Bioethics Discussion Blog: December 2006





Sunday, December 31, 2006

Halting Scientific Inquiry and Is It Ethical?: The Case of the Gay Sheep

As we end the year 2006 on the Bioethics Discussion Blog, I want to challenge my visitors with the final ethical question of the year: Are there some areas of biology where it would not be ethical for scientists to study at all because of the concern of some groups that the potential results of such scientific biological study could potentially be used for acts which would be detrimental and not be in the best interest of those groups or others? What should be the limits of biologic research? Does the public and governmental reactions to stem cell research and cloning tell us anything?

There happens to be, currently, concerns about this matter. And where are the concern directed? Why, it’s the research that is being carried out at Oregon State University and at the Oregon Health and Science University. The research? Learning about what sets the sexual orientation of rams that makes some of them “gay”. These sheep prefer to mount other rams rather than mating with ewes. This behavior reduces the farming value of these animals. If the animal’s sexual orientation could be changed to behave in a heterosexual manner, this would be of benefit. Unfortunately, these studies are felt by some as the beginning of a slippery slope toward the “treatment” of human gay and lesbians, and therefore further studies of sexual-orientation should be stopped.

So the question is whether there is just some research in biology that should never be carried out and it would be better and safer to keep humankind ignorant of some parts the interesting world around us? You can read all about this particular issue in December 31, 2006 Timesonline. Let me know what you think.

May we all have a happy and healthy and ETHICAL New Year with or without gay sheep.

Saturday, December 30, 2006

Self-Interests and Disinterest in Science and the Patient’s Best Interests

Do you actually believe that articles written in medical journals, particularly about medications, that your doctor reads and that the science reporter on radio or TV broadcasts to the nation all are based on the facts and interpretation of the facts obtained by independent and unbiased researchers? If so, you, as patients and even we, as doctors, are sadly misinformed. Just read this article "How Great Researchers Get By-lines, Get Paid, and Get Medicine in Trouble" by Kate Jirik in the Hastings Center Bioethics Forum to get a perspective of the extent pharmaceutical companies and medical education companies are using the authority of the names of prominent and respected researchers to publish articles in prominent and respected medical journals all to promote their own goal of getting physicians to prescribe and patients to accept (and pay for) their drugs. This behavior increases the pharmaceutical company profits presumably with little regard to science, reputations, patient benefit and the social costs of medical care. And the sad part is that this behavior on the part of these companies and those researchers who are willing to get money just for their names to be attached to a “ghost written by pharmaceutical company” medical article is that it is not being substantially prevented by prompt disclosure,legal or administrative action. If physicians cannot have faith in medical research information as provided by the medical journals or other medical education resources, we will not deserve the trust of our patients who depend on us to “know and do” the right thing for them.

Go and read the article and then return and let me hear from you about this important but not well publicized aspect of medical care. ..Maurice.

Thursday, December 28, 2006

A Suspected Piece of Evidence and the Limits of Physician Responsibility and Personal Rights

In the December 21, 2006 news from Texas: A 17 year old male allegedly has a bullet just below the skin about two inches above his eyes fired by a robbery victim. Prosecutors claim that the bullet will prove that the youth tried to fatally shoot a used car lot owner last July after he and other gang members robbed the business. His family and their attorney are fighting a court order to force him to undergo surgery to remove the projectile which prosecutors say would be the evidence that could send the teen to prison for attempted murder. On the basis of a search warrant in October, a physician evaluated a bump on the patient’s head and told prosecutors that operating room surgery under anesthesia would be needed to remove the suspected bullet. A second search warrant requested a Texas hospital to remove the bullet but the hospital refused. Prosecutors are currently trying to find a physician to perform the surgery. (Here is the link to the whole story from which I adapted the synopsis.)

This news item can raise a number of interesting ethical/professional and legal questions such as: to whom does a physician owe the trust and responsibility?: to the physician’s patient or to the police? Can the police force a physician to provide a search of the suspect's body? When does a criminal suspect become a patient? When does the individual’s right to preserve the integrity of one’s body become trumped by the duty of the police to obtain evidence in order to protect the public? Any answers? ..Maurice.

Saturday, December 23, 2006


Today, I completed a 12 hour continuing medical education requirement set by the state of California for all licensed physicians. Why was this requirement necessary? Most physicians are poorly educated in the all the details of how to manage acute or persistent pain in their patients. In addition, there is unnecessary uncertainty both by the physicians and their patients about the legal and addiction consequences of pain treatments particularly with narcotics. And it turns out that patients are not being adequately treated for their pains. Because of this requirement, I learned many things that I never knew or only partially knew or understood about pain and pain management. For those who would like to read more about what your doctors should be learning, you can go to this American Medical Association link.

