Reacting to Bad News: Forget and Smile?

Christina Georgina Rossetti, one of the most important women poets writing in nineteenth-century England wrote:“Better by far you should forget and smile/Than that you should remember and be sad” But is being sad always something to avoid? Read this excerpt from a blogger’s current life experience with cancer.

Somehow we got this idea, and Christians are the absolute worst about this, that being sad or angry is a bad thing.
Whenever I post something to the effect that "Cancer is bumming me out today," I get a bunch of emails and comments to the effect of "Buck, up, little camper - God will provide! God loves you! Be happy! I'll pray that you stop being sad!"
Well, sad is an appropriate response to cancer sometimes. My doctors are all saying I have a great, healthy, positive attitude about my disease, but they are also aware that I have a potentially fatal illness that has spread far and rapidly and that sometimes I'll be less-than-joyous about that.
Sad is ok. Feeling the way you feel is ok, until it becomes destructive. I'd worry about me if I went around all day with a goofy grin and never looked at the negative consequences of cancer.
I say all that to say this: I'm sad right now.

I agree that a cancer patient, such as the blogger above, being sad is an emotion that can represent the patient’s realistic reappraisal of their life. Their goals, which they have set in the past, now must be reconsidered in view of the diagnosis and prognosis. The role of the physicians in treating their cancer patients who demonstrate sadness is to understand what the patient has concluded on reappraisal of their life and, if unrealistic from the known clinical facts, educate the patient about this. However, if realistic, allow the patient an opportunity to ventilate about the consequences of the diagnosis and express his or her feelings. Perhaps in this way the patient, with emotional support by the physician, can set and accept more limited goals, which will provide more comfort for the patient in their remaining life. In my view, prescribing “Forgetting and smiling” is an unreasonable and unwise approach to therapy. ..Maurice.

Doctor,Doctor: Just How Long is there To Go?

From the chorus of “Doctor,Doctor” by Who:

Do you think it's time that I made out my will?
I'll leave everything to you to pay my bill
Just how long is there to go
Please tell me I want to know
But on second thoughts don't tell me, I'm too ill.

“Just how long is there to go”(“How much time do I have to live?”) is a question that is often posed by patients when they first learn that they have a potentially terminal illness. And it is often one of the most difficult questions for a physician to answer. We discuss this issue with the medical students in their first year.

What is the answer? Do doctors really know the answer? No. Doctors really don’t know for the specific patients who question them. There may be some statistical information about the disease in the literature and there is the physician’s own clinical experience with the disease but is that sufficient to yield an answer to the distraught patient? Not really. If so, then on what basis should the physician reply with anything beyond “I don’t know”. Students are taught to ask the patient for the reason for the question. The patient’s reply often provides a host of issues for which the physician can get insight into the patient’s psycho-social life and may be able to provide emotional or other support even without giving a definitive answer.

It is the physician who promptly replies to the patient’s question with a short, arbitrary answer and without further questioning or discussion who will be long remembered, but not in a helpful sense, by the patient who has also long survived the “6 months” death sentence.

Students are taught to be certain that the patient wants to talk about the prognosis in quantitative terms since “on second thoughts, don’t tell me”. If it is clear the patient wants to talk about their remaining lifespan, the only thing the physician can do is describe the data in the literature to the patient and explain the uncertainty of the statistics as applied to the individual patient.

It is a difficult experience for a doctor to give the patient “bad news” and it is most difficult to find answers to all the questions that follow. I would be most interested to read from other physicians who visit my blog how they approach the answer to the question “Just how long is there to go?”

Feather in Our Physician's Cap but a Knife in the Patient's Heart.

This story has been published on various blogs including The Onion. If it is a true story (or even if it was a madeup scenario) it does represent a behavior that could be common to most all physicians. But it also provides a basis for caution.

ROCHESTER, MN—Dr. Erich Stellbrach, a general practitioner at the Mayo Clinic, could barely contain his exhilaration Monday upon discovering that patient Oliver Patterson, 54, has the extremely rare degenerative nerve disease Gertsmann-Straussler-Scheinker syndrome. "Mr. Patterson, I'm so sorry to tell you this, but you have—you're not going to believe it—spinocerebellar ataxia!" Stellbrach said, waving an x-ray of Patterson's spinal cord. "It afflicts only one in 2.9 million people!" Stellbrach recommended Patterson begin aggressive treatment to mitigate his impending brain dysfunction and onset of dementia, and made the patient promise to remain in his care.

Physicians are humans. We work hard. There is pleasure in our work by watching a patient recover from an illness. Unless we are a surgeon, we think and hope we had something to do with the recovery but often it is the patient's own body that heals itself. And we know that too. We often look forward to making a discovery in a patient that others have missed, especially if something constructive can be done for the patient. Finding the patient has a rare disorder is a thrill and something to be remembered thoughout our careers. But for the patient, the diagnosis may be no thrill that brings pleasantness or happiness, in fact it may bring anxiety and concern. To the patient "rare" means very unusual, that it hasn't been carefully studied, that noone knows anything about the cause or outcome and there hasn't been enough cases for a treatment to be devised.

