need anymore. It's good to have permission, but sometimes not all people have a chance to give permission. I think you should always do the best for people. If that's what it takes, give it away. Your dead already! ....

I feel that yes they should ask for permission before just taking the organs. Because if you take someones organs without permission thats stealing. They should get arrested for it. Even if their dead it don't matter they should ask permission first.

Date: Mon, Apr 20, 1998 5:47 PM From: nforton@wcnet.org To: DoktorMo@aol.com
It doesn't matter if you have given permission while you are alive if your family disputes the issue they won't harvest.

nforton@wcnet.org

Date: Thu, Apr 2, 1998 4:13 PM From: et1cindy@epix.net To: DoktorMo@aol.com
No, organs should not be take without prior premission from the patient or family. What would keep a persons wishes to be inturned intact? I do believe that more people need to be made aware of the benifits of donating but we (society) need also be made aware of who pays what costs. Why should the recipient be charge large sums of money for organs that were dontated. Why should the family be charged for the removal of the organs. Money talks.... I think more could be done with this issue.

Date: Wed, Mar 18, 1998 3:30 PM From: jjordan@preferred.com To: DoktorMo@aol.com
I believe that organ donation is very important. It helps many people. When you die you have no use for your organs so why not help someone who aren't as fortunate. Many people believe that it is wrong for religious reasons and that is their opinion . I am not the one to judge whether or not it is right or wrong. The only thing I know is that a person I knew died and his eyes were used to help some young teenage boy to see. I think that is wonderful. Someone who was deprived of never seeing the beautiful world and all it colors, now can. What a wonderful gift to be able to give someone! I just thought that I would share that experience with you.

Jessica Hendrickson

Date: Wed, Mar 18, 1998 7:44 AM From: rabdalla@ehc.edu To: DoktorMo@aol.com
Anybody have to have freedom to decide. The Government should create new law to encourage and not to enforce organ donation. First of all they should look more to the illegal market, which makes people to not donate.

Regis Abdallah, Emory & Henry College, PO Box 677, E-mail: rabdalla@ehc.edu

Date: Tue, Nov 25, 1997 2:00 PM From: cgouthro@prodigy.net To: DoktorMo@aol.com
I don't think it is right for anyone to take anything that belongs to anyone else without their permission, in any case. Especially a case in which human life is involved. The whole point of becoming an organ donor and having an organ donor card is so that doctor's and family members will know what you want ahead of time. If a person dies without having a card or being a donor, they obviously don't want to be a donor and would not consent to donating their organs, even if they were alive. The main reason why there aren't enough organs to be transplanted is because people are afraid that if they are terminally ill, a doctor might figure that there is a shortage on organs, so they'll just let the patient die so they can use their organs. There is also the factor of informed consent. Even though the person is dead, does this mean that they are fair game for transplants? Because there is no prior permission given to the doctors, laws should not be passed that would allow organ harvesting.

Date: Tue, Nov 11, 1997 12:38 PM From: cpeters@ldgo.columbia.edu To: DoktorMo@aol.com
I have what I think is a separate question related to the havesting of organs without permission. What happens to the placenta after birth? The tissue is the property of the mother, but I've heard that many OBS sell the tissue to researchers without consent.

Craig Peters (cpeters@ldeo.columbia.edu), voice: (914) 365-8826 fax: (914) 365-8150, Lamont-Doherty Earth Observatory, http://www.ldeo.columbia.edu/~cpeters

Date: Sat, Jul 26, 1997 1:35 PM From: DocReading@sprintmail.com (William H. Reading, MD) To: DoktorMo@aol.com
There should be no involuntary harvesting of human tissue. The principle of autonomy should govern. Allowing harvesting of tissue without permission does not allow the individual to keep dignity. Education of the public is necessary along with some expansion of harvesting to people who will die within hours granted that permission is obtained.

Date: Fri, Jun 13, 1997 9:12 PM From: jtpapworth@msn.com (John Papworth) To: DoktorMo@aol.com
Doktormo, I think that this law you mentioned is great. Personally I would not mind if some one took one or all of my organs to save a persons life. Its almost heroic Giving your self to others, the gift of life. It's only ok if the person(s) are no longer in need of them ie dead or dying. I'm no doctor or college student with some fancy Ph.D. in medicine or something, just a kid studying Bio. Well that's all I've got to say.

Date: Fri, Apr 11, 1997 9:01 AM From: rbyrd@REX.RE.uokhsc.edu (Robert H. Byrd) To: DoktorMo@aol.com
I think that in order to really consider this issue one needs to bring up the concept of "ownership" of our bodies. Without getting into any religious discussion of this subject, what does a family stand to gain by preserving the integrity of a loved one's body after they are dead? Whether a body is cremated or buried, the remains will eventually be returned to the earth, and how many of us go around looking at the dead bodies of our loved ones? Given the great deal of respect that donor bodies are treated with and the care that is taken to preserve as much bodily integrity as possible after harvesting (e.g. use of wooden prostheses, etc.), how much of a sacrifice is it really to allow the body of a loved one to be harvested for the immeasurable benefit of numerous other human beings? I think that if we as a society are even to consider the thought of using donated organs for needy recipients, then we must be willing to realize that the human respect, loving memories, and decent treatment of our loved ones is of utmost importance to those that harvest organs, and little is lost when we allow the more material and much less meaningful eyes, bone marrow, etc. to be respectfully removed from a body that we most likely will never see again - with the full intent of benefitting a large number of very ill persons. With the principle of beneficence in mind, refusal of families to "allow" their loved ones' organs to be removed, when, as stated above, the ratio of need is so ill-balanced, almost seems selfish. However, I do think that there will need to be great strides taken in medical ethics before we can allow the medical community to automatically "claim" organs from every potential donor.

