Rape and Plan B in Colorado: The Ethics of Not Informing

Colorado lawmakers sent governor Bill Owens a bill yesterday that would require Catholic hospitals to tell rape victims about emergency contraception (Plan B pills). House Bill 1042, requires all health care providers in the state to offer information and referrals on how to get pills that let rape victims avoid pregnancy. There is question whether the governor, who is Catholic, will veto, sign or allow the bill to become law in 10 days without his action.

Plan B pills generally do not work by causing an abortion but act by preventing fertilization or implantation of the fertilized ovum in the uterus.

The issue is whether rape victims who are not as yet pregnant should not be given by healthcare providers important information and referred to resources where the pills can be obtained because of religious doctrine against doing so. The ethics is whether the victim should be, in a way, further victimized (healthcare malificence) by becoming unwillingly pregnant. This behavior of the healthcare institution could put the patient in a state where she would be forced to accept the product of the pregnancy or have an abortion, the very act that the Catholic institution erroneously contended that the Plan B pills would accomplish. Are there any arguments by my visitors regarding the ethics of this controversy? ..Maurice.

Schiavo case: Is the World News Media and People Around the World Interested?

In America, the Schiavo case has been dominating the news media for almost the past two weeks. There is much discussion here about the fairness of the legal process, the powers and responsibilities of the Congress, President and the Governor of Florida, the issue of who is a more reliable surrogate, what diagnosis is the most correct, what does removing food and fluid signify (removing comfort care or removing an unwanted medical treatment), is a body forever without awareness something to preserve at all monetary, legal and ethical costs.. and so on and so on.

Most interesting for me and perhaps others here would be for my visitors coming to this blog from outside America to comment on what impact this case is having, if any, on the news media of their countries and what are the folks on the street or in their homes discussing, if at all, about the Schiavo case. Let us know about your observations. ..Maurice.

Living Will and Will to Live

I want to emphasize again, a Living Will is not an end-all regarding autonomous medical decision-making. Often a Living Will written years before it is to be applied provides the physicians none or vague, ambiguous information about the will to live and desired final quality of life of the patient if the patient was aware of the current clinical situation being faced. What is needed is a written selection by a person of a Durable Power of Attorney for Healthcare, the legal surrogate. That selected surrogate becomes that person’s eyes, ears, mind and voice once the person becomes a patient and cannot communicate. Again, what the selected surrogate decides to the medical healthcare team is the patient speaking. Others, no matter how closely related do not have similar power and can only provide evidence of their understanding of the wishes and behavior of the patient when competent but their voices are for information only and not commands.

It is very important, therefore, that the patient finds an individual to be the selected legal surrogate who has an interest in speaking for the patient, who is free of any obvious self-interest when speaking for the patient and who has the intelligence and capacity themselves to make those substituted decisions when the patient is unable. This surrogate could be a spouse but it could be someone else. The most important point is that the person selecting the surrogate spend time, if possible repeatedly over time, discussing the person’s desires in general regarding making any medical decisions including those at potentially end of life. As time goes on, the person’s views of their goals may change and as they do, these should be discussed with the selected surrogate. Written notations in the Living Will should also be updated. The person selecting a surrogate should also identify another individual to be a substitute in case the primary surrogate is too ill and incapacitated to perform the role at the time of need or no longer wants the responsibility. This substitute proxy should also be kept informed. Moreover, family members should be made aware of who is the selected legal surrogate and also kept aware of the general wishes regarding care and treatment. If all of this is done, the physicians and others on the healthcare team should have a continuum of understanding of what the patient would have wanted and hopefully nothing on the order of the Schiavo case would occur. Any questions? ..Maurice.

Schiavo case: Visitor Comments and News Media Reporting

If you go back to the posting on January 24, 2005 titled
Schiavo Case: Beyond Compassion, Beyond Ethics, Beyond Law you will find a number of comments by my visitors. There are some written recently including today but, notwithstanding the earlier date of my posting, the views expressed are timeless and worth reading.

There is another issue that I want to bring up. It is about behavior in this Schiavo case.

As the general public think that the Congress and the President have demonstrated behavior that was inappropriate for their duties, I think that the news media in all their various public expressions have also often behaved inappropriately in the Schiavo case. On TV, was it really necessary to keep bombarding the viewer with the home-video segments presumably selected by the family and possibly showing a biased representation of Terri's activity? How many times did we need to see it? And what was the purpose? And then are the comments of the various stakeholders or their friends. Some of the quoted expressions, though presumably a reflection of the severe emotional distress, are unnecessarily negative and represented, at times, distasteful ad hominem characterizations. Are all these quotes necessary? The Kansas City Star (but also heard on the radio), as an example of unnecessary and possibly overly dramatic description, wrote:

"On Thursday, her sixth full day without food or water, Schiavo, 41, was described by distraught family members as looking like an Auschwitz survivor.."

Why that comparison? Might this be insulting to living Auschwitz survivors reading or hearing this. Why couldn't they paraphrase the family member with the word "poorly". I think you can recall other examples of news media reporting that seemed unnecessary and/or inflammatory. This kind of reporting makes one wonder.. WHY?

Perhaps when this case is finally over, some pathologic examination of the behavior of the politicians and the news media be carried out. Also some consideration of the behavior of the physicians involved. The only parties that looked pretty "clean" was that of the judicial system. What do you think? ..Maurice.

Schiavo case: Is Withholding Food and Fluid Euthanasia by Omission?

My view of the act of euthanasia is that of a physician or other person administering to the patient who requests to die some chemical which will itself cause the death and the death would not be due to the patient’s underlying illness. My view of the termination of life-support on the request of a patient is that the intent is not to kill the patient but the intent is to follow the patient’s autonomous request. A death following terminating life-support is, therefore, due to the patient’s underlying illness after the life-support is removed. This latter act is called by some “euthanasia by omission or neglect”.

Out of intellectual fairness, I would like to post here an excerpt from an article on the website of the Society for the Protection of Unborn Children. The article is titled “What is Euthanasia by neglect and why is it wrong?” by Anthony Ozimic (SPUC) and Dr John Fleming (SCBI). I strongly advise all my visitors, regardless of their views on this issue, to go to the website to read the entire article. I think in ethics it is always important to keep an “open mind” in all matters and be curious even about views one doesn’t hold. The excerpt from the article follows. ..Maurice.

One popular account of medical ethics, makes appeal to "the four principles":
1. non-maleficence (to avoid harm)
2. beneficence (to do good)
3. autonomy (the right to act freely) and
4. justice (acting fairly towards the patient).

Leaving aside the obvious shortcomings of such an abbreviated approach to medical ethics, we can nevertheless see how euthanasia by neglect violates all four principles:

1. Euthanasia by neglect is maleficent: it causes harm by killing a patient through a very long drawn out process of starvation and dehydration, a process which is uncomfortable and painful for the patient.

2. Euthanasia by neglect cannot be beneficent: A doctor is ethically and legally obliged to act in a patient's best interests. Intentionally killing the patient by neglect of reasonable care can never be in the patient's best interests.

3. Euthanasia by neglect extinguishes the autonomy of patients and diminishes the autonomy of doctors. Autonomy is not an absolute the exercise of which trumps all other considerations.. The patient must exercise his or her right to autonomy in a responsible and ethically sound manner. Both ethics and the law say that, just as we cannot sell ourselves into slavery, we cannot consent to be murdered. This is because the right to life, like the right to liberty, is inalienable. The obligation to respect the right to life extends to respecting one's own life. It is unethical to intentionally deprive oneself of life. Making euthanasia by neglect available to patients would lead to pressure on doctors and nurses to assist suicide and intentionally kill their patients by neglect. The effect of this is to significantly diminish their autonomy to practise their professional arts ethically, and according to their consciences and the Hippocratic Oath. Legalising assisted suicide and intentional killing by neglect of reasonable care turns a class of private citizens into public killers. It changes doctors and nurses from being healers and carers into poisoners and killers.

4. Euthanasia by neglect violates justice, the requirement to treat all patients impartially and to be fair when allocating health care resources. The possibility of euthanasia by neglect would lead to pressure (real or perceived) on the elderly and the chronically ill to cease being a burden on society, on the health service, and on their relatives. Legalising euthanasia by neglect reduces the patient from being an individual to whom the doctor has a professional obligation, into a utile, a unit in a utilitarian system of healthcare rationing, with an implied duty to die if they became too difficult or time-consuming or expensive to treat.

Schiavo case: Justice for All?

As we are awaiting the decision of the courts this morning, particularly the decision of the United States Supreme Court, we should be considering the outcome of this case from another ethical point of view: the ethical principle of justice (impartiality and fairness).

