Bioethics Discussion Blog: January 2006





Saturday, January 28, 2006

Using the Newly Dead

As a segue from the last posting on ethics and law in organ donation of the deceased, I want to bring to the attention to my visitors the full picture of the issues involved in the practice of “using the newly dead”. Are my visitors also aware that the newly dead are used for other medical purposes, in addition to organ procurement? Did you know about medical research and medical training to perform procedures?

First, with regard to tissue and/or organ procurement, this is performed on patients who are pronounced dead by classical cardio-respiratory criteria (spontaneous absence of heart beat and respiration), they are also obtained from patients who are pronounced dead by neurologic criteria (absence of whole brain function including brain stem), so-called “brain dead”, and finally from those who are dead by cardio-respiratory criteria but which was the result of the voluntary and intentional turning off of all life-support and awaiting for the heartbeat and respiration to stop. This latter criteria is used for the “donation by cardiac death”(DCD). There is still concern by the public and also by some medical professionals about the ethics of procurement using death by neurologic criteria and the DCD mechanism of producing death. The concerns involved in “brain death” is that the heart is still beating and the patient is being ventilated up to and as the organs are being removed. The patient doesn’t seem “as dead” as with the classical criteria. The concerns about DCD is whether the patient has been observed long enough (usually 5 to 10 minutes) to be sure there is no spontaneous revival of heart function before the organs are removed. Since the intentional turning off of life-support in a patient, as a candidate for DCD. who is terminal or has no chance for any meaningful recovery, is done because of the previous autonomous request of the patient or on the substituted judgment of a legal surrogate or with approval of the family as being in the patient’s best interest, there usually is no controversy about this act itself. But there is concern about the “premature” removal of the organs.

Now we come to another use of the newly dead. For years now, particularly since the advent of ventilator support and the concept of death by neurologic criteria, patients who are “brain dead” are being used for a great variety of research projects in which because the heart and respiration can be maintained for some time, the body can be functionally almost normal despite the absence of brain function. This means that medical research, though various techniques, can be performed on these newly dead which would be unethical or harmful if performed on live volunteers. For more details and examples of this use, you might want to read the Chicago SunTimes article “Ethical Frontier: Research on the Dead” by Jim Ritter in the Jan 3, 2006 issue. There are many ethical issues involve with this use. There have been various ethical guidelines set up by ethics groups to attempt to make sure that the research team follows certain ethical and legal standards. A discussion of the ethical considerations and the presentation of another, more recent, guideline is written in November 2005 issue of Nature Medicine by the multidisciplinary expert Consensus Panel on Research with the Recently Dead.

Respect for the dead is an important moral point.“ Such respect requires that research with the dead abide by the deceased person’s life goals and treats his or her body in a dignified manner.” Other reasons for maintaining the dignity of the person is that “many living people have preferences about the disposition of their bodies after they die; an aversion to disrespectful treatment is commonly among them. Honoring such preferences after death expresses respect for the person who once lived and may prevent emotional distress among the living.” In addition this behavior with regard to honoring preferences may avoid mistrust by the living, without which might generate research opposition. Disrespect may also “cause family and friends anguish and feelings of guilt (for failing to protect a deceased loved one). Some points based on ethical concerns that are covered in the guideline is the need for the research to address an important clinical problem and there should be formal unbiased review by a research board before the research is started. In addition, amongst other points is that prior consent by the patient or surrogates is necessary and there should be confidentiality and an opportunity for health care workers who find the research against their moral values to have an opportunity to opt out.

Finally, another use of the newly dead is that of the use for medical training of students, interns and residents to perform important potentially life-saving procedures such as endotracheal intubation or various other procedures which could cause harm in a living patient if they were performed improperly. To read more about the ethics of this use, go to Virtual Mentor. Prior consent is an ethical requirement, however there is literature which suggests that often prior consent is not obtained. If there is no consent from an advance directive by the patient, an argument that may be offered is that attempting to get such consent from a often distraught and grieving family at the last minute may not be in the family’s best interest.

I hope that this posting gives my visitors some idea of what is being done with the newly dead in medical practice. Since all these uses are clearly done for the benefit of society and we may all have the opportunity to benefit from the results of them, I would be interested to read from my visitors what concerns they may have about the practices involved in organ procurement, medical research and medical training using the newly dead. ..Maurice.