Date: Wed, Apr 9, 1997 1:55 PM From: ANDJEFF@aol.com To: DoktorMo@aol.com
I do not agree with harvesting organs without consent. I believe that everyone has a right to decide what happens to their body not only when they are alive but also when they are dead. I think instead of passing laws not requiring consent we need to concentrate on informing people of their options. Perhaps its not a lack of "common sense" but a lack of information.

Andrea, University of Oklahoma College of Nursing

Date: Mon, Apr 7, 1997 4:06 PM From: LBC7773@aol.com To: DoktorMo@aol.com
I feel that organ donation is a wonderful thing that saves thousands of lives and fully intend on donating my own. However, although we are in need of more organ donation, I feel it is infringing upon the rights of the individual, dead or alive, to harvest his or her organs without consent. There are many reasons people choose not to donate, religious or otherwise, and we should honor that choice.

Date: Fri, Mar 28, 1997 7:16 PM From: Danny_Audet@UQTR.UQuebec.CA (Danny Audet) To: DoktorMo@aol.com
Yes. One argument: If a person dies and wanted to be buried, it would be logical to take organs from the body: otherwise, it would be a waste and a mistake; that would legitimate risking the life of an individual for a few more days.... About family members who are against this idea, they simply don't have sufficient common sense.

Date: Fri, Mar 21, 1997 11:31 AM From: BSNRN2B@aol.com To: DoktorMo@aol.com
I feel that the decision to donate my organs is completely up me, not my family or anyone else. This is something I want done because I know it can improve the lives of others after I have died. However, my family does not approve of this. There should be something implented similar to an advanced directive that allows for consent of donation, because once I die my family has the final decision to donate my organs. They do not have to follow through with my wishes if this is what they want. I do not believe there should be a law passed that allows for harvesting without permission because not everyone agrees with this action and that is there right and choice.

Emily

University of Oklahoma College of Nursing

Date: Thu, Mar 20, 1997 8:32 AM From: efought@fdldotnet.com (Eric S. Fought) To: DoktorMo@aol.com
What ever happened to the rights of the patient? I understand the increasing need for the harvesting of organs...however that need should exceed the right of the individual to govern his/her own body. Some people, for various reasons, religious and otherwise feel strongly about keeping their body intact. We need to respect that. Many people don't understand how to go about donating their organs at death. We need to market the possibilities better. And maybe, as someone else mentioned earlier, we could turn the tables, having those who don't want to donate sign the back of their drivers license. However, just going in and taking what you need is unethical and should not be explored further.

Date: Tue, Mar 18, 1997 6:12 PM From: joders@juno.com (Jodie L Ludwig) To: DoktorMo@aol.com
I was reading comments regarding passing laws allowing the harvesting of organs without prior permission from the patient or family members. I feel that the passing of laws is taking the situation a little to far. I can understand the need or desire to harvest organs from a patient who has indicated the desire to donate on a driver's license, but harvesting without consent from the family would be wrong. Even though it is my wish to donate my organs if the situation arose, I would want my family to be consulted. I would want them to feel good about the decision because they are the ones who will live with the decision, not me. Some family members don't like the idea of their loved one 'dismembered' or 'mutilated' after death and these feelings must be taken into account. If the patient did not have family and every attempt was made to locate them, it may be different, but we should not harvest organs without making the attempt and getting consent. This is not a situation that should be handled by law makers. The way to alleviate the organ shortage is to educate the public about organ donation and educate people about talking to their family before the situation arises and letting their desires be made known to family members.

Jodie

University of Oklahoma College of Nursing joders@juno.com

Date: Fri, Mar 14, 1997 9:54 PM From: Boo1175@aol.com To: DoktorMo@aol.com
I have three points to make: 1) In making advanced directives, we are generally capable of effective deliberation (i.e., we are guided by reason, unhindered by emotion, and not coerced by others) which is in great contrast to a state of terminal illness, trauma, etc. 2) In answering the proposed question, maybe we should ask, "What is the ethical basis for the value given to autonomy?" 3) If you plan to donate your organs/body after passing on, it is important to be aware that signing the back on your drivers license is often not suffcient--family members need to be aware of your wishes.

Date: Wed, Mar 12, 1997 12:19 PM From: wweil@innovgrp.com (Bill Weil) To: DoktorMo@aol.com
Since, in most areas of this planet, money talks, why don't we pay people to register as organ donors and incent them in this fashion? While I happily am donating mine, and hopefully not too soon, I imagine there are lots of people in dire need of money that, if asked, would be glad to get some cash while their alive in exchange for having their dead body be of use to others still living.

Forcing people to do this ain't gonna work. Too many people feel too strongly. If you want to spend your time and energy making a difference, don't argue with millions of people that are not going to change their minds; rather, figure out how to reach out to the millions on the fence, whom, with a decent campaign, could easily be swayed into donating their organs.

I also like the idea of "If you didn't have a card that said you object, you're in", but this will need to be reconciled with family members. If my 22 year old son dies, and didn't have a card, and I'm of the ilk that abhors the idea of organ donation, I'm going to put up a hell of a fight. Let's figure out how to accommodate this group as well.

Date: Tue, Mar 11, 1997 6:46 AM From: Rich 1945@aol.com To: DoktorMo@aol.com
Yes, as an individual working in a compassionate field of health care, I feel that any chance to give another human being the gift of life is a wonderful thing. Presumed consent takes this concept of choice away from each and every individual concerned. Brokering of harvested organs also takes away from a gift of love of human beings and adds a tone of mercenary taking of a person's loved one. As a health care professional I feel strongly that the emphasis needs to be on increasing the medical and general public on the reasons that organ donations have almost been cut in half over the past five years.

