Bioethics Discussion Blog: October 2005





Monday, October 31, 2005

Want to Do Hospital Committee Ethics? (2): Ventilating the Dead

The ICU of the hospital is filled to capacity and there is a patient with a myocardial infarction who is awaiting a bed there. One of the patients already in the ICU for the past 2 days is J.W., a 34 year old white male, who lives at home with his widowed mother. There are no other family members. The patient suffered a ruptured aneurysm of the brain with massive bleeding into the brain and is totally unresponsive, cannot breathe without the ventilator and meets all the criteria for death by neurologic criteria (“brain death”). The patient’s physician and a consulting neurosurgeon has told the mother that even though the patient’s heart is still beating for a while if the ventilator continues to work, her son is dead and the physician is going to write an order to stop all treatments including the ventilator.

THE ISSUE: The mother rejects the conclusion that her son is dead and says that he is warm and pink and “breathing” and that he is still alive and may, if the treatment is not stopped, have a chance for a miracle recovery. She says that under no circumstances should the ventilator be stopped and if necessary she will take her son home with a ventilator. She says she can arrange for him to be cared for at home. The physicians call for the hospital ethics committee to meet and the plan of the committee is to have the physicians, attending nurses and the mother sitting together in a quiet room to discuss the issue with the committee.


What should the ethics committee first hope to hear from the mother?
What should the ethics committee ask the mother?
What should the ethics committee ask the physicians?
What ethical issues should be considered?
What other information should the physicians or ethics committee relate to the mother?
What should the ethics committee consider as a reasonable and ethical outcome decision to be made by the physicians and the mother?

If you would be sitting as an impartial ethics committee member what thoughts would be going through your head? ..Maurice.

Saturday, October 29, 2005

Want to Do Hospital Committee Ethics? (1): Withdrawal of MNH

This scenario will be the first in a series of scenarios that are examples of what hospital ethics committees experience. One of the roles of ethics committee members is to come to a consensus and inform the stakeholders about the ethics and the current law regarding the issue and anticipated action.

For this exercise to be of interest and worthwhile, it will require my visitors reading the scenario to contribute their comments regarding the issue. Remember, you don’t have to be a professional ethicist to give an opinion; you just have to be an interested member of society.

94-year-old Catholic woman with advanced Alzheimer’s Disease,
5-year resident of a Catholic care facility.
A feeding tube to provide medical nutrition and hydration (MNH) was placed a few years ago because of difficulty swallowing during a prolonged respiratory infection, with the intention that it would be temporary but the feeding tube still remains in the patient. It is not clear why the tube was left in place but, perhaps, it was providing good nutrition without complications and was more efficient for the nurses.
The patient now has moderately severe trouble swallowing attributed to Alzheimer’s..
The patient has no terminal illness. She has only severe Alzheimer’s yet is still aware of her environment.
Years ago, while mentally competent the patient prepared an Advance Directive stating that she did not want medical nutrition and hydration(MNH).
The family wishes to have the feeding tube removed.
There has been no recent change in the patient’s condition.

Should the feeding tube be removed now from the patient? Is the intention of removal of the tube a decision to end the patient’s life, if she can’t be adequately given oral food and fluid or is the decision to relieve the patient of an extraordinary burden imposed by the tube. Should the physician be compelled to have the tube removed even if the physician, for moral and religious reasons, does not want to write an order for this act?
What if the nurses refuse to follow an order to have the tube removed?
Would it make any difference in the analysis of the issue if the patient was NOT Catholic and was a resident in a NON-CATHOLIC care facility?

DECISIONS: Now it is up to you my dear visitors to tell us all your opinions. ..Maurice.

Friday, October 28, 2005

When Medications Fail to Work: Is It Pharmacological or Psychosocial?

Not infrequently, physicians find that their patients are not responding to the prescribed therapy. The elevated blood pressure doesn’t improve, the elevated blood sugars are not falling, the signs and symptoms of congestive heart failure are still present. The physician may scratch his or her head wondering why there was a lack of therapeutic efficacy. But it may not be that the prescribed medication wasn’t effective, it may be that the prescribed medication was not taken properly or even not taken. Pharmacists Kenreigh and Wagner posting in the Medscape web article about medication adherence report that a recent study “found that the risk of hospitalization was more than double in patients with diabetes mellitus, hypercholesterolemia, hypertension, or congestive heart failure who were nonadherent to prescribed therapies compared with the general population.” The article suggests that patients with chronic illnesses are more likely to fail adherence to a prescribed medical program than those with acute illnesses. In addition, issues of literacy of the patient should be considered as a factor.

There are a couple other factors involved in non-compliance not specifically mentioned in the article which should also be considered. One involves the doctor-patient relationship and the degree of confidence the patient has in the doctor. Doctors who don’t or can’t take the time to explain to the patient’s understanding the therapy and schedules could face non- or poor compliance response by the patient. Schedules are often an important factor in poor compliance especially if the schedules fail to take into account the patient’s individual scheduling problems. The other involves financial burdens placed on the patient and the decisions patients have to make with regard to how they allocate their available income to the various necessities.

One change in the system that is greatly needed is that the physician become more educated and kept updated on the cost of medications. Ask your doctor to tell you the cost of a drug. I bet he or she can't give you a spontaneous answer. It is a simple task to select a drug that has been shown to be potentially pharmacologically effective. But that is only one factor for the physician to consider. The other obviously includes the medical risks of the drug but yet another is the financial burden of the medication to the patient. That requires an knowledge of the cost of the medication and the financial status of the patient. Perhaps physicians should take time to also discussing this burden with the patient and, if necessary, prescribe a medication perhaps not as “new” or direct-to-consumer advertised which could be equally effective. But I just wonder how often physicians do that.

The reflex response by a doctor when a medication doesn’t seem to be working should not be to change drugs. It should be first to establish whether the patient is taking the medication or taking the medication as prescribed. And then, if this is the problem, the physician should try to mitigate it. ..Maurice.

Tuesday, October 25, 2005

Expectation in Medicine

In my previous postings on the angry patient, I think much of the etiology of the anger is related to the simple and common psychologic activity of expectation. We all generally go into a medical relationship, either as the patient or the physician, expecting something good to come out of it. But as Emily Dickinson seems to be warning us, expectation, though anticipated as satisfactory may lead to, one might say, unexpected consequences.