Wednesday, January 25, 2006

Organ Donation: Ignoring the Advance Directive in Deference to the Family: Is that Ethical and Beneficial?

It is generally common knowledge that there is a vital need for people to agree to be an organ donor so that when they die their organs can be transplanted into critically ill patients in hopes of saving those patients’ lives. Filling out a form, identified on a driver’s license, giving permission for organ procurement is all the current law says is necessary to be a donor. In certain cases the problem is that when the patient has died and the request to be a donor is identified, the organs are not procured and they go to the grave with the body. Why, you may ask, is the request of the person not followed? In those cases, the Organ Procurement Organization, which is the federally mandated organization to arrange the procurement and assist in the distribution of organs, may decide not to accept the request of the person, now deceased, not because the organs would be unhealthy but because of strong family opposition regarding the donation. Why should this happen? Why should the autonomous and legal request of the person be ignored?

An excellent discussion of this issue can be found in the American Medical Association’s Virtual Mentor website.

It is suggested in the article written by Ben Berkman that issues of concern about public opinion by going against the wishes of the alive family and who could be able to argue their case while respecting the prior wishes of the patient who, now dead, cannot argue, “unwillingness to inflict more conflict and grief on a reluctant family who is already in great pain,” “concern about potential law suits [since] the deceased’s wishes take lower precedence than the family’s wishes because only the family can sue."

Through the Federal Patient Self-Determination Act which was passed in 1991, the concept of patient autonomy, encouraging and validating the use of advanced directives (living will, power of attorney, etc.) was reinforced from previous acts. Despite this Act, those responsible for organ procurement “still insist on consulting the family about organ donation, even if there is a clear advanced directive or donor card.”

What can be done to make this aspect of organ procurement ethically fair to the autonomous wishes of the patient? The article suggests a court test case based on the current laws, or add laws that would encourage pro-active implementation of the patients request or punish those involved in organ procurement who disregarded the patient’s documentation requesting organ donation. Another option, not mentioned in the article, which has occurred in European countries is that all persons are potential donors by default unless they formally opt out.

A visitor to my bioethics website, who identifies himself as an organ recovery coordinator, previous paramedic and also a double lung transplant recipient, recently wrote me the following:

"In the state that I work in, we have first person license consent. It has been our practice if a deceased person has made a decision to be a donor on his license, we WILL do our best to make that happen. And yes we have had some families disagree. At that point we will evaluate the situation. If the deceased donor is "young" or good health where many organs could be recovered ,thus saving up to 8 lives we will proceed with the recovery. We have had a few families that were very opposed to the donation. The deceased were in very poor health and most likely would not have been a good donor. At best they were going to be liver only donors due to their health situation. Twice now (that I can remember) we have decided it wasn't worth proceeding with the donation, because of poor donor quality and family opposition. We believe that it is our responsibility to carry out that persons wish when it has been put on their drivers license. Starting in 2003 my state changed the law where a family cannot change someone’s decision on their drivers license. As a recipient and a resident of this state I agree with that law. I have seen many times in my career of working in a hospital (in various roles),a family will rescind the wish of the deceased cause "they" didn't understand or agree with donation. I would love to see the program that MANY European country have (and is very successful); you are a donor UNLESS you fill out a form and op-out. I know what kind of hoop-la that would cause in this country if we tried to get that passed.”

I, too, understand the need for organs for transplant and I am appalled that despite the need and the federal government setting high goals for procurement, that the legal requests of deceased patients who had authorized the donation of their organs are being ignored in deference to the family. Is this an ethical and beneficent action? I think not. And who is really winning from this behavior? I would be most interested to read how my visitors to this blog stand on this issue. ..Maurice..

p.s.- For more on organ procurement and transplant, go to the postings here in February 2005 archive.

Saturday, January 21, 2006

"Legitimate Medical Purpose": Two Ethicists Views

Continuing on with the discussion of whether physician assisted suicide represents a "legitimate medical purpose". In the previous posting, I gave the basis for my conclusion that the state is, as the regulator of medical practice, consistent with the U.S. Constitution, the government involved in establishing whether such an act is indeed ligitimate. This subject of the legitimate medical purpose of physician assisted suicide was discussed on a bioethics listserv recently. With their permission, I would like to post here the two contrasting views of two ethicists who wrote to the listserv. What do you think about the role of physicians in assisted suicide? ..Maurice.