Date: Wed, Jan 29, 1997 8:23 AM From: jpieniadz@mindspring.com (John Pieniadz) To: DoktorMo@aol.com
no we should not allow that to happen. what we should do however is to start brokering organs.......a patient knows that they are dying and have a designated time left here on earth...we offer to buy the organs, this gives them a few hundred or thousand dollars to leave to their heirs or spend for the last fling....meanwhile we have a contract for the disposition of their organs which we can sell to the highest bidders....yes this sounds real morbid however when people are on their last leg they are willing to buy, even if it is a chance....we could even start selling organ insurance. morbid but almost reality.

Date: Tue, Jan 14, 1997 5:29 PM From: MMORITI1@ic3.ithaca.edu To: DoktorMo@aol.com
Yes, Presumed consent laws should be enacted in the United States. Such a law should have opting out arrangements for those with religous or moral objections. This kind of automatic system would save time and save lives. Better methods of publicizing the need for donors need to be developed.

What can be done to lower the transplant organ need in poorer countries? What can be done to ensure that everyone has equal access to newly available organs? It is know that in the U.S. money and/or publicity has enabled some people to have an advantage over others? Is this right? Isn't the right to health care a basic human right?

Michele Moritis MMORITI1@ic3.ithaca.edu

Date: Fri, Nov 22, 1996 3:15 PM EDT From: gwest@emc.org To: DoktorMo@aol.com
I would like to see a law of "implied consent" that states that, unless a person has signed a form (driver's license, etc) against donating their organs, it is implied that they are willing to donate at their death.

Date: Thu, Nov 21, 1996 5:39 AM EDT From: prenella@uci.edu To: DoktorMo@aol.com
I believe that legislation concerning post-mortem organ harvesting should be enacted. Each donor would truly be doing a great service to society and it's sick. Best of all, it would greatly reduce the need for specific guidelines about who is to get which organ first. Furthermore, with more donors comes a higher probability that each potential recipient will find a good match. Clearly, this would serve the most amount of organ recipients, with no additional burden on society.

Date: Wed, Nov 6, 1996 12:14 AM EDT From: starfleet@taconic.net To: DoktorMo@aol.com
I do think that after death, all usable organs should be harvested and distributed accordingly, however, if the family objected on religious or moral grounds, then that should be respected. I agree with the person who said that education could go along way in increasing the number of voluntary donations of organs, and then we would not have to be debating whether or not it is acceptable to just take them.

Date: Mon, Oct 28, 1996 7:34 PM EDT From: ctetmi@mchmeds.mchis.mcgill.ca To: DoktorMo@aol.com

Yes, I believe organs should be harvested everytime it is possible in order to benefit patients waiting for a transplant.

Date: Tue, Oct 15, 1996 8:15 PM EDT From: bkbf@worldnet.att.net To: DoktorMo@aol.com
Perhaps because of being raised in the USA, a "free" country I have a problem with taking organs from the deceased without the previous consent of family or self. I work in a dialysis unit and see the suffering and misery caused by lack of kidneys for transplantation. I myself have instructed my family that whatever usable organs/tissue left upon my death should be donated to whomever and the remains of my organic shell should be creamated, what was really "me" vacated this life with my last breath. They for the most part feel the same way.

If we as a nation would commit the financial resources to educating the people about this issue I don't believe we would need to pass laws to TAKE the organs. I feel that the organs would be given freely once people were educated. This may include pressing the individuals with organ failure into some community service hours. Exposure to people with organ failure may be the best form of education we could have. These are just 1 persons thoughts and feelings.

Thinking About Copenhagen, Climate Change, Catastrophes, Human Cloning and a Simple Life

I think that people who are promoting cloning are just afraid of dying… If there is nothing that can be done to save you from death, accept it, no one was meant to live forever… keep dreaming guys, we all have to die some day… The earlier one dies the better. That way that person will no longer have to face the harsh environment that we ourselves have created (note, the type of death I am referring to is not through suicide, there are better solutions to our problems that’s all).


As for the future generation, the tasks of living a better life is not within cloning, but let’s go back to the environment for a while? How many diseases have we accumulated within the last hundred years just because of Industrialization, Bio Hazardous activities, and others? Do you think cancer developed naturally? How much has the population of obese people grown just because of the way we process the food we take in or because of the un-satisfaction these people have? How many strains of each different virus are present today? Do you think that these things would have taken place if the human beings were just satisfied with the simple things in life?

Well that’s human nature for us. WE ARE JUST PLAIN UNSATISFIED with everything that was provided to supplement our daily lives.

The real solution in my opinion, we should look back to where we have started: NATURE.

The unsatisfactory conclusion which came out of the Copenhagen Summit Conference on climate change today makes this e-mail I just received from a visitor about human cloning and living a better life even more meaningful and significant. If it is true that there is global warming that will soon negatively impact the lives of everyone living on this earth and if it is true that the cause of the warming is related to activities by those of us living on this earth then maybe we should all look to ways to live a more simpler life and work to preserve the nature into which we were born. Is this realistic or is my visitor too pessimistic? Let me know. ..Maurice.

Stranglehold in the Name of Ethics

As the vine entwines and creates a stranglehold on the tree, should ethics be used by some not simply as a means to sort out what is a good practice and what is not good but used, in the name of ethics, to entwine and inhibit rational development and progress?