”Expectation—is Contentment” by Emily Dickinson

Expectation -- is Contentment --
Gain -- Satiety --
But Satiety -- Conviction
Of Necessity

Of an Austere trait in Pleasure --
Good, without alarm
Is a too established Fortune --
Danger -- deepens Sum --

What is being expected in medicine? From the patient’s viewpoint, it is having a pleasant and empathetic and conscientious physician who has the knowledge and skill to treat satisfactorily the illness. Additionally, the physician is expected to take or make the time to listen to the patient, perform a proper examination and communicate in way that the patient understands the diagnosis and the recommendations. The physician’s office must also reflect the same personal attention that is being provided by the physician. I think that these qualities are something which most patients expect.

What is being expected from a physician’s viewpoint? I think doctors want the patient and the family, in general, to be tolerant regarding the limits of medical practice in the 21st century. That they should be realistic and therefore be understanding and supportive of the issues the physician faces with regard to office management as well as diagnosis and treatment management. Specifically, the doctors want an educated patient or one who can be easily educated in personal medical matters and desires to be compliant. They want a patient who presents with a problem that can, even if challenging, be managed by the physician to the benefit of the patient.

Unfortunately, for both parties, expectations may never be fully realized to the anguish of each. To the patient, in many ways, if the physician fails to meet the patient’s needs, the resulting discomfort adds to the burden of the illness itself. To the physician, if the patient, the family, the disease or the response to treatment fail to be the hoped for ideal, personal or professional confidence may be lost and the physician may project the loss toward the patient or family. And so with expectations by one party or the other or both, not leading to that “contentment”, the relationship deteriorates and display of the discontent including anger in one form or the other may appear.

What do you think a patient or a physician expect out of their relationship? ..Maurice.

Saturday, October 22, 2005

The Angry Patient (2) and the Internet

What about angry patients expressing their feelings not solely to the doctor involved but broadcasting it to the world on an Internet Web site? This is happening, as documented in a Wall Street Journal article of September 14, 2005. This behavior by patients has led to various libel lawsuits. As noted in the article there are, of course, two views of the issue:

"The potential problems are huge," said Matt Messina, a dentist in Fairview Park, Ohio, and a spokesman for the American Dental Association. "My reputation is my stock in trade … and we work years and years to build that reputation. To have that shattered potentially [by an Internet posting] is a concern."

Patient advocates, meanwhile, say patients have First Amendment rights to describe their experiences with physicians. "Blogs and personal Web sites are no different than talking over the back fence," said Charles Inlander, president of People's Medical Society, a patient advocacy group in Allentown, Pa. "Those who read it have to take it with whatever grain of salt you would take, just like a neighbor. It's too bad if doctors are insulted by this."

If a disgruntled patient is asked by a neighbor for a recommendation for a doctor, specifically the patient’s doctor, is it slander to tell that neighbor about the patient’s own unhappy experience? If it is part of our right to free speech, then is this act just as permissible if same description of the doctor is displayed on a Web site? According to the Columbia University Press Encyclopedia, “In recent years, the U.S. Supreme Court has allowed that only factual misrepresentation is to be considered libel or slander, not expression of opinion. It has also ruled that libel suits may be filed across state lines, not only in the state where the plaintiff lives.”

The law is one aspect but what about the ethics? Is it ethical to “spread the word” of one’s personal anger. Well, the way I would look at it would be all about intent. If the intent was to present to others only the facts about one’s own personal experience with a physician and not to generalize about how that physician might behave with another patient or to demean or degrade the physician then this act might be ethical. However, if the intent is specifically to do damage to the physician and his or her practice, this would be maleficent, unjust and therefore unethical. What do you think of an angry patient expressing personal discontent on the Internet? ..Maurice.

Friday, October 21, 2005

The Angry Patient

The Angry Patient

The angry patient is a like a thorn suddenly
Pricking the finger of the unwary doctor
But, perhaps, sticking there with great pain and consternation
The doctor trying some way to pull it out
And not push it in deeper

I want to expound a bit on my poem. In our American and perhaps generally within the western culture, physicians will experience sometime in their practice angry patients. The anger may be expressed directly to the physician because of some sort of unhappiness which was experienced by the patient. The experience could have been happened during care by a previous physician but the patient is entering the new relationship with much suspicion and may want to set control. The patient may be dissatisfied by something currently experienced and may represent unhappiness with the physician or the office. Or sometimes the anger may represent an attempt by the patient to exert control in any way because of anxiety and fear about the patient’s own illness for which therapeutic control is lacking. Whatever the basis of the anger, the presence of an angry patient confronting the physician presents a challenge to that doctor. There is the natural reaction for the physician to be immediately defensive and return anger with a similar behavior except for one thing.. the basis of all medical care: the aim of medicine to be therapeutic. And returning anger is not productive and certainly not therapeutic. So what guidelines can a physician use to be therapeutic in the response?

On the website of The Reporter publication by the Texas Medical Liability Trust, I found a great article by Barbara Rose on how to defuse angry patients. I would like to present the article’s suggestions (References are listed in the article):_

• Be curious; ask why they are angry as this
may have a therapeutic effect.
• Don’t be defensive and engage in a power
• Listen carefully; this alone may defuse the
patient’s anger.
• Use active-listening techniques — repetition,
summary, validation, and empathetic statements.2
When physicians are uncomfortable interacting
with a patient, a barrier to effective communication
exists. “Being aware of the tension, identifying the
barrier, and acknowledging with the patient that
there is difficulty in the relationship are important
steps in re-establishing understanding between a
patient and clinician.” 2
In Anger Management Techniques, J. Alfonso
describes visceral responses that may defuse a heated
encounter with a patient.
• Maintain slow and steady breathing.
• Monitor the pace and tone of your voice. Speak
slowly and calmly.
• Maintain open body language as a nonverbal
sign of listening. 3
Also, avoid standing with your hands on your
hips, in your pockets, or arms crossed as this body
language connotes a defensive reaction.
What if the source of the anger legitimately rests
within your practice? A patient who experienced
difficulty in scheduling an appointment, a long
waiting time, or unresponsive staff members will
very likely direct anger toward the physician. Use
the techniques listed above. Get specifics and give
the patient assurance that the matter will be acted
on and resolved. Don’t avoid the angry or dissatisfied
patient. Being an advocate for your patients will
enhance your effectiveness. “As difficult as it may
be, the more you talk with and listen to an angry
patient, the more likely you are to avoid converting
an incident into a claim.” 4
Another model for dealing effectively with critical
and angry patients triggered by events in your practice
suggests the following:
1. Make a disarming statement, e.g. “You are
right. You did have to wait today.” This is nondefensive
and validates some of what the patient
is saying.
2. Make an empathic statement, e.g. “Your time is
important and it is frustrating when you have to
wait.” This reflects putting yourself in the
patient’s position and understanding his or her
3. Make an inquiry, e.g. “What can we do to
resolve this problem today?” This demonstrates
your shared relationship and interest in the
patient and may move the exchange to a productive
solution. 5