The notion of 'legitimate medical purpose' should illuminate the status of
medicine as a distinct discipline. I invite one and all to attempt to parse this
notion in a way that avoids conflating 'medical legitimacy' with 'moral
legitimacy' and shows how intentional killilng serves a legitimate medical

To the best of my knowledge, the only serious attempt along these lines is:
Miller, F. G., & Brody, H. (1995). Professional integrity and physician-assisted
death. Hastings Center Report, 25, 8 * 17.
The way these authors approach the task is to include helping patients to
achieve a good death among the constitutive goals of medicine. But it turns out
to be an odd sort of constitutive goal, since it can't underwrite a
determination of medical indications.
Bob Koepp

Me too. Please include me in the good company of Miller & Brody, and the good
company actually includes many more.

Rhodes R. Physicians, Assisted Suicide, and the Right to Live or Die, chapter in
Assisted Suicide: Expanding the Debate, Battin MP, Rhodes R and Silvers A,
Routledge: New York. 1998:165-176.

If you see medicine as a human creation (rather than an immutable feature of the
universe with a telos), then it is reasonable to see the profession as entrusted
with a socially defined set of knowledge, powers, & privileges to be used for
the good of patients and society. Then, just as we call the fire department to
rescue children and cats from trees when no fire is involved, we call upon
doctors to assist patients in implementing their end of life decisions.

Rosamond Rhodes, PhD

"Legitimate Medical Purpose" and State Medical Boards

In the previous posting, regarding "legitimate medical purpose", I wrote: "What still remains is the question as to what physician acts represent “legitimate medical purpose” and particularly who are the ones to define it? My visitor Moof wrote a comment:Dr. Bernstein ... do you believe that the government should even be involved in any of this?
and I responded:Moof, federal government--no. State government and its physicians--yes. Moof then asked: Dr. Bernstein ... why would the state gov be any better? I know that it's more local, but still ... what real business does any government have in medicine?

My response would be the following:

In response to the 10th Amendment of the U.S. Constitution (“The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.”) , each state legislature created a Medical Practice Act that defines the proper practice of medicine and the responsibility of the medical board to regulate that practice. The Federation of Medical Boards, established in 1912, provided a sounding board for establishing a consensus of what each state could put into their own Medical Practice Acts. The following is a brief description of the Federation and it’s guidelines for the states as taken from the above link. I think this should answer the question of how state government got into the regulation of medical practice. ..Maurice.

The Federation of State Medical Boards is a national non-profit association established in 1912, which serves as a collective voice for 70 state medical licensing and disciplinary boards of the U.S. and its territories. The Federation′s primary mission is to improve the quality, safety, and integrity of health care by promoting high standards for physician licensure and practice, as well as supporting and assisting state medical boards in the protection of the public.

State Medical Boards

Under the 10th Amendment of the U.S. Constitution, states have the authority to regulate activities that affect health, safety and welfare of their citizens. To protect the public from the unprofessional, improper, unlawful, fraudulent and/or incompetent practice of medicine, states provide laws and regulations that outline the practice of medicine and the responsibility of the medical board to regulate that practice in the state′s ″Medical Practice Act.″

The primary function of a state medical board is to protect consumers of health care through proper licensing and regulation of physicians.

Public protection begins with the licensure process which is designed to ensure that practicing physicians have appropriate education and training, and that they abide by recognized standards of professional conduct in treating patients. Licensed physicians must periodically reregister with the board. During reregistration, a physician is required to demonstrate that they have maintained acceptable standards of ethics and medical practice by a variety of means, such as, compliance with continuing education requirements and/or recertification by a specialty board, etc. In addition, the board will review complaints regarding a physician′’s medical practice to verify their compliance with state law and board rules and regulations and to identify patterns of substandard care.

On its own initiative or upon receipt of information reported by others, the state medical board investigates any evidence that appears to indicate that a physician is or may be incompetent, guilty of unprofessional conduct, or mentally or physically unable to engage safely in the practice of medicine or that the Medical Practice Act or the rules and regulations of the Board have been violated. The Board has full discretion and authority with respect to disciplinary actions when it determines that a violation has occurred.