In the world of commerce and business, if the management finds that certain actions by employees do not meet set standards of ethical practice, the employees may be told their actions are “unethical”. But how are these standards set, by whom and for what purpose? And what comprises an ethical standard? And for whom should these standards benefit: the management, the employees or the public or others who trade and an engage in business with the companies? Can standards defined as “ethical” actually lead to a stranglehold on development and progress?


The same might be asked when discussing the establishment of ethical practices in science and medicine. If one group sets certain actions as “unethical” and inhibits progress with benefit to all by disallowing such actions, is that really “a good”? Such an example of such a reaction by a group might be President G.W. Bush preventing federal funding for further development and use of embryonic stem cells all in the name of a moral concept, an action reversed by the current Obama administration who apparently looked at the ethical decision of Bush in a different way.


The question is whether all ethics, all morality when acted upon in the name of “ethics” can represent a “good”. If one says, “I want it done this way because this way is ethical” is that all that needs to be said? Should all ethical decisions be first researched and tested out to be sure that they are truly good for the greatest number of stakeholders, enhancing life and not strangling, before the word “ethical” is attached to that decision? What do you think? ..Maurice.

Graphic: Photograph of a tree and an entwined vine taken by me 12-16-09 in O’Melveny Park, Los Angeles County, California.

Suicide: Views of Christianity and Islam

On November 1 2009, I created a thread "The Muslim Faith and Ethical Issues: Questions to My Muslim Visitors" A student wrote to me the following comment about suicide, comparing Christianity and Islam. I thought the topic was worthy for a separate thread for specific discussion about suicide from the religious perspective. Can any of my visitors comment further about what the student wrote? ..Maurice.

The world religions of Christianity and Islam have many common themes. For example, both faiths believe: in a monotheistic deity, to have divinely inspired scriptures, in the sanctity or dignity of human life and that ‘gift’ of human life should be preserved, in the notion of eternal life and the ‘Day of Judgement,’ and that God is the owner of all life and has pre-determined the time of birth, life and death. These shared ideas can help to formulate Christian or Islamic perspectives for and against ‘active’ forms of euthanasia and physician-assisted suicide.


Religious opponents may view euthanasia as a form of suicide, as a way of interfering with the divinely appointed time of death (e.g. ‘Playing God’), as a way of destroying the sanctity of human life, and as a way of possibly incurring divine punishment. For example, a Christian opponent of euthanasia may cite the Biblical commandment of ‘You shall not kill,’ the idea of respecting the dignity of human life and the pre-destined moment of death, and enduring suffering as arguments against euthanasia. Similarly, a Muslim opponent may refer to: the Quranic verse 4:29 which states, ‘Do not kill yourselves, surely God is merciful to you,’ the Prophet Muhammad’s (pbuh) viewpoint of not desiring one’s own death, the traditional notion of caring for or respecting older persons, and submitting to the divinely appointed time of death. Since similar arguments can be developed from different faith or traditional backgrounds, it is possible that a Christian principle against euthanasia may appeal to a Muslim or vice versa.


On the other hand, some proponents of euthanasia may also formulate their arguments based on religiously based principles. For example a Christian or Muslim supporter of euthanasia may use the concepts of mercy and compassion to intentionally hasten death in a terminal disease or extreme pain to relieve pain and suffering and not be a burden on others. In addition, some proponents have cited deterioration in quality of life, the thought of God’s unwillingness to make one suffer, the notion of treating human life as one wishes since it is considered a ‘gift,’ autonomy to make one’s own decisions (e.g. ‘Right to Die’), and preserving respect for the dignity of human life as further reasons for euthanasia in terminal or extreme cases. Another religious argument for intentionally hastening death blurs the line between martyrdom and suicide and questions individual intention since some have argued that aiming at death is justified in order to reach paradise ‘faster.’

Graphic: Artistic composition by George Grie 2007 and contributed to Wikipedia and subsequently minimally modified by me using Picasa3 and displayed on this blog under Fair Use provision.

WHAT DO YOU THINK ABOUT ETHICS, BIOETHICS, MEDICAL ETHICS, ETHICISTS AND HOSPITAL ETHICS COMMITTEES?

As of this date, this blog has been up for 5 1/2 years and contains over 750 threads on ethical issues. And you, the visitor, may have been to this blog previously or this may be the first time that you came. Why did you come in the first place? Was it to learn about bioethics in general or specifically to follow up on some topic which interested or challenged you? And what do you know and understand and think about ethics, bioethics, medical ethics, ethicists and hospital ethics committees?

Do we need ethics when most countries have laws which may trump any consensus of the society as to what is ethical and what is not? Anyway, if we do have ethics and some moral consensus in certain areas, who really are the ones to set those moral boundaries? Is the people or should it be the philosophers or other professionals or even those who call themselves ethicists? And who are ethicists and what do they do or what are they supposed to be doing? What makes it our responsibility to make sure that we stay within those boundaries? Have you heard about ethical issues in medicine? what do you think about them? Do you think that those working in the medical profession are ethical? And has anyone ever talked to you about hospital ethics committees and what they do and what they do not do. Do you believe that hospital ethics committees are the "death panels" that are frequently talked about these days? Do you think that ethics is too much about death and dying and not about living a good life? Can you have a good life and still be ethical?

Many questions and there are many more, but I would most appreciate knowing what you think and asking me what you would like to know. I'll try to explain what I know. ..Maurice.