The caution: What is a feather in our physician's cap can be a knife in the patient's heart. As physicians, in this moment of glory, we must contain our internal exuberance and remain aware what we say or do in the patient's presence. Our duty is to our patients, to serve them well and keep the professional glory to ourselves. ..Maurice.

Physician Autonomy vs Beneficence to the Patient and Plan B

When Dr Ward comes into the exam room Theresa explains to him that she was out at a party, had a few too many drinks, and ended up having unprotected sex with her boyfriend. She says she is worried about the possibility of being pregnant and wants the Plan B® pill.
“I don’t want to have a baby right now. I’m too young. I have to finish school,” she says. “And I don’t want to have to make a decision about an abortion. I want to just take this pill and move on.”
Dr Ward listens to Theresa’s concerns and then says, “I understand why you are here. I have always had a policy of not performing abortions, and I won't start now by prescribing the morning-after pill. You can make an appointment with me in a couple of weeks for a pregnancy test to find out if you are pregnant. If you really want the morning-after pill I can give you the card of a physician I know in Gardendale who will see you.”
“Gardendale?” Theresa says. “But Gardendale is 115 miles away. How will I get there without telling my parents why I am going? And how will I get there soon enough for the pill to work?”

I have written recently about Plan B and the anticipated decision by the FDA to allow over-the-counter (OTC) patient access (see postings of Jan 18 and Jan 23, 2005). The above scenario with two commentaries following, in the September 2004 issue of Virtual Mentor illuminates an important ethical issue that could be resolved by approval of OTC use. The issue involves the right of a physician not to engage in a treatment, which to the physician is morally wrong. This autonomous right of the physician has generally accepted ethical consensus. However, in certain situations, acting on this right may be non-beneficent for the patient by leading to the patient experiencing personally serious consequences. This conflict between the principle of professional autonomy and the professional duty to patient beneficence, in the case of Plan B could be mitigated by the FDA approval of the OTC procurement of this drug. ..Maurice.

Political Ethics: Leveling with the Public

The stem cell lines which are now available for federally supported research are contaminated with a protein from animals whose serum is used in the culture medium. This fact is confirmed in a study by researchers at the University of Califonia, San Diego and published yesterday in the online "Nature Medicine".

The article indicates that humans have antibodies against the foreign protein and when in contact cause the stem cells to die. The contamination cannot be removed. The researchers suggest that the only way to develop a non-contaminated line of stem cells is to start over with new lines and use of human sera for culture.

However, in a news release by Associated Press today:
"The White House is shrugging off the study's findings. Press Secretary Scott McClellan said the president is satisfied those existing lines are 'adequate for the basic research that needs to be done.'"

"McClellan said Bush knew about the contamination issue in 2001 but agreed with the view of top government scientists that it wouldn't prevent research into potential breakthrough disease cures."

I don't recall the president ever mentioning this contamination during his TV presentation to the public. I also can't find it in the White House press release at the time.

Could this be another example of the president not leveling with the U.S. public? Is national security at stake for the president not to disclose the contamination issue?
..Maurice.

Schiavo Case: Beyond Compassion, Beyond Ethics, Beyond Law

Here is today's story from AP News - from Tampa Bay Online: "WASHINGTON (AP) -- The Supreme Court refused on Monday [January 24, 2005] to step in and keep a severely brain-damaged woman hooked to a feeding tube, all but ending a long-running right-to-die battle pitting her husband against her parents.

It was the second time the Supreme Court dodged the politically charged case from Florida, where Republican Gov. Jeb Bush successfully lobbied the Legislature to pass a law to keep 41-year-old Terri Schiavo on life support.

The decision was criticized as 'judicial homicide' by Mrs. Schiavo's father, Robert Schindler, but applauded by her husband, Michael Schiavo, who contends his wife never wanted to be kept alive artificially."

I think this case has gone beyond consideration and compassion for the emotions of the family. It has gone beyond the legal decisions by the courts. It has gone beyond all ethical principles. The behavior of the family, after all the legal and ethical decisions were made to allow patient autonomy through the substituted judgment of a legal surrogate, the husband, appears to be solely in the family's own self-interest. And this behavior is wrong. Hopefully, with today's decision of the Supreme Court, the appropriate. ethical and legal conclusion of the case is soon to occur. ..Maurice.

Why the FDA Delay in Plan B Decision-Making? Politics?

From Reuters AlertNet - FDA delays nonprescription morning-after pill rule: "WASHINGTON, Jan 21 (Reuters) - U.S. regulators on Friday delayed a decision on whether to approve over-the-counter sales of a Barr Pharmaceuticals 'morning-after pill' to prevent pregnancy, prompting a lawsuit from a women's rights group.