State medical boards are typically comprised of physician and public members who are, in most cases, appointed by the governor. Some boards are independent in structure, exercising all licensing and disciplinary powers, while others are part of a larger state agency, such as the Department of Health, which exercises varied levels of responsibility or functions in an advisory capacity. State medical boards employ an administrative staff that may include an executive officer, attorneys and investigators. Legal services are often provided by the state′s Attorney General′s Office. The structure and responsibilities of each state medical board are set out by the state legislature in the Medical Practice Act. While these statutes have many similarities, each is unique in its specific language which means there is variety in how boards are structured and how their responsibilities are described.

Funding for medical board staff and activities comes from physician licensing and registration fees, as well as fines imposed as part of a disciplinary action. Some specific activities, such as physician profiling, may receive a special appropriation of state funds.

Medical Practice Act
A state Medical Practice Act is created by legislative authorization. Each state Act is unique, therefore, there are some significant variations among states in how they address the privilege of practicing medicine. Medical Practice Acts generally include:

  1. A definition of the practice of medicine
  2. What constitutes the unlawful practice of medicine
  3. Structure of the state medical board
  4. Provisions for medical licensing examinations
  5. Requirements for licensure and reregistration
  6. The range of disciplinary actions that may be taken against physicians
  7. Procedures for enforcement of disciplinary actions
  8. Handling impaired physicians
  9. Authority for investigations
  10. Legal protection and immunity for board members
  11. Authority for the board to promulgate rules and regulations to facilitate enforcement of the Act.
  12. Source of funding for the board

The Federation of State Medical Boards publishes a guide for states in reviewing and revising Medical Practice Acts: A Guide to the Essentials of a Modern Medical Practice Act.

Policy Development
Additionally, the Federation supports its member boards through policy analysis and development. The Federation periodically convenes representatives of state medical boards, together with experts in specific subject areas, to study and develop recommendations on issues pertinent to medical regulation. The policies are intended to give guidance and encourage consistency among state medical boards in addressing trends in medical practice and regulation in order to protect the public and improve the quality, safety, and integrity of health care.

Enforcement Procedures and Disciplinary Actions
The Medical Practice Act sets out procedures that permit the board to take appropriate enforcement and disciplinary action, while assuring fairness and due process to the physician subject of a report. Common board actions include:

  1. Revocation – A permanent loss of license to practice medicine. Under certain conditions, a physician may petition for reinstatement after a specific time period.
  2. Probation – Physician′s practice is monitored for a specific period of time.
  3. Suspension – Physician may not practice for a specific period of time.
  4. Summary Suspension – Immediate suspension of a physician′s license when there is evidence that his/her continued practice presents an immediate danger to the public health and safety.
  5. Reprimand or Censure – A public admonishment.
  6. Voluntary Surrender of License – Physician surrenders his/her license to practice in lieu of further disciplinary action.
  7. Limitation or Restriction – Physician′s license to practice is restricted in some way; e.g. prohibited from performing specific procedures.
  8. Denial – Physician’s license is not initially awarded or subsequently renewed.
  9. Administrative Fine/Monetary Penalty – A civil penalty imposed by the board for certain types of professional misconduct.
  10. Restitution – Statutory authority to require a physician to reimburse an individual/entity for monies improperly obtained.
  11. "Stay" – The board withholds enforcement of a board action, usually under some enumerated conditions.

Tuesday, January 17, 2006

“Legitimate Medical Purpose”: What is it and who defines it?

Ashcroft's directive declared that as assisting suicide was not "a legitimate medical purpose" under the Controlled Substances Act of 1970 and that prescribing federally controlled drugs for that purpose was against the federal law. In today’s Supreme Court decision, Justice Scalia said in his dissent that he would uphold the administration's position. "If the term 'legitimate medical purpose' has any meaning, it surely excludes the prescription of drugs to produce death," he said.

What still remains is the question as to what physician acts represent “legitimate medical purpose” and particularly who are the ones to define it. ..Maurice.

Monday, January 16, 2006

More Unethics in Medical Research: Is There Prevention?