Patient Modesty: Volume 29

The issue of patient physical modesty continues and currently there is discussion of the role of spouses or intimate mates in the active support or reaction to their opposites' personal experiences with regard to possible nudity or genital exams or procedures carried out by healthcare providers, perhaps of either gender. In other words, to what extent should spouses or the others react? Should sex in marriage or other intimate relationship be disrupted or ended if their opposite was examined or had a procedure performed? How is consideration of this concern related to the overall issue of providing an opportunity for patients to make gender selection in healthcare providers to ease patient's modesty issues? As we begin Volume 29, continue writing on this and the general topic of patient modesty. ..Maurice.

Graphic: Postcard:“Don't Be Afraid” - Man and woman in bathing suits with bathing machine, c. 1910 from Wikipedia and modified by me with Picasa3.

ADDENDUM 1-3-2010: CONTRIBUTORS TO THESE PATIENT MODESTY THREADS HAVE AN OPPORTUNITY TO EXPRESS THEIR MODESTY CONCERNS TO A BROADER AND MORE SIGNIFICANT AUDIENCE THAN SIMPLY AND ONLY WRITING COMMENTS HERE. THE ONLINE PUBLICATION HOSPITAL.COM HAS OFFERED TO CONTINUE THIS DISCUSSION ON THEIR PUBLICATION. WITH A GREATER AND MULTI-DISCIPLINE MEDICAL SYSTEM AUDIENCE THEIR PARTICIPATION WILL BE A VALUABLE CONTRIBUTION TO THE BROADCASTING OF THE CONCERNS BEING EXPRESSED HERE. ..Maurice.


NOTICE: AS OF TODAY JANUARY 9, 2010 "PATIENT MODESTY: VOLUME 29 WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 30

"Manufactured Babies": Who are the Parents?

An excerpt from the December 13 2009 issue of the New York Times "Uncertain Laws on Surrogates Leave Custody at Issue" by Stephanie Saul (Free registration may be necessary to access the article)

Unable to have a baby of her own, Amy Kehoe became her own general contractor to manufacture one. For Ms. Kehoe and her husband, Scott, the idea seemed like their best hope after years of infertility.
Working mostly over the Internet, Ms. Kehoe handpicked the egg donor, a pre-med student at the University of Michigan. From the Web site of California Cryobank, she chose the anonymous sperm donor, an athletic man with a 4.0 high school grade-point average.
On another Web site, surromomsonline.com, Ms. Kehoe found a gestational carrier who would deliver her baby.
Finally, she hired the fertility clinic, IVF Michigan, which put together her creation last December.

That was just the beginning. The birth of two children was not the end of the story since it turned out that the woman into whom the embryo was implanted and who carried twin fetuses to term shortly discovered that Amy had a mental illness and through the courts obtained custody of the children.

Read the whole story and the revelation that there are no consistent laws regarding “manufactured babies” nor even the adoption process itself for those children who were “manufactured” or not. What criteria would you suggest be incorporated into law and would be also ethical in the determination of “who are the parents”? ..Maurice.

Infant Male Circumcision: Chapter 3

If patient modesty is not enough of a "hot button issue" on this blog, certainly in the past history of my blog the topic of infant male circumcision had drawn a lot of attention but as the number of comments grew on the first thread, the blogger.com program seemed to fail to continue publishing any additional comments. So about 3 years ago, I started a second thread on the topic and that grew to about 60 or so comments. Now for the first time in the past 3 years, there seems to be some interest to continue the discussion with the following 2 postings. I decided to start a current version of the topic with this Chapter 3 thread. Those who want to write on the topic of infant male circumcision should write here. The previous threads are no longer accepting postings. But read them first and if you write, try to present new aspects of the issue that were not presented previously or where new information is available.

The first new posting is from FredR 12-7-2009:

Many people are taught to believe in the living creator of all life, also known as Yahway and Jehova for the Jews and the Christians, Allah for the Islamics, The Heavenly Father, and now the Supreme Singularity for the scientific evolutionists, astronomists, geologists, and biologists. It is illogical to assume that the original Singularity is still in exsistanse, therefore we now have Atheists.
We know that many myths are created out of fear of the unknown, but when factual, logical, scientific data is presented properly these myths can be dispelled. Fear can cause PTSD and prevent new knowledge from being accepted.
What we know about creation for sure is this. In asexual reproduction, one life form that can replicate or reproduce variations of itself, or evolve, or mutate is necessary. In sexual reproduction, this one feminine life form that can reproduce is essential, but the evolution part is provided by the variations of the masculine sex. No known masculine life forms can reproduce without being part feminine in the first place. Therefore it is illogical to presume that the original Creator/Singularity was masculine and is an insult, even blasphemy, to our inteleigence.
So the BIG QUESTION now is, DID this feminine singularity actually speak to Abraham and tell him to cut off his own prepuce and all his male decendance so they can be His chosen race? The logical answer is NO, She did not, would not, and could not say or speak to any one, ever, anywhere. PTSD's and Fear of the unknown, or superstitions prevents people from accepting, or causes denial of this logical fact.
There are known causes of urinary tract infection. In infancy the common causes of UTI in both male and female, is poop from dirty diapers introduces into the uritha, because diapers are unnatural.Infant UTI's are also caused from sexual molestions/surgical woundings. For grown people, UTI's can be caused from drinking bad waters,having sex with animals, anal sex and not cleancing your sex organs before and after sex. UTI's in the elderly are commonly caused from dirty diapers again when we begin to loose control of our bowls with age.
Some UTI's can be deadly, while others can be treated. Left undiagnosed and untreated the toxins build up in our blood and can cause delirium and delusional thoughts with audio and visual halusination.
Abraham, Jesus, and Mohammad all showed signs of PTSD's and UTI's in there lives. Abe and Moe both cut their own prepuce off where as Jesus' prepuce was cut off by the sacrificial law of Abraham's Covenant with his delusional god. PTSD's can also lead to delusional thoughts. The logical conclusion as to why these men thought that the Singularity spoke to them was that Abe and Moe were suffering from untreated UTI's,which most likely left Abe sterile,too, While Jesus suffered the symptoms of PTSD from being sexually mutilated,traumatised, terrorized by the law, as an infant.
While there is lots of denial of the evolved functions of the masculine and feminine prepuce, people whose parents were able to raise there children with healthy prepuces, and people whose parents did not cut all of their childrens prepuce off, will agree that masturbating or playing with the prepuce brings great pleasure.
To avoid causing your children to have their prepuce excised for any reason, knowledge should be shared.