Barr said it was optimistic the Food and Drug Administration ultimately would grant its request to sell the product, called Plan B, without a prescription to women and girls age 16 and older.

The FDA said it would complete its review 'in the near future,' according to a statement from Barr."

Barr had earlier agreed with FDA request to require a physician's prescription for those under age 16. It is worrisome that this delay in FDA's decision may have its basis more on politics rather than science. ..Maurice.

On the Other Hand---The Best Acts of Military Physicians

A story from Associated Press on Jan. 5 2005: "A military doctor whose Web site chronicled the bloody aftermath of the suicide bombing of a mess tent in Iraq has shut down the site after being told his postings violated Army regulations.

In an e-mail from Iraq on Tuesday, Maj. Michael Cohen, a doctor with the 67th Combat Support Hospital unit, said he received a written warning but was not told which Army regulations were being violated.

A short notice replaced the account on Cohen's site, www.67cshdocs.com.

'Levels above me have ordered, yes ORDERED, me to shut down this website. They cite that the information contained in these pages violates several Army Regulations. I certainly disagree with this,' it said."

We have been discussing here the ethical conflicts of military physicians and the possible failures of medical professionalism which might ensue. But there is another side to the story of the military physician. You MUST, MUST read Dr. Cohen's blog describing his experience with regard to the Mosul catastrophe. It is very enlightening regarding the very best actions of the military physicians and all the other caregivers.. Apparently, it was this description which caused the military to order that his website shut down! ..Maurice.

More On: Doctors Going to War

Very appropriate to our recent discussions of the ethical conflict which appears to be present when a physician becomes a military physician (see postings December 23, 2004 and January 8, 2005) is the book review (New England Journal of Medicine, January 20, 2005 page 312) of Military Medical Ethics published by the Office of the Surgeon General, Dept of the Army and Borden Institute,2003..
The review written by Michael Grodin, M.D. and George J. Annas, J.D. starts out with "A military physician at Abu Ghraib prison in Iraq is asked to treat wounds caused by prisoner abuse; a soldier is ordered by a military physician to receive an investigational vaccine; a military physician is ordered to treat a wounded soldier who can return to combat quickly before treating others; a military psychiatrist is asked to order a psychologically traumatized soldier to return to combat..." which effectively sets the tone of what the rest of the 2 1/4 page, rather comprehensive, review is about. The 2 volume textbook apparently actually allows an opposing viewpoint. The review is well written and is itself worth reading and certainly stimulates one to read the books themselves. ..Maurice.

FDA's Interest: Science or Morality

As reported by the Associated Press on Yahoo yesterday
FDA Set to Decide on Morning-After Pill "The government is considering whether to make morning-after birth control available without a prescription, and like most issues that involve sex and pregnancy, it has generated heated debate. Fierce arguments have gone on inside and outside the Food and Drug Administration , which may decide as soon as this week whether drug stores can sell the emergency contraception known as Plan B without a prescription to women age 16 and older." The FDA rejected the first request by the manufacturer to make the pill available without a prescription. There is apparently no clear evidence that Plan B is not effective and not medically safe. The debate, as noted, may be within the FDA itself. "'Some staff have expressed the concern that this decision is based on non-medical implications of teen sexual behavior, or judgments about the propriety of this activity,' said the memo by the FDA's acting drug chief, Dr. Steven Galson.'These issues are beyond the scope of our drug approval process, and I have not considered them in this decision,' wrote Galson, who last spring rejected the first application for Plan B's sale over the counter."
The question arises as to what should be the FDA's interest in the authorization of OTC sales of prescription drugs. Should it be whether the drug, by scientific studies, is effective and safe for the consumer or should moral/political concerns be also included? What do you think? ..Maurice.

The Mevacor Decision: Limits to Consumerism and Self-Care

For those who are disappointed, and I am sure there are some, about the FDA panel’s advice not to make Mevacor an over-the-counter (OTC) drug and those who may have had hopes that virtually all prescription drugs be relegated to OTC, I have a few words for them. There are limits to consumerism and self-care and self-treatment. Despite the Internet and TV drug ads and other sources away from the physician’s office, in no way can the general public have the medical knowledge and diagnostic and therapeutic skills that are a routine component of a physician’s armamentarium. Physicians may get 7 years or more of medical training and may have had many more years of hands-on experience in practice. There is no way to compare the medical expertise of a physician to that of a non-physician. And it is this medical expertise that is the basis for society at least in the U.S. and many other countries to limit the ability of the public to obtain drugs without prescription.

Notwithstanding what is implied in the TV drug ads, physicians should be aware of the indications, contraindications and drug–to-drug conflicts, doses and adverse reactions to most drugs and have the skill to monitor the benefit and adverse reactions of their patient’s medications. This commentary, however, is not to have physicians return to the degree of paternalism as practiced years ago and this commentary is not to ignore the major role the patient plays in their own medical care. This includes giving a complete history to the physician and through truly informed consent based on patient autonomous decision-making and self-monitoring and reporting benefits and side-effects. Thus the patient is participating with the physician in a true partnership to accomplish the diagnosis and effective treatment.