From BBC News October 7 2005:

Drugs similar to aspirin reduce the risk of mouth cancer but possibly at a cost to the heart, say researchers.

The Norwegian-led team looked at the cancer protection offered by non-steroidal anti-inflammatory drugs among nearly 1,000 heavy smokers.

Those drugs cut the risk of oral cancer by more than half - the same as stopping smoking.

However, they also appeared to double the risk of death due to heart disease, the Lancet journal reports.

From the BBC News today January 16, 2006:

Cancer study patients 'made up'

A cancer expert invented patients for a study which concluded taking common painkillers could protect against oral cancer, it is alleged.

Dr Jon Sudbo reportedly made up patients and case histories for the study published in highly-respected Lancet medical journal last October. Dr Sudbo has not commented publicly on the claims.
But a spokeswoman for Oslo's Norwegian Radium Hospital, where he works, said he had admitted falsifying data.

Dr Richard Horton, editor of The Lancet, is attempting to have the paper retracted from the journal. He defends the peer-review process of journals in their goal to prevent poorly designed studies from being published. However, this process is not designed to identify fabricated research. He says "Just as in society you cannot always prevent crime, in science you cannot always prevent fabrication."
One wonders about the motivational forces present in research which lead to unethical behavior in the falsifying of experiments. Is there anything society can do to prevent such behavior? ..Maurice

ADDENDUM 1-16-2006:

There is an excellent article in the August 15 2005 issue of the Boston Globe which describes the controversy as to the results of so-called peer-review of medical research papers. “..after a study that sent reverberations through the medical profession by finding that almost one-third of top research articles have been either contradicted or seriously questioned, some specialists are calling for radical changes in the system.”

The question is how could so many poorly documented studies be accepted for publication in major journals that were later found to be erroneous and yet had been under the scrutiny of peer-review. It seems, according to the article, that there is a lack of public transparency in the peer-review process. Those who were reviewing the peer-review process itself “… found that it was almost impossible to discover what had happened in the vetting process, since peer reviewers are unpaid, anonymous, and unaccountable. Moreover, their reviews are kept confidential, making it impossible to know the parameters of the reviews.”

If the goal of peer-review is to prevent poorly designed studies from being published, granted that this process is not designed to identify fabricated research, then it appears that something is defective in whatever the peer reviewers are trying to accomplish. As the Boston Globe article suggests, there are those who think the whole system of vetting for publication should be overhauled. ..Maurice.

Sunday, January 15, 2006

Ounce of Prevention Worth a Pound of Cure?: When No Prevention and No Cure

“An ounce of prevention is worth a pound of cure” so the saying goes. But what happens when there is no means of prevention and there is no effective or permanent cure? In the worldview, I can think of war as one example. In the view of clinical medicine, I can think illnesses of today, which include some degenerative or inflammatory diseases and cancers or isolated symptoms of fatigue or pain as examples where the mechanism of onset is unknown and therefore prevention is unclear and there is no treatment towards an effective cure. As with war, we are committed to simply, for our time being, “live with it.” But how do we do that? And as physicians, what is our role and duty when currently prevention and cure is impossible?

It is important that all students as they learn to be physicians realize that despite all the science they are taught and all the medical gadgetry and procedures that are available, they are going to be faced with patients with such diseases as I described. This may be a hard realization to accept but surely this will repeatedly happen in their careers. The concept that the students must learn is that the role of physicians is not only to prevent and cure disease but to be responsible for ongoing support of the ill patient even with no probability of doing something curative. This is the very hard and frustrating part of being a patient’s physician, particularly if the doctor and patient’s goals are for a cure.

In this kind of illness, the approach should be one of changing the emphasis of the goal to support and attempt at comfort rather than cure and yet not abandoning hope. If this is done well and the patient is comfortable, this treatment can be almost as rewarding to the doctor as a cure.

The burden which the physician needs to realize that he or she may have to bear is that of “living with” the patient’s illness. And “living with” a number of patient’s illnesses is to some physicians intolerable and leads to annoyance with the person as a patient, delaying of patient visits or the transfer of the patient to care of another physician. Hopefully, the hospice concept, the education of physicians with regard to chronic illness, chronic physical and mental disability, pain management and comfort care, there will come a day when “no prevention” and “no cure” will become "no problem”. ..Maurice.