On my now inactive Bioethics Discussion Pages, I had an interesting topic a few years ago in which I wanted to read what my visitors there thought about pain in general or their own pain and how they looked at the relief of pain. I think that their comments were kind of interesting. I have posted a copy of that topic and the responses below. The more recent responses are at the top of the posting. I look forward for my current visitors to add their own views and comments to the question. Also I would like to know your own personal experiences with pain and pain management by your physicians—but no names please. ..Maurice.


Pain is one of the most common personal experiences that virtually all humans can have during their lifetime. It is a subjective occurrence that often cannot be easily quantitated and compared between individuals since it appears that each individual looks at his or her pain in their own way. Pain may be viewed by the affected individual in the context of the source of the pain, the intensity, the disability and the effect the individual's disability from the pain on others including his or her loved ones and the possibility for resolution of the pain either spontaneously or with help. In addition, religious or spiritual interpretations can be given to one's pains and how the individual responds may depend on how the individual looks at and accepts these interpretations. The medical profession in modern and post-modern times, with availability more and more tools or approaches to try to relieve pain, has looked at pain as a symptom needing to be treated by these tools and either substantially relieved or eliminated. Most patients look to their physicians to do just that. And many ethical issues have involved conflicts regarding pain and suffering and pain management. But do all patients find that relief of pain is a good action? And if not, why not? These are the questions I would like to pose for this page. I would like to know from my visitors what pain means to them and whether they consider that relief of pain is always a good.
Here is the question:
What Does Pain Mean to You? Is Relief of Pain Always a Good Thing?

The Discussions

Date: Tue, Jul 22, 2003 2:47 PM From: To:
A bioethicist, Daniel Callahan, claimed that medicine should not be used to relieve suffering caused by despair. What an ignorant claim. Only those who have not experienced the pain that depression can cause. It is medicine's duty to work with psychiatrists and counsellors to relieve all suffering, regardless of how they are caused. Sincerely, Winston

Date: Mon, Jun 23, 2003 8:53 PM From: To:
Pain to me is anything that makes me feel physically uncomfortable, a noticable difference from the way I would normally feel. I have to say that all pain is not bad. Pain serves as a wonderful radar system for our bodies to inform us of a problem. We must listen to our bodies and then tell our phsycians! Pain also is a great tool for instruction, from the toddler and the hot stove to the 40year old trying to work out and straining muscles, etc. The type of pain I have problems with is that in the terminally ill patient. I have had hospice patients who refuse to take medication for their pain and though it may bother me, I have to allow them to make that decision for themselves. The ones that really get to me are the ones when the patient is desperate for any help in getting relief from their pain and the family or the physician (ok, sometimes even a nurse) stand in the way of the patient getting relief. Folks worry about addiction, they worry about inadequacy of meds later down the road (like it will just stop working), family gets upset because if you make the patient comfortable they may sleep more and not be quite as responsive to the family then. Physicians aren't always informed well about pain management issues and all aren't comfortable with letting a nurse guide them through the nuances of good pain management. It is incredibly frustrating to have a patient in pain, who wants the pain relieved, you know what you need to have or give to alleviate the pain and the physician is not cooperative with it.
I usually think of all pain as bad but your comments on the good of pain were incredible!

Date: Wed, Jun 11, 2003 6:34 AM From: To:
I agree with many of the comments regarding pain. Pain is an important warning mechanism that body has that something is wrong. I think it is one of the reasons that brings patients to seek medical care. It can also serve as a protection against danger in the case of skin burns. And as a nursing student I have learned that pain is subjective and that everyone's threshold is different. I think proper pain management is still either facilitated or constrained by the environment, including social and political factors. Some of the factors include emotions, behaviors, beliefs and attitudes.
Pain can also have a social impact this missed work due to persistent unrelieved chronic pain causing an economical impact. Insufficient pain relief is still a problem. Some patients are still willing to endure high levels of pain instead of asking for an analgesics. Some professionals still reluctant to give adequate levels of a medication out of concern that the patient may become dependent or addicted or they have been duped by a patient in the past. However, empowering the patient to be an active partner in reporting information about pain rather than being stoic is important and one must respect the patient's response to pain.
Rebecca, Salem State College Nursing Student