These are all excellent suggestions. But, physicians are human too and an angry patient can strain sometimes the strongest self-confidence. However, I think if the physician looks at the patient’s expression of anger as a patient symptom and tries, with the help of these guidelines, to understand and then treat the symptom, the experience will be something positive and perhaps of value to all involved.

I would be most interested in reading from my visitors whether they, as patients, displayed anger at their physician and how the physician responded. Did the doctor demonstrate any of the guidelines as noted above? What was the outcome? Again, no names please. ..Maurice.

Tuesday, October 18, 2005

Teaching of Medical Students to Become Physicians (3): The Middle Finger, Index Finger Trick

As the old story goes:

First-year students at Medical School were receiving their first anatomy class with a real dead human body. They all gathered around the surgery table with the body covered with a white sheet. The professor started the class by telling them, "In medicine, it is necessary to have two important qualities as a doctor: the first is that you can not be disgusted by anything involving the human body". For an example, the professor pulled back the sheet, stuck his finger in the butt of the corpse, withdrew it and stuck it in his mouth. "Go ahead and do the same thing," he told his students. The students freaked out, hesitated for several minutes, but eventually took turns sticking a finger in the butt of the dead body and sucking on it. When everyone finished, the professor looked at them and told them, "The second most important quality is observation. I stuck in my middle finger and sucked on my index finger. Now learn to pay attention."

Would you believe that I actually watched a physician, teaching 2nd year medical students the skill of observation, performing virtually the same deception? However the physician used a plastic cup filled with a yellowish liquid he identified as urine and did the same middle finger, index finger trick and actually got a student up in front of his fellow students to stick in a finger then suck. Then the physician admitted that the container was not filled with urine but actually a potable drink. Everyone laughed.

Though it was all fun and hopefully educational, I always wondered whether this act was really ethical and fair, taking advantage of a vulnerable young medical student.
Am I being overly concerned about this particular way of teaching? Or should our teaching of medical students, including those in the later years on the wards, be tempered by more concern with ethical boundaries? ..Maurice.

Monday, October 17, 2005

More on Teaching Intelligent Design

Writing in the National Review Online,(and please read the entire article) John Derbyshire makes a good argument why there is no reasonable basis for the president or anyone else to proclaim the teaching of intelligent design to students should trump teaching each of the other “pseudoscientific flapdoodle”
The title of the article is "Teaching Science--
The president is wrong on Intelligent Design.

...I caught President Bush's endorsement of teaching Intelligent Design in public school science classes. "Both sides ought to be properly taught," President Bush told a reporter August 2, "so people can understand what the debate is all about."
This is Bush at his muddle-headed worst, conferring all the authority of the presidency on the teaching of pseudoscience in science classes. Why stop with Intelligent Design (the theory that life on earth has developed by a series of supernatural miracles performed by the God of the Christian Bible, for which it is pointless to seek any naturalistic explanation)? Why not teach the little ones astrology? Lysenkoism? Orgonomy? Dianetics? Reflexology? Dowsing and radiesthesia? Forteanism? Velikovskianism? Lawsonomy? Secrets of the Great Pyramid? ESP and psychokinesis? Atlantis and Lemuria? The hollow-earth theory? Does the president have any idea, does he have any idea, how many varieties of pseudoscientific flapdoodle there are in the world? If you are going to teach one, why not teach the rest? Shouldn't all sides be "properly taught"? To give our kids, you know, a rounded picture? Has the president scrutinized Velikovsky's theories? Can he refute them? Can you?

I think that proponents of each theory could argue the value of their view to be included in an educational curriculum and probably they should. But I also think that they certainly should not be taught in a class dealing with science. I would think that a philosophy class would be more appropriate. Do you agree? ..Maurice.

Thursday, October 13, 2005

Teaching Medical Students to Become Physicians(2): Teaching Intelligent Design?

Now I am worried. Maybe we all should be worried. I just finished reading the Perspective article by Robert S. Schwartz, M.D. “Faith Healers and Physicians—Teaching Pseudoscience by Mandate” in the New England Journal of Medicine, October 6, 2005 issue. I knew about the intelligent design movement (anti-evolution but proposing “a supernatural being—a hidden wizard—has a hidden hand in shaping the living world.”) [Note: these quotes and quotes below taken from the article.] I knew it was being debated in school boards around the country regarding starting teaching intelligent design to school children beginning in the 9th grade.

What I didn’t know was according to the article “Bill Frist, the Senate majority leader and a graduate of Harvard Medical School, has come out in favor of teaching of intelligent design.” Could this mean there may come political pressure to have medical schools teach intelligent design? “Its proponents tell us that gaps in our knowledge of how living organisms evolved vitiate the theory of evolution.” Think.. if this catches on as medical teaching, what could be the result? Any explanation that our scientists cannot explain must then be explained as part of the intelligent design. Therefore, no further attempt at another explanation would be necessary. This could put an end to scientific medical research. Treatment of medical illness and search for new drugs would be de-emphasized since there is no trumping the product of the “designer”.

Dr. Schwartz urges us in medicine, as physicians, leaders of professional societies and prominent academicians to protect the public from pseudoscience and begin to “understand what the debate is about and consider the consequences for the future of medicine.” ..Maurice.