Friday, January 13, 2006

Medical Ethics of Complementary and Alternative Medicine (7)

Back in November 2004, I started writing a series of posts on the medical ethics of complementary and alternative medicine. Because of inadequate management of symptoms by modern medicine and perhaps because of the poor communication skills by modern physicians, many patients are turning to alternative medicine for relief. I found the following “historical” listing of prescriptions for one symptom on several joke websites and thought it reflected some truism about medical treatment through the ages. What do you think? ..Maurice.

A Brief History Of Medicine

I have an earache.

2000 B.C. - Here, eat this root.
1000 A.D. - That root is heathen, say this prayer.
1850 A.D. - That prayer is superstition, drink this potion.
1940 A.D. - That potion is snake oil, swallow this pill.
1985 A.D. - That pill is ineffective, take this antibiotic.
2003 A.D. - That antibiotic is artificial. Here, eat this root.

Tuesday, January 10, 2006

Would You Desire Your End-of-Life Care Managed by a DEA Agent?

A Perspective commentary by Timothy E. Quill, M.D., and Diane E. Meier, M.D. in the January 5th 2006 issue of the New England Journal of Medicine describes the chilling effect on physicians' provision of comfort care of terminally ill patients because of the November 2001 U.S. Attorney General John Ashcroft directive which states that the prescription of Schedule 2 medications under the Oregon law violates the Controlled Substance Act since “assisting in a suicide is not a ‘legitimate medical purpose’” The commentary suggests that “If passed, this directive would allow the federal government to overrule established state law, empower the [Drug Enforcement Agency] DEA to investigate whether a violation had occurred, and potentially open to investigation every instance of prescribing of a controlled substance for a dying patient.” and not simply if administered under Oregon law.

The directive was taken to court by the state of Oregon and others with the argument that it should be the state’s responsibility to determine “legitimate medical purpose” and not the Controlled Substance Act. While the Ninth Circuit Court of Appeals supported the Oregon argument, the case was subsequently heard in the U.S. Supreme Court, which has as yet not announced a decision.

The authors conclude: “This type of DEA involvement in medical practice would adversely affect far more patients than those few who seek assistance with a hastened death in Oregon. If the government thus oversteps its legitimate role and expertise, allowing DEA agents, trained only to combat criminal substance abuse and diversion, to dictate to physicians what constitutes acceptable medical practice for seriously ill and dying persons, it will undermine palliative care and pain management for the much larger number of seriously ill patients in all states. Physicians may become hesitant to prescribe the best available medications to manage the pain, agitation, and shortness of breath that sometimes accompany the end stages of illness. As a result, they may, in essence, abandon patients and their families in their moment of the greatest need”

I have no doubt that the dire predictions of Quill and Meier will come true if the directive is sustained. We physicians will not risk jail time or heavy fines for performing humane patient comfort care. Better, society finally decides who sets the standards of practice, the States and their physicians or DEA agents And if the latter, perhaps the DEA agents would want to take over end-of-life patient management themselves. Any sarcastic comments to my sarcastic suggestion? ..Maurice.

Sunday, January 08, 2006

More on Immortality

Joyce Kilmer has humanized trees in this well known poem “Trees”

I think that I shall never see
A poem lovely as a tree,
A tree whose hungry mouth is prest
Against the earth's sweet flowing breast;
A tree that looks at God aft day,
And lifts her leafy arms to pray;
A tree that may in Summer wear
A nest of robins in her hair;
Upon whose bosom snow has lain;
Who intimately lives with rain.
Poems are made by fools like me,
But only God can make a tree.

As I was hiking today through Towsley Canyon in Southern California, I came upon this tree clinging on to the rocky side of a mountain and I wondered if there was a common yearning between man and tree for longevity and/or immortality. Any thoughts? ..Maurice.

Saturday, January 07, 2006

Does Standards of Medical Practice Change for a King? (2)

Continuing with the discussion of VIP medical treatment (Very Important Person medical treatment primarily affected by the importance of the person), based on my clinical knowledge and experience, I can devise a simple scenario that might easily explain the medical predicament that Mr. Sharon's physicians and family now face. I see two factors involved and perhaps both apply.