Date: Thu, Jun 5, 2003 6:02 AM From: To:
I also agree and think that some pain is necessary. Pain in life can be behavioral, cognitive, sensory and physiologic. In life some pain is good as it can serve as a protector against danger or a possible opportunity to for the person to grow spiritually or intellectually after experiencing cognitive pain. Pain can serve as a protector; for example when exposed to a possible danger like fire when pain is felt the body's immediate response to pull way because of a pain trigger. I also feel that it is the body's way of warning that something is wrong internally or a signal that it is time to take better care and slow down in the case of headaches.
As a nursing student, I know that pain is subjective and pain thresholds vary from person to person. Pain can interfere with the things in life that bring joy and satisfaction. Unrelieved pain can cause emotional responses such as fear, depression, anxiety and anger that can be detrimental to recovery; and no one needs to suffer needlessly.
Rebecca, SSC

Date: Tue, Jun 3, 2003 3:31 PM From: To:
Pain mean that I will have some difficulty functiong on a daily basis. I would try alternative methods such as yoga and relaxation before I became dependent on a drug because the implications of using prescription drugs can be addictive and can cause other problems. I have to admit that my pain tolerence is low and I am the first one to pop an asprine when I have a headache. kim

Date: Fri, Apr 25, 2003 3:37 PM From: To:
While I think that we agree that all pain is not bad, we must look on the impact of pain to the person. In western society, a person's function in society does play a role in ethics according to Garrett, Baillie, and Garrett's book Health Care Ethics: Principles and Problems (2000). If pain that is manageable is keeping a person from functioning in society or limiting his or her autonomy, then it is a tragic instance. In this situation, if the person requests, the pain should be managed. As in every topic, there is no black and white. In some instances pain is a good thing (in alerting someone that something is wrong with their bodies) and in some instances, a bad thing (when chronic pain that cannot be cured limits a persons activity, autonomy, and independence). Thanks.

Date: Tue, Apr 8, 2003 9:20 PM From: To:
This summer, I had a paradigm shift about pain. Throughout my first year of nursing school, I had been taught that pain is subjective and we must control it. I believe that patient comfort is one of a nurse's highest priorities.
However, my ideas and beliefs about pain were tweaked a bit this summer when I read a book called, The Gift of Pain by Dr. Paul Brand. Paul Brand grew up in India, the child of missionary parents. After many years back in England struggling with what to do with his life, he became a doctor (like his father) and returned to India. There he treated leprosy patients.
After several years of treating his patients and studying their disease, Dr. Brand created what are now the international standards of care for leprosy patients. You see, for hundreds of years almost no one had treated a leprosy patient or even been near one. It was assumed that leprosy patients were extremely contagious and that they lost fingers, toes, feet, noses, and various other parts of their anatomy due to the disease process itself. Dr. Brand found that this was not true. What was true was that leprosy patients lost not their body parts due to leprosy, but their ability to feel any pain at all. Leprosy patients can set their hand on a hot stove and never know anything is wrong until they smell the odor of burning flesh!
Now, you may be wondering where I am going with this. In his book, Dr. Brand presented a new perspective of pain--that of a precious gift to be appreciated, not a curse to be avoided. Dr. Brand very eloquently made his case for understanding that pain is a gift God gave when he created us. It serves to warn us that something is amiss in our bodies. Imagine how many patients would die from the infection of a ruptured organ if they did not feel the classic one-sided pain of appendicitis!
After reading The Gift of Pain, I have become truly grateful for sore feet and indigestion, for they tell me when I need to buy new shoes or eat less at the next meal! I truly believe that a patients pain needs to be controlled, but while I will do my best to keep my patients comfortable, I will be sure to investigate the cause of their pain in order to fix the problem that prompted it.
So what was my paradigm shift? To me, pain is no longer the enemy, but is one of my closest allies.

Date: Tue, Apr 8, 2003 2:13 PM From: To:
I believe that everyone is going to have pain at one time or another. I think that pain can be a good thing at times and that it should not always be treated. Pain is a way of our bodies letting us know that something is wrong. Instead of going straight for the pain pill or asking for an Rx, find out the real reason for the pain. Too many people are abusing pain meds these days. And I think that Rx's for pain meds are way overwritten also.I feel that a patient that is terminally ill should get as much pain med as needed to keep that person comfortable, and also a woman in labor as well. But just everyday aches and pains dont need narcotics or even a Tylenol every single time. Give your body a chance to tell you what's going on.