Wednesday, October 12, 2005

Teaching Medical Students to Become Physicians (1)

As with all teaching, I think there is an art in teaching medical students. As with many other skills, the art is developed over time with experience along with some education. The art is not related to teaching these students how to study. The techniques of study have been worked out by the students themselves over the many previous years of their academic schooling. The art is to effectively facilitate their medical learning process and help them not act like a doctor but instead be a doctor.

Learning the science of medicine doesn’t require much didactic teaching since many resources beyond the professors are readily available to the students and coming to class to listen is becoming less common. What the students need is direction toward the content of what is necessary to learn and they need proctoring and mentoring as they develop their physical and intellectual/behavioral skills. But there is also the need for psychologic and emotional counseling.

In the first two years, the exposure to real patients with real illnesses is not always easy for a student to handle emotionally. Students are faced with issues relating to personal identification with patients or personal identification with their illnesses. In these years, the students are beginning to develop skills for taking intimate history from the patient and physically touching the patient in the physical exam. These activities involve degrees of student hesitation or embarrassment. Boundaries of history taking, self-disclosure and physical contact have to be set.

In the 3rd and 4th years, as they work on the wards in their clinical clerkships, the students are then faced with multiple pressures, uncertainties particularly related to their increasing patient responsibilities, fatigue and at times difficult relationships developing between themselves and their superiors. In addition, the students’ private lives are beginning to be disrupted by their clerkship responsibilities. Further, there is also the increasing student concerns about the issue of selecting specialties and post-graduate training competition. The students also need to think at this time further into the future about how their professional and private lives are going to be managed.

Becoming a professional physician is definitely not easy and may be handicapped by institutional systems that carry along educational and behavioral baggage, repeated over the years, which is neither beneficent nor helpful for the development of a physician. More on teaching medical students later. ..Maurice.

Sunday, October 09, 2005

No Ability, No Dignity Can Fail Him Now...

Delmore Schwartz : "Yeats Died Saturday In France"

Published/Written in 1939

Yeats died Saturday in France.
Freedom from his animal
Has come at last in alien Nice,
His heart beat separate from his will:
He knows at last the old abyss
Which always faced his staring face.

No ability, no dignity
Can fail him now who trained so long
For the outrage of eternity,
Teaching his heart to beat a song
In which man's strict humanity,
Erect as a soldier, became a tongue.

This poem about William Butler Yeats, the Nobel Prize winning Irish poet sort of tells us what is true of every one of us. Dignity is truly in the eyes of the beholder after death since it no longer becomes personally necessary for the deceased. But.. before death as it was most likely with Yeats, if the person is aware, perhaps it may be very personally important. ..Maurice.

Saturday, October 08, 2005

What is Death with Dignity?

The dictionary shows that the word is derived finally from Latin meaning worthy. The definition includes the following:

1. The quality or state of being worthy of esteem or respect.
2. Inherent nobility and worth: the dignity of honest labor.
a. Poise and self-respect.
b. Stateliness and formality in manner and appearance.
4. The respect and honor associated with an important position.
5. A high office or rank.

So one would wonder what is the expression used these days “death with dignity” could possibly mean. When we use dignity in that expression, surely we are not talking about a persons high office, rank or necessarily an important position nor would we be considering stateliness and formality in manner or appearance. We must be talking about being worthy or esteem or respect by others and also, perhaps, poise and self-respect.

Could these elements be what is missing when a death is not dignified? Can a person in great pain, suffering, perhaps mentally obtunded to varying degrees demonstrate personal poise and self-respect? Probably not. Beyond what the person is presenting as him/herself is what others consider is common consideration of all human beings: esteem, the holding a human as a high value for the potential of a human and respect, as a civilized notion, for the values, rights and beliefs of all persons. With regard to the dying person, this esteem and respect by others should be shown in care and concern about seeing that no further discomfort, anguish or alteration of the physical body, appearance or condition occurs. This esteem and respect should carry over to the person once deceased. If these elements of dignity expressed through the patient’s self or by others are missing then the death is undignified, something we, who are not in the patient’s condition at the moment, should not ignore.

I would appreciate other views from my visitors regarding what is meant by “death with dignity”. ..Maurice.

Wednesday, October 05, 2005

Death with Dignity: Where is the Compassion in the Federal Government?

Today, the U.S. Supreme Court is taking up the issue of whether it is the federal government or it is the states which can control medical practice and define what or what is not “medical treatment”. The case is that of the U.S. Attorney General vs the State of Oregon. And the object of the discussion is the Oregon’s Death with Dignity Act which allows physicians with licenses to practice in Oregon the right to prescribe a lethal dose of medication to Oregon citizens who are competent and who have a terminal illness and who personally desire to have the opportunity to time their own death by their own hand. The federal government through the drug control laws has decided that the prescribed “controlled” medication cannot be prescribed for the use intended in the Oregon law since these medications can only be prescribed for “medical treatment” and the federal government does not classify assisted-suicide use as a “medical treatment”.

So that those visitors here who would like to know more about this Oregon law, I have copied the FAQ list from the Oregon State government website. The issue, as I see it, is whether it is the federal government can dictate and define how medicine is practiced in any state, rather than, as it has all these many years, being a state responsibility. We saw what seemed like "compassion" (or was it politics>) exuding out of our federal government and our president for Terri Schiavo and her family. But, in fact, Terri was unable to suffer. Now where is the compassion for the Oregon patients who can suffer? .Maurice.