It should be no secret that all over the United States, every single day, doctors and hospital ethics committees are considering whether to terminate all kinds of life supportive treatment for patients who have the capacity to make medical decisions and those who do not have that capacity. There may be surrogates, legal or otherwise or occasionally no surrogates appear or can be found. Many of these patients have written no advance directive. Some families of the patient are in agreement with the physician’s advice, some are not.

If judgments are made by the courts today or tomorrow to overturn the long adjudicated case of Terri Schiavo and only Terri Schiavo will justice really be served? No. What happens to all the patient throughout the country, who had no capacity to decide and no living will, but had or will have today, tomorrow or next week decisions made by surrogates or physicians/ethics committees? Their life support has been or is going to be removed, they will die but will they have the same opportunity as Terri to have the President rush, the Congress rush, state legislators rush to create laws specifically intended to keep that individual patient alive? If not, there is no justice in our political or legal system. ..Maurice.

Schiavo case: Professional Standards of Practice Leading to Judgment and Diagnosis

I wrote the following comment in Galen’s Log where Galen pointed out really the main issue in the Schiavo case.

Galen wrote: "The question is only if Michael is a credible witness in relaying his wife's wishes in absence of such legal documentation." Though I am not a lawyer, I suspect that making a legal "diagnosis" of this question is based on careful evaluation of all the facts with as much documentation as possible and in the end a conclusion is reached and acted upon. If this is done in good faith and according to the standards of judicial practice that is all one can expect. Of course there will be occasional errors. Is this the case with Mr. Schiavo's declaration of his wife's wishes? Who knows.. but the evidence and the decision is that it is not. Notice, how similar this is to the medical decision that the patient is in a permanent vegetative state. This is a clinical diagnosis without much help from outside documentation (EEG, MRI etc.). The diagnosis must be reached by careful examination of the history, the physical exam and the patient's course. Finally, a diagnosis is reached. There will be occasional errors. Is this the case with Terri Schiavo? Maybe, but she has apparently had a consensus by a number of neurologists, examining Terri, who were responsible for clarifying a diagnosis who agreed with a PVS diagnosis and which diagnosis was accepted by the court. That should be sufficient in both questions to settle the issue for this one tragic medical condition.

I feel that many in our Congress and perhaps the President himself and, indeed, the public itself either out of political bias or emotion or lack of knowledge, haven’t taken into consideration the standards of practice requirements that are part of the judicial and medical systems and how they played out in the Schiavo case. Decisions must be made in either discipline, sometimes swiftly. But everyone should know that if the established standards are followed faithfully, the decisions can and should be accepted. I think it would be rational and realistic at this time we accept them for the Schiavo case and go on to other issues with the goal to make life for the living better. Don’t you? ..Maurice.

Schiavo Case: Would an Advance Directive Helped?

In these past few days with all the discussion about the Schiavo case, I have noticed a huge avalanche of advice from various sources to the public. The gist of the advice is: Better write an advance directive or you might end up in a mess like Terri Schiavo. The advice seems to be taking off, at least based on what I hear on radio and TV interviews with your average Joe and Jane on the street. But is the public getting fully informing information about advance directives? Not that I can tell.

There are two components of many advance directives: there is a living will portion which states, usually not in the patients own words, what the patient wants done under conditions where there is no hope for recovery from a life threatening illness. If it simply a check off box---that is bad! Better write it out what you want in your own words in your handwriting or dictate it to your lawyer who might help you with some of the wording. Best of all, talk out your wishes with you own physician. You will learn a lot more about the possibilities but unfortunately not all. More later about that. The second portion is the assignment of a person designated as a Durable Power of Attorney for Healthcare. Unfortunately, many folks are satisfied with the living will portion and fail to select that important person.

Now I will tell you why a designated Durable Power of Attorney for Healthcare should be identified. Think this out. Someone writes “I don’t want any life-support if I have a terminal illness and am unable to communicate.”. This is written years earlier when the patient is healthy and has no idea of what the terminal illness will be and what is the life-support that would be used. Further, does this mean that if the patient had HIV (a potentially terminal illness but the patient is now stable except for a mild infection for which an antibiotic was prescribed) would he want intubation and attachment to a ventilator if he had an acute anaphylactic reaction to the antibiotic? The ventilator treatment would be often just temporary and prevent death from the lack of oxygen because of the allergic reaction. Could this be interpreted by the patient’s physicians and the courts as to exactly what the patient would really want when the patient becomes ill? What I am trying to explain is that the words in an advance directive can be confusing as to what really were the desires of the patient if the patient was full aware and informed about the patient’s current condition. There also may be missing from the advance directive important details about the patient wishes: the patient’s value, goals and the degree of quality of life the patient would want to live with after the acute phase of the illness is resolved and some residual abnormalities persist.

All of this ambiguity can be more readily resolved if the patient has selected a legal surrogate, has spent time talking with the surrogate about values, goals and quality of life desired and any other personal factors the surrogate should consider. Now, when the patient is ill and unconscious and can’t make medical decisions at the time, the legal surrogate (the person named as surrogate as the Durable Power of Attorney of Healthcare) can now act in the patient’s place. The legal surrogate is informed by the physician about the clinical situation and the treatments and then can make an informed consent or dissent based on the surrogate’s knowledge of the patient’s wishes. The legal surrogate can also interpret, in light of the current known medical information, the wording of the living will portion of the advance directive. In addition, the legal surrogate can make the many medical decisions about accepting tests or treatments not specifically related to life support.

Remember, unless our Congress and our President change the laws now in existence or there is clear evidence that the surrogate is not considering the patient’s interest but considering only the surrogate’s own self- interest or is mentally incompetent at the time, a person who is the Durable Power of Attorney for Healthcare “speaks” with virtually as much clout as the patient. Note that a person at the top of a nominal potential surrogate list including a spouse may not be given the same legal power in directly speaking as the patient compared with a court-appointed conservator or the patient selected Attorney for Healthcare.

I hope this explanation of the need for at the least a designation of a legal surrogate by the patient is helpful. With regard to the answer to the question in the title of this posting, an advance directive for Terri probably and sadly would not have helped once the case moved from a personal family issue to a political issue. ..Maurice.

Schiavo Case: Some Real Priorities for Congressional Interventions

Two ethicists have written on a bioethics list some very, very pertinent questions regarding need for additional congressional intervention that would affect the lives of many more people and be much more within the responsibilities of Congress and the President than what they did last night. ..Maurice.


++++++++++++++++++++++++++++++++++++++++++++++++++
Will someone please let me know when Congress convenes an emergency
session, and the president returns early from vacation and signs a bill
in the early morning hours to:

a) intervene to prevent the death of a child starving from poverty?
b) "err on the side of life" with regard to a capital punishment case?
c) move a Medicaid program from the state's purview to federal purview
because of concern for the lives at stake?

++++++++++++++++++++++++++++++++++++++++++++++++++
This national obsession with the Schiavo case yet
again reminds me of the venerable quote (attributed to
Stalin, no less) "A single death is a tragedy, a
million deaths is a statistic"

Where was the national outcry from our political
leaders when Time magazine ran its cover story about
the AIDS pandemic in Africa a few years ago:
http://www.time.com/time/covers/0,16641,1101010212,00.html

Or when it more recently ran a cover story about the
death of 8 million people worldwide each year because
of extreme poverty:
http://www.time.com/time/covers/0,16641,1101050314,00.html

In some way, the intense focus this case has generated
reminds me of the Bijanis, the conjoined twins who
underwent risky surgery to be separated. These tragic
cases generate such enormous media attention that no
larger issues dealing with health care access or
poverty can ever hope to match them for emotional
power.
++++++++++++++++++++++++++++++++++++++

Schiavo case: Federal Courts- No Political Bias but Only the Law?

It appears that the midnight ride of the Congress has brought the Word that the “Federal Courts are coming!” And as those of us who are interested in ethics and the fair analysis of the law, we will await their arrival. I pray now not for Terri, she has plenty of prayers today for her “miracle”, but I pray that the entry of the federal court system into the case will provide a rational decision based only on law and in no way looking one direction or another to find a “politically correct” answer to this common but also needlessly complicated case. ..Maurice.

If Schiavo Why Not Jones? (2)

From today's The New York Times : "Representative Tom DeLay, Republican of Texas and the House majority leader, who is at the center of the Congressional intervention, said on Saturday: ''We should investigate every avenue before we take the life of a living human being. That is the very least we can do.'

In Crawford, the White House press secretary, Scott McClellan, said: ''Everyone recognizes that time is important here. This is about defending life.'"