The second was from Bella 12-8-2009

There are many reasons why a man choose to be circumcised. One of them is health. I hope there is someone who can find a new comfort and painless circumcision to be done.

I'll be looking forward toward further discussions. ..Maurice.

Graphic: Photograph Scène de la fr:circoncision de fr:Jésus. fr:Cathédrale de Chartres; source: Wikipedia and modified by me using Picasa3.

Patient Modesty: Volume 28

We continue on with a discussion about physicians, nurses and others in the healthcare system ignoring some patients’ modesty concerns and the need for a gender selection option offered to patients who wish to have their say in who examines and treats them. ..Maurice.

Graphic: Photograph from the Faculty of Nursing Science, Assumption University of Thailand and modified by me with Picasa3. If this was a real man and not a manikin in the photograph, some visitors to these Patient Modesty threads would find such a gathering rather disturbing.

NOTICE: AS OF TODAY DECEMBER 13, 2009 "PATIENT MODESTY: VOLUME 28 WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 29.

Doctors and Nurses and the Problem of Their Disruptive Behavior

One group of nurses banded together to try to get a physician unfairly disciplined, while another encouraged fellow nurses to disobey doctors' orders outright. A surgeon told his staff that monkeys could be trained to do what scrub nurses do, while another doctor told a patient that the nurse in the room didn't know what she was doing.
A nurse witnessed the onset of complications in an intensive care patient but refused to contact the on-call physician for fear of his temper -- a delay at least one observer thought contributed to the patient's death.

This excerpt is from November 16, 2009 American Medical Association News, amednews.com




The article is all about what is happening now in hospitals, clinics and other healthcare facilities around the United States. It is all about disruptive and intimidating behavior of physicians and nurses which has been going on for years but now, starting about a year ago, the Joint Commission which certifies hospitals and other institutions for government reimbursement in the interest of patient safety declared that these institutions must present evidence of “zero-tolerance” for these unprofessional behaviors which potentially can impact negatively on the care and safety of the patients. However, there still is a lot still missing in institutional and personal compliance to the Joint Commission’s order.

A 2009 study of behaviors "Bad Blood: Doctor-Nurse Behavior Problems Impact Patient Care," American College of Physician Executives 2009 Doctor-Nurse Behavior Survey,Physician Executive Journal, November/December showed the following:degrading comments and insults comprised 84.5% of the behaviors followed by yelling 73.3%,cursing 49.4%, inappropriate joking 45.5%, refusing to work with colleague 38.4%, refusing to speak to colleague 34.3%, trying to get someone unjustly disciplined 32.3%, throwing objects 18.9%, trying to get someone unjustly fired 18.6%, spreading malicious rumors 17.1%, sexual harassment 13.4%, physical assault 2.8% and others 10%.


However, what is happening is that there seems to be a difficulty in separating disruptive speech and actions from honest attempts in certain situations to protect patients and to disclose to hospital administration of weaknesses in the hospital’s healthcare system or in the harmful behavior of certain physicians or nurses—that is, “whistle blowing”. Unfortunately, these actions may be considered disruptive, not constructive and behavior which must be suppressed to keep to the Joint Commission’s rule and it is the “whistle blower” who is accused of being disruptive. Further, staff may be reluctant to report on behavior of superiors or other colleagues in fear for personal repercussions.


Obviously, much more has to be done besides hospitals simply writing a policy about these matters. Read the full article and the linked references there and return and give your opinion about the issue and any disruptive behavior you have witnessed, but please give no names. ..Maurice.

Graphic: Photograph, taken by me, of a painting ("Self-portrait, Yawning, Joseph H. Ducreux, 1783 from the Getty Museum, Los Angeles)but modified with Picasa3. Basis for selection of this graphic for this thread: Somehow, the painting looked to me like a disruptive yelling rather than a benign yawn. What do you think?

Violation of the Patient’s Autonomy?: Is that Ethical?

Patient autonomy is the ethical principle which represents that a patient who has the capacity to understand their medical condition and the risks and benefits of some action upon them, has the ethical right, under most circumstances, to make that decision for themselves and expect the physician to abide with their request.


But that is “under most circumstances”. I want to present two scenarios where a patient has stated “stop! I don’t want…” The question I pose to my visitors is whether a physician can ignore that request in each of the scenarios and if so why or why not should the patient’s request be followed or not followed. When do standards of medical practice trump a patient’s request? Standards of medical or surgical practice are specific behaviors, based on scientific literature but also based on the consensus of physicians about certain diagnostic or therapeutic actions and also on common behaviors or actions of doctors where they practice and which the profession of medicine place upon physicians as the physicians carries out their care of their patients. In this regard, if there is a difference between the two cases, what is the difference? ..Maurice.


Scenario 1:
Brain surgery of lesions is often performed on conscious patients to establish safe dissection around motor and sensory areas. A patient with skull opened and brain exposed demanded the surgeon to stop the operation at once despite understanding the consequences of fully terminating the surgery at this point and leaving the skull open. Instead of stopping, the surgeon had the patient anesthetized to allow proper closure of the skull thus was violating the patient's demand. Is what the surgeon did ethical?