FAQ about Physician-Assisted Suicide

In 1997, Oregon enacted the first and, so far, only physician-assisted suicide law
in the United States. This law (known as the Death with Dignity Act) requires the
Oregon Department of Human Services to collect and analyze data on who
participates in the Act and to issue an annual report. These data are important to
parties on both sides of the issue. Our position is a neutral one, and we offer no
subjective opinions about these questions. We routinely receive inquiries about the
Act. Here are some answers to commonly asked questions.
Q: What is Oregon’s Death with Dignity Act?
A: The Death with Dignity Act permits physicians to write prescriptions for a lethal dosage of medication to people with a terminal illness. This procedure is also known as physician-assisted suicide.
The Death with Dignity Act was a citizens’ initiative passed twice by Oregon voters. The first time was in a general election in November 1994 when it passed by a margin of 51% to 49%. An injunction delayed implementation of the Act until it was lifted on October 27, 1997. In November 1997, a measure was placed on the general election ballot to repeal the Death with Dignity Act. Voters chose to retain the Act by a margin of 60% to 40%.
There is no state “program” for Death with Dignity/physician-assisted suicide.
People interested in participating do not “make application” to the State of Oregon or the Department of Human Services. It is up to qualified patients and licensed physicians to implement the Act on an individual basis. The Act requires the Department of Human Services to collect data on patients who participate each
year in order to determine compliance with the terms of the Act and to issue an annual report.
Q: Who can request physician-assisted suicide?
A: The law states that, in order to participate, a patient must be: 1) 18 years of age
or older, 2) a resident of Oregon, 3) capable of making and communicating health
care decisions for him/herself, and 4) diagnosed with a terminal illness that will lead to death within six (6) months. It is up to the attending physician to determine whether these criteria have been met.
Q: Can someone who doesn’t live in Oregon participate in physician-assisted suicide?
A: No. Only patients who establish that they are residents of Oregon can
participate if they meet certain criteria.
Q: How does a patient demonstrate residency?
A: A patient must provide adequate documentation to the attending physician to verify that s/he is a current resident of Oregon. Documentation might include an Oregon Driver License, a lease agreement or property ownership document showing that the patient rents or owns property in Oregon, an Oregon voter registration, a recent Oregon tax return, etc. It is up to the attending physician to
determine whether or not the patient has adequately established residency.
Q: How long does someone have to be a resident of Oregon to participate in physician-assisted suicide?
A: There is no minimum residency requirement. A patient must simply be able to establish that s/he is currently a bona fide resident of Oregon.
Q: Can a non-resident move to Oregon in order to participate in physician-assisted suicide?
A: There is nothing in the law that prevents someone from doing this. However, the patient must be able to prove to the attending doctor that s/he is currently a bona fide resident of Oregon.
Q: Who can give a patient a prescription for physician-assisted suicide?
A: Patients who meet certain criteria can request a prescription for lethal
medication from a licensed Oregon physician. The physician must be a Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) licensed to practice medicine by
the Board of Medical Examiners for the State of Oregon. The physician must also be willing to participate in physician-assisted suicide. Physicians are not required to provide prescriptions to patients. Physician participation in physician-assisted
suicide is voluntary. Additionally, some health care systems (for example, a Catholic hospital or the Veterans Administration) have prohibitions against
practicing physician-assisted suicide that physicians must abide by as terms of their employment.
Q: If a patient’s doctor does not participate in physician-assisted suicide, how can s/he get a prescription?
A: The patient must find another M.D. or D.O. licensed to practice medicine in Oregon who is willing to participate. The Oregon Department of Human Services does not recommend doctors, nor can we provide the names of participating physicians or patients due to the need to protect confidentiality.
Q: If a patient’s primary care doctor is located in another state, can that doctor write a prescription for the patient?
A: No. Only M.D.s or D.O.s licensed to practice medicine by the Board of
Medical Examiners for the State of Oregon can write a valid prescription for lethal medication under the Death with Dignity Act.
Q: How does a patient get a prescription from a participating physician?
A: The patient must meet certain criteria to be able to request to participate in physician-assisted suicide. Then, the following steps must be fulfilled: 1) the
patient must make two oral requests to the attending physician, separated by at least 15 days; 2) the patient must provide a written request to the attending physician, signed in the presence of two witnesses, at least one of whom is not related to the patient; 3) the attending physician and a consulting physician must confirm the patient’s diagnosis and prognosis; 4) the attending physician and a consulting physician must determine whether the patient is capable of making and communicating health care decisions for him/herself; 5) if either physician believes
the patient’s judgment is impaired by a psychiatric or psychological disorder (such
as depression), the patient must be referred for a psychological examination; 6) the attending physician must inform the patient of feasible alternatives to assisted suicide including comfort care, hospice care, and pain control; 7) the attending physician must request, but may not require, the patient to notify their next-of-kin of the prescription request. A patient can rescind a request at any time and in any
manner. The attending physician will also offer the patient an opportunity to rescind his/her request at the end of the 15-day waiting period following the initial request to participate.
The law makes every attempt to ensure that patients who engage in physicianassisted
suicide are doing so voluntarily, fully informed, and with the ability to
make rational health care decisions for themselves.
Physicians must report all prescriptions for lethal medications to the Department of Human Services, Vital Records. As of 1999, pharmacists must be informed of the prescribed medication’s ultimate use.
Q: What kind of prescription will a patient receive?
A: It is up to the physician to determine the prescription. To date, most patients have received a prescription for an oral dosage of a barbiturate.
Q: What will happen if a physician doesn’t follow the prescribing or reporting requirements of the Act?
A: The Department of Human Services will notify the Board of Medical
Examiners of any deviations. If a formal investigation is warranted by the Board of Medical Examiners, physicians might be subject to disciplinary action.
Q: Must a physician be present at the time the medications are taken?
A: The law does not require the presence of a physician when a patient takes lethal medication. A physician may be present if a patient wishes it, as long as the physician does not administer the medication him/herself.
Q: Can a patient rescind a request for physician-assisted suicide?
A: Yes, a patient can rescind a request at any time and in any manner. The
attending physician will also offer the patient an opportunity to rescind his/her request at the end of the 15-day waiting period following the initial request to participate.
Q: How much does physician-assisted suicide cost?
A: We do not collect cost data. However, direct costs for physician-assisted suicide might include office calls relating to the Death with Dignity request, a psychological consult (if required), and the cost of the prescription.
Q: Will insurance cover the cost of physician-assisted suicide?
A: The Death with Dignity Act does not specify who must pay for the services. Individual insurers determine whether physician-assisted suicide is covered under their policies (just as they do with any other medical procedure). Oregon statute specifies that participation under the Death with Dignity Act is not suicide, so should not affect insurance benefits by that definition. However, federal funding cannot be used for services rendered under Oregon’s Death with Dignity Act. For
instance, the Oregon Medicaid program, which is paid for by federal funding, ensures that charges for physician-assisted suicide services are paid only with state funds.
Q: Can a patient’s family members request physician-assisted suicide on behalf of the patient (for example, in cases where the patient is comatose)?
A: No. The law requires that the patient ask to participate voluntarily on his or her own behalf.
Q: Are euthanasia and physician-assisted suicide the same thing?
A: No. They are two legally distinct procedures for hastening death. In
euthanasia, a doctor injects a patient with a lethal dosage of medication. In physician-assisted suicide, a physician prescribes a lethal dose of medication to a patient, but the patient – not the doctor – administers the medication. Euthanasia is illegal in every state in the union, including Oregon. Physician-assisted suicide has been legal in Oregon since November 1997. Oregon is the only state in the Unionthat has legalized physician-assisted suicide.
Q: What information is available on Oregon’s Death with Dignity website?
A: You can find links to all our annual reports, forms, legislation, rules, press releases and other articles. The annual reports themselves contain an historical background of the Act, a description of the laws pertaining to physician-assisted suicide in Oregon, how data is reported, collected and analyzed, a summary of the year’s results, and tables that outline the participant demographics and disease
characteristics. The Department of Human Services does not collect some
information (such as religious affiliation of participants or cost of the physicianassisted suicide procedure); other information is strictly confidential (such as names of participating patients and physicians).
Q: What is the Department of Human Services’ opinion of physician-assisted
suicide? Does it encourage people to hasten their deaths? Should this law have been passed? What are the pros and cons of physician-assisted suicide?
A: The Death with Dignity Act was a citizen’s initiative, enacted because a majority of voting Oregonians believed that persons afflicted with certain terminal
illnesses should have the legal right to hasten death. The role of the Department of Human Services is to collect and analyze data annually on physician-assisted suicide participation in Oregon. These data are important to parties on both sides of the issue. Our position is a neutral one, and we offer no subjective opinions about these questions.
Q: What is the status of the federal lawsuit against Oregon’s Death with Dignity law?
A: November 6, 2001: U.S. Attorney General John Ashcroft issues a directive which states, in part, that prescribing, dispensing or administering federally controlled substances to assist suicide violates the Controlled Substances Act
(CSA). This new interpretation of the CSA allows the federal Drug Enforcement Agency (DEA) to pursue action to revoke prescription-writing privileges and to pursue federal criminal prosecution of participating Oregon physicians. November 7, 2001: Oregon Attorney General Hardy Myers files suit in U.S.
District Court for a temporary restraining order and preliminary injunction. November 8, 2001: U.S. District Court Judge Robert Jones issues 10-day stay barring implementation of Ashcroft’s order.
November 20, 2001: Judge Jones issues a temporary restraining order against Ashcroft's ruling pending a new hearing.
January 22, 2002: Oregon Attorney General Hardy Myers files a motion for summary judgment.
April 17, 2002: U.S. District Court Judge Robert Jones upholds the Death with Dignity Act. Permanent injunction is filed.
September 23, 2002: Attorney General Ashcroft files an appeal, asking the 9th U.S. Circuit Court of Appeals to overturn the District Court's ruling. May 26, 2004: a three-judge panel upholds Judge Jones’ ruling.
July 13, 2004: Ashcroft files an appeal requesting that the 9th U.S. Circuit Court of Appeals rehear his previous motion with an 11-judge panel.
August 13, 2004: 9th U.S. District Court of Appeals denies Ashcroft’s request. November 9, 2004: Ashcroft appeals the case to the U.S. Supreme Court. February 22, 2005: U.S. Supreme Court agrees to hear the appeal.
Present: Arguments will be held during the U.S. Supreme Court's next term.
At this time, Oregon's law remains in effect.
Further information on the case of the State of Oregon v. John Ashcroft, et al. can
be found at the Department of Justice’s Physician-Assisted Suicide website
Q: Where can I find a copy of the statutes and administrative rules governing the
Death with Dignity Act?
A: The statutes can be found at and
the administrative rules are at
Q: Where can I find the forms used for Death with Dignity?
Revised 5/23/05