Some may argue that the position I am taking in this argument is simply to protect the physician’s ability to make a living. They may say that with more or all OTC drugs, patient self-care and less office visits and less prescription writing there will be less work for the physician and less money for the physician. This is not the point of my commentary. There will always be enough work for physicians and to be able to make a decent living. My point remains; patient self-care has great potential for harms. Even physicians are warned against self-medication and self-treatment.

It is not sufficient to argue that any of the drugs which have in recent years been switched from prescription to OTC could be dangerous or lethal if taken in sufficient amounts so why be concerned about the statins or other prescription drugs for that matter. The point is that having drugs switched from prescription to OTC which carry significant risks in (1). their usual indications or vague criteria for self-use, if left up to the public to decide and (2) their use even in normally intended dosages is bad medicine and therefore is bad policy for the FDA.

Do you think that I am just writing this as a physician who is pleased that the FDA panel made the right decision because my profession has an interest in the decision? Yes, I am and I say that the interest is to assure the best, safest and most ethical patient care. What is your interest? ..Maurice.

Good Ethics: FDA Panel Shows Concern for the Patient

Here is an update regarding today's final decision by the FDA panel regarding whether Mevacor should be made an over-the-counter drug as reported by

Bloomberg: "Merck & Co. and Johnson & Johnson shouldn't be allowed to sell their Mevacor cholesterol drug without a doctor's prescription, U.S. government advisers said today, signaling that future applicants need to prove the safety of selling medicines for chronic illnesses over the counter.

A committee of doctors and scientists recommended that the Food and Drug Administration deny the companies' a bid for a nonprescription Mevacor. During a two-day meeting in Bethesda, Maryland, panelists found fault with Merck's research. They said it showed patients would be confused about taking the drug.

``I am concerned that the precedent has really serious ramifications that go beyond this,'' said Nelson Watts, a doctor from Cincinnati who was one of 20 panelists to vote no, against three in favor."

I am pleased that the panel made the right decision and ethically showed beneficence to the public. In view of the ciriticisms the FDA itself is having with regard to other drug issues currently, it is doubtful that the FDA will go against the decision of the panel. ..Maurice.

FDA Panel Backs Rationale for Over-the-Counter Mevacor

Today's FDA panel backed the rationale for OTC Mevacor. What the FDA will finally decide is yet to come.
From today'sBloomberg News Service: "In today's deliberations before deciding whether to recommend that the FDA approve the application, the committee voted 25 to 0 to tell the agency that Merck and marketing partner Johnson & Johnson showed enough reason for using a 20-milligram dose of Mevacor to help people reduce their LDL, or bad, cholesterol, to a recommended level of less than 130 milligrams a deciliter.

The panel also voted 25 to 0 against recommending that the FDA require liver tests and found that the risk of muscle damage from the medication is ``acceptable.'' Statins reduce the liver's production of cholesterol, and the medicines also can cause muscle and kidney damage"

My question would be: what are the pharmaceutical affiliations of the members of the FDA panel and are they looking at the decision from a purely scientific and medically oriented point of view or also considering the financial implications of the switch? If, the latter, then their conclusions may be suspect and unethical. ..Maurice.

Switching Mevacor to an OTC Drug: An Ethical Dilemma?

What is an ethical dilemma? It is when an ethical issue can’t be easily decided because there is no obvious decision, amongst those that could be made, which would trump the others. To start to make an ethical decision, one must look at each of the stakeholders in the decision and consider the benefits vs. the burdens each decision might create for them. Then based on ethical principles and previous similar decisions, select the one which will be the most beneficial and the least burdensome to all the stakeholders.

How does this apply to the consideration of the switch of Mevacor from a prescription to an over-the-counter (OTC) drug? Who are the stakeholders? Well, they include the general public and particularly those who are at high risk for cardio-vascular disease, the physicians, the drug company, the insurance company and the government. Any others?

What is the ethical issue regarding Mevacor? Is the switch being requested by the pharmaceutical company for their own self-interest or primarily for the benefit of the public? If it is for the former, a decision to accept the switch would, in my opinion, be unethical

What are the ethical principles? I would say that the main stakeholder is the public and that beneficence (doing good to public) and non-malificence (doing no harm to the public) are the main considerations. What would be the benefits to each? For the public, one benefit would be more people would be taking the potentially beneficial drug since the current evidence suggests a tendency toward non-treatment by physicians of appropriate patients with statin drugs, such as Mevacor. There might be a substantial improvement in public health with the documented affects of statins on cardio-vascular disease.
The other benefit would be, in theory, less expensive medication and also they would not, if the person desired, be required to see a physician and pay for a visit and prescription—“self-care”. The benefit for the drug company would be that a drug like Mevacor which was losing it’s patent protection would, as an OTC brand, assure continued income to the company. The benefit for the insurance company and government would be related to the possibility that the drug, if present on their formulary, could be removed and thus save the costs of paying for the drug. Unfortunately, this benefit for the insurance company becomes a burden to the patient in that the OTC drug may actually cost more since the patient will no longer pay only a co-payment but the full charge. If the drug prevents or improves cardio-vascular disease, there will be less of a financial burden to the insurance company and government for paying for care of patients with the disease. For the physician, there is very little benefit.