1) Would it be reasonable to assume that, in response to the thrombotic (? or embolic) CVA in a man with great social importance and responsibility and the great need not to be again incapacitated,his physicians began him on a very energetic anti-coagulation therapy, perhaps 2 or more drugs started together without careful and more prolonged monitoring of the effects of the individual pharmacologic agents?

2) Mr. Sharon, after the ischemic event, felt well and because of his personal strong will and need to resume his governmental and political functions, was not as willing as some other person to remain under careful daily anti-coagulation monitoring, couldn't find time for the necessary venipunctures and, of course, his physicians may have been psychologically oriented or pressured by Sharon's colleagues not to interfere with the "strong man". And so.. the consequence: massive cerebral hemorrhage due to inappropriate anti-coagulation program and/or inadequate monitoring of the anti-coagulation.

The scenario could be as simple as that and behind the whole story was the VIP medical treatment. Again, I must make this disclaimer--this is only a reasonable possible scenario since obviously I don't know the clinical facts.
Will we ever know if this is what happened? If we will and the scenario is correct, this should add more weight against the practice of VIP medical management that to me seems, generally, not at all beneficent to the patient. ..Maurice.

Friday, January 06, 2006

Does Standards of Medical Practice Change for a King?

From Bloomberg news today: "Stroke specialists in the U.S. judged Sharon's prognosis as poor, given the information announced about his condition yesterday. David S. Liebeskind, associate neurology director of the stroke center at the University of California at Los Angeles, said Sharon's chances of full recovery are low.
The benefits of surgery to reduce pressure on the brain are unclear, said Robert D. Brown Jr., professor of neurology and chairman of the stroke division at the Mayo Clinic in Rochester, Minnesota.
``We still don't have good evidence that surgical treatment of hemorrhagic strokes will have an effect on survival or disability,'' Brown said. "

Today, Israeli Prime Minister Ariel Sharon apparently underwent his 3rd brain surgery for cerebral bleeding. In view of what appears to be a dismal prognosis and even though the public doesn't know all the clinical details nor the requests of the Sharon family, I would like to pose an ethical issue: should standards of medical practice be guided by the social importance of the patient and not by clinical experience and evidence-based medicine? If other factors are equal, such as ability to afford the medical care, should standard and accepted therapy be trumped by a "do everything and anything" attempts at therapy simply because the patient is a king or a prime minister and not a plain citizen? Again, we have no proof that this is the case with Mr. Sharon.. but I just wondered about justice and non-malificence and so on. ..Maurice.

1/6/2006 ADDENDUM: I just thought of another question: Do you think that V.I.P. (very important person) treatment is a standard of medical practice? If so.. my original question is moot. ..Maurice.

Sunday, January 01, 2006

Are You Depressed Today?The APA Says It's SAD

From Today's Los Angeles Times:
Psychiatry's sick compulsion: turning weaknesses into diseases

By Irwin Savodnik
Irwin Savodnik is a psychiatrist and philosopher who teaches at UCLA.

January 1 2006

IT'S JAN. 1. Past time to get your inoculation against seasonal affective
disorder, or SAD #8212; at least according to the American Psychiatric Assn. As
Americans rush to return Christmas junk, bumping into each other in Macy's and
Best Buy, the psychiatric association ponders its latest iteration of feeling
bad for the holidays. And what is the association selling? Mental illness. With
its panoply of major depression, dysthymic disorder, bipolar disorder and
generalized anxiety disorder, the association is waving its Calvinist flag to
remind everyone that amid all the celebration, all the festivities, all the
exuberance, many people will "come down with" or "contract" or "develop" some
variation of depressive illness.

The complete article can be viewed at:
The Los Angeles Times
. The gist of the article is that the American Psychiatric Association has been over the years developing many more named and classified illnesses as psychiatric conditions than probably it should. Anyway, that is this psychiatrist's opinion. I wonder what Shrinkette or others in the profession think about this.
Can't make and keep a list of New Years resolutions? Looking forward to paying your holiday bills? Feeling a bit depressed? Well, it is January 1st and time to develop SAD (8212), Seasonal Affective Disorder, that is. Happy New Year! ..Maurice.