Monday, October 03, 2005

Science vs Ethics: Three Years of Public Comments

Since I first started my original "Bioethics Discussion Pages" many years ago, I have always been impressed by the observation, from the responses to various ethical issues, that the general public has as much insight into the discipline of ethics as do the professional ethicists. Most of the time they can express and support their conclusions regarding these issues in a clear and logical way.

If you have time, read this example issue page. It's about the relationship of ethics and science. Chronologically, the order of the comments starts at the bottom of this posting. Some of the comments are written by students and perhaps a professor has written one of them but I think most are just written by thoughtful individuals. And I think together they have parsed out a feeling about the relationship which in many ways is something we all must consider as we see how science is expanding. What do you think? ..Maurice.


Can Science be ever Separated From the Question of Ethics?

Science is a discipline of knowledge which involves many aspects of human thought and endeavour. Ethics is concerned with human character and conduct. One might think that science cannot be science without a consideration of the ethics involved. But is that really true? Wendy, a Jr. College student from Singapore writes the following:

Date: Sat, Feb 14, 1998 8:14 AM From: To:

Hi! My name is Wendy and I'm an Arts Student researching for my essay entitled " Can science be ever separated from the question of ethics " I would appreciate it if you will post this question for discussion. Please include your own views about this question.

Thank you

Here is the question:
Can Science be ever Separated From the Question of Ethics?


Date: Fri, Apr 6, 2001 7:11 AM From: To:

I think there exist two level of relationship between science and ethics: 1) The reasoning level. From this point of view ethics is distinct from science, because we can't derive a moral judgement from mere assertions of facts (i.e. Hume'law). We need of premises that contains moral judgments, in addiction with empirical (factual and therefore scientific) observations. 2) The practical level. This is the level of the possibile control of ethics over science. It doesn't mean that ethics should say always "no" to science but that scientific advances have to be compared with our moral standards. I think that the most powerful standard that we have is the utilitarian model, combined with rules of justice in certain areas of biomedical research (i.e. the allocation of health resources).