With regard to the burdens or risks, for the public there is a potentially large one. First, is the fact that Mevacor would be the first drug to be sold OTC that would not be used for acute or occasional symptoms or illnesses or taken for brief periods as with all the other OTC drugs. The statin drugs will be started as something to protect or improve cardio-vascular disease, an illness that may not have any symptoms at the time. The other difference is that the drug is expected to be taken continuously, life-long. Further, it was simply the symptoms that have motivated the public to purchase and take the previous OTC drugs. In the case of Mevicor, without symptoms, it will require the public to go out and get a blood test of cholesterol levels and then themselves evaluate whether with these values and knowledge of their personal risk factors they should start taking the drug. Of course they could go to their physician for help but then that would eliminate the self-care benefit. In addition, the public would have to understand the potential adverse effects of the drug and also complications with drug interactions and be conscientious enough to continue periodic blood tests over their lifetime to check for toxicity and sufficient lowering of cholesterol or other markers of benefit. Also they would need to be aware when to seek a physician's evaluation regarding abnormal test results including need to switch to a more potent dosage or medication, requiring a prescription. Would the public have the motivation with Mevacor to faithfully carry out all these requirements indefinitely by themselves? Such a task would be unknown to those purchasing current OTC medications.

The burden for the pharmaceutical company is to be sure that the public was sufficiently informed before and after purchasing the statin drug about its indications, dosages, side-effects and cautions. The company must provide everyone proof that the statin drug can be used OTC and safely. In the case of Mevacor, the pharmaceutical company completed one study that suggests this is true. (Here again is the link to a review of the study.)
However, one might argue the possibility of conflict of interest for a pharmaceutical company to make such a study themselves and there might be bias present. Although a statin drug has been made available to the public without a prescription in the U.K. and the change has been said to be satisfactory. However, I understand that the way the public obtains the drug is different in the U.K. than in the U.S. in that they do not themselves take it off the shelf but are handed the drug by the pharmacist who may be doing some screening and educating at the same time. If any complications in the use of the OTC drug by the public develop, the pharmaceutical company will bear a large part of the burden.

With regard to the risks and burdens for the insurance company or the government, treatment of the patient's medical complications because of taking the OTC drug will have to be paid for. For the physician, there may be only a downside for this action. New patients who should have made an office visit seeking physician’s advice might not do so and patients who have been under a physicians care and monitoring may fail to appear or the self-care may complicate overall management. I may be wrong in this assessment.

And what are the benefits and risks of the other stakeholder, the FDA, which I failed to mention at the outset of this post? Remember, it is the FDA that is responsible for the final decision to switch. If everything goes well with the switch to OTC, everybody including the public, Congress and of course the drug companies will congratulate the FDA. If there are serious complications.. well, look at the current concern and finger pointing about FDA with regard to Vioxx and other drugs.

So what is the conclusion? Is this an ethical dilemma? Not really. The decision is clear. I would say that at this time, the potential harms to the public have not been unequivocally proven to be so minimal that the benefits would easily trump them. I would advise additional behavioral testing of public use of OTC Mevacor be performed by groups other than the pharmaceutical companies before the switch is decided. That is my opinion. What is yours? ..Maurice.

Public Good vs Money in the Pockets or Both?

The FDA is about to consider again whether Mevacor, a cholesterol lowering statin drug, should be sold over-the-counter (OTC)without prescription and without any required physician supervision.

Robert Steyer writes currently an extensive article "FDA Peers Over the Counter" in TheStreet.com:

"When federal advisory committees meet later this week to decide if Merck's cholesterol drug Mevacor can be sold without a prescription, they may be taking the next step in putting more health care responsibility into the hands of patients -- or more money in the pockets of drugmakers and insurers."