All political motives by the Republicans and the President are denied and only the moral, humanitarian motivations are stressed as the basis for this unusual congressional and presidential action. If that is so, there seems to be some ignorance of facts by these parties. Shouldn't they be aware that termination of life support is going on every day in hospitals all over the country. Mostly the requests come from surrogates since the patients usually are in a mental state where they have no capacity to make medical decisions at that time. Mostly, there may be no advance directive to read. So where has the Congress and President been in these past years to "investigate every avenue before we take the life" or sign laws to "defend life"? Where will they be tomorrow and the day after to make sure that Mr.
Jones, a 33 year old man unconscious with a massive cerebral hemorrhage and who has been on the respira tor for 3 months can be prevented from having his respirator life support terminated even though his wife reports that he told her that he would not want to live if he was unable to have the quality of life he had described to her?

And then there is Joanie, Grace, William, Mary... What are you going to do about their requests? Sorry, they have no advance directive except they do have a legal surrogate who speaks for them and, by the way, their surrogates are approved by the patient's physician and the courts. And if the Congress doesn't know where they are located, they should check with any hospital. ..Maurice.

If Schiavo Why Not Jones? (1)

If the U.S. House and Senate agree on a law which President Bush signs tomorrow which will permit the family of Terri Schiavo to attempt to overturn 7 years of detailed and consistent judgments in the Florida courts by starting the whole process in the federal courts, does everyone realize what the consequences of this action would be? Unless the federal courts refuse to take up the case because, for example, considering the congressional action unconstitutional, this precedent could be applied to hundreds or even many more instances throughout the country where there is a conflict between family and a legal surrogate of a incompetent patient regarding termination of life support after taken to state court and the family is unsatisfied with the judgments. If there is no agreement to generalize a law to include all conflicting judgments in termination of life support issues, this would mean that the Congress would be engaging most of their time and energy in preparing a law for each case.

If all parties in the Congress agree on a law that applies to every case, then it would put a great work burden on the federal courts after the work and delays by state courts. Such an unreasonable cumulative delay in carrying out the ethical request by the patient as represented by the surrogate would turn this legal practice into gross malificence and disrespect for the ill patient.

What the Congress and presumably the President is forgetting is who is the person who deserves the actions in the best interest. It is not the President, the Congress, the court system, political or religious groups, news media, the legal surrogate or the family. It is the patient. And what is in the patient’s best interest? It certainly is not the moral, philosophical, political or emotionally based views by any of these parties. Any self-interest by others beyond that of the patient is ethically unacceptable. The patient’s best interest is served only by following the autonomous request to stop unwanted treatment. Let’s hope that if the Schiavo case goes to the federal court system, judges there will use understanding and reason rather than the bizarre behavior of our Congress. ..Maurice.

Schiavo Case: Physicians Wearing Two Hats

I have written about physicians wearing two hats on this blog previously. Physicians who have been elected to a political office may also find that they may lose thair physician's hat as they engage in the political function. I think what happened today in the Schiavo case is a perfect example of physicians discarding their academic garment of a professional doctor of medicine, ignoring facts, ethics and law and behaving as a shameful politician out to develop some political capital for themselves. Dr. Bill Frist of the Senate and Dr. Dave Weldon, representative from Florida are two of the examples. If there is something Congress needed to have fixed in the laws related to termination of life support, advance directives, durable power of attorney for health care and so on, then they should have investigated with appropriate resources without rush and if needed fix it. If there were problems, they were longstanding problems, nothing acute, nothing emergenct. But these laws have been around for years and no Congress has paid attentiono except to attempt to reinforce the laws already present with the Patient Self-Determination Act requiring hospitals to remind each patient to prepare an advance directive. (And included in the advance directive can be assigning a durable power of attorney for healthcare.) And the Sciavo case has been in judication for the past 7 years or so. Where was the congressional concern during this time? Why attempt to serve a supoena on a non-communicating patient in the last moment with threats of punishment for interfering with the supoena if this was not for political grand-standing? I think Judge Greer said it well with "The fact that you -- your committee -- decided to do something today doesn't create an emergency,"

Of course, I think it is valuable to have a physician enter politics. But the public who send the physician to Congress should be made aware before hand (informed consent) that the physician is going to think, analyze and behave in the professional manner of a physician. I think applying a little medical professionalism into politics might raise the public's view of a politician from the basement to something higher. Anyway, that is my opinion. ..Maurice.

3-19-2005 Addition to My Posting

Supporting my view about the physician two hat issue in politics
is the excellent review of Dr. Bill Frist's recent behaviors by Charles
Babington in the March 19th issue of the
Washington Post. The article describes concern by others of what I would consider Bill Frist's medical unprofessionalism when he threw off his physician's hat and now acting as a pure politician. Below is a brief excerpt. ..Maurice.

Some medical professionals questioned the appropriateness of Frist
challenging court-approved doctors who have treated Schiavo. Laurie Zoloth, director of
bioethics for the Center for Genetic Medicine at Northwestern University, said
she was surprised to hear Frist weigh in, given that he has not examined
Schiavo. "It is extremely unusual -- and by a non-neurologist, I might add,"
Zoloth said in an interview.

Were Frist rendering an official medical judgment, she said, relying on an
"amateur video" could raise liability issues. After 15 years, "there should be
no confusion about the medical data, and that's what was so surprising to me
about Dr. Frist disagreeing about her medical status," Zoloth said.

Schiavo on Thursday: Loss of Patient Autonomy on Friday?

The Schiavo case is to be affected by some action taken tomorrow, Friday March 18, 2005. The feeding tube of this lady in a persistent vegetative state may be pulled or some laws either in Florida or the U.S. Congress will be signed. The pulling of the tube is legal and ethical and represents the substituted judgment provided by the Mrs. Schiavo’s husband as the court confirmed legal surrogate. The laws which may be signed tomorrow will all be suspect and surely will undergo court scrutiny. The reason for the legal concern about these laws is that they will upset the whole ethical and legal concept of the court appointed or the patient’s advance directive appointed legal surrogate and remove the powers such an appointment currently provides. In effect, it will no longer be the legal surrogate to speak for the incompetent patient regarding what is known as the patient’s wishes but it will be the Florida legislature or the U.S. Congress who will make the decisions or allow other individuals or committees or judges to do so. And that will be a tragedy since these laws if passed will not only affect the decision making of this one tragic medical case but will affect all decisions by legal surrogates both in Florida and perhaps throughout the country.

The Schiavo issue is not one of termination of this patient’s tube feedings but has turned into an issue of termination of all the rights for autonomous personal medical decision-making for all patients. Mrs. Schiavo will never recover, with or without the tube feedings and that is sad but the greater sadness is that if these laws are signed, an important part of the ethical and legal ideal of autonomy and free choice in America will be lost. A big day, Friday. ..Maurice.

"Physician's Grotesque System"

I am wondering if America has the same fascination with “ingesting” medications as Mark Twain described in his Mark Twain's Letters 1886-1900. Do you think whether 2005 America continues the “physician's grotesque system--the emptying of miscellaneous and harmful drugs into a person's stomach”? If it is not anabolic steroids, the topic of the day today, then it is the anti-inflammatories, the proton pump inhibitors (to antagonize the gastric effects of the anti-inflammatories), the mood elevators, the tranquilizers, the erection promoting drugs and so on. Do you think that the majority of those folks who take these drugs and their doctors who write the prescriptions in response to their patient’s requests are being beneficent to themselves or their patients? Are they or we just a bunch of “pudd'nheads” and “jackasses”? Read the excerpt below from the Letters and let me know what you think. ..Maurice.

I cannot help feeling rather inordinately proud of America for the gay and hearty way in which she takes hold of any new thing that comes along and gives it a first rate trial. Many an ass in America, is getting a deal of benefit out of X-Science's new exploitation of an age-old healing principle--faith, combined with the patient's imagination--let it boom along! I have no objection. Let them call it by what name they choose, so long as it does helpful work among the class which is numerically vastly the largest bulk of the human race, i.e. the fools, the idiots, the pudd'nheads.
We do not guess, we know that 9 in 10 of the species are pudd'nheads. We know it by various evidences; and one of them is, that for ages the race has respected (and almost venerated) the physician's grotesque system--the emptying of miscellaneous and harmful drugs into a person's stomach to remove ailments which in many cases the drugs could not reach at all; in many cases could reach and help, but only at cost of damage to some other part of the man; and in the remainder of the cases the drug either retarded the cure, or the disease was cured by nature in spite of the nostrums. The doctor's insane system has not only been permitted to continue its follies for ages, but has been protected by the State and made a close monopoly--an infamous thing, a crime against a free-man's proper right to choose his own assassin or his own method of defending his body against disease and death.
And yet at the same time, with curious and senile inconsistency, the State has allowed the man to choose his own assassin--in one detail--the patent-medicine detail--making itself the protector of that perilous business, collecting money out of it, and appointing no committee of experts to examine the medicines and forbid them when extra dangerous. Really, when a man can prove that he is not a jackass, I think he is in the way to prove that he is no legitimate member of the race.