Date: Thu, Mar 15, 2001 4:33 PM From: To:

Ethics: The system of human mental activities that allows us to assign a degree of "goodness" or "badness" to a situation, action, or idea based on the societal perceptions of the time. The most common moral ethic is an aversion to anything that harms a person, or something seen to be alive. This is due to an underlying fear response that assumes that anything that can affect a living system in a seemingly adverse way can also affect you personally. Our brains evolved in such a way as to process potentially harmful stimuli and direct them to parts of the brain that will ultimately cause us to abhor or at least be wary of the stimulus again. This is merely part of our survival "instinct", an unchangeable set of physical neural pathways that serve as the program for self preservation. Without this, we would simply have not had a physical reason to avoid a lion, and would have died off, maybe or maybe not to be replaced by an organism who had happened to develop a similar categorization system.

Science: The process of gathering and interpreting facts and measurments to deduce underlying patterns. A scientific experiment, or for that matter anything a human "does", consists of a highly, highly, highly, complex collection of atoms and energy (the human) manipulating or otherwise changing it's surrounding collection of atoms and energy(the environment). In a carefully designed experiment, the reorganization of the environment will give new or previously unrecognized knowledge about something. So therefore an experiment, or science, is merely changing one's viewpoint to allow the human brain to accept or realize information through specific sensory neural pathways.

Ethics and Science: Both ethics and science are therefore physical phenomena occuring or being caused by the brain. As such, they are for the most part inseparable, both being abstract and inevitable processes of the mind. A scientific experiment is conducted by human beings for what they "think" is their betterment, but in actuality fullfils a similar drive to attain knowledge. We humans are stuck, for the time being, constantly interpreting this knowledge and assigning it levels of importance and deadliness, degrees to which it will stop our collection of atoms from "living".

Date: Thu, Jul 13, 2000 4:24 PM From: To:

I think that we can't separete ethics question from science, because we don't find a science real and general ethic. This situation made the world what he is today, we are just loking for a science general ethic, without one we might have a unethic world.

Date: Thu, Apr 27, 2000 7:59 PM From: To:

CAN SCIENCE EVER BE SEPARATED FROM THE QUESTION OF ETHICS? Science is a branch of study concerned with facts, principles, and methods. However, ethics is the moral science that governs what we do with it. It is the branch of philosophy that studies the principles of right and wrong in human conduct. The question of their individuality has been in existence for quite some time. I would argue that in theory they can exist separately but in practice they cannot. In Aristotle's structure of the soul, one can see that science takes precedence over ethics. In the rational side of the human soul, there are two divisions. They are the practical and the contemplative. Aristotle always gave the contemplative side superiority over the practical. The contemplative division consisted of the pure sciences (math, physics, metaphysics), but the practical enabled the human with moral actions (ethics, politics). Though this trend was set many, many years ago, it still holds true today. I agree with a response on the web-page. Ethics do govern what is allowed in science. Some one also mentioned that every act has its own consequences. Because of this, ethics can never be separated from science. There should always be the Kantian question of the end justifying the means.

Date: Thu, Apr 27, 2000 7:13 PM From: To:

Does the end justify the means? Since there is no universal answer to this question, it must be applied to situations as they occur. Ethics serve as a check on the power of scientific study. Without the limitations that our ethics impose on science, scientists would have enough power to drastically alter the world as it exists today. Examples of this unregulated power lie in cloning as well as human and animal experimentation. As noted in previous responses to this question, ethics will always play a role in regulating scientific activities. Although it may be helpful to learn new things by unethical methods, the result of this experimentation and discovery could be devastating to our culture. Because of these risks, ethics will always be a part of science.

Ethics also act as insurance to scientists since their every idea is heavily scrutinized before it is carried out. This gives scientists a method of defense if anything should go wrong because their experiments must be approved, and the blame for any negative results is shared with the moral regulators of science.

Date: Tue, Apr 25, 2000 7:47 PM From: To:

"Science is a discipline of knowledge which involves many aspects of human thought and endeavor. Ethics is concerned with human character and conduct." With this basic definition in mind, there is no finite interaction between these two disciplines. L. Wingblade's response presents some ideal points. The methodical approach of science and ethics are very different. Science uses empirical methods and interprets data, while ethics focuses on the moral grounds as to why we should or should not do things. In that aspect, the two disciplines do differ. However, it is in defining the two through daily actions that they intertwine. As E. Portilla presented, it is hard to think of any human doing or interaction without thinking in an ethical mindset. Society as a whole strives to maintain standards that provide respect, justice, and truth to all its members. In order to do this, questions of how to treat people and what things are right and wrong are always at hand. Science is definitely an area where ethical consideration will always need attention. As technology increases, and the progression of science opens doors to further engineering of human lives, ethical dilemmas will only increase. Issues of euthanasia, abortion, cloning, and others will forever be attached to ethical issues because they deal with the direct treatment of human lives. To separate this scientific approach from the extensive realm of morality separates human beings from human thought. I agree that ethics is a set of rules that are constantly changing and govern to what degree science may act. The necessity of ethics in our society is only increasing to keep the human race in check. Without this moral code and thought, science could overpower the human race.

Date: Tue, Nov 9, 1999 1:38 PM From: To:

Wendy: In one sense science is already seperated from ethics because they use different methods. Science is empirical--it collects data and tries to interpret it. Ethics tries to answer the question "how best should we live our lives." Philosophy and ethics are armchair "sciences" which use logic instead of empirical data and tries by rational approaches to come to the correct answer. So in this sense they are seperate and always will be.

On the other hand, ethics gives us values in by which to guide our lives. Science never attempts this, so science relies on ethics to give us values. Our material culture (technology, science, engineering) always moves at a faster rate than our non-material culture (values, ethics, norms, rules of law, philosophy). In the future we will need even more so than now ethical guidelines in which to structure the use of our technology and our sciences. Our technical expertise is growing faster than our ability to handle it. Because of science we are moving into areas which humans have not explored before. We need the guidelines that ethics can provide.

Loren C. Wingblade

Date: Sun, Sep 26, 1999 8:23 PM From: To:

Science cannot be separated from ethics especially where the issues of genetic manipulation are considered. For example in stem cell research, we find those who view the act of harvesting aborted fetuses for use in creating cells for implantation into humans with various infirmities. While the end result seems quite noble, that of curing or improving the human condition of those who are ill, does that justify using fetuses? Are we not further devaluing human life? What is to prevent women from becoming pregnant so they can sell the aborted fetus to the highest bidder for stem cell use?