As a physician, I truely am concerned whether Merk's request is in the best interest of the public. It is true that, despite recommendations regarding the importance of beginning statin therapy in certain groups of patients to prevent primary or secondary heart attack and founded on evidence-based studies, there has not been an adequate physician response. Patients who should be put on statins are not. However, our understanding of what doses of which statins will be most protective against heart attack and what criteria to use in establishing dosage is still in the developing stage. In addition, the statins are not without significant potential complications even though rare. The question I have is whether,if Mevacor is available without prescription, whether the general public perhaps without any professional supervision but, nevertheless, need for blood tests to check for effectiveness and toxicity can be safe and successful in essentially treating themselves with only the information provided by the drug company in the package.
Although Eric P. Brass MD, PhD writing in the American Journal of Cardiology Nov. 4 2004 supplement pages 22-29, reviewing a study (called CUSTOM) in which the Mevacor was made available to public subjects simulating an OTC situation concluded "The results showed that most study participants appropriately self-selected OTC statin therapy and managed their treatment. Use of OTC statins by consumers needing more intensive statin therapy or facing the risk of potential drug–drug interactions remains an area of concern but occurred infrequently in CUSTOM. These data are important for making an informed risk-benefit decision concerning OTC statin availability."

The article Steyer linked above goes into extensive detail of the financial benefit to both Merk and the insurance companies of making Mevacor an OTC product. And this worries me in terms of whether the money to the companies trump the benefit or harm to the public. The FDA has the responsibility to make the decision but in view of comments in recent years and currently about the lack of independence of the FDA in relationship to the pharmaceutical industry, I worry. ..Maurice.
p.s. Another article on the subject is from USA Today

With A Loud Ethics Voice:"Physicians Are Always Physicians" (2)

More of My Sincere Rant


I wrote about this issue yesterday to a bioethics listserv of which I am a subscriber. One of the ethicists on the listserv wrote back
"So, the challenge I post to this group is to argue
'against' the notion that the physicians who participate in interrogations
are not physicians
per se, but rather should be construed as hostile interrogators (or
enemy combatants) to whom the standards duties of medical
professionalism (e.g., confidentiality, beneficence, nonmalfeasance,
etc.) do not apply" That's the point I am and I think the NEJM authors are
making. Those physicians in the military who are participating in this manner
are violating their duties of medical professionalism since they are still
physicians.

I have never heard that it was the duty of a physician to go into
poverty but I understood it was the duty of a physician to maintain the moral
integrety, whether treating patients or not, which is set by his/her profession.
And physicians are penalized, as an example, by having their licenses revoked
for personal or legal misbehavior even when not directly related to the medical
care of a patient.

I can't believe that there is lack of consensus amongst those in the
profession of medicine or those on the sidelines such as the ethicists or the
general public that it is acceptible for physicians to maintain a Jekyl and Hyde
posture depending on who is requesting their services.

The responsibilities of America in Iraq will continue on.. the "war" on
terrorism will continue on.. there will still be persons confined in
Guantanamo Bay indefinitely and unless the government's and military mindset regarding
physicians is changed, there will always continue the misuse of physicians. I
have always felt that if society wants to have euthanasia, if society needs
to have a death warrent signed or execution completed, if society needs
investigation of the mental state of a criminal, if society needs special assistance
in military interrogation, let society select, train and give power to
technicians for each of the needs but let the physicians behave and do what they have
been doing all these many centuries.

We should all accept the decision of what society-- people, including
us, want of our doctors. We should actively encourage maintaining the
professional ethics and discourage those who would "use" doctors for their own
important but non-humanitarian objectives. I think that professional ethics and medical organizations not just mumble medical ethics but proceed promptly with a loud
ethics voice (through newspapers, TV, radio, communication to
government,legislatures and state medical boards) that physicians are always physicians and that
any other definition is morally unacceptable. And I think the time to start is
now.

Of course, what may have happened in Iraq and Guantanamo Bay is being
investigated but that should not deter us all from simply reasserting the
ethical definition of a physician. ..Maurice.

With A Loud Ethics Voice:"Physicians Are Always Physicians"

"!$#%&# it!" We are different than other professions or occupations!
As physicians, we are different and I think that this difference can be
documented by our history as a profession and by the privileges given to us by
society and by simple moral concepts.

We are physicians at all times.. not part time.. but at all times. We have
taken an oath when we became physicians and we are always responsible to that
oath and our professional standards.And we are physicians even when we
interact with society but have not established a doctor-patient therapeutic
relationship with a person or persons.And we never, as physicians, wear two hats! Our attention to the ethical and professional standards of being a physician never changes. Those physicians who enter other roles such as politics, forensic psychiatry or become members of the armed forces cannot ignore this fact.

The article "When Doctors Go To War" by Bloche and Marks in the Jan 6,
2005 issue of the New England Journal of Medicine, based on personal research, describes the conflicting
activities of physicians in Iraq and Guantanamo Bay including failure to
report possible torture and also to participate in the interrogation process. These
activities could be found to be contrary to medical professional ethics and
contrary to the Geneva Conventions. They describe the military's response to
these concerns pointing to "civilian parallels, including forensic psychiatry
and occupational health." The military argues, "that the medical profession
sometimes serves purposes at odds with patient welfare… the Hippocratic ideal of
undivided loyalty to patients fails to capture the breadth of the profession's
social role. This role encompasses the legitimate needs of the criminal and
civil justice systems, employer's concerns about workers' fitness for duty,
allocation of limited medical resources, and protection of public health." Bloche
and Marks argue that "the proposition that doctors who serve these social
purposes don't act as physicians is self-contradictory. Their
'physicianhood'---encompassing technical skill, scientific understanding, a caring ethos and cultural authority---is the reason they are called upon to assume these roes… and the military physician's contributions to interrogation-to it's
effectiveness, lawfulness and social acceptance in a rights-respecting society-arise from his or her psychological insight, clinical knowledge, and perceived humanistic
commitment."