Scenario 2:
An adult Jehovah’s Witness patient because of acute massive bleeding which cannot be rapidly stopped requires life saving blood transfusion but is awake and refuses blood transfusions based on the patient’s religion. The patient is informed that with the transfusion, the patient will live and the underlying bleeding problem can be resolved with no long term medical consequences. Without the transfusion, the patient could most likely die. The patient still refuses but the physician, as the patient is beginning to lose consciousness, violates the patient’s autonomous demand and begins the blood transfusions. Is what the physician did ethical?

Patient Modesty: Volume 27

Yes, throughout these threads on patient modesty, it does appear that often what is missing and what should be corrected is the lack of communication on this issue both on the part of the patient but also on the part of the various healthcare providers, clinics and hospitals. It may be that many of both parties display modesty in communication by not speaking out or asking out about modesty. Hopefully, this issue of modesty in communication can be eliminated on both sides and that the concerns of patients in physical modesty can be resolved.

Continue writing.. ..Maurice.

Graphic: A photograph taken by myself at a local clinic and modified with Picasa3.

NOTICE: AS OF TODAY NOVEMBER 28, 2009 "PATIENT MODESTY: VOLUME 27" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 28.

A Medical Student’s Anatomic Gift: There is More Involved than Dissection

From a medical student to the student’s group human cadaver:


“You are an exponential gift, from one man to eight future doctors to hundreds of patients to the multitudes that make up their family and friends ... You gave us access to the wonder that is human life and challenged us to discover all the intricate parts working together to make one man.”


To read the whole story of the Boston University School of Medicine’s anatomical gift program and its manager and anatomy lab director, Robert Bouchie, go to this link. There you will find a find a fine video about the program but importantly read about the ethics and consideration given to the donated bodies but also to the deceased person’s family. Very inspiring. Do you want to donate your body to a medical school like Boston U.? ..Maurice.

The Elderly and the Four Ethical Principles

With more and more people living longer, attributed to various factors including advances in medical treatments, there are more and more elderly now present in the population.

But, first, what is the definition of an older person or the elderly? One definition included in a World Health Organization online document regarding the elderly and old age is by M. Gorman: "The ageing process is of course a biological reality which has its own dynamic, largely beyond human control. However, it is also subject to the constructions by which each society makes sense of old age. In the developed world, chronological time plays a paramount role. The age of 60 or 65, roughly equivalent to retirement ages in most developed countries, is said to be the beginning of old age. In many parts of the developing world, chronological time has little or no importance in the meaning of old age. Other socially constructed meanings of age are more significant such as the roles assigned to older people; in some cases it is the loss of roles accompanying physical decline which is significant in defining old age. Thus, in contrast to the chronological milestones which mark life stages in the developed world, old age in many developing countries is seen to begin at the point when active contribution is no longer possible."


There are the four ethical principles which should be considered and which can apply to the medical care of the elderly. The principles are beneficence, non-maleficence, autonomy and justice. How can they apply? I think that others might give different examples, however the following are the ones that come to my mind presently.


Beneficence is the principle “to do good”. Non-maleficence is the principle “to do no harm”. We, as physicians, are required, as part of our profession, to adhere to these two principles as we proceed in the care of our patients. The question arises as to whether at some point in the life cycle, what these two principles mean in practice is different between the elderly and those who are younger. And then who is to characterize the actions: the doctor, the patient, the profession or society?


For example, is there a point in the care of an elderly patient who has symptomatic cancer where administration of classic or novel cancer chemotherapy with its significant side-effects might no longer be considered a beneficent act but actually a harmful act? Would this point be considered as readily in a patient who is significantly younger? Would the use of a cancer drug in an elderly patient, which by statistics would only prolong the patient’s life by a few months but with continued suffering from the underlying disease be considered a non-beneficent act on the part of the physician? Would the consideration that a new drug might come out during that extra time of life that would be more effective rationalize the current management? Would this issue be the same in a patient who was considerably younger? Should the decision as to whether a treatment represents a “good” or a “not good” be one of the physician based on knowledge and experience or should such decisions be left only to the patient who is the one who has the burdens of the illness, the symptoms, the costs and the effects on the patient’s ways of life and goals?


The third principle, the principle of autonomy, the right of the patients to speak for themselves as to how they want their illnesses to be treated, plays a important role in how beneficence and non-maleficence is judged. As one grows older, some patients may lose their capacity to make their own medical decisions and, without an Advance Directive or legal surrogate to help, the bearing of responsibility for defining the physician’s actions as beneficent and non-maleficent or “wanted” vs “unwanted” in terms of the patient’s own desires may be placed more on the physician’s shoulders or others. Is the principle of autonomy just as valid an ethical principle in the elderly as in the younger patient?


And finally, comes the principle of justice. One reads about the tremendous amount of money spent on disease management within the United States just during the last months of a person’s life. Is that fair? is that spending a fair act to other patients who are sick but have the potential of many more years of life ahead and where the money might be put to use which is more constructive to society? Isn’t the issue of justice most pertinent about the medical care which is given to the elderly? Or is bedside rationing against the elderly an unethical and abhorrent concept?


Many, many questions and mostly about whether the elderly should have the four ethical principles applied differently than to those who are younger . However, I look to my visitors for the answers. ..Maurice.

Graphic: Photograph of the elderly walking in a city park in Southern California by me 11-4-2009.