Date: Sat, Jul 17, 1999 11:46 PM From: To:

Science is a collection of the results of a search for facts about our physical reality. Ethics is an arbitrary set of rules for behaving in a way that is acceptable to the culture setting forth those rules. In Medical Science, it seems the major ethical question is, "does the end justify the means?" Until various cultural societies unify their beliefs, the ethical standards practiced by each might vary considerably. In that regard, Medical Science has the choice to either ignore ethical standards altogether, or try to find an acceptable standard within whatever culture it operates. The latter choice seems the most rewarding probability, since funding for scientific research comes out of the power bases in the cultures which it serves. Another reason for adopting a set of ethical standards arises from human nature--researchers, themselves, hold widely disparate belief systems. Differing beliefs within any given discipline can breed chaos.

Date: Sat, Jan 9, 1999 3:02 PM From: To:

Science itself can stand alone without ethics because science should be the factual basis behind debates in ethics, and if ethics are mixed in with the science in the first place, we would have no basis for discussion of the ethics. And, if that seemed too circular, science: fact; ethics: opinion based (hopefully) on fact.

Sincerely, Danielle, danib54321@

Date: Tue, Oct 27, 1998 8:52 AM From: To:

It was done before, this separation of science from ethics, maybe you heard about it. Joseph Mengela was the scientest and his subjects were the people of the death camps.
Date: Sat, Jun 27, 1998 7:35 PM From: To:

I think no human task can be separated from ethics in a general context. But, obviously, particularities arise. Despite the so called universality of science, points of view differ culturally, and no mater how an apparatus shows us the universe, each one of us interprets things differently. The same happens with the ethics of science, "cloning" or "vivisection" will mean different things to distinct human groups. So in this sense, science has nothing directly to do with ethics. If science pursues knowledge, maybe we should first discuss the morality of knowing things. On the other side, the USES of scientific knowledge will have to be discussed by non-scientists as well as scientists within each community's context, with no exclusion of global implications.

Eliseo Portilla, Guadalajara, MŽxico

Date: Mon, Mar 23, 1998 9:03 AM From: To:

Science is an unending quest for knowledge. In that quest there are some revelations that should be kept under ceratin controls. Every action has a consequence. Science can not be separated from the consequences of the "fruits" of its efforts. Many things that science has revealed to the medical field are particularly useful. However, there are some aspects of science that seem to be dangerous, i.e. cloning humans. Although we may someday in the technical aspects be able to accomplish this task. The question still remains whether or not we should. Ethics and morality can not be separated from science because it is the only thing that prevents humans from destroying ourselves. Ethics and morality should force each person (especially scientists) to evaluate their motives.

Kellye, Pre-med major at Middle Tennessee State University

Date: Mon, Mar 23, 1998 8:52 AM From: To:

I think that ethics is linked to science in such a way that they could never be divided. Ethics acts as a set of ever changing rules that govern what is allowed in science. I think that the fields of science have advanced to the point where anything is possible-- however, as a science student I would not want to be a part of a field that had no guidelines. Ethics helps to keep our knowlege in check and used solely for our betterment as a world. Dr. Richard Seed is a perfect example of science going off half-cocked. Although the cloning of humans may eventually be a reality the morality of the action must be taken into account and the needs of the people must be paramount to the action.

Mindy and Candice at MTSU

Date: Mon, Mar 23, 1998 8:50 AM From: To:

The basis for the scientific study is the quest for knowledge. Science itself is neutral, however new technologies are not always used in ethical ways. It is only those that pay for it that decide what ethical ramifications will come from new discoveries. The real question is, "Who's ethics are the standard?" There should be a separation from science and ethics. This is however is idealistic and not possible because the man with the gold makes the rules.

mark and bill

Date: Mon, Mar 23, 1998 8:50 AM From: To:

Greetings. I am a biology student at Middle Tennessee State University and have a rather unique opinion. I believe "ethics" in the sense of right and wrong is just a way to mask human frailty. People seem to lack the ability to separate feelings and beliefs (religious or otherwise) from what needs to be done. If something is "objectionable" we say it is not ethical, ie. the cloning debate. We, the scientific community, need to stop worrying about feelings and the rest of the "touchy-feely" garbage going on in our politically correct society. Unfortunately, humans, being the perverse and untrustworthy beings that we are, cannot handle responsibility of such grand magnitudes.Some one will undoubtably abuse the privilages that science has afforded them. As much as I believe that ethics and science should be separated, they will not be anytime soon. The human race is still in it's infancy, and concepts such as ethics and morality are the borders we use to keep ourselves in check.

Cutting it short, Tim

Date: Sat, Feb 28, 1998 8:26 AM From: To:

An old question that always needs new answers.

a) Clearly certain ethical categories are present in scientific inquiry...commitment to truth, a sense of integrity, a respect for truthfulness, an appreciation of differences/conflict.

b) Less directly, it is not really possible to isolate inquiry from use. Thus, attention to the ends to which inquiries are put is part of the process of doing science although this should not be confused with censorship (by self, by scientific community (see Charles Peirce), by the state...). In this connection, the alleged separation of "pure" from "applied" science needs to be reexamined critically. They flow so obviously into each other. The separation reflects a classical dualism which is unwarranted.

c) Finally, "science" should not be denotes what scientists are doing at a given time and in a given culture. To that extent, it is not separable from moral as from other values, e.g. aesthetic values as in notions like an "elegant" proof or "simplicity" (Ockham's razor). Further the "problems" that stir scientific interest reflect implicit cultural and social values and priorities.

Obviously, there's lots more...but these are the directions an inquiry into the relationship of the sciences and ethical values should take. Hence, John Dewey's notion of "intersubjectivity" rather than the illusory notion of "objectivity."

Howard B. Radest

Sunday, October 02, 2005

The Death of A Patient: To Bill or Not to Bill, That is the Question

Here is a non-classical limerick (6 lines: aabbba) I wrote this evening:

Pre-Operative Billing

There was a surgeon so skilled
His patients were preoperatively billed
But one didn’t survive
To leave his surgery alive
And when the mail did arrive,
The wife was not thrilled.

The ethical and professional issue is whether physicians should bill for services when the outcome is unfavorable or ends in the death of the patient. What factors should a doctor consider as appropriate for not billing for services rendered? ..Maurice.