I have agreed with some ethicists about the lack of a strong
and persistent public voice and action by ethicists regarding the society's
inadequate active attention and correction of the problems of the poor and those
without adequate medical care within the United States and throughout the
world. Maybe this lack is due to our thinking about the complexity of the issue
and the lack of a simple solution.

On the other hand, with regard to the physician conflicts as
described in this posting, the solution is not complex and is very simple. Instead of ethicists talking to each other about the issue of physician's wearing "two hats", we should publicly, together, though bioethics and medical organizations, and with the loudest voice possible, make it clear to all in society that physicians are physicians at all times and under all circumstances and that anything less is unethical and not acceptable. I think that this simple declaration is all that is necessary. If this concept is made clear, perhaps systems in society which call on physicians to participate and have not as yet understood will finally understand what
behavior is ethical and not. …Maurice.

For additional commentary related to this topic, if you haven’t already read the previous postings, you may wish to scroll down to Thursday December 23 and the first posting of Thursday December 16, 2004. In addition, I placed links to my sources regarding forensic psychiatry and the responsibilities of a military physician

The Unethics of Denial of Prophylaxis for Injury and Death

Solomon Moore, reporter from the Los Angeles Times was interviewed on "Reporter's Notebook" segment of the KCRW program "To the Point" titled "Mexico Issues Handbook on Illegal Border-Crossing".

"Since America's crackdown along the Mexican border, immigrants without papers are taking riskier routes to get to their destination. A rising death toll has led the Mexican government to publish an illustrated handbook on crossing the border safely. That guide, which tells migrants to carry enough water, follow railroad tracks and utility lines, and wear the right clothing, has anti-immigrant groups angry, reports the Los Angeles Times' Solomon Moore."

The reason I bring this political issue to this bioethics blog is because there is something unethical in this particular response of the anti-immigrant groups with regard to what amounts to Mexico's attempt to prevent injury and death to individuals
who intend to start out on a potentially unhealthful trip and who cannot be totally prevented from doing this by either Mexico or the United States. There must be some other way to handle the illegal immigration problem other than attacking a humanitarian and beneficent action. I am sure the anti-immigrant groups would find nothing wrong with advice to prevent injuries, illness and death of persons carrying out other activities from obesity to alcoholism to smoking to illegal drug abuse to prostitution. Society attempts to teach illness and injury prevention for these unhealthy or illegal habitual conditions why can't the same approach be applied in the case of those trying to cross the Arizona desert into the U.S. whose motivation for this illegal activity cannot be otherwise fully contained?

To listen to the 7 minute interview, you need RealPlayer and click on the link above.
..Maurice.

Ethical Dilemmas Regarding Cardiac Resuscitation (2): DNR in the Operating Room

One dilemma over the years has regarded a request by the patient not to receive cardio-pulmonary resuscitation (DNR). The problem was that the patient had consented to surgery. Often, the patient’s clinical condition was that of a terminally ill patient, perhaps with cancer or organ failure, who needed the surgery for palliative reasons. That is: the surgery would accomplish something that would prevent pain and suffering for the patient in his/her last months or weeks. However, an essential part of all surgery performed by surgeons and anesthesiologists is to maintain the life of the patient during the surgery. It may not be obvious to the layperson, but whenever the anesthesiologist puts the patient to sleep with an anesthetic, the patients’ breathing and thus ventilation may become impaired or can cease and so patients are intubated and artificially ventilated, essentially on respiratory life-support, just to keep them asleep and alive.. Other life-support measures are also carried out in virtually all major surgeries including medication and fluids to maintain blood pressure, replacement of lost blood and medications to control heart rate and rhythm. If the patient had a cardiac arrest during surgery, surgeons have refused to stand by, do nothing, and let the patient die simply because a DNR order had been written. In a way this refusal was out of concern for the standard of professionalism of their specialty but also out of self-interest since the patient’s death would add an unnecessary death to the surgeon’s mortality statistics. So how could surgery be performed if a DNR remained in effect? It couldn’t since it was a very rare surgeon or anesthesiologist or surgical staff would think of accepting a DNR.