Additional Comment 3-17-05: The reason for this posting is to bring up the issue of whether the American public has become too enamored with taking medication without regard to their own physical, emotional and financial harm. "Direct to consumer advertising" is particularly disturbing to me since I see this technique of "educating the public" as a stimulus for unnecessary prescription and use of drugs to patients who don't really need the medication or could benefit from a less expensive drug and one which has been longer studied for side-effects and therapeutic value. I am not saying that we should rely mainly on "faith" as prescribed by Mark Twain although realistically applied faith can often be beneficial in treating disease. However, we shouldn't assume, as many do, that there is a "right" pill out there for what ails us and if we can just learn that it's there and take it we will surely be better off. What do you think? ..Maurice.

Patient's Code of Ethics

Don't you think that ethics in medicine should be a two-way street? If there is to be a partnership between the patient and physician to work to heal the illness, shouldn't the patient have consideration of the physician's burdens and suffering in the process? You do? Good! From Belleview College here is the "Patient's code of ethics". Now stick to it. Your doctor will appreciate your behavior. ..Maurice.

1. Do not expect your doctor to share your discomfort.
Involvement with the patient's suffering might cause him to lose his valuable scientific objectivity.
2. Be cheerful at all times.
Your doctor leads a busy and trying life and requires all the gentleness and reassurance he can get.
3. Try to suffer from the disease for which you are being treated. Remember that your doctor has a professional reputation to uphold.
4. Do not complain if the treatment fails to bring relief.
You must believe that your doctor has achieved a deep insight into the true nature of your illness, which transcends any mere permanent disability you may have experienced.
5. Never ask your doctor to explain what he is doing or why he is doing it.
It is presumptuous to assume that such profound matters could be explained in terms that you would understand.
6. Submit to novel experimental treatment readily.
Though the surgery may not benefit you directly, the resulting research paper will surely be of widespread interest.
7. Pay your medical bills promptly and willingly.
You should consider it a privilege to contribute, however modestly, to the well-being of physicians and other humanitarians. It is sheer arrogance to contract illnesses that are beyond your means.
8. Never reveal any of the shortcomings that have come to light in the course of treatment by your doctor.
The patient-doctor relationship is a privileged one, and you have a sacred duty to protect him from exposure.
9. Never die while in your doctor's presence or under his direct care.
This will only cause him needless inconvenience and embarrassment.

Killing or Letting Die?

The patient who has the capacity to make autonomous decisions themselves may terminate life-supporting treatment. In most cases within hospital intensive care units where many of these decisions are requested, the patient may not have the physical ability to perform the act to discontinue the treatment. This means that physicians or hospital staff must carry out the act. The question then arises as to whether the perhaps lethal consequence of the act represents the act itself or represents the patient’s underlying disease; in essence, does “pulling the plug” by the healthcare professionals represent an act of killing the patient or allowing the patient to die from his or her illness which required the life-support? The current usual view that has been suggested to make the distinction is regarding the intent of the person who performs the act. Is the person simply following the patient’s legal request as an ethical responsibility with perhaps knowing that death is possible due to the patient’s illness but not intending that the patient should die? If so, this does not represent “killing”. On the other hand, if the intent was clearly that the patient should die, whether beneficent or not then the act would represent “killing”. Obviously, physicians who perform the act will do so with the former intent. That is one view of the distinction. However, there are some life supporting treatments which have been used as examples where the distinction is based on whether the treatment can represent a substituted organ. Applying this view, the action represents removal of a vital organ and death is no longer related to the underlying disease but in the act of organ removal itself. This distinction has been considered rather hazy but consider the following examples:

In a quadriplegic patient who cannot breathe on his or her own, if a ventilator machine has provided a period of life sustaining function that only normal lungs and normal spinal cord conduction could provide, the ventilator might be interpreted as an artificial and substituted “organ” which has become part of the patient’s body. Removing the ventilator function might be the same as taking out both lungs of a normal person, clearly a “killing” act.

Another similar example would be that of a patient who requests turning off of a cardiac pacemaker, which had been inserted to prevent the heart from stopping because of a diseased heart with a complete heart block condition. This pacemaker represents now a part of the patient’s body, in place of the diseased pacemaker mechanism, to keep the heart beating. Turning off the implanted pacemaker would be like the injection of a chemical into a normal person to stop the heart from beating.

One could argue that, as in the Schiavo case, the feeding tube inserted thru the abdominal wall and into the stomach to provide nutriments and fluids essential for life has become for the patient the new “organ” substituting for the patient’s own swallowing mechanism and esophagus, connecting the mouth to the stomach, which may be lost forever. If the tube were removed, it would be like disconnecting the mouth from the stomach in a normal person.

In each case, if one considers the proposition logical, then the act would represent the removal of a normally functioning but substituted “vital organ” and this act would not be considered simply allowing the patient to die from his or her underlying illness and could be considered “killing” regardless of the intent.

I present this issue to point out that the concept of the autonomous request by a patient for someone to discontinue an unwanted therapy is not a simple request devoid of any controversy. It is this uncertainty beween killing and letting die which may give healthcare providers a moral pause when considering whether to accept the patient’s request. ..Maurice.

3-19-2005 Addition to My Posting

Today DB's Medical Rants wrote about my discussion here of this issue. I posted the following comment to that fine medical blog:

I should make it clear (and I only used the word "hazy" in my piece)that the concept of the removal of an "artificial organ" that was functioning as the life-supporting natural organ representing a "killing" is NOT generally considered and is NOT the current ethical consensus. However, this view has been discussed in ethics literature in the past. The currently, the ethical consensus accepted as distinguishing betwee "killing" or "letting die" is simply that of the intent of the one performing the act. I also should make clear that the word "killing" is a term used as the opposite of the condition where the patient is dying because of the lethal effect of the underlying illness ("letting die"). I don't think the ethical view is that of a homicide if the patient cannot perform the act on his/her own. Whether one wants to consider this act "assisted suicide" depends on whether one wants to ignore that the act is NOT one of directly causing death but following the autonomous patient's decision to stop unwanted treatment with the death being caused by the underlying illness.

In "assisted suicide" such as practiced in the state of Oregon, the immediate death is due directly to the pills prescribed and not due to the patient's underlying illness. I hope this explains the current understanding of the issue. In the Schiavo case, the issue is not one of "killing", it is simply one of a legal surrogate requesting that the patient's wishes be followed regarding unwanted treatment. ..Maurice.

What is Death? (5): Do Not Stand at My Grave and Weep

I found this poem, "Do not stand at my grave and weep" by Mary Elizabeth Frye and the history of how it happened to be written at the Businessballs.com website. This poem, too, tells us again, like the poem by Walt Whitman in my first posting, that death may not be the end of some sort of existence. I think because it has been difficult to ascribe a finality of life to death, this may contribute to the difficulty in defining death itself. In fact, physicians know about families who have taken their dead family members home from the hospital to maintain some sort of continued “support”. ..Maurice.

Do not stand at my grave and weep

Do not stand at my grave and weep
I am not there; I do not sleep.
I am a thousand winds that blow,
I am the diamond glints on snow,
I am the sun on ripened grain,
I am the gentle autumn rain.
When you awaken in the morning's hush
I am the swift uplifting rush
Of quiet birds in circled flight.
I am the soft stars that shine at night.
Do not stand at my grave and cry,
I am not there; I did not die.

What is Death? (4) More on Personhood:View of Peter Singer

I hope my visitors got the idea from my last posting that the concept of personhood, which is an important element to consider when discussing both life and what is death is complicated and controversial. One side of the controversy are the views of the Australian ethicist, Peter Singer who is currently at the University Center for Human Values at Princeton University in Princeton, N.J. He has supporters of his view of personhood and,of course, many detractors. But for those who haven't formed opinions, his view definitely should be heard. He has a Princeton website where you will find much information about his academic background, positions and rewards and you will find a very interesting FAQ section from which I extracted the portion below to portray his views regarding the definition and significance of personhood, not by my interpretation, but in his own words. Don't write comments to him. I am sure he has heard plenty good and bad but write them to my blog. I myself and I am sure other visitors would be most interested to read them. No, this is not a college ethics class and I am not grading you, but I hope you will think the concepts out carefully and provide a rational basis for your particular views. ..Maurice.