Date: Tue, Mar 18, 2003 8:06 AM From: To:
Pain is a part of life.It may not always be your favorite part but it is around for a reason. Pain is like a 6th sense a warning sign if you will. People need this sensation to comprehend how their body is feeling. Life without pain is like shoes without lases, it just dosen't fit. People have limitations and boundries and pain provides these boundries. Pain gives the limitations to people and is a must have even though it is unpleasant.

Date: Sun, Mar 9, 2003 10:04 PM From: To:
What Does Pain Mean to You? Is Relief of Pain Always a Good Thing?
I think that before we ask this question we should consider different pain tolerances of different people and patients. To one person a needle prick might be a slight irritation and to someone else it might feel like someone had just stuck a knife into thier limb. I think that every patient should be asked what his or her tolerance is to pain by filling out a simple survey. This survey could tell how often medications could be given and by what route. This could be intertwined with costs of drugs and what route to give.
Now the real question is what is Pain to you and is Pain relief always a good thing. Pain to me means that something is wrong. Of course everyone knows that Pain is the body's way of saying "hey something bad is happening" But i believe after the intial pain it is felt it is ok to get rid of the pain. If one is in control of the patient and knows what is going on, I believe it is ok to make the patient comfortable. We must be careful of which drugs we are giving to make sure that patients do not become addicted. This can lead to a case of addiction which is a whole different topic.

Date: Sat, Mar 8, 2003 7:42 AM From: To:
I define pain, in the physical sense, as noticeable discomfort during any waking activity of daily living. For example, if your ankle joints hurt when you walk, this is pain. If you are lying in bed and your neck and shoulders ache, this is pain. If you normally bound down stairs 2 or 3 at a time, but now you have to go one at a time and use the railing because your knees are sore and popping, that's pain. Like beauty, pain is in the eye of the beholder, or in this case, the one who feels it. I know from my experience in health care that different people would describe and qualify the same pains altogether differently than others...tolerance levels cover the gamut. And how people deal with and react to pain is very different as well. But ultimately, pain is defined by and quantified/qualified by the one who feels it.
Jeff Keener, Joplin, MO

Date: Tue, Jan 28, 2003 8:49 PM From: To:
Hi. Recently I had a myomectomy. A large fibroid mass was taken from my uterus. This happened because of pain and other complications. I know I made the right choice even though I know must deal for a time with post-operative pain. The doctors wanted me to be able to "manage" my pain. I don't think the idea was to completely mask it. Anyway, while I still have pain--I've got about four more weeks to go at least, it is much less than the first day after the operation. I look at it as a sign that my inside is not healed up. In fact, my sutures on the outside could heal before my uterus does. As far as drugs go, one day a couple weeks back, I inadvertantly took too much vicadin. I had to drink a lot of water and tea to wash it out of my system. I decided afterwards that I would rather feel as much pain as I can handle right now then be in the doped-up zombie-like state I was in. Yes, I think pain has its purpose, if for no other reason, to tell you when you are fine and not fine. It forces you to listen.

Date: Thu, Nov 14, 2002 11:52 PM From: To:
I worked for 8 weeks in a Leprosy Research Centre in India on a clinical Physiotherapy placement.
And on of the main reasons people develop the deformities of leprosy is a "Lack of their ability to feel Pain". Because of this, they can't feel that little stone or pebble or thorn which has hurt their foot and is bleeding, and they carry on (pebble in shoe) and cause it to ulcerate and become infectious, granted this would not happen as often in a developed country BUT the example still illustrates the IMPORTANCE OF PAIN and as with anything it should not be in excess.
The right amount of pain in other words is very helpful as a a warning to something going wrong. Its in cases when it goes out of control or is not present,that we need to worry about.
Abrar 'MagicHands' Waliuddin,

Date: Thu, Nov 7, 2002 9:51 PM From: To:
What does pain mean to me? What it means to everyone! I hurt!!
Is relief of pain always good? Absolutely not! I know this is not going to be popular with the whiney ones out there, but pain is, by itself, not life threatening, unless it is so intense that it brings on shock, which can kill. It is also a way to monitor the recovery process. Less pain, more recovery. I know it sounds simplistic, but it is a necessary way to determine the seriousness of an injury or, less commonly, a disease.
If you have suffered a back injury, then the intensity of the pain you feel may be a way to judge the intelligence of the activities you engage in after the injury. If you mask this feedback with drugs, then you may cause yourself irreparable harm.
If you have a toothache, and you DON'T medicate to relieve the pain, you could suffer incredible pain for no reason. If you DO medicate for the pain, and continue to medicate without seeking professional relief through surgery to remove the cause of the pain, then you risk complications that could be very dangerous.
What level of pain shoud you accept? Whatever you can bear without damaging your physical or mental self. And whatever level of pain you chose to accept, be aware of the physical effects that non-treatment of the CAUSE might have.