Finally, in recent years, after much consultation with physicians and staff, ethics committees and lawyers, hospital policies have been re-written to set some consensus protocols for carrying out needed surgery on a patient with a pre-surgery DNR. The protocols might describe that the patient and family must be informed, as part of the pre-operative consent, that during the time the patient is in the operating room and after surgery while awakening in the recovery room, including time the patient needs to be ventilated because of consequences of the operation, itself, the DNR is temporarily revoked to be later re-established. Although, probably not as common as this protocol for surgery, hospitals have also considered whether to suspend DNR orders for other procedures including radiology. Again, it represents self-interest of the profession not to allow a patient to die as a direct result of some procedure and not directly related to the patient’s underlying illness.

What do you think? If a patient directs the hospital and physician to “let me die” in the event of a cardiac or respiratory arrest regardless of the circumstances, is it right and ethical for them to follow the request? ..Maurice.

Ethical Dilemmas Regarding Cardiac Resuscitation

The lengthy history of attempted resuscitation of the dying is summarized nicely at the ukdivers.net site and extends from the Bible description through the years with many and various methods to the current cardio-pulmonary resuscitation (CPR).

The first apparent attempt at resuscitation interestingly enough was recorded around 800 BC. The first resuscitation was Elijah's mouth to mouth (Bible, 2 Kings, iv, 34.).
"...And he went up, and lay upon the child, and put his mouth upon his mouth, and his eyes upon his eyes, and his hands upon his hands; and he stretched himself upon the child; and the flesh of the child waxed warm."

A visitor came to my blog today from a search engine requesting information about “ethical dilemmas regarding cardiac resuscitation” Unfortunately, I hadn’t put up anything on this blog previously but thought this would be an appropriate time to begin the discussion.

I would say that the most common ethical dilemmas regarding CPR is when to perform it and when not to. Unfortunately, making the decision has been made a dilemma because some years ago when CPR was beginning to be widely used there was an informal tendency for it to be applied by default to any person who appeared in cardio-pulmonary arrest. This was because of the almost uniformly successful results. However, the success was because the very earliest use of CPR was applied only in conditions that were readily reversible such as in healthy young people who nearly drowned or had been subjected to severe electric shock. The default use of CPR still continues today in and out of the hospital unless there is a written order or advance directive not to attempt resuscitation. But the outlook for recovery from CPR is much worse now that CPR is used in patients who have uncorrected severe metabolic abnormalities and/or chronic underlying disease of vital organs or end-stage cancer. The result of attempted CPR currently is either no response or poor recovery with dying simply prolonged often associated with rib fractures or liver trauma or brain damage. Not many patients leave the hospital recovered.

Thus when a medical team arrives at the bedside of a patient with cardiac arrest the first questions include the diagnosis and whether a “do not attempt resuscitation” order has been written. If no such order has been found, the team must begin CPR but with questions as to whether it is the “right” thing to do especially when such treatment appears futile. Sometimes, this leads to a “half-hearted” attempt at CPR that is really unprofessional and which subjects the patient to unnecessary additional trauma with no intent to achieve the goal of full resuscitation. More rare is a situation in which there is a “do not resuscitate” directive by the patient or family and the medical staff may disagree, believing that the patient can be rehabilitated. The staff must consider in this situation that carrying out a CPR attempt in face of such a directive may represent legal battery.

What can be done to avoid uncertainties in responding to cardiac arrest situations? One would be if there were general consensus that at least in the hospital situation the default policy is that no patient receives CPR unless there is a specific order before hand readily available to the contrary. Every patient admitted to the hospital must get an evaluation and then reevaluated throughout the hospital course for CPR. The other would be, if CPR is to remain as the default order for all patients, all patients (along with their families) should be informed and make decisions about not receiving CPR and if that decision is made, there should be readily available documentation confirming that no resuscitation should be performed.

Unfortunately, most considerations about CPR or no CPR occur too late in the hospital course when the patient is no longer competent to decide and the family is not able or willing to take responsibility to decide. And when left to the last second.. well..good luck! ..Maurice.

Tsunami and The Gaia Hypothesis

In trying to think of some sort of an explanation to the catastrophe produced by the recent southern Asia tsunami, one could try a simple geo-physical approach (earthquake disturbing a body of water) or a more philosophical/religious/spiritual meaning depending on one’s philosophy or religion. Another way of explaining what happened is considering the Gaia Hypothesis. Gaia in Greek mythology was a goddess who is the personification of the earth, the mother of the Titans. The hypothesis states, "the earth is a group of interdependent organisms and environmental systems that function as a single, self-regulating organism."

Perhaps we should then say that that we do to promote global warming, what earthquakes and tsunamis and volcanos will do, what cutting down the rain forests will do, what tornedos, floods, hurricanes and cyclones and droughts will do, what infectious or other diseases will do and how we communicate or act with each other (ignore or attack each other) is eventually going to change where we live, how we live, how we behave and what kind of creatures we will become and how the earth continues to support life.

Perhaps we should simply say that the disaster which recently occurred in south Asia is just part of a bigger picture. How do you look at it? ..Maurice.