The Hospital Ethics Committee: Was it of Help?: Tell Your Story

I have been the chair person of two hospital ethics committees over the past 23 years and my current committee continues to do its assigned job. The role of the committee includes being the educator, being the facilitator, being the mediator when an ethical issue appears as a patient is being treated and one or more stakeholders in the issue request help from our committee. We sort out the issues and explain to the stakeholders the possible ethical and legal courses but we don’t make the final decisions. We, as members, hope that our education, facilitation and mediation has been beneficial to all those who look to us for help and, of course, particularly the patient.


In my own experience, the grades of our performance as given to us by the stakeholders have been good. It does seem that our committee fills a need. But that is only by my personal experience. In all these over 700 threads on ethics, I have never asked my visitors about their experiences with hospital ethics committees. I strongly suspect that most of the patients and their families who have had a hospital experience never had any interaction with that hospital’s ethics committee. In fact, there may be many visitors here who didn’t even know that there was such a resource available in your hospital.


But to those who do know and had the experience, usually as a family member of the sick patient or even that of the patient, I would be interested to read about that experience and whether you felt that the interaction with the committee was to the good of the patient and a beneficial experience. If you tell your stories, tell them anonymously and don’t name names, for reasons of privacy to the patient and fairness to the hospital. Tell us what was the issue and in which way the hospital ethics committee itself helped or didn’t help. As I suggested, I am not expecting a large number of replies but I still wanted to provide a means for the public to grade these committees. ..Maurice.

“One Who Becomes Compassionate to the Cruel will Ultimately Become Cruel to the Compassionate”: Should Terrorists be given Medical Treatment?

This is the ethical issue that has, as yet, not been fully answered by international law or by consensus ethics. And yet the issue is certainly not hypothetical. If the journal is available to you, you must read the Target Article in the American Journal of Bioethics, October 2009 titled “Medical Care for Terrorists—To Treat or Not to Treat” by Gesundheit, Ash, Blazer and Rivkind. (It is followed by a series of comment articles by other ethicists). In the article, the authors, from Hadassah University Hospital (G, R), Rambaum Medical Center(B) and Israeli Defense Forces (A) present two cases for discussion, both Hamas terrorists, both severely injured and both given immediate and extensive medical and surgical treatment in the Israeli hospitals over 20 days and a year respectively with the costs borne by the hospitals.

The physicians and caregivers provided excellent management despite whatever their own feelings or views were regarding what these terrorists had already done to the public. The ethical principles of autonomy, beneficence and non-maleficence was observed and practiced in the care of these men. An ethical question which might now be raised is whether the fourth principle of justice was observed. In the triage of these critically ill terrorists to provide emergency management, there were other patients, civilians, who needed prompt attention for whom attention to them may have been delayed. Also, in terms of justice, shouldn’t the great financial cost of caring for both terrorists have been used instead to the care of non-terrorist sick civilians? There may be a debate as to the definition of “terrorist” and some may say that they were simply “criminals” but wouldn’t the indiscriminate killing of civilians for no specific purpose but only to terrorize the population be an adequate description. Both terrorists when recovered were handed over to the government, tried and convicted.


So should all the humanistic, professional and ethical standards which physicians take from their Hippocratic Oath and their profession be set aside when it comes to medical care for a terrorist? And should the medical profession bear in mind what was written in the Ecclesiastes Rabba 7:16 “One who becomes compassionate to the cruel will ultimately become cruel to the compassionate”?
What do you think? ..Maurice.

The Muslim Faith and Ethical Issues: Questions to My Muslim Visitors

I would like to pose the following questions to my visitors and who come to this blog from Muslim countries so that we all can learn and understand how bioethical issues are looked upon by people in their countries who are of Muslim faith. Muslim visitors to my blog who lives within the United States are also certainly welcome to write but also tell us how you see your views as similar or different from those of your faith in other countries. I assume that some of the views taken for granted within the American bioethics may be quite different in other countries. I think those of us not of the Muslim faith would like to know. ..Maurice.


SOME QUESTIONS (answer any or all):

1) What is the view of stem cell research and human cloning? How about simply animal cloning? How about the manipulating the genes of plants used for food?

2) How is invitro fertilization looked upon: taking the egg of a woman and mixing it with the husband’s sperm and then inserting it into that woman’s womb so that a child might be created in a couple who otherwise were unable to normally have a child? What if the husband was sterile and the woman was fertilized by a sperm of another man to create a child for the husband and wife?

3) How does the Muslim faith look at the possibility of adoption of a child?

4) How about organ donation to a needy patient from a live donor? How about organ donation to a needy patient from a newly deceased donor?

5) Should hydration and nutrition be continued in a patient who is in a permanent vegetative state (permanently in a unconscious state, apparently unaware and not reactive to the external environment)?

6) Should a conscious patient who understands his or her medical condition have the right to order that life-sustaining treatment (like a mechanical ventilator) be turned off even though it will cause the death of the patient)?

7) Is euthanasia (physician, responding to a patient’s request and causing the patient to die) permissible? Is suicide permissible? Would physician assisted suicide as practiced in Oregon and Washington (physician writing a prescription for a lethal dose of drug which the patient can fill and take if they desire at their own time) be allowed by the Muslim faith?

8) Is medical research using animals which may be killed for the research studies permissible? Are certain animals protected from such use?

9) Is it ethical for a physician and a patient to have a romantic relationship while the patient is still under the physician’s care?

10) Should the doctor tell “bad news” to the patient (such as cancer or a fatal illness)? If not, to whom? A family member?


ADDENDUM 12-16-2009: You may be interested in a new thread I put up today titled "Suicide: Views of Christianity and Islam".