Date: Mon, Oct 14, 2002 2:13 PM From: To:

Hi, Pain is a natural an important response that must not be ignored if we are to maintain maximum health. Whether it is physical or emotional, pain is necessary to help us respond to the changing needs of our minds and bodies. Although it is important, at times, to mask pain in order to begin the journey through the healing process, pain is good and should not be ignored. Pain allows us to acknowledge there is a problem, and later, to evaluate the progress of treatment. While we are learning how to manage pain and keep patients as comfortable as possible, we must not forget that it is an effective way for our mind and body to communicate to us.

Respectfully, Sue

Wednesday, December 20, 2006

The Authentic Right to Health Care: Treating Yourself as You Desire

There is a philosophy of healthcare in this country and elsewhere that there should be total freedom for people to select how they want to be treated for their illnesses. If that happened, it is believed that medical costs would drop and everyone could obtain healthcare. The freedom would include treating themselves with whatever medications they understand will be helpful without any prescriptions and/or go to any person they want for medical attention who need not have gone to a medical school or be licensed to practice medicine. Those persons who offered themselves as practitioners and didn’t practice effective medicine would be eliminated by attrition. What do you think about this right and whether, in the end, it would take the politics and laws out of medicine and make medical care more affordable to everyone? Is there any merit to this philosophy?

The following article is from the self-described “raw data for raw nerves” website by Sheldon Richman, representing the libertarian organization The Future of Freedom Foundation, who presents a discussion about this “authentic right”. ..Maurice.

Right to Self-Treatment

by Sheldon Richman, January 1995


Over the last year or so, much has been said about the right to health care. The advocates of government management of the health-care system believe that everyone should be able to obtain the services of doctors and related practitioners regardless of ability to pay. That is what has fueled the push by the Clinton Administration and others for so-called universal coverage.

Truth be told, there is no right to health care as the advocates of socialized medicine conceive it. In their view, anyone who needs medical attention ought to be able to count on the government to force others to provide or pay for it. But no one can have a right to the services or money of unwilling providers. One has a right to buy services from willing providers. One has a right to request free services or financial donations. But one has no right to use the threat of physical force--directly or indirectly (i.e., through the state)--to obtain those things. The right to health care in that sense is a counterfeit right.

There is, however, an authentic right to health care, which was recognized in the United States until 1914. It is typical of our age that while nearly everyone embraces the counterfeit right, almost no one accepts the authentic right. Even worse, few realize they are denied an important freedom. That authentic right may be called, as the noted psychiatrist Thomas S. Szasz has called it, the right to self-medication. It is the right to care for one's own health without prior permission from the state.

At first glance, many people will believe we already have that right. They are wrong. For example, one may not seek treatment from a practitioner who is not licensed by the state. Although one may be perfectly content with the treatment provided by an unlicensed practitioner, the state will prohibit that therapeutic relationship; it will even jail the practitioner if it wishes. True, it will not jail the patient. It will merely prevent a consenting adult from engaging in the medical acts of his choice.

Another way that the government interferes with the authentic right to health care is through the system of prescription medicines. Citizens of this theoretically free country may not use certain medicines without the written permission of an officer of the state. Yes, doctors are officers of the state by virtue of their having been
deputized by the state to grant, or withhold, such permission. That was not true before 1914. Until then, adult citizens could enter a pharmacy and buy any drug they wished, from headache powders to opium. They needed no one's permission. They were, in a phrase, pharmacologically free.

That freedom was abolished as the paternalist ethic gained currency. People had to be protected from their own unwise choices. For their own good, they could not be allowed to prescribe medicines for themselves. At least, that is what they were told. In fact, we know otherwise. When Americans were pharmacologically free, they managed not to kill themselves with overdoses or inappropriate medicines. When they felt it necessary, they sought advice from physicians or others who had greater experience than themselves. Americans somehow knew not to swallow purported medicines without wondering about the consequences. (We know this because population and life expectancy grew all during the period.)

Then they lost this right. They were told they were no longer able to make those kinds of decisions. For some unfathomable reason, they surrendered their authentic right to health care without a bloody struggle.

They were lied to, of course. The doctors and the politicians did not really believe that Americans had suddenly become too benighted to medicate themselves. No, the doctors and politicians wanted power. The prescription law was just one piece of a larger conspiracy against the public. At about this time, the United States got its first laws to license doctors and accredit medical schools. The same paternalistic rationalizations were fed to the public. But the minutes of the medical societies' meetings tell another story. Historian Ronald Hamowy has documented what was really on the minds of the doctors: income. They were concerned that free entry, and hence unrestricted competition, into the medical profession was driving down fees. Only government regulation could keep the doctors living in the manner to which they had become accustomed.

That regulation took several forms. Accreditation of medical schools regulated how many doctors would graduate each year. Licensing similarly metered the number of practitioners and prohibited competitors,such as nurses and paramedics, from performing services they were perfectly capable of performing. Finally, prescription laws guaranteed that people would have to see a doctor to obtain medicines they had previously been able to get on their own. The doctors and politicians succeeded in supporting the medical profession's income; they also contributed to the infantilization of the American people. We have never recovered.

The same laws have also subverted the medical profession, since doctors can be--and have been--prosecuted for prescribing drugs "in amounts that exceed a legitimate medical purpose." In some states, doctors must send a copy of prescriptions for certain drugs to a government bureaucracy. Government thus reserves the power to decide what is legitimate.

Some will say, things were simpler before 1914. Surely in our complex age, people cannot be expected to make those decisions for themselves. This is fallacious. Despite all the purported protection against self-treatment, the one thing that is supposed to activate the system for the individual is left entirely to his own discretion: the visit to the doctor. What protects a person against his decision not to see a doctor? Even the most extreme proponents of socialized medicine donot advocate compelling people to see a doctor against their will. The freedom to do without medical care, at least, is respected. If the paternalists were truly consistent, they would call for protecting us from that dangerous freedom by requiring periodic visits to the doctor. But perhaps that would bare their totalitarian talons a little too much.

However, if we can be trusted to make such a basic decision, why can't we be trusted with other decision-making related to health care? The reason cannot be that people are ignorant in these matters. We are ignorant in lots of matters in which the consequences of unwise decisions can be great. Most of us know little about automobiles. An improperly serviced auto can be dangerous to others. Yet, there is no law against my servicing my own auto. The law does not stop me from working on my own furnace, though a mistake could kill me and others. If I am spiritually distressed, I am free to console myself or seek comfort from a bartender, friend, or anyone else. If I can work on my car, my furnace, and my mind, why can't I work on my own body?

But surely no medicine should be allowed on the market before it is approved by the government, right? Wrong. The right to self-treatment means just that--the right to choose and administer (or have administered) any treatment. Each individual should be free to determine his own level of confidence about a medicine. A desperately sick person quite reasonably may be willing to seize on a new, untested drug. He may not survive the years of testing required by the Food and Drug Administration. (That systemic delay kills thousands of people each year.) Someone less ill or more risk averse may be more selective. A third person may only want medicines that have stood the test of time. The key question is, who should decide one's level of confidence? Should the government impose one level on everyone? Or should each decide for himself? In a free society, there can be only one answer.

It is certainly wise to know what one is doing before treating oneself. And that is why the free market provides an abundance of medical information to the layman. It would provide even more in a free medical marketplace. Sources of information would include doctors, medical societies, insurance companies, Prevention magazine, Consumer Reports, newspapers, and more. Competition and the civil law against fraud and malpractice are the best assurances of quality in both information and services. But in the end, people must have the right to enter into any mutually agreed-on contracts for medical services that they choose. Anything less makes a mockery of the idea that we are free.

Permission is granted to reprint this article, provided appropriate
credit is given. Please send two copies of the reprint to The Future
of Freedom Foundation


Sheldon Richman is senior editor at the Cato Institute in Washington,
D.C., and the author of The Future of Freedom Foundation.

Friday, December 15, 2006

The Mentally Disabled Women: Sterilization at the Request of Others

On December 13, 2006, the United Nations General Assembly,as reported in the
International Herald Tribune approved the “first convention protecting rights of world’s 600 million disabled people.” According to the article,the convention “guarantees that the disabled have the inherent right to life on an equal basis with the able-bodied and requires countries to prohibit discrimination on the basis of disability and guarantee equal legal protection. Countries must also ensure the equal right of the disabled to own and inherit property, to control their financial affairs, and to privacy over their personal lives.” The convention will enter into