Bioethics Discussion Blog: September 2005





Friday, September 30, 2005

How to Tell the Bad News: Telling It First or Telling it Last?

An issue in practice for all physicians is how to tell the patient bad news. Would it be better to tell the worst at the onset of the discussion or gradually build up to the worst? It would seem that preparation and an empathetic leading up to the bad news is an appropriate technique. (See the professional advice below). However, I would like to first present two humorous versions of telling worst news at the end. You may have already heard this story.

A man returning home after a few months away is met by his servant who tells him his dog died from eating burnt horseflesh after the barn burned down from a spark blown from the fire that consumed his house. The house fire started from candles placed around the coffin of his mother-in-law who died after learning that her daughter ran off with the hired man. "Other than that," the servant said, "there's no news."

Here is a more ancient expression of the same story from The Project Gutenberg EBook of McGuffey's Fifth Eclectic Reader
by William Holmes McGuffey


Mr. H. and the Steward.

Mr. H. Ha! Steward, how are you, my old boy? How do things go on at home?

Steward. Bad enough, your honor; the magpie's dead.

H. Poor Mag! So he's gone. How came he to die?

S. Overeat himself, sir.

H. Did he? A greedy dog; why, what did he get he liked so well?

S. Horseflesh, sir; he died of eating horseflesh,

H. How came he to get so much horseflesh?

S. All your father's horses, sir.

H. What! are they dead, too?

S. Ay, sir; they died of overwork.

H. And why were they overworked, pray?

S. To carry water, sir.

H. To carry water! and what were they carrying water for?

S. Sure, sir, to put out the fire.

H. Fire! what fire?

S. O, sir, your father's house is burned to the ground.

H. My father's house burned down! and how came it set on fire?

S. I think, sir, it must have been the torches.

H. Torches! what torches?

S. At your mother's funeral.

H. My mother dead!

S. Ah, poor lady! she never looked up, after it.

H. After what?

S. The loss of your father.

H. My father gone, too?

S. Yes, poor gentleman! he took to his bed as soon as he heard of it.

H. Heard of what?

S. The bad news, sir, and please your honor.

H. What! more miseries! more bad news!

S. Yes, sir; your bank has failed, and your credit is lost, and you are
not worth a shilling in the world. I made bold, sir, to wait on you about
it, for I thought you would like to hear the news.

I found the following good example, as a teaching tool for medical students, interns and residents (and, of course, to practicing physicians who never learned how to do it) inWeissman, D. Fast Fact and Concepts #11: Delivering Bad News, Part I and Part II-- Talking to Patients and Precepting Trainees. June, 2000. End-of-Life Physician Education Resource Center

Case Scenario: You are caring for a previously healthy 52 y/o man with a new problem of abdominal pain. After conservative treatments fail, a diagnostic abdominal CT scan is done showing a focal mass with ulceration in the body of the stomach and numerous (more than 10) densities in the liver compatible with liver metastases. The radiologist feels that the findings are absolutely typical of metastatic stomach cancer. [How do you prepare and then deliver the bad news to the patient?]

Preparing to Deliver the Bad News:

1. Create an appropriate physical setting: A quiet, comfortable room, turn off beeper, check personal appearance, have participants, including yourself, sitting down.

2. Determine who should be present? Ask the patient whom they want to participate--clarify relationships to patient. Decide if you want others present (e.g. nurse, consultant, chaplain, social worker) and obtain patient/family permission.

3. Think through your goals for the meeting as well as possible goals of the patient.

4. Make sure you know basic information about the patient's disease, prognosis, treatment options.

5. Special circumstances: Patient not competent (developmentally delayed, dementia, etc.) Make sure legal decision-maker is present.

6. Special circumstances: Patient doesn't speak English. Obtain a skilled medical interpreter if the patient or family do not speak English. Use ATT translation service or other phone service is necessary.