From FAQ by Peter Singer


Q. I’ve read that you think humans and animals are equal. Do you really believe that a human being is no more valuable than an animal?

A. I argued in the opening chapter of Animal Liberation that humans and animals are equal in the sense that the fact that a being is human does not mean that we should give the interests of that being preference over the similar interests of other beings. That would be speciesism, and wrong for the same reasons that racism and sexism are wrong. Pain is equally bad, if it is felt by a human being or a mouse. We should treat beings as individuals, rather than as members of a species. But that doesn’t mean that all individuals are equally valuable – see my answer to the next question for more details.


Q. If you had to save either a human being or a mouse from a fire, with no time to save them both, wouldn’t you save the human being?

A. Yes, in almost all cases I would save the human being. But not because the human being is human, that is, a member of the species Homo sapiens. Species membership alone isn't morally significant, but equal consideration for similar interests allows different consideration for different interests. The qualities that are ethically significant are, firstly, a capacity to experience something -- that is, a capacity to feel pain, or to have any kind of feelings. That's really basic, and it’s something that a mouse shares with us. But when it comes to a question of taking life, or allowing life to end, it matters whether a being is the kind of being who can see that he or she actually has a life -- that is, can see that he or she is the same being who exists now, who existed in the past, and who will exist in the future. Such a being has more to lose than a being incapable of understand this.
Any normal human being past infancy will have such a sense of existing over time. I’m not sure that mice do, and if they do, their time frame is probably much more limited. So normally, the death of a human being is a greater loss to the human than the death of a mouse is to the mouse – for the human, it cuts off plans for the distant future, for example, but not in the case of the mouse. And we can add to that the greater extent of grief and distress that, in most cases, the family of the human being will experience, as compared with the family of the mouse (although we should not forget that animals, especially mammals and birds, can have close ties to their offspring and mates).
That’s why, in general, it would be right to save the human, and not the mouse, from the burning building, if one could not save both. But this depends on the qualities and characteristics that the human being has. If, for example, the human being had suffered brain damage so severe as to be in an irreversible state of unconsciousness, then it might not be better to save the human.

...

Q. You have been quoted as saying: "Killing a defective infant is not morally equivalent to killing a person. Sometimes it is not wrong at all." Is that quote accurate?

A. It is accurate, but can be misleading if read without an understanding of what I mean by the term “person” (which is discussed in Practical Ethics, from which that quotation is taken). I use the term "person" to refer to a being who is capable of anticipating the future, of having wants and desires for the future. As I have said in answer to the previous question, I think that it is generally a greater wrong to kill such a being than it is to kill a being that has no sense of existing over time. Newborn human babies have no sense of their own existence over time. So killing a newborn baby is never equivalent to killing a person, that is, a being who wants to go on living. That doesn’t mean that it is not almost always a terrible thing to do. It is, but that is because most infants are loved and cherished by their parents, and to kill an infant is usually to do a great wrong to its parents.
Sometimes, perhaps because the baby has a serious disability, parents think it better that their newborn infant should die. Many doctors will accept their wishes, to the extent of not giving the baby life-supporting medical treatment. That will often ensure that the baby dies. My view is different from this, only to the extent that if a decision is taken, by the parents and doctors, that it is better that a baby should die, I believe it should be possible to carry out that decision, not only by withholding or withdrawing life-support – which can lead to the baby dying slowly from dehydration or from an infection - but also by taking active steps to end the baby’s life swiftly and humanely.


Q. What about a normal baby? Doesn’t your theory of personhood imply that parents can kill a healthy, normal baby that they do not want, because it has no sense of the future?

A. Most parents, fortunately, love their children and would be horrified by the idea of killing it. And that’s a good thing, of course. We want to encourage parents to care for their children, and help them to do so. Moreover, although a normal newborn baby has no sense of the future, and therefore is not a person, that does not mean that it is all right to kill such a baby. It only means that the wrong done to the infant is not as great as the wrong that would be done to a person who was killed. But in our society there are many couples who would be very happy to love and care for that child. Hence even if the parents do not want their own child, it would be wrong to kill it.


Q. Elderly people with dementia, or people who have been injured in accidents, may also have no sense of the future. Can they also be killed?

A. When a human being once had a sense of the future, but has now lost it, we should be guided by what he or she would have wanted to happen in these circumstances. So if someone would not have wanted to be kept alive after losing their awareness of their future, we may be justified in ending their life; but if they would not have wanted to be killed under these circumstances, that is an important reason why we should not do so.

What is Death? (3)

As I noted, the issue of what is personhood and who are you and what are you worth if you don’t have personhood is contributing to the controversy of when a person is dead.
Why is personhood up for debate? Well, philosophers have felt that personhood defines who is a human person. Not just a human being or homo sapiens but a human person. What makes a human person important? Well, certain rights and legal protections are given by society to a human who is also a person that are not given to those who do not possess personhood. That means that if a human person becomes a corpse, personhood no longer exists and the rights and legal protections are gone. So what makes a person? That’s the problem and it starts from the very beginning of life, from the fertilized egg. Some view this zygote as a person and should be given all the protection that is given to an adult human. And that means it would be immoral and could be made illegal to hurt or destroy the egg. And this philosophy of personhood continues as an implanted embryo develops into a fetus. But some have suggested that those who hold this view are conflating a human being with a person. It is argued that personhood represents a being who has a conscious awareness of self so that the being can set personal values and goals. It is impossible to consider an egg or zygote or embryo or an unborn fetus to meet that criterion. So where does personhood begin? Is a newborn infant a person? One view is that it is. What about a baby at term who is yet to be born into this world? How much consciousness and self-awareness are present in those individuals? Complicating this topic further is the status of the anencephalic child.

One of the sad abnormalities that can occur is that of an anencephalic child who is born with no brain tissue where all the consciousness, awareness and all the complex interaction with the environment takes place, the cerebrum. Thus the child misses the “higher brain” as described by Kenneth Kipnis in the last posting. There is only a brain stem present which controls the vegetative mechanisms such as breathing and control of the heart and blood pressure. Should this infant be given the status of a person without the higher brain? Is this infant considered a person and is this infant considered alive? Currently, the legal answer in the U.S. is yes to both. The anencephalic doesn’t meet the criteria for brain death since a functioning brainstem is still present. As a person, the anencephalic must be given treatments if necessary in emergency room visits. As alive, vital organs necessary to maintain existence cannot be procured for transplant.

And now we must consider whether those who are apparently not aware of themselves or conscious, not just reflexly, of their environment still maintain personhood. For example, for those patients in a persistent vegetative state are they as good as dead based on the definition of personhood? They maintain brainstem function and therefore can’t qualify as dead on the basis of permanent absence of whole brain function but they might qualify if the criteria for death was the permanent absence of higher brain function and thus fail the personhood test. And then one can go on to speculate about those patients who are severely demented and what the criteria for personhood and death means for them.

As you can see by the discussion by Kenneth Kipnis in the last post and mine here that the definitions of personhood and death are not fully satisfactory to everyone. Concerns, ethical/philosophical, political, legal and religious, still remain to be resolved. Issues regarding use of embryonic stem cells, in vitro fertilization with residual embryos, treatment of the not yet born, the newborn, the anencephalics, the status of those who are severely demented or in a persistent vegetative state all remain to be examined and resolved. And these are not just theoretical issues for philosophers to contemplate but issues which all society has to contend with.. matters of what represents life of a human person and what represents that person’s death. ..Maurice.

What is Death?( 2)

Did Walt Whitman and his poem, in my last post, explain death to your satisfaction? No? Maybe Ken Kipnis, who is a philosopher/bioethicist, can explain it better in the following article he wrote for The Philosophers' Magazine. My thanks to Ken and his publishers for allowing me to post the entire article here. ..Maurice.

______________________________________________________________
When Are You dead?
by
Kenneth Kipnis
Department of Philosophy
University of Hawaii at Manoa
kkipnis@hawaii.edu


It is, alas, one of the most familiar things in the world. Alive one
minute, dead the next. But what exactly happened?

On the surface, there has been a dramatic change in social standing: a
living human being has become a corpse. The former might have enjoyed
rights to health care and legal protections against an array of
wrongs. Death makes an end to these, and to marriage, citizenship, and
even legal personhood. It is perhaps the most complete and final
alteration of status known to law. We can now cut open the body out of
intelligent curiosity, burn or bury it; hand it over to medical
students for dissection; gather up personal property and distribute it
to others, all of which would be grave wrongs if ever done to the
living. It is no wonder that premature burials and twitching body bags
are the stuff of horror stories. It is no mystery why communities take
exquisite care to avoid mistakes that are beyond embarrassing. Because
so much hangs on the official pronouncement, only the most
knowledgeable are authorized to certify that death has occurred. But
what exactly is the warrant for their judgment?

Conversations about the definition of death are commonly plagued by
ambiguity in the level of analysis. Beyond the social account set out
just above, it is useful to distinguish among four other levels:
biological, physiological, clinical and legal. The stories we tell
about the nature of death have to have at least that many chapters.

We begin, at the deepest biological level, with the nature of animal
life. Herewith a thumbnail history of biological metaphors for the
living body. If, as an animal, our essential Aristotelian nature
involves locomotion, then we cease to exist (as animal-natured beings)
when our capacity for locomotion ends. But if, as Harvey discovered,
we are pulsating, vascularized circulations of life-giving blood, then
we cease to exist as living creatures when the vital flow stops. And,
finally, if we are wet computers, neurologically connected to input
and output peripherals (as many have come to believe) then we cease to
exist just when our central processing units fail, permanently and
completely.

Within each of these three conceptions, the next task is to draw upon
physiology (the second level) to define biological death. Breathing
is a most subtle locomotion, perhaps the most essential and the last
to disappear. We still speak of people "expiring." So understood,
death occurs when respiration ceases. Later on, for theorists
following Harvey's discovery, a person could be said to have died when
the essential cardiac pump stopped beating. No pump, no blood flow,
no life. Finally, for most contemporary theorists, death occurs
decisively when the brain (or some substantial portion of it - the
jury is still out) dies, even if the heart continues to function. The
phone can ring but nobody is home.

The third level is clinical. In practice, how should health care
professionals determine that the critical physiological state is
present. One very old test involved a mirror held near the nostrils.
The patient was alive if the glass fogged, dead if it remained clear.
Following Harvey, the stethoscope allowed physicians to ascertain the
absence of heartbeat, the cessation of circulation and, therefore,
death. But the cardiac criterion became problematic perhaps fifty
years ago as advancements in resuscitation, life support and surgery
allowed patients to survive the stilling of their hearts. People joked
about having been dead for twenty minutes, reveling in the patent
contradiction. While no dramatic changes in social standing were
occurring, it was time to revise the cardiac conception of death. The
transition to death by neurological criteria is still evolving.

The process began shortly after the first heart transplants, with the
1968 publication in JAMA of the Report of the Ad Hoc Committee of the
Harvard Medical School to Examine the Definition of Brain Death. The
Ad Hoc Committee urged that death be understood as the irreversible
loss of function of the whole brain, including the brain stem. This
medical conception was quickly and widely adapted as a legal criterion
in the United States. By 1981 the American Bar and Medical
Associations had endorsed the Uniform Determination of Death Act which
held that:

An individual who has sustained either (1) irreversible cessation of
circulatory and respiratory functions, or (2) irreversible cessation
of all functions of the entire brain, including the brain stem, is
dead. A determination of death must be made in accordance with
accepted medical standards.

Notice how the new standard is piggy-backed onto the Aristotelian and
cardiac conceptions of death. The added definition effectively
eliminates the inherent legal risks associated with harvesting
transplantable hearts.

Notice also how the language of the Act sets out a procedural
criterion for brain death as well as a substantive one. Though
irreversible cessation of all brain functions is essential, the
determination of brain death requires physician compliance with
"accepted medical standards." As doctors became comfortable with the
new definition, gold-standard confirmation by brain-wave and
blood-flow analysis fell out of use. Along with some other clinical
observations (absence of a gag reflex, unresponsiveness of the pupils
to light, etc.), the most dramatic assessment tool has been the apnea
test. The unconscious, brain-injured patient is removed from the
ventilator for several minutes. If breathing does not begin as the
seconds pass -- as carbon dioxide builds up in the blood stream --
doctors can infer the destruction of those brain stem regions
governing unconscious respiration. While the law is clear enough about
physiology, it hands off the clinical practicalities to physicians.

But islands of neurological activity can persist even when brain death
is established according to the accepted tests. The regulation of
temperature is one example. When certain neurological structures are
disabled, body temperature destabilizes. Clinicians must then use
thermal blankets and sensors to heat and cool patients. Despite the
legal requirement that there be "irreversible cessation of all
functions of the entire brain . . ." death is often pronounced when
some brain functions are evidently unimpaired. In these situations, do
the physiological or the medical standards have priority? If some
activity persists, exactly how much of the brain has to be
irreversibly lacking in function before death is present? And how
certain must clinicians be that this condition is met?

Michael Green and Dan Wikler offered some useful analysis in their
1980 paper, "Brain Death and Personal Identity." They begin with a
rough distinction between the lower brain (including the brain stem)
and what we will term the higher brain (including the cerebral
hemispheres). The lower brain manages many autonomic biological
functions: movement of food through the intestines, breathing while
asleep, temperature regulation etc. The higher brain is where
personhood is lodged: memories, skills, emotional traces, knowledge,
etc. While many have thought that a higher-brain criterion is superior
to a whole-brain criterion, in 1968 EEGs could not reliably determine
whether weak electrical impulses were emerging from the brain stem or
elsewhere. As a practical matter, it made sense to include destruction
of the brain stem in the definition of death. It is always safer to
err by treating a corpse as a living person rather than risk treating
a living person as a corpse.

Green and Wikler challenged several standard justifications for the
neurological criterion. Some had defended it by pointing out that
those declared "brain dead" would shortly be dead by cardiac criteria.
But even if some present condition were invariably followed by cardiac
death, that would not entail that one were dead already. Some had
defended it by noting that those declared "brain dead" could no longer
have lives that were subjectively valuable. But even if one no longer
cared about being alive (or anything else), that would not entail
that one had died (though it might mean that one could no longer be
harmed by dying).

Drawing on John Perry's work in metaphysics, Green and Wikler argued
that, despite errors in the standard justifications, the death of the
higher brain really is death. Their reasoning can perhaps be
succinctly captured in two thought experiments.

1. The Getaway: Pursued by the police for heinous crimes, Moriarty
engineers the ultimate escape. Using science fiction technologies, he
arranges to have his higher brain transplanted into the skull of
Alfred, a kidnapped dustman. Recovering from the surgery, he
eventually opens what used to be Alfred's eyes and continues writing
his autobiography using what used to be Alfred's hand.

It would appear that the police should now be looking for a man with
Alfred's body: i.e., Moriarty. The philosophical implication: personal
identity follows the higher brain.

2. The Mishap: In the operating room, Moriarty's higher brain has been
removed and is being carried in a basin to what had been Alfred's
body, with its now vacant cranium. Suddenly the basin-carrier trips,
the grey mass launches into the air and breaks into moist fragments as
it plops onto the floor.

Though what used to be Moriarty's body is still robust, Moriarty has
ceased to exist. The philosophical implication: the death of the
higher brain marks the death of the person.

Considerations like these, and the scientific findings that make them
relevant, are persuasive in showing that higher-brain death marks the
end of personal life.

But what about those islands of neurological activity in patients who
are brain dead according to the tests in current usage? Alas, there is
no reliable, quick, cheap and simple way to rule out the presence of
potentially functional regions; no neurological analog to the mirror
and stethoscope. And even if we could locate and identify the tiniest
active areas, we are far from being able to decide what kinds and
amounts of neurological activity are compatible with a determination
of death.

Though neurology has made enormous progress in recent years, we are
still importantly in the dark. Our legal systems and medical
professions are muddling through the most consequential judgments we
will ever face. But while clinicians are probably doing well enough.
there is a troubling concern that we have left behind the old
paradigms without fully appreciating the life-and-death issues arising
out of the new one.

First published in The Philosophers' Magazine, Issue 27, 3rd Quarter
2004. Reprinted with the permission of the author and the publisher.


================

RECOMMENDED READINGS

McMahan, Jeff. The Ethics of Killing. Oxford University Press: New
York, 2002. Chapter 5, pp. 423-503.

Green, Michael, and Daniel Wikler. 1980. "Brain death and personal
identity." Philosophy and Public Affairs 9:105-133.

John Perry, ed. Personal Identity (Berkely and Los Angeles:
University of California Press: 1975).

Stuart J. Youngner, Robert M. Arnold, Renie Schapiro, eds. Definition
of Death: Contemporary Controversies, (Baltimore: Johns Hopkins
University Press: 1999).
_________________________________________________________________

What is Death? (1)

Defining death should be simple. It used to be simple but now it is very complex and controversial. To start out this thread and “get into the mood”, I would like to post a poem by Walt Whitman “Song of Myself” Part VI where he talks about the grass of the graveyard to help him understand what is happening to those buried there and what they are now representing. The discussion of what is death also deals with the issue of what is personhood. And this is one of the elements of the complexity. ..Maurice.

A child said What is the grass? fetching it to me with full
hands;
How could I answer the child? I do not know what it is any
more than he.
I guess it must be the flag of my disposition, out of hopeful
green stuff woven.

Or I guess if is the handkerchief of the Lord,
A scented gift and remembrancer designedly dropt,
Bearing the owner's name someway in the corners, that we
may see and remark, and say Whose?

Or I guess the grass is itself a child, the produced babe of
the vegetation.

Or I guess it is a uniform hieroglyphic,
And it means, Sprouting alike in broad zones and narrow
zones,
Growing among black folks as among white,
Kanuck, Tuckahoe, Congressman, Cuff, I give them the
same, I receive then the same.

And now it seems to me the beautiful uncut hair of graves.

Tenderly will I use you curling grass,
It may be you transpire from the breasts of young men,
It may be you are from old people, or from offspring taken,
It may be if I had known them I would have loved them,
soon out of their mother's laps,
And here you are the mothers' laps.

This grass is very dark to be from the white heads of old
mothers,
Darker than the colorless beards of old men,
Dark to come from under the faint red roofs of mouths.

O I perceive after all so many uttering tongues,
And I perceive they do not come from the roofs of mouths
for nothing.

I wish I could translate the hints about the dead young men
and women,
And the hints about old men and mothers, and the offspring
taken soon out of their laps.
What do you think has become of the young and old men?
And what do you think has become of the women and
children?

They are alive and well somewhere,
The smallest sprout shows there is really no death,
And if ever there was it led forward life, and does not wait
at the end to arrest it,
And ceas'd the moment life appear'd.

All goes onward and outward, nothing collapses,
And to die is different from what any one supposed, and
luckier.

What is an Ethical Dilemma?

I see that a visitor had been directed to my blog from a web search engine with the question “What is an ethical dilemma?” I am not sure that I have defined this term previously. I would like to do so now. I found a definition noted by T.Y. Lee to which I agree. The examples below, however, are my own. Maybe a valuable mind game would be to think of some other examples.

“What is an ethical dilemma?” It is a Conflict between…

Ones PERSONAL and PROFESSIONAL values
A physician has a duty to his family (go to the football game) but he also has a duty to the patient (admit the patient to the hospital).

Two values/ethical PRINCIPLES
A patient has right to reject a treatment (autonomy) but a physician has a responsibility to protect the patient from a harmful decision (non-malificence)

Two possible actions, each with reasons strongly FAVORABLE and UNFAVORABLE
Treating the patient with a drug which though may have bad side-effects could possibly improve patient’s illness but by withholding the drug the patient has a possible chance of spontaneously improving and not be burdened by the bad side effects of a drug.

Two UNSATISFACTORY alternatives
The patient with terminal cancer who has stopped breathing will die quickly if nothing is done but his family would not be able to arrive soon enough to be with him before the patient’s death. However intubating the patient and putting the patient on a respirator will allow time for the family to come to visit him but only prolong an uncomfortable period of dying.

One’s VALUES/PRINCIPLES and one’s PERCEIVED ROLE
A physician has personal values that define abortion as immoral and yet as an obstetrician in a small community far from medical centers is now asked by a long-time patient to perform an abortion.

The need to ACT and the need to REFLECT
The psychiatrist suspects that his patient might commit a homicide and should notify authorities about his suspicion but he is uncertain that he should divulge to the authorities the patient’s private history without more proof of the patient’s intentions.

An important point about ethical dilemmas to carry away is that it is wise to try to avoid the situation, if possible, where they can occur but also one should be aware that not all ethical dilemmas if they do occur are settled to everyone’s satisfaction. Often in medical ethical dilemmas, it requires some consensus amongst the public and/or physicians, ethicists, lawyers and the courts to provide guidance.

I hope this posting helps those who wonder what are ethical dilemmas. ..Maurice.

ADDENDUM 9-2-2008: Those who would like to "play" ethicist and try to solve some hypothetical ethical dilemmas, after you have, if desired, read the comments or posted here, you may go to the "Ethical Dilemmas:Playing Ethicist: Almost Anyone Can Do It" thread.

Standardized Patients, Actors, Acting in Medical School Teaching and Empathy

As a follow-up on the issue of teaching medical students empathy through method-acting, I would like to point out that acting out clinical encounters is going on all the time in medical school teaching. If you don’t already know of the role of “standardized patients” as used for this teaching, read on.

For a number of years, more and more medical schools have incorporated professional actors in their teaching programs related to the first and second year students learning how to take a history and how to perform a physical examination. These actors are trained to provide the students with a simulation of a real patient, a clinical case, but with teaching advantages included. Those advantages include interviewing and examining in a non-threatening environment, with the support of a group of fellow students and the instructor-facilitator. This is in contrast to the experience “on the hospital wards” where the students are often alone with a patient and have to struggle with their own uncertainties and inexperience with no immediate assistance.

With the standardized patient, the student who is doing the interviewing can, when their own ability to know what to say or what to do next fails, can call a “time out”. The interview may abruptly stop, with the standardized patient ignoring what follows and the student can then communicate with his or her colleagues and the facilitator for help. When “time in” is called the interview proceeds as though there was no break. Another advantage for the students is the feedback that the standardized patient actor, who is again trained for this function, can deliver to the students. The actor can express how he or she, in the role they played, reacted to the questions and behavior of the student and provide valuable constructive criticism or encouragement to the student. This kind of feedback is not uniformly available from the real patients the student examines. Standardized patients can also provide a more comfortable environment for the student to practice physical examination. Though often pathologic findings may be absent, nevertheless on occasion a standardized patient with an abnormal physical finding may be discovered this becomes a valuable asset.

My experience with teaching first and second year medical students, even when they are role-playing the doctor and patient, is that we never encourage their “acting” out a certain behavior toward the patient except to keep in mind the requirement to be professional in their relationship with their patient with the goal of caring, being empathetic, therapeutic and beneficent.

Teaching “light empathy” as described in the literature, is essentially acting to maintain an emotional posture which is acceptable by the patient even though the student is upset with the patient or has moral differences of opinion but with no real understanding of the patient’s motivations and no intent to change the student’s own attitude or emotions, This may be effective and financially rewarding if the student was going into a non-medical care business but I think is unacceptable in medicine.

If anything, “deep empathy” is worthy of teaching where there is no acting in a theatrical sense. With “deep empathy”, the student is encouraged to pay attention to and try to understand what the patient is going through and try to understand his or her own emotions based on a previous similar personal experience. For example, for a patient complaining of pain, the student might remember some injury long ago which caused pain but the student didn’t know the severity of the injury or how long it would last or whether there would be residuals. Would there be some similarity of how the student felt with that the patient is feeling currently? With this contemplation, the student may be able change his or her own feelings about the patient and the patient’s perhaps disturbing reaction to pain.

So this is what I can tell you about “acting” as a part of the teaching clinical medicine in medical school. I hope it has given those visitors who have not been involved in such teaching an idea of what is going on these days. ..Maurice.

Should Doctors Cry? (3)

No. Doctors may shed one tear as part of the empathetic understanding of the patient's situation. But frank crying represents true sympathy and sympathy is not a therapeutic behavior for a physician towards a patient.

Read this poem by George Elliot, the English novelist, titled "Empathy" detailing a relationship which could represent what a patient sees in an empathetic physician.

Oh, the comfort, the inexpressible
Comfort of feeling safe with a person,
Having neither to weight thoughts,
Nor measure words--but pouring them
All right out--just as they are
Chaff and grain together,
Certain that a faithful hand will
Take and sift them,
Keep what is worth keeping,
And with the breath of kindness
Blow the rest away.

..Maurice.

Leading Questions Make for Questionable Answers

It is not unusual to hear about the use of a leading question (where the answer is implied in the question) as a physician or nurse or family member attempts to get an advance directive regarding “do not resusitate” or “no intubation” statement or some other treatment decision from a sick hospitalized patient. The leading question may come in the form of “You don’t want to be intubated and suffer the discomfort, do you?” or “You don’t want them to pull the plug”, “You want everything done, don’t you?” Often there might not be a whole lot more of an explanation to a patient who is more concerned at the moment with the discomfort and suffering of the illness or who is in a somewhat mentally obtunded state. Use of these questions, in this way or even if given as a direct question such as “Do you want everything done?” is hardly the way to ask a sick patient to make a decision. It really comes down to “what is everything?”, “what is going to be done and how effective will it be to achieve the goals of the patient?” “What does pulling the plug actually mean? Is it to terminate unwanted treatment that is keeping the patient alive or is also to terminate needed comfort care?” Unfortunately when these decisions are left to the last minute, there doesn’t seem to be enough time, enough knowledge or just plain not enough understanding about how to communicate to be certain that the patient’s answer is what the patient really wants. And if answers to these questions are acted on as valid, well.. someone is fooling themselves.

These questions which may be requesting life and death decisions on the part of the patient deserve first a careful evaluation of the patient’s mental capacity to make medical decisions. Secondly it requires the questioner to provide some reasonable detail of the clinical situation so that the patient can make an informed decision. And finally, questions should be presented to the patient in non-coercive ways with the absence of leading questions. Leading questions are acceptable in the courtroom but never in medical communication. I want to emphasize that the proper communication with the patient should apply not only to the healthcare workers but also to family members who quiz the patient about their wishes.

As I have noted above, the first duty of anyone trying to obtain a medical decision from a patient is to verify that the patient has the mental capacity to form that decision for themselves. This is best determined by the patient’s physician. It is usually not necessary to request a psychiatric consultation to make the determination. The method is relatively simple. The patient should be alert, oriented and able to communicate. The patient should be able to demonstrate at least good short-term memory so that when information is presented or questions asked by the examiner, the patient will be able to recollect at the time of making a decision. The next step is to test the patient’s judgment. “You find an envelope on the sidewalk which has an address printed on it and bears an uncancelled stamp, what should you do?” What would you do? The examiner knows the correct answer, does the patient? If the patient passes this far, the next steps would deal with the clinical situation. I would suggest the following questions to see if the patient understands the significance of a personal medical decision. The examiner might not use these exact words but the request should be used in these contexts: 1) “Tell me what you know about your illness, treatment, result of treatment or no treatment” 2) Then instruct the patient regarding the illness, treatment and the result of treatment or no treatment.
3) Now discover whether the patient has learned from the examiner’s explanations. “Can you tell me what you now understand about your illness, treatment, result of treatment or no treatment?” 4) “What is your hope, goal or wish?” 5) “What would you want to be done about your illness?” 6) “Tell me why you decided as you did.” Notice that none of the questions are leading questions and the question 5 which requests a decision is open-ended in that it doesn’t give any hints of what could or could not be decided. From the answers to these questions and particularly question 6, the examiner might sense some significant depression. In this event, consultation with a psychiatrist might be helpful.

All of the above discourse is my own personal opinion and my way of thinking of how to make for a medical decision by the patient that one can feel confident that it will represent a truly autonomous and informed decision and that one has confidence that acting on it will be fair and ethical. I would appreciate reading any visitors views of this important part of medical care based on their own past experience. ..Maurice.

Should Doctors Cry (2): Empathy vs Sympathy

In the Fall 2003 issue of the Permanente Journal, James Hardee, M.D. presents what I feel is a very good overview of empathy and how it is different from sympathy. I have extracted the following from the Conclusion. Please read the entire article.

Despite some divergent opinion on the matter, we may propose a subtle but important distinction between empathy and sympathy.

Whereas empathy is used by skilled clinicians to enhance communication and delivery of care, sympathy can be burdensome and emotionally exhausting and can lead to burnout. Sympathy implies feeling shared with the sufferer as if the pain belonged to both persons: We sympathize with other human beings when we share and suffer with them. It would stand to reason, therefore, that completely shared suffering can never exist between physician and patient; otherwise, the physician would share the patient's plight and would therefore be unable to help.

Empathy is concerned with a much higher order of human relationship and understanding: engaged detachment. In empathy, we 'borrow' another's feelings to observe, feel, and understand them--but not to take them onto ourselves. By being a participant-observer, we come to understand how the other person feels. An empathetic observer enters into the equation and then is removed.

Harry Wilmer (Wilmer HA. The doctor-patient relationship and issues of pity, sympathy and empathy. Br J Med Psychol 1968 Sep;41(3):243-8.) summarizes these three emotions--Empathy, Sympathy, and Pity--as follows:

* Pity describes a relationship which separates physician and patient. Pity is often condescending and may entail feelings of contempt and rejection.
* Sympathy is when the physician experiences feelings as if he or she were the sufferer. Sympathy is thus shared suffering.
* Empathy is the feeling relationship in which the physician understands the patient's plight as if the physician were the patient. The physician identifies with the patient and at the same time maintains a distance. Empathetic communication enhances the therapeutic effectiveness of the clinician-patient relationship.

One of the difficulties written about in becoming truely empathetic is how we can "borrow" the true feelings of the patient, if physicians themselves have never experienced the same or similar stories. And even if the physicians did, might not their own individual past history, their own strengths and weaknesses affect their understanding of their patient's suffering? It is difficult but there is no doubt that not to provide empathy to a patient represents a great absence in the relationship and can have consequences for the patient's health. Empathy is the way to therapeutically and spiritually "connect" to the patient. This connection, if and when it occurs, is felt both on the part of the patient and also the physician. In fact, physicians will tell you that at the moment of this connection the physician may experience "goose-bumps", this event having such a physiological effect.

More on empathy later. ..Maurice.

Should Doctors Cry? (1)

Go to retired doc's thoughts where James writes his views of the article in the March 2, 2005 issue of JAMA by E.B. Larson and X. Yao who suggested that method acting be part of the training and use by physicians in creating effective empathy in the patient-doctor relationship. I wrote a comment there but I also wanted to extend the issue a bit here on my blog.

One of the emotional issues which my first year medical students experience and are concerned about is what should they do if the story related by the patient in the bed in front of them is causing the student to feel so sad that tears are welling up in the student's eyes. They ask because they have experinced this reaction. The students ask me "should doctors cry?"

In view of the article, the question arises should doctors be actors and train to supress any emotional unsupportive response on their part whether sadness or anger or any form of irritability? And in the other direction, should they act fresh, composed, in tip-top mental and physical condition, happy and encouraging even when the doctor feels just the opposite? After all, shouldn't the doctor always be therapeutic in their behavior to the patient and wouldn't showing the wrong emotion be not helpful for the patient?

Before I go on any further, I would like to read the views of my visitors, both as a patient or as a physician, on this subject. ..Maurice.

Putting “Baby” to Rest

My visitors may have wondered why I needed to write four days of postings for a movie. After all isn’t a movie just a movie. I suppose what that expression could mean is that a movie is valuable for its financial benefit to the producers, for its “escape” value to its viewers who want to get into another life for an hour or two and for the ego and perhaps for the pocket books of its staff and casts if the result is to win an Oscar. Do you think I missed something else of value? Sure. A movie can be a life-moment teaching/learning experience if it brings to the screen what the viewer appreciates as a bit of his or her life or experience or awareness. When the viewer can fully understand and identify with the life of the characters as one easily can in “Baby”, what goes on around the character and what happens to the character is significant to bring about that learning moment, adding something new and important to the viewer’s life experience and knowledge. That is why it is important that what the viewer carries away is something of value for their own life and experience. I think that “Baby” missed the opportunity to do that very thing.
Well, you might say, many movies, maybe even the previous ones that Clint played in, nobody cares about unethical or illegal behavior within the film or at the ending. It’s a “shoot-em up” story. But “Baby” is different. The film is so powerful that I am sure the vast majority of the audience felt personally understanding and emotionally attached to each of the major characters. And when it came to the very ending, what was taken away was something not in keeping with the power of the rest of the film but something tawdry and misleading. What are all those viewers who are or have family members who are severely disabled or who are in a medically terminal condition going to think about what ethical and legal alternatives there are available for them?

Look.. one of the biggest problems physicians face when caring for critically ill patients is ignorance but also misunderstanding by the public about the facts and options in the management of the seriously ill. This misunderstanding is derived from a number of factors including poor physician communication but also by distortions presented on TV medical programs and stories, direct to consumer advertising and the comments of the over-the-fence neighbor amongst others. This lack or misinformation leads to ethical conflicts often between patients, their families and the healthcare providers. As a chairperson of a hospital ethics committee, I can tell you that this provides work for us but I would like to see ethical issues that have already been solved years ago not to arise again and be brought to the ethics committee for the conflict resolution. The newer issues where there is no ethical consensus.. those are the ones we want!

So this why I and others interested in medical ethics would have been pleased if there was a more simple, ethical, legal and realistic ending to such a fine motion picture as “Million Dollar Baby”. And with this final commentary, I will put “Baby” to rest. ..Maurice.