"Erst kommt das Fressen, dann kommt die Moral"--first comes a full stomach, then comes ethics

With the first partial face transplant carried out in France, there is much in the news about this event and the ethics involved. I am not sure, if face transplants are to be carried out only to rehabilitate the injured or diseased faces, that there is much ethical debate necessary. The main ethical requirement, as with other surgery and experimental procedures, is that the patient be fully informed as to the risks and expected outcome before patient consent is given. It is doubtful that any total face transplant will result in the same face and facial expressions that were present on the donor.

There is another issue, however, which this news has brought out. That issue is regarding the work of the professional ethicists with regard to investigating societal issues in ethical terms and if these issues are found ethically wanting then to publicize the problem and suggest ethical remediation. To some, it appears that bioethicists have, in recent decades, seemingly devoted their time and energy to what has been considered as minor ethical issues when greater ethical issues loom in the United States and throughout the world.

One such critic of current bioethical concerns is Dr Erich H. Loewy,
Professor of Medicine (emeritus), Founding Alumni Association Chair of Bioethics, Associate of Philosophy, University of California, Davis. He has repeatedly argued in favor of ethicists dealing with those bigger issues.
He wrote the following comments to a bioethics listserv today and I have obtained permission from him to reproduce his comments here below. As you read in the newspapers and watch on TV what ethical issues are discussed by the ethics consultants, do you think that there is merit to Dr. Loewy’s concerns? ..Maurice.

I do not--from a technical point of view--know enough about facial transplant to say anything worthwhile. If the technique works well, then accident, burn, etc. victims
most certainly be allowed to benefit from this just like a man with an accidentally amputated limb should have a prosthesis. My fear is that now this will become another plastic surgery device for the rich and well-born like liposuction, etc. It is interesting that on the German discussion list we have for two weeks discussed what is called BID (body image distortion) and doing amputations of perfectly healthy limbs because the person allegedly feels that their body image requires such a reputation. My own feeling is that this is probably a psychiatric problem, that the patient belongs under psychiatric care and above all whether such an amputation actually heals or whether three weeks later they must have some other part chopped off. Then, of course, they are entitled to support for the disabled, etc., etc. should this be called the "Van Gogh Syndrome?" It is remarkable that anorexia nervosa or bulimia is rare in the Ghetto.

In a time and age where poverty throughout the world is widespread, where going without basic health care (either in the US in the uninsured) or in the developing world because basic things are lacking we should really waste our time discussing these "far out" problems rather than concentrating our energy on filling empty stomachs, giving to all access to basic health care and education, etc. I feel that we spend far too much time on "rich man's ethics" (partly because that's were the power is) and far too little on innovative ways of bringing good basic health care and eliminating crass poverty for all.

Ms. Blare--who works on an $ 8.50 job, has not enough to feed her child (this is beneath the poverty line), has no time to be trained for a better job and has no time to do so seems a more worthy subject of discussion than the ownership of a dead man's sperm, BID or facial transplants. We do (or ought to) have priorities in what we spend our time doing. And in my view poverty, malarial swamps, universal health care, hunger, poor education, exploitation of the "developing world" using children to work and produce inexpensive matting for our patio are far more important subjects. "People live lives of quiet desperation" is, I think, true enough.

Brecht in his three penny opera put it, I think, quite right: "Erst kommt das Fressen, dann kommt die Moral"--first comes a full stomach, then comes ethics.

Patients as Teachers: Time for Giving Thanks

During this season of the year characterized by a holiday of extending thanks, there is one class of people for whom, I think, physicians fail to recognize in this regard: their patients. And the thanksgiving is not for the patients’ contribution to the finances of the doctors. It is for their unending role as teachers to their physicians.

One may wonder about the relationship between patients and teaching. But in our world of medical care, patients actually provide two forms of teaching: passive and active. Passive teaching is one that is certainly the most common and the least recognized. It starts literally from almost the first day of medical school when the medical student faces the daunting task of dissecting their first patient (or in non-humanistic terms, their anatomic cadaver.) It is the deceased patient who provides the student with the map of the human body but also something more. The deceased, by the cold, stiff, non-breathing, non-heart beating existence of a previously live and living human creature, now in death teaches the student about the ultimate outcome of all life and the lesson: the need for respect of persons both in life and in death since even physicians share the same fate.

And then the passive teaching goes on as the students begin interviewing and later examining their real patients. I have witnessed, while facilitating first and second year medical students when they are doing this activity, first hand. Each patient with their own individual history gives their own take on their disease, the symptoms, course, response to treatment and the effect on their quality of life and goals, a lesson that cannot be simulated by any textbook. In addition, patients are often technically wiser about their disease than the student at the time and can educate the student as to the details in diagnosis and treatment.

Later, in the medical career, the physician now is practicing medicine. Practicing represent still learning. It is their patients who continue the learning process by providing the physician with their varied history and therapeutic responses to the same established diagnosis. The value of this passive teaching to the doctor who stays aware and recognizes the teaching is enormous. I believe it is for these learning moments and hours to the student and later the physician in practice from the patients themselves which deserve the thanks.

Finally, and perhaps not fully known by the public, is the developing role of patients in the active teaching of students. So-called “standardized patients”, which I have discussed on previous postings, have been in existence for medical education for a number of years. These “patients”, of course, are not really patients but are actors trained to present as patients to the students both for history taking and physical examination. As you might imagine, it is difficult indeed to find actors with physical signs of the required illness. A new trend in medical education is the use of trained genuine patients. A patient who has the disease and the physical findings can be trained how to teach the students. The patient, therefore, can speak to the student with true understanding of the pain or impact of a disease (only attempted to be simulated by the standardized patient) and also have additionally the physical finding to go with the disease. (To read more about trained patient teachers go to the following link BMJ 2002;325:818-821 ( 12 October ))

For me, as a medical school facilitator, I have personally thanked many patients for their participation with my medical students. As a physician of many years, I really never directly thanked a patient for teaching me though I recall complimenting patients as being “good patients” but unfortunately never as “good teachers”. Maybe now is the time, at least, to blog my thanks to all the patients. ..Maurice.

A History of Medical Professionalism and Ethics and Some Questions

As a segue from the previous posting about the medical professionalism issue of Dr. Vlasak’s speech and also as a followup on a number of previous postings on “physicians wearing two hats” and other professionalism issues and along with current concerns about the treatment or torture of military prisoners, I have posted below a very good brief summary of the history of medical professionalism and ethics which was recently written to a bioethics listserv. The author, from whom I have permission to reproduce his writing here, is Robert Baker, PhD, Chair, Alden March Bioethics Institute
Professor of Bioethics, Graduate College of Union University and
Professor of Philosophy, Union College. Read the history and then maybe you could comment on what points in medical professionalism you would emphasize in terms of physician public advocacy or simultaneously wearing another occupational hat if you were writing a code of ethics for doctors. ..Maurice.

The modern concept of a professional is absent from eighteenth century English (e.g. is not to be found in Dr. Samuel Johnson's Dictionary 1755 and later eds.) emerging in the early nineteenth century initially in Percival's Medical Ethics (1803). In that book Percival looks back to Cicero and Stoic philosophy (the source of an early effort to create a notion of professionalism by the Greek physician Scribonius Largus, fl. 14-54 CE ) to offer the concept of an occupational role, that of physicians and/or surgeons, whose obligations--because they entail duties of service to others--transcend that of mere employee, and whose prerogatives are justified by an implicit social contract which makes their position a "public trust" (Percival's words). Percival's innovative conception was ignored by physicians and surgeons everywhere--except for a few receptive young men in America. These men would ultimately draft a code of medical ethics for the AMA in 1847. By means of the code and the AMA the concept of being a professional (and the correlative notion of unprofessional conduct) gradually displaced the older conception of the physician as gentleman bound by precepts of gentlemanly honor. American conceptions of professionalism and professional ethics--with it presumptions of competence formally bound by medical ethics-- did not definitively displace older concept of honor until the end of WWII (a post-Holocaust/post-Nuremberg phenomenon).

To teach professionalism, in my view, is to teach both how and why the concept was constructed, as well as the nature and limitations of its construction--it is to teach the lived experience of medicine, the history of its response and failures to respond to a variety of challenges.

More specifically, it is not self-evident that physicians shouldn't act as patriots, and use their medical knowledge to aid their countryman and to thwart its enemies.

Hippocrates VITAE --a life of Hippocrates written some time after his death--states clearly that Hippocrates refused to treat Persians suffering from a plague because they were the enemies of the Greeks. Benjamin Rush (1745-1813) lectured to his students using this example to argue that physicians must be patriots.

(See: Jouanna, Jacques. Hipporcrate Translated as Hippocrates by M. B. DeBevoise (Baltimore, MD: Johns Hopkins University Press, 1999; Temkin, Owsei. Hippocrates in a World of Pagans and Christians. (Baltimore, MD: Johns Hopkins University Press, 1991).


The notion that physicians are above the battle and should treat the wounded from all sides emerges from military medicine. It becomes wedded to professionalism only after the formation of the World Medical Association in 1947 and is a post-Holocaust phenomenon. Hence the importance of teaching not only the Nuremberg trials--but the international codes of medical ethics, oaths and declarations that derive from them.

As physicians became involved in military conflicts in the second half of the twentieth century-- British physicians' treatment of IRA hunger strikers, the revelations of physician complicity at the South African Truth and Reconciliation Hearings (http://shr.aaas.org/trc-med/default.htm ), etc.,--medical societies began to rethink the obligations of physicians.

What sort of medical care/information should they supply in these contexts? Should they force feed prisoners? Do they have a professional obligation to protest torture? To reveal what they see? etc.

Free Speech vs Ethics of Medical Professionalism: Is There a Boundary?

Did anyone watch CBS's "60 Minutes" on Sunday? The one segment I wish to consider is the one on "eco-terrorists" and particularly the Animal Liberation Front and Dr. Jerry Vlasak, a practicing trauma surgeon in Southern California, who is an apparent spokesperson for some extreme animal rights groups and who has told audiences that it is time to consider assassinating people who do research on animals.

The Animal Liberation Front (ALF) website quotes Dr. Vlasak as saying:

“I think there is a use for violence in our movement. And I think it can be an effective strategy. Not only is it morally acceptable, I think that there are places where it could be used quite effectively from a pragmatic standpoint.

For instance, if vivisectors were routinely being killed, I think it would give other vivisectors pause in what they were doing in their work - and if these vivisectors were being targeted for assassination, and call it political assassination or what have you, I think if -- and I wouldn't pick some guy way down the totem pole, but if there were prominent vivisectors being assassinated, I think that there would be a trickle-down effect and many, many people who are lower on that totem pole would say, ‘I'm not going to get into this business because it's a very dangerous business and there's other things I can do with my life that don't involve getting into a dangerous business.’ And I think that the -- strictly from a fear and intimidation factor, that would be an effective tactic.[ Ref: Dr. Jerry Vlasak Replies to Media Libel]

And I don't think you'd have to kill -- assassinate -- too many vivisectors before you would see a marked decrease in the amount of vivisection going on. And I think for 5 lives, 10 lives, 15 human lives, we could save a million, 2 million, 10 million non-human animals.

And I -- you know - people get all excited about, "Oh what's going to happen when - the ALF accidentally kills somebody in an arson?" Well, you know I mean -- I think we need to get used to this idea. It's going to happen, okay? It's going to happen.”

In the ALF link above, the Animal Liberation Front defends Dr. Vlasak’s comments with:

In making these claims, Vlasak certainly entered into controversial territory, shocked and angered vivisectors and other speciesists, and even got banned from the UK. But his words fall squarely within the First Amendment of the US Constitution and therefore are constitutionally protected. The very essence of the First Amendment is to protect unpopular speech, words that many people might find offensive and objectionable, statements such as Vlasak made at the AR2003 conference. Everyone knows that exploiters of any kind love free speech so long as they are the ones using it in honor of their detestable motives and unconscionable actions. Had Vlasak actually advocated violence against vivisectors in such a way as to incite and possibly provoke immanent violence, he would have crossed a legal line. Despite the frenzied distortions of critics who favor violence toward animals but not toward humans, Vlasak in fact did not cross this line.

My concern is not about Dr. Vlasak’s view on the treatment of animals. He has every right to his view and to his wide-spread dissemination of his view even as a physician. Incidentally, with regard to that view, it is difficult for me to understand the rationale a physician against animal research can give treating emergency room patients with instruments and drugs and procedures that are the result of animal experimentation. On the other hand I wonder how a humanistic physician can have compassion for a patient and working for patient survival and at the same time bear views and at times broadcasting the suggestion to kill those humans with whom he disagrees but who have not committed any crime or penalized with a death sentence by the courts?

The issue I would like to present is whether speech that may be considered as free speech and within legal bounds for a layperson becomes restricted speech for a physician. In other words, does becoming a physician and accepting the professional role as set by society, sets a boundary to free speech which is limited by the ethics set by the profession of medicine. All physicians, I believe, should be humanistic in their intent and their acts. Thus speech by a physician should not be free that encourages vigilantes to kill persons carrying out some unacceptable but legal activities. ..Maurice.

More on Politics and Religion Trumping Science

It seems to me very likely that the FDAs rejection of over-the-counter availability for Plan B was an example of politics and religion acting to trump science and setting restrictions on what should be autonomous personal behavior. I would like to present another gross example of such trumping, through the HIV/AIDS prevention and treatment funds for Africa provided by the U.S. government. This behavior of the U.S. government may have an even more disastrous effect than the restrictions of Plan B procurement.

The Human Rights Watch, in their most recent study, presents us with the situation in Uganda where previous improvement in the HIV/AIDS epidemic is now worsening and suggests the cause may be the restriction of funding unless the teaching is that abstinence until marriage is the primary approach and general condom use is to be de-emphasized. The statistical facts regarding the weakness of abstinence teaching in preventing HIV/AIDS and the scientifically known strength of condoms is ignored by the U.S. funding source. Please read the following Conclusion and go to the above link to read the entire report. ..Maurice.

As an activist and woman living with AIDS, it makes me feel judged. You are supposed to abstain and be faithful. Condoms are only for those who are promiscuous. I got HIV in marriage. I was faithful in my relationship. The battle to come out and be open was a struggle. Now, instead of moving forward, we are moving strides back.
—Ugandan woman living with AIDS

Uganda is unique among African nations for its early and high-level leadership against HIV/AIDS. The government’s willingness to address HIV/AIDS openly and break taboos surrounding sexually transmitted diseases is widely acknowledged as the cornerstone of its early success against the epidemic. By involving a wide range of nongovernmental organizations in the AIDS struggle and allowing candid messages about sex to reach a wide audience, Uganda achieved high levels of awareness of HIV, increased voluntary HIV testing, and ultimately fewer new HIV infections.
Today, this progress may unravel as U.S.-funded organizations scale up programs that promote sexual abstinence and fidelity within heterosexual marriage to the exclusion of all other HIV prevention strategies. These programs deprive young people of information that could save their lives. They mock the plight of countless Ugandan women and girls who abstain until marriage and are faithful within it but nevertheless become infected with HIV. They provide scant information or assistance to those at highest risk of HIV infection, including street children who trade sex for survival, children affected by conflict, and lesbian, gay, bisexual, and transgender youth. They distort factual information about condoms and safer sex strategies, placing young people at a higher risk of HIV and other sexually transmitted diseases.

As their proponents admit, abstinence-only programs are not simply about preventing HIV/AIDS, but about promoting moral values. However, censoring or distorting factual information about HIV/AIDS is not a moral value. Moreover, casting HIV/AIDS as a “moral” disease that results from “promiscuity”—as abstinence-only programs invariably do—reinforces the deadly stigma associated with HIV/AIDS. Throughout the 1990s, Uganda stood for the idea that AIDS could affect anyone, not simply “promiscuous” people. This idea proved critical to respecting the human rights of people living with AIDS and protecting them from violence and discrimination. Now, abstinence-only programs give Ugandans a new reason to stigmatize people living with AIDS and to judge their actions as immoral or blameworthy.

To its credit, Uganda continues to recognize that its young people face a high risk of HIV infection and has faced up to that challenge by expanding school-based sex education programs. However, as a perceived global leader in HIV prevention, Uganda is accountable to evidence and best practices in HIV prevention. The country’s high-profile U-turn toward unproven HIV prevention strategies for young people has, at this writing, already begun to resonate throughout other parts of Africa. Its complicity in the rewriting of history around its HIV prevention “success” could have implications on HIV prevention programs for years to come. Ultimately, it is not just Ugandans who will pay the price for the country’s back-steps in HIV prevention. It is the entire effort against the global AIDS pandemic.

Plan B and FDA: Why Can't Science Trump Politics?

From today’s San Jose Mercury News, the following headline and the following article excerpt


Report stokes charges of political meddling over `morning after' pill

BY TONY PUGH

WASHINGTON - Top officials at the Food and Drug Administration appear to have decided to block over-the-counter sales of a controversial emergency contraceptive months before completing their review of the application in 2004, a new government report said Monday.
According to the Government Accountability Office, top officials - some of them political appointees of President Bush - took "unusual" steps to impede the approval process.
The GAO's findings renew accusations of political meddling at the FDA, which has been criticized for more than two years for failing to bring the Plan B contraceptive to market despite the urging of its scientific staff. ...
Dr. Janet Woodcock, the FDA's deputy commissioner for operations, denied the allegations as well in a written response filed with the GAO. ...
In a written response to the report, the FDA's Woodcock took issue with its contention that high-level FDA management was more involved in the Plan B review than usual. She said the level of public interest necessitated the involvement of top officials at the FDA's Center for Drug Evaluation and Research.

I think it is pitiful that a governmental agency whose duty is to protect the public is apparently, in my view, simply protecting the votes for some politicians; another example of FDA organizational unethics. ..Maurice.

More on Organ Transplant Injustice and Uncertainties

Our United States government continues to call for more organs to be procured and the transplant programs continue, but is the whole program as thought out and transparent as it could be? The U.S. organ transplant program with its social as well as clinical consequences is not as uncomplicated and rosy as those who are not involved might think. There is much uncertainty for recipient patients and their families if the patient is put on a organ waiting list such as how long is the wait going to be, will an organ be available before the patient dies and if one is transplanted what complications will occur, what will be the quality of life and how long will life be extended. There are protocols for the just distribution of organs but as seen in the case of St.Vincent Medical Center, unknown to the patients and their families, they don’t always work.

To demonstrate some of the uncertainties patients experience, two visitors recently wrote me the following comments and questions about the transplantation process.

“I received a liver transplant last year. The group that I was with in the post transplant clinic had a mean age of 50. Most of them have HCV, and most will be asking for a retransplant within 5 years. If retransplanted, %35 will not leave the hospital. The long term survival rate for the rest is all over the grid.

Should retransplant even be reconsidered? If so, who gets one? “



From another visitor:




“I recieved a liver tramsplant a year ago June. Like the majority of liver transplant patients( LTP) I have HCV. The HCV returned within a year. I went from stage 1 to stage 3.5 in 6 months.

There is no protocol for re-transplantation of HCV patients. Many are never the less performed on a "case by case" basis.

Having a retransplant performed in India is an option. $ 75 grand and a partial donor in-tow seems to be all they require. Their sucess rate seems to be inline with many domestic institutes. The primary motivation of the Indians is money. Oh yea, the Solons of our domestic medical institutes claim to be above such pedestrian motives as money; try to get a transplant without it.

So, does one take $ 75 grand, plus, and lawyer-up, and then take it your former life savers. Or does one blast off to New Delhi in hopes of a sucessful outcome?”


Finally, from the November 10, 2005 issue of the Los Angeles Times,I have excerpted the following disclosure which would be unpleasant news for patients and families involved regarding what has been going on at the University of California at Irvine. Please go to the link above and read the entire article.

Irvine Liver Transplant Program Loses Government Approval
By Charles Ornstein and Alan Zarembo, Times Staff Writers

The federal government today rescinded its approval for the liver transplant program at UC Irvine Medical Center after The Times reported that more than 30 people died awaiting liver transplants in the last two years as the hospital turned down scores of donated organs. …

The move means that many of the 106 patients on UC Irvine's waiting list for a liver transplant will have to be transferred to lists at other hospitals. Twenty eight of those people were added to the roster this year -- despite a staffing shortage that dampens their prospects for a transplant.
Although patients may not know it, the UC Irvine Medical Center has not had a full-time liver transplant surgeon since July 2004…

The low number of surgeries was not because of a lack of offers. Between August 2004 and July 2005, the hospital received 122 liver offers, most of them from the regional organ procurement agency, which coordinates donations and offers in Southern California. But only 12 were transplanted, including two that went to the same patient because the first one failed, according to an Aug. 5 federal report obtained by The Times under the Freedom of Information Act.

Even when patients did get transplants, the report says, they did not fare as well as they should have. Only 68.6% of patients who received liver transplants at UCI from January 2002 to June 2004 survived at least a year -- well below the 77% survival rate required for federal certification.

What does this all mean? You tell me! ..Maurice.

AMA on Torture (2): Potential Conflict Between Ethics and Law

I really didn’t know the answer to my concern regarding the opinion presented by the AMA I posed in my last post on Torture, so I wrote to a bioethics listserv to which I subscribe: “Is this opinion of the AMA applicable to physicians in the U.S. armed forces or to any physicians who might be working in the Central Intelligence Agency?” Herbert Rakatansky, M.D., a former member of the American Medical Association Council on Ethical and Judicial Affairs (CEJA) wrote back to the list the following, which is reproduced here with Dr. Rakatansky’s permission.


CEJA Opinions are standards of professional behavior. They carry a moral imperative but have no legal power. A government such as a state may adopt them as standards and apply them as it sees fit. Most states use the AMA Code as a reference standard for what constitutes professional behavior, There is a printed version of the Code which is annotated with legal decisions from state and federal courts in which the Code is cited as part of the court decision. In the latest version (2004-5) the Opinion on torture has no citations. Just for example, the Opinion on capital punishment has 41 citations. So the CEJA Opinions carry the same moral weight for all physicians regardless of who they work for. It would be very dangerous for an employer, private or governmental to assert that ethical standards do not apply to it’s employees. If the employer is a government then some physician behaviors may be legal but not ethical . (Shades of Soviet Russia, Nazi Germany, etc.) We have a situation right now in [Rhode Island] where a convicted schizophrenic violent sex offender has reached the end of his sentence. The state has ordered a physician employed by the state to keep him locked up in the hospital. The physician feels that person does not need hospital level care – though he may need to be separated from society. That doctor has resigned from his state job citing the Code as part of his reason. I wrote an op-ed published in the Providence Journal which follows. The Code applies to all – enforcement is variable but doctors have the right and perhaps the obligation to consider the Opinions as a basis for their professional behavior. Herbert Rakatansky, M.D., FACP, FACG Clinical Professor of Medicine, Brown University


Herbert Rakatansky: Patients as prisoners

01:00 AM EST on Friday, November 4, 2005

THE CASE of the Rhode Island sex offender Todd McElroy, who has reached the terminus of his sentence but will remain locked up in a state psychiatric ward, has created a controversy. There are some who think he is a risk to society if released, and others who suggest that he has paid his price and should be released into some "observational" and supervised status.
He apparently has a diagnosis of schizophrenia and perhaps other disorders. Many schizophrenics do quite well on medications. Hospitalizations tend to be short, and devoted to resolving acute situations and resuming or adjusting medications. In our Rhode Island case, then, a transfer to a psychiatric hospital might be medically indicated but of short duration.

Mr. McElroy will be in a state psychiatric ward at least until December, when a judge will determine whether he should be civilly committed for a longer time. The problem of preventing future destructive behavior would not be solved.
The proposition that doctors, at the behest of the state, commit him to hospitalization to isolate him is not acceptable; doctors cannot and should not address this problem. Only the judicial system, with appropriate due process, should have the right to deprive a person of liberty.

If the government believes that it is important to protect society from future criminal behavior, then the legislature and the judiciary must find a way to do this.
The court cannot make a medical diagnosis or prescribe a treatment; nor should it be able to order a doctor to make a specific diagnosis or prescribe a specific treatment, such as long-term hospitalization. (If the court sentences a person and that prisoner develops a physical or mental illness, the appropriate diagnosis and treatment, including hospitalization, are provided, based solely on the medical facts.)

The American Medical Association Code of Ethics addresses the issue of court-ordered treatment. It requires that the diagnosis be made by a doctor who is, in the case of a prisoner, likely to be employed by the state; another doctor, not employed by the state, must confirm the diagnosis.
The medical profession must generally accept the proposed treatment. Having the treatment approved by or included in guidelines approved by a national medical society specifically satisfies this criterion. This prevents a doctor or small group of doctors from administering "far-out," ineffective, or dangerous therapy ordered by the court.

Finally, informed consent must be obtained, to the extent possible, and confirmed by a doctor not employed by the state.
The present situation -- in which the state is asking that a doctor commit a person to an indefinite hospitalization for nonmedical reasons -- is analogous to the approval by the government of doctor participation in torture or execution. These actions may be "legal," but they are not ethical. In these situations, ethics trumps the law. If we accept this concept, there is no qualitative difference between physician participation in state-approved executions and what the doctors did in Nazi Germany. After all, the Nazi state said those experiments were legal. In the totalitarian Soviet Union, many political dissidents were committed to mental hospitals; this was legal, but I doubt that any of us would say that it was ethical.

Another danger is that the government may define such actions as being outside the practice of medicine, thus not allowing the Board of Licensure to deem them unprofessional. It has been said that these situations would never occur at this time in our society. But Illinois has decreed that physician participation in executions is not the practice of medicine. Also think about the recent revelations about doctor participation in torture of Iraqi prisoners.

Our government, at least initially, condoned and perhaps even encouraged these behaviors. Allowing the government to exclude any professional behavior from the definition of medical practice is a bright line that we should never cross!
So what should we do with our prisoner-patient? The legal system must decide whether the evidence substantiates that he is a risk to society, and, if so, deal with this problem. The role of the doctor is to provide the courts with medical data, the diagnosis, the role of treatment, and the expectation of success; the role of the courts is to afford due process and make the decision about deprivation of liberty.

I would not want to go to a doctor who accepted an order by the government to make a certain diagnosis and prescribe treatment that might not be medically indicated. And I doubt that you would want to go to that doctor, either.

Herbert Rakatansky, M.D., is a Brown University professor of medicine.

AMA on Torture

Here is the current American Medical Association ethics statement on torture.

E-2.067 Torture

Torture refers to the deliberate, systematic, or wanton administration of cruel, inhumane, and degrading treatments or punishments during imprisonment or detainment.
Physicians must oppose and must not participate in torture for any reason. Participation in torture includes, but is not limited to, providing or withholding any services, substances, or knowledge to facilitate the practice of torture. Physicians must not be present when torture is used or threatened.
Physicians may treat prisoners or detainees if doing so is in their best interest, but physicians should not treat individuals to verify their health so that torture can begin or continue. Physicians who treat torture victims should not be persecuted. Physicians should help provide support for victims of torture and, whenever possible, strive to change situations in which torture is practiced or the potential for torture is great. (I, III)
Issued December 1999.

This statement applies to all physicians including, I would hope, applying to physicians who are within the U.S. Armed forces and the C.I.A. ..Maurice.

Some Thoughts about Medical Advice: Patient/Family vs Physicians

Here are some ruminations on this subject by a member of the President’s Bioethics Committee. It comes from the transcript of
Session 6: Bioethical Issues of Aging II: The Wisdom of Advance Directives Friday, April 2, 2004 and was spoken by Member Daniel Foster, M.D., John Denis McGarry, Ph.D. Distinguished Chair in Diabetes and Metabolic Research, University of Texas Southwestern Medical School.


Let me just say one other thing very quickly, and I don't want to sound self-serving about a profession and so forth, but the courts have clearly held that families and patients cannot require a physician to do or not to do any things. These are advice. I mean, we're not obligated for an 85 year old person to do chemotherapy. The courts have made that clear.

There is a second issue of judgment that the physician may have. The late Franz Ingelfinger, who was the long time editor of the New England Journal of Medicine, himself a gastroenterologist who worked on the esophagus developed esophageal cancer. And he wrote an article in the New England Journal of Medicine called "Arrogance." This was a time of the peak of autonomy for patients. Women would be squatting over mirrors to try to see if they could do their own pelvic examinations and see if they could just see — because they had the autonomy for their own health.

Because he was probably the most famous physician in the world, the editor of the New England Journal of Medicine usually is in terms of name, he received advice from all over the world telling him radiation first, surgery this, that and the other. And finally someone told him, he says "Franz, what you need is a doctor." And so he chose an internist and said, "I put myself in your care." And afterwards he said it was like a huge burden off of his life. He got back to editing the New England Journal of Medicine. And, by the way, his two children were doctors and so forth and so on. And he wanted somebody who was competent who cared for him to make the decisions should we do this or should we not do that.

Now, one could say that's a very arrogant position to say that maybe the physician would be the best person to make a choice as to whether this was good or helpful or not. And I'm not defending that at all. But I think that most physicians — I don't have statistics. But I think that many physicians will always want to do what they would do for their own family. That's a question that's asked us all the time; if this was your wife or this was your mother, what would you do. And when one answers under those circumstances, almost always in my experience the family will go with the judgment of the physician which is there. Because you try to explain what the downsides are, what the upsides are, what a treatment that might add two months, you know, but makes one sick is usually not — there might be circumstances where you would do that if somebody didn't have time to make a will or something. I mean, I've done that. Do a treatment that might be give me two or three months because of some critical issue in the family.

So I do think that there's been an arrogance about doctors who think they're gods, you know. But on the other hand, we probably do have a better sense of what should be done than the family does.

When my own father died of lung cancer—he wasn't a smoker, he just had an endocarcinoma — he had not wanted anything. He just had an IV glucose, just a glucose to keep open so they could give, you know, if he needed anything to do. And his granddaughter came in there and began screaming that when that was taken out of the arm. It was just giving fluids. She began to scream, "They're killing grandpa." It was not killing grandpa, I mean it was just glucose and water going in there. He had no need for it. And we just took it out.

So, anyway, I think that there is sense where the physician should have, you know, at least advice in these things and maybe more than that. I don't know.

It’s all about who should be giving the advice to whom and which advice should trump the other. Any suggestions? ..Maurice.

“I think I will not hang myself to-day”

From Poetry Online comes the classic poem on suicide by G.K. Chesterton.

A Ballade of Suicide
G.K. Chesterton

The gallows in my garden, people say,
Is new and neat and adequately tall;
I tie the noose on in a knowing way
As one that knots his necktie for a ball;
But just as all the neighbours on the wall
Are drawing a long breath to shout "Hurray!"
The strangest whim has seized me. . . After all
I think I will not hang myself to-day.

To-morrow is the time I get my pay
My uncle's sword is hanging in the hall
I see a little cloud all pink and grey
Perhaps the rector's mother will NOT call
I fancy that I heard from Mr. Gall
That mushrooms could be cooked another way
I never read the works of Juvenal
I think I will not hang myself to-day.

The world will have another washing-day;
The decadents decay; the pedants pall;
And H.G. Wells has found that children play,
And Bernard Shaw discovered that they squall;
Rationalists are growing rational
And through thick woods one finds a stream astray,
So secret that the very sky seems small
I think I will not hang myself to-day.


ENVOI

Prince, I can hear the trumpet of Germinal,
The tumbrils toiling up the terrible way;
Even to-day your royal head may fall
I think I will not hang myself to-day.

Actually, Chesterton’s poem is quite upbeat in that suicide is being set aside day after day because life and world are not as bad as initially thought as the day begins.

It is interesting to read about society’s view of suicide down through the ages. Lance Stell, an ethicist, writing recently on a bioethics listserv noted:

Suicide isn't a crime anymore. But at common law it was, involving as
Blackstone colorfully put it, a double offense - against the King, who
has an interest in the preservation of all his subjects and against God,
for rushing into the presence of the Almighty, uncalled for. [Although
Locke said something similar by way of explaining why the jurisdiction
we have over our lives isn't a property right, Blackstone's theological
imagery is interesting to reflect on for a few minutes].

On the thought that suicide is a very serious matter and should be
criminal, the problem arises - how to punish offenders.
Lawyers proved up to the task - the suicide's estate would be taken by
the Crown, burial in sacred ground was prevented, the body would be
desecrated. Powerful deterrents to such willful wrongdoing!

The African Ashanti proved more inventive still. If a suicide were
buried prior to a legal investigation, the corpse was ordered dug up and
put on trial for murder (I assume w/o the privilege of cross-examining
witnesses).

From Wikipedia:

“Ironically, the punishment for attempted suicide in some jurisdictions has been death. In addition, suicide can have other legal consequences. For example, in the United Kingdom prior to 1961 their estate was forfeited.
The United Kingdom decriminalized suicide and attempted suicide in the Suicide Act 1961. By the early 1990s only two US states still listed suicide as a crime, and these have since removed that classification. Increasingly, the term commit suicide is being consciously avoided, as it implies that suicide is a crime by equating it with other acts that are committed, such as murder or burglary.”

Discussing the past philosophical thought regarding suicide, an article in Wikipedia presents these further views:

… Thomas Szasz would argue that suicide is the most basic right of all. If freedom is self-ownership, ownership over one's own life and body, then the right to end that life is the most basic of all. If others can force you to live, you do not own yourself, and belong to them.

It is important to note that the liberal view above is not associated with classical liberalism; John Stuart Mill, for instance, argued in his influential essay On Liberty that since the sine qua non of liberty is the power of the individual to make choices, any choice that one might make that would deprive him or her of the ability to make further choices should be prevented. Thus, for Mill, selling oneself into slavery or killing oneself should be prevented, in order to avoid precluding the ability to make further choices. Concerning these matters, Mill writes in On Liberty:

“Not only persons are not held to engagements which violate the rights of third parties, but it is sometimes considered a sufficient reason for releasing them from an engagement, that it is injurious to themselves. In this and most other civilized countries, for example, an engagement by which a person should sell himself, or allow himself to be sold, as a slave, would be null and void; neither enforced by law nor by opinion. The ground for thus limiting his power of voluntarily disposing of his own lot in life, is apparent, and is very clearly seen in this extreme case. The reason for not interfering, unless for the sake of others, with a person's voluntary acts, is consideration for his liberty. His voluntary choice is evidence that what he so chooses is desirable, or at the least endurable, to him, and his good is on the whole best provided for by allowing him to take his own means of pursuing it. But by selling himself for a slave, he abdicates his liberty; he foregoes any future use of it, beyond that single act. He therefore defeats, in his own case, the very purpose which is the justification of allowing him to dispose of himself. He is no longer free; but is thenceforth in a position which has no longer the presumption in its favor, that would be afforded by his voluntarily remaining in it. The principle of freedom cannot require that he should be free not to be free. It is not freedom, to be allowed to alienate his freedom.”

Philosophical thinking in the 19th and 20th century has led, in some cases, beyond thinking in terms of pro-choice, to the point that suicide is no longer a last resort, or even something that one must justify, but something that one must justify not doing. Existentialist thinking essentially begins with the premise that life is objectively meaningless, and then poses the question "why not just kill oneself?". It then proceeds to answer this by suggesting the individual has the power to give personal meaning. Nihilist thinkers reject this emphasis on the power of the individual to create meaning, and acknowledge that all things are equally meaningless, including suicide.

On the other hand, some thinkers have had positive or at least neutral views on suicide. Some of the pessimist philosophers (Nietzsche, Goethe, Schopenhauer) see suicide - or knowing that at any time, one can escape the suffering of life - as the greatest comfort in life. Herodotus wrote "When life is so burdensome death has become for man a sought after refuge". Schopenahuer affirmed "They tell us that suicide is the greatest piece of cowardice... that suicide is wrong; when it is quite obvious that there is nothing in the world to which every man has a more unassailable title than to his own life and person". In Thus Spoke Zarathustra Nietzsche discusses the importance of "dying at the right time", claiming that one must not outlive his work (or "purpose") of life.

Unlike Chesterton, ruminating about suicide but finding an excuse against attempting, people, of course, do think about suicide and act it out.

One may find an ethical issue involving physicians who care for attempted suicide victims. If we, as physicians, save their lives are we violating their autonomous right to decide about their own life? Can we always excuse our resuscitation on the basis that the patient is depressed and their attempt is not purely voluntary? Is there, as I have mentioned in previous postings, such an act as a rational suicide attempt? How about if we decide not to interfere, especially if a patient says by voice or note not to interfere, are we thus aiding and abetting the suicide? Is this in a sense an "assisted suicide"? And then comes the issue of true intentional medically assisted suicide but that demands a different posting on another day. ..Maurice.

Want to Do Hospital Committee Ethics? (3): Case of Apparent Conflict of Interest

FACTS: The patient is a 72 year old man who was to be admitted to the hospital from a private nursing home to have a defective feeding tube replaced through the abdominal wall. The patient has been in a coma, but can breathe on his own, for the past 9 months after a head injury suffered in an auto accident. He has no family except for a brother, age 60, who is his designated Durable Power of Attorney for Health Care but who lives far away and who has visited the patient only on a couple of occasions. Other than this designation, there is no written expression of the patient’s personal desires. The only other relative is a male cousin who lives near by and has visited the patient several times each month. The brother has contacted the patient’s physician and requests that the feeding tube not be replaced and the patient allowed to die peacefully. He stated that he knew his brother would not like to remain in a comatose condition. The physician, with neurology consultation, has related to the brother that the patient may eventually recover to some degree. The cousin has contacted the doctor and informed him that the brother is known to be the beneficiary of the patient’s estate and questions the motives of the brother’s decision. The physician has taken the matter to his hospital’s ethics committee for help in resolution.

THE ISSUE: The ethics of termination of life support for this head injury patient and to what extent should the decisions of the legal surrogate be followed if conflict of interest is suspected.

QUESTION: Should the defective feeding tube not be replaced and patient allowed to die on the request of the legal surrogate? ..Maurice.