Delivering the Bad News

1. Determine what the patient & family knows; make no assumptions. Examples: "What is your understanding of your present condition?" "What have the doctors told you?"
2. Before presenting bad news, consider providing a brief overview of the patient's course so that every one has a common source of information.
3. Speak slowly, deliberately and clearly. Provide information in small chunks. Check reception frequently
4. Give fair warning -- "I am afraid I have some bad news" then pause for a moment.
5. Present bad news in a succinct and direct manner. Be prepared to repeat information and present additional information in response to patient and family needs.
6. Sit quietly. Allow the news to sink in. Wait for the patient to respond.
7. Listen carefully and acknowledge patient's and family's emotions, for example by reflecting both the meaning and emotion of their response.
8. Normalize and validate emotional responses: feeling numb, angry, sad, and fearful.
9. Give an early opportunity for questions, comments
10. Present information at the patient's or family's pace; do not overwhelm with detail. The discussion is like pealing an onion. Provide an initial overview. Assess understanding. Answer questions. Provide the next level of detail or repeat more general information depending upon the patient's and family's needs.
11. Assess thoughts of self-harm
12. Agree on a specific follow-up plan ("I will return later today, write down any questions"). Make sure this plan meets the patient's needs. Involve other team members in follow-up.

Just yesterday, my medical student was in the hospital room with a patient. The attending surgeon along with a troop of residents and interns came into the room. The surgeon then without any further preparation and without any attempt at privacy or compassion told the patient of the results of the surgery—the finding of a cancerous liver, a diagnosis the patient had not previously known. My student was shocked by the attending physician’s behavior and provided me with a great teaching moment for our medical school group. Yes, even “grown” physicians need to learn the ethical and compassionate way to do it. ..Maurice.

Tuesday, September 27, 2005

Transplant Injustice and the Response:Which Is The Greater Injustice?

From today's Los Angeles Times comes a story regarding St. Vincent Medical Center, a Los Angeles liver transplant center hospital, that in 2003 (just discovered now by the hospital doing a routine evaluation required by UNOS, the federal transplant agency) performed a liver transplant paid for by the Royal Embassy of Saudi Arabia. "The patient who received the successful transplant was, [however], actually 52nd on the list, which covers much of Southern California and takes into account such factors as who is sickest and who has been waiting longest."
The CEO of St. Vincent stated "A patient at UCLA Medical Center was entitled to receive the organ and St. Vincent should have declined it." The St. Vincent liver transplant program has now been suspended The involved director and assistant director surgeons associated with the liver transplant program were now no longer affiliated with the program.
"Suspending the program means that 75 patients on the waiting list for livers may have to seek care at other hospitals, possibly delaying their chances for a life-saving transplant. Patients who need livers typically suffer from end-stage liver failure, cirrhosis and other liver and metabolic diseases."

I see the ethical issue: the injustice of the original act vs an injustice to those 75 patients by the suspension of the liver transplant progrram. How does one work out this ethical equation? ..Maurice.

Sunday, September 25, 2005

Doctors Telling “Bad News”: But There Is More To Tell

Shrinkette links to a blog-posting by a neurologist who talks about giving “bad news”, having to tell a patient that the diagnosis is a malignant brain tumor. The author tells about what to consider when telling the “bad news”:

"You have to have some sense of your own feelings, but mostly you must be vigilant to the signs of feelings of others, the signs that someone else is either tuned in or out. If you can't explain things in nonmedical terms, you don't understand them well enough yourself and you should have come better prepared. You also must know when to quit, when to pause to let the information sink in, when to quit for now and come back later.

I've had people thank me for telling them what they were going to die of. It's uncomfortable to be in that position. I know they're thanking me for my honesty, for spending time to explain, answer their questions. But it's hard to say, "You're welcome" after being the bearer of bad news."

However, as I explained in my comment on Shrinkette’s blog, the physician must follow the “bad news” with essential “good news”. I wrote:

It is not enough to give the "bad news". It is even more important to give the "good news" too. "Good news?" "What good news?" you might ask. It's the news that some physicians fail to follow up with, telling the patient "I am going to continue to take care of you and try to make sure that your upcoming days are as comfortable as possible." The patients need the feeling that with the bad news, the doctor-patient relationship that led to this point is not over. They want to know that the doctor is not now relatively abandoning them. On the other hand, it is understandable why some physicians want to "pull back" after giving their diagnosis and prognosis. They may feel that they have not much else to offer and if they continue close contact they will only be, uncomfortably, following the course of their "failure".

So doctors should be encouraged to follow the "bad" with the "good" and render, with help as necessary, the comfort care that always should follow this kind of "bad news".

If you are a physician, what do you say after giving the "bad news"? ..Maurice.

Saturday, September 24, 2005

Acronyms of Life, Death and Disability: CPR, DNR, DNAR,AND

Since the technique and tools to provide cardio-pulmonary resuscitation (CPR) was first used, the procedure has been a default exercise, attempted both in a hospital and non-hospital environment, for those in acute cardio-pulmonary collapse. At first, use with patients suffering cardiac arrest in electrocutions or drownings comprising generally healthy patients the success rate was high. Since then, use in patients with other illnesses leading to cardio-pulmonary arrest including those with multi-system involvement and late cancer has not been as successful in restoration of vital function. In addition, if spontaneous cardio-pulmonary activity had been restored, often there would be severe ischemic encephalopathic complications affecting neurologic recovery.

The very latest data from the largest multisite, in-hospital CPR dataset to date, was published by Peberdy et al in Resuscitation 2003 using the National Registry of CPR. (Peberdy MA, Kaye W, Ornato JP, Larkin GL, Nadkarni V, Mancinin E, Berg RA, Nichol G, Lane-Truitt T. Cardiopulmonary resuscitation of adults in the hospital: A Report of 14,720 Cardiac Arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003;58:297-308).

Rates of intact survival depend greatly on the rhythm. For shockable rhythms, the survival to discharge rate is about 35% (for pulseless Ventricular Tachycardia and Ventricular Fibrillation)
For unshockable (asystole and electromechanical dissociation) the survival is actually 10.5%, an improvement over the past. Remember, that these figures are only the “survival to discharge” and they do not tell about the consequential neurologic impairment of the patient. Also they don’t tell how many died because of another cardiac arrest which was not treated. Also the rate of resuscitation will vary between whether the patient has arrested out of the hospital and if in a hospital which hospital, which ward, what staffing, and at what hour and what day of the week

There are patients who should not be given CPR. They would be the patients who have an end-stage terminal illness or those with severe multi-system disorders where recovery of cardiac function would be less likely or only prolong the dying process. In addition, there are patients, when informed, have decided against receiving CPR. The orders, written by a physician, not to provide CPR has been termed “do not resuscitate” (DNR) or perhaps a more specific order “do not attempt resuscitation” (DNAR). These terms have left the public (patients and families) often confused regarding whether other treatments would still be provided if these orders are signed. Medical care providers have always considered DNR or DNAR as specifically related to cardio-pulmonary arrest and when written would not affect any other supportive or comfort treatments.

There is some current discussion about the use of another expression: “allowing natural death” or AND for short. This term could be used for termination of all life supportive treatments for the patient as well as resuscitation attempt for cardio-pulmonary arrest. The question can be raised whether this term might also mislead the public to assume that treatments for the comfort of patient would not be given. It is a medical principle that comfort care is never terminated in any patient including those whose life support is terminated or orders are written not to resuscitate.

Because of the consideration that CPR is over-used and applied to the wrong patients, there has been a suggestion that CPR should not be the default action but that resuscitation of a hospitalized patient should be part of a specific order on admission. If not written then there is no attempt at resuscitation. This would help eliminate a dilemma that often faces hospital nurses when a terminal patient with no DNR orders has a cardiac arrest. Should the nurse start CPR that could be a non-beneficent and futile act for this patient?

As you see, this issue is not really about semantics but about the proper treatment of a patient: providing medical standards of care ( risk vs benefits) and ethics (beneficence and autonomy). ..Maurice.

The Spelling of RITA: Revelation of Intellectual Thoughtlessness Again

First there was the spelling of Katrina:

K is for the Knowledge that was ignored, A is for the Aftermath that was not early acknowledged, T is for the Test of leadership that failed, R is for Recognition of the deficiencies that was delayed, I is for Insight that was unfortunately late in coming,
N is for the Needs that were too long unmet, A is for Again. Will it all happen Again?

And Katrina was followed by Rita: Revelation of Intellectual Thoughtlessness Again

It is worrisome that those in government should be so casual in broadcasting the need for public evacuation of an area by hundreds of thousands or millions of residents in a day or two without doing the most basic analysis of the consequences of that order. With no provision for making the evacuation efficient (allowing travel out on both outgoing and incoming freeway lanes) or practical (providing access to gasoline for vehicles running low on gas) or safe (formally providing sources of water, preventing heat exhaustion, etc), the government again showed a flaw in behavior that is, to me, of concern. What happened was equivalent to a fire in a theater, the audience told to leave, but some of the exit doors had not been unlocked. Is this thoughtlessness, with the consequence of doing harm to the evacuees, an example of even worse inattention and inactions by the government to come? ..Maurice.

Tuesday, September 20, 2005

The Effect of Physician Self-Disclosure: Surgeons vs Primary Care Physicians

An article in the J Gen Intern Med. 2004 Sep;19(9):905-10 titled “Is physician self-disclosure related to patient evaluation of office visits?” by MC. Beach et al describes a study about how patients,reporting after either a primary care visit or surgical visit, felt about the visit in which the physician self-disclosed “a personal experience that had medical and/or emotional relevance for the patient.” The study involved 1,265 patients who visited 59 primary care physicians and 65 surgeons. Self-disclosure was not found to be rare since “physician self-disclosure occurred in 15.4% of routine office visits, and there was no statistically significant difference in the prevalence of self-disclosure at the visit level between surgery and primary care (17%[102/589] of primary care visits and 14%[93/676] of surgical visits). “

The results showed statistically that “fewer patients reported feelings of warmth/friendliness (37% vs 52%; P =.008) and reassurance/comfort (42% vs 55%; P =.027), and fewer reported being very satisfied with the visit” following self-disclosure by a primary care physician. On the other hand, “following visits in which a surgeon self-disclosed, more patients reported feelings of warmth/friendliness (60% vs 45%; P =.009) and reassurance/comfort (59% vs 47%; P=.044), and more reported being very satisfied with the visit (88% vs 75%; P =.007)”

The conclusion was “Physician self-disclosure is significantly associated with higher patient satisfaction ratings for surgical visits and lower patient satisfaction ratings for primary care visits. Further study is needed to explore these intriguing findings and to define the circumstances under which physician self-disclosure is either well or poorly received.”

Of course, read the article for details but if verified the question is why should surgeons have better patient responses to self-disclosure? The authors suggest “Facing an invasive procedure with an unknown outcome and inherent risk, surgical patients may be more acutely anxious and vulnerable than primary care patients. Within this context, every form of self-disclosure seemed to be appreciated by patients, but especially evident was the higher satisfaction of surgical patients (in contrast to primary care patients) when the disclosure was characterized as reassuring. Self-disclosure from a surgeon may function as a sign of personal interest and emotional support.” On the other hand , primary care physicians “are more involved in chronic disease management in which cure is often not a realistic goal.” In view of this difference in outcome, “it is not hard to imagine that reassurance in the primary care context, while well-intentioned, might be heard as premature and promising something that cannot easily be delivered. Perhaps in the context of chronic illness, reassuring disclosures appear dismissive or to invalidate a patient's concerns.”

What is your ideas as to the reason for the differences? ..Maurice.

Monday, September 19, 2005

The Charisma of the Vulnerable Human Physician: The Decline of Charismatic Authority?

The Resourceful Patient is a printed but also an online book about the relationships of patients to medical care. I found chapter 1.7 "The decline in charismatic authority" quite interesting in view of my previous posting about physicians telling about themselves to their patients. I think that by being “more human” by appropriate self-disclosure perhaps the work of the physician can be more effective through empathy, better understanding by both patient and doctor of each other leading to more satisfactory compliance by the patient along with less tendency to find fault with the doctor.

The book describes charisma as “'a favour specially vouchsafed by God; a grace; a talent'.” and then proceeds to explain its course through time: how the charisma was maintained over the hundreds of years and in recent times, through secularism, the doctor replacing the priest in some communities and in the middle years of the 20th century how idealistic medical drama raised the charisma of the medical profession. Finally, there began a decline in charisma as medical drama was becoming more realistic and tended to “demythologise the healing professions.” In addition, medicine itself is demystifying itself through the clinicians “mode of dress, mode of consulting style and mode of address to patients.” Beyond that, “new healers are emerging” as the alternate and complementary medical practitioners are becoming more popular. In addition, it is also my opinion that the development of the era of consumerism, direct to consumer drug advertising and bioethics with the stressing of patient autonomy over physician paternalism that has also contributed.

Here is a brief extract from the book:

The charisma of the vulnerable human

The charisma of the remotely impressive doctor of the 20th century was powerful and had some beneficial effects for some patients, but for many the effect was demeaning. The charisma of that type of doctor derived from the reverence in which the profession was held, often augmented by the behaviour of the individual doctor. The diminution of this type of charisma may have been replaced by another type of charisma.

The word 'charisma' is now used to describe the superficial image of a public figure, closer to the adjective 'glamorous' than to the original meaning which referred to certain personal characteristics of the individual. The 21st century clinician, stripped back of the image from which 20th century charisma derived, can offer a substitute - his or her own, honest person, frailties and all. The doctor as superman has been replaced by the doctor as human being, willing to relate to another person - the patient - and the charisma of the human being who is the clinician may be as powerful as charisma derived from the false image.

What do you think is happening to the appearance of the medical profession in the eyes of the patients? ..Maurice.

Saturday, September 17, 2005

Good Journalism Demands Good Ethics: A Schiavo News Article

The Empire Journal, published by American Free Media on September 17, 2005 presented an article informing the readers that Michael Schiavo, husband of Terri Schiavo, was to be speaking at a conference on ethics. in Minneapolis, Minn. September 23. What I was surprised by the article was the description given of Michael Schiavo. He is identified as “the man who killed his handicapped wife by pulling her feeding tube resulting in her slow agonizing very public death over 13 days.” Does anyone really believe that Michael actually pulled his wife’s feeding tube out of her body? Did he actually kill his wife? Didn’t she die because her damaged brain prevented her from swallowing and ingesting food and fluids? If her underlying illness had allowed her to eat and drink she would not have died from lack of fluid.

Yes and unfortunately her death was a “public death” but it was “agonizing” only to the family and public but certainly not to Terri herself. It was public simply because of the media attention. Yes, it was “slow” only because of the expected pathophysiologic course of clinical dehydration.

The description goes on with the following: “an adulterer, father of two illegitimate children whose testimony given under oath indicates that he made false statements.”
Well, I can’t counter the out-of-marriage descriptions, however with regard to the other accusations one would have expected that if he, under oath, had made “false statements” and indeed “killed” his wife, clearly no legal action has been taken against him for these alleged crimes. Wouldn’t he have been arrested by now?

Finally, the publication’s concern appears to be that Michael Schiavo, despite these allegations, is speaking at an ethics conference, “yes ethics.”

My comment about this article is that good journalism as in medicine and other professions demands good ethics. And unsubstantiated allegations of wrongdoing, naming the object of such allegations, is itself bad ethics—or worse. What do you think? ..Maurice.

Friday, September 16, 2005

Doctors Talking to Patients About Themselves: How Much and What?

There has been much consideration about how much a physician should talk to the patient about him/herself. More importantly beyond “how much” is the concern about “about what”. The question is whether there is an ethical and professional boundary which physicians should not cross when revealing their own lives. There appears to be evidence that some revelation is therapeutic providing some confidence to the patient that the physician and patient are working together, avoiding a patient impression of physician paternalism. There is some evidence that patients may sue physicians less often if the physician says the appropriate words about him/herself.

What do physicians reveal? From Journal of General Internal Medicine vol 19, nr.9, 2004, there is an article describing a research study on this topic titled
“What Do Physicians Tell Patients About Themselves? A Qualitative Analysis of Physician Self-Disclosure” by Mary Catherine Beach, MD, MPH; Debra Roter, DrPH; Susan Larson, MS, Wendy Levinson, MD; Daniel E. Ford, MD, MPH; Richard Frankel, PhD
The following is the abstract of the article:

Objective: Physician self-disclosure (PSD) has been alternatively described as a boundary violation or a means to foster trust and rapport with patients. We analyzed a series of physician self-disclosure statements to inform the current controversy.

Design: Qualitative analysis of all PSD statements identified using the Roter Interaction Analysis System (RIAS) during 1,265 audiotaped office visits.
Setting and Participants: One hundred twenty-four physicians and 1,265 of their patients.

Main Results: Some form of PSD occurred in 195/1,265 (15.4%) of routine office visits. In some visits, disclosure occurred more than once; thus, there were 242 PSD statements available for analysis. PSD statements fell into the following categories: reassurance (n= 71), counseling (n= 60), rapport building (n= 55), casual (n= 31), intimate (n= 14), and extended narratives (n= 11). Reassurance disclosures indicated the physician had the same experience as the patient ("I've used quite a bit of that medicine myself"). Counseling disclosures seemed intended to guide action ("I just got my flu shot"). Rapport-building disclosures were either humorous anecdotes or statements of empathy ("I know I'd be nervous, too"). Casual disclosures were short statements that had little obvious connection to the patient's condition ("I wish I could sleep sitting up"). Intimate disclosures refer to private revelations ("I cried a lot with my divorce, too") and extended narratives were extremely long and had no relation to the patient's condition.

Conclusions: Physician self-disclosure encompasses complex and varied communication behaviors. Self-disclosing statements that are self-preoccupied or intimate are rare. When debating whether physicians ought to reveal their personal experiences to patients, it is important for researchers to be more specific about the types of statements physicians should or should not make.

As I noted on a previous posting on this blog, ethicist Robert Veatch has written about the importance of the patient finding a personal physician who carries the same goals and values as the patient and perhaps also the same culture or religion. This would suggest that at some point, the physician would engage in self-disclosure to make this information available to the patient.

There is no doubt that empathy is an important tool in making a connection with the patient and his/her illness. As noted in a previous post (March 3, 2005), the words of Harry Wilmer: “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.”

And for empathy to be most true and not “acted”, the physician must have had some similar life-experience. Thoughtful documenting that experience to the patient can validate empathy, this more real understanding by the doctor of the patient’s concerns.

What has your doctor told you about him/herself? ..Maurice.

ADDENDUM: You may wish to also read a subsequent posting on September 19, 2005 titled
"The Charisma of the Vulnerable Human Physician: The Decline of Charismatic Authority?" which I think is related to the topic of physicians self-disclosure.

Thursday, September 15, 2005

Deletion of Bioethics Discussion Blog2

This message is to notify those interested that I have deleted the Bioethics Discussion Blog2 which I started recently when this original blog was sick. The postings to the substitute blog have been transferred to this blog. I hope this action hasn't confused or upset any visitor. ..Maurice.

What's in a Name? and The Fading of 9/11

Here are the two posts which I orignially was unable to post here but was posted on my substitution blog "Bioethics Discussion Blog2". I now include them in this blog for completeness.

Monday, September 12, 2005
What's in a Name?>

From the September 11, 2005 issue of the New York Times

EACH Katrina is handling the problem in her own way.
One, Katrina Petrillo, 13, an eighth grader at Convent of the Sacred Heart school in Manhattan, got so tired of being mocked as "Hurricane Katrina" by her summer vacation acquaintances that she told teachers on the first day of school on Thursday that she is now going by "Kat."

A wonderful narrative of a mother speaking to her daughter named Katrina was posted on the Medical College of Wisconsin bioethics listserv and I am reproducing it below with the permission of the author.

What's in a Name?
by Grace Fill

It's 2:30 in the morning and I'm safe and warm in my tent on what
may be the last really great camping weekend in northern Illinois this season.
I'm enjoying a rare bout of inadvertently caffeine-induced insomnia and my thoughts
inevitably turn to my now grown and only daughter, Katrina. It is less than a
week since the hurricane of the same name struck the gulf coast.

For Katrina, the daughter, it is suddenly troublesome to bear a name which
is associated with so much destruction and terror and suffering. Her name
will be forever linked to the worst natural catastrophe in the history of the
United States. Overnight the entire country knows how to pronounce and spell her
once uncommon name (Catarina, did you say? Krystina?)

Katrina, the hurricane, though no longer physically present, has
left chaos, uncertainty, violence and unspeakable horror. It is these negative aspects
that cause embarrassment for my daughter now when she is asked her name.

But Katrina, the hurricane, may also wield her power for good, shining an immense light into some profoundly dark places. In her wake lies also tremendous opportunity. Perhaps Katrina, the hurricane, will one day be seen as a
very critically needed wake-up call, Mother Nature's way of delivering a message
in no uncertain terms.

In the weeks and months and years ahead, no doubt there will be endless
debate about homeland security and the failure of our federal government, whose
focus is so much and so tragically elsewhere, to care righteously and properly
for its own citizens. But talk is cheap, very cheap indeed.

Katrina, the hurricane, has brought some things to light that cannot be
further ignored. The human beings who have suffered the most in New Orleans are
the same human beings who have lived in poverty for generations. And if we
choose to see, in the light that Katrina so amply provides, if we choose not to
turn away from a truth that existed before the winds, before the flooding,
before the cries of betrayal, if we have the courage to look, it is clear:
Poverty makes people vulnerable. The same poverty that makes people vulnerable to
disease, to ignorance, to violence, to early deaths, makes human beings
vulnerable in times of crisis, during natural disasters, and in the wake of catastrophe. A system that perpetuates poverty, perpetuates vulnerability. If we couldn't see this before, the force and power of Katrina ought certainly to make
it visible to us now.

And so, Katrina, my daughter, let me say this: You are no longer a
child, but I am still and will always be your mother. Allow me, if you will,
one more opportunity to offer some motherly advice, woman to woman, as you make your way as a young adult into our uncertain world. You are a strong force, not
unlike the hurricane that shares your name. Bear your beautiful name with
pride, Katrina. Know your power and use it wisely. Shine your awesome light into
the dark places and do not cower in the face of what you see there. Have
compassion, daughter for all living beings. Care about the most vulnerable, as
you always have. Keep doing what you can to help make this world a
better place.

What do YOU think about the ethics of assigning a persons name to a hurricane for identification purposes. Has anyone thought before about the emotional and social implications of that naming of a destructive event to the person with the same name? ..Maurice.

posted by Maurice Bernstein, M.D. @ 12:19 PM

Sunday, September 11, 2005
The Fading of 9/11

Petula Dvorak writing in today’s September 11
Washington Post discusses the possibility, as suggested by historians, that the 9/11 date and what happened on that day will fade as the years go on with the day becoming another Labor Day, Memorial Day, Presidents’ Day. Even December 7, the day that the United States was attacked, Pearl Harbor bombed, “a date that will live in infamy” is probably only vaguely in the memories of those who were not alive then.

Though the media describe some memorials going on today throughout the nation, I would guess that most of the population of the United States and certainly those from the Gulf Coast are thinking of the consequences of hurricane Katrina. And when you think about it, why not? Almost 3000 individuals lost their lives on 9/11 but they are gone and the most personal effects of their deaths is being carried year after year by their living loved ones. In a way, the New Orleans and Gulf Coast disaster has produced a even more profound loss of life---actually a loss of the lives, the living lives of over a million people or more. And they live to daily suffer the losses and uncertainties. In addition, the physical damage to the city of New Orleans and the other affected communities within three states, represent far more to rebuild and rehabilitate then essentially a couple of towers in New York. So I am not surprised if September 11 is found to be fading today.

You know, beyond the damage and loss of life or lives, there is an awful similarity between the two events. Have you also noticed too that our country and our government was unprepared for either? ..Maurice.

posted by Maurice Bernstein, M.D. @ 10:09 PM

My Original "Bioethics Discussion Blog" is Fixed and Working

This note is to all who are interested that this website, my original "Bioethics Discussion Blog" has the posting problem fixed (there were too many posts on the home page) and I intend to continue posting on this site. ..Maurice.

Saturday, September 10, 2005

The Spelling of KATRINA

The Spelling of Katrina
by Maurice Bernstein, M.D.

K is for the Knowledge that was ignored
A is for the Aftermath that was not early acknowledged
T is for the Test of leadership that failed
R is for Recognition of the deficiencies that was delayed
I is for Insight that was unfortunately late in coming
N is for the Needs that were too long unmet
A is for Again. Will it all happen Again?

Friday, September 09, 2005

Posting Problem with This Blog

To Anyone Who Can Read This: I suddenly have not been able to post to the front page of my Bioethics Discussion Blog for over a week because of some error disorder unknown and untreatable by me. I am trying to make contact with a live helper from but so far to no avail. At present I am in good health and I am eager to continue posting but, until I get help, I ask all my faithful visitors to be patient. If you want to console me, my e-mail address is:
Thanks ..Maurice.

Saturday, September 03, 2005

Ethics of the New Orleans Disaster: Absence of Justice

Later on there will be a dissection of what went wrong with the management of the current New Orleans disaster. But one ethical issue strikes me right away. It is the issue of ethical justice that I see had been ignored.

Here was a natural disaster anticipated for several days. An order was given by city officials for the population of New Orleans to evacuate. And many did, driving out of the city and fending for themselves somewhere. But where in the planning for this order was there thought that for evacuation, transportation is required and that only the economic class of people who have cars that run and have gasoline can follow the order? The justice issue is that it appears that there was no thought of the other class of people, the sick or infirm or those who could not afford to have cars to take them away from the potential danger.

There was no attempt for the city to provide transportation out of the city for this class of people and they were allowed to remain and suffer the consequences of the flooding of the city and perhaps perish. This ignorance of the lives of this class of citizens represents total lack of ethical justice, denying equal protection to all the citizens of New Orleans.

One wonders what was the rationalization by city officials for this unequality. Did it represent some class prejudice or just official amnesia?

Any thoughts? ..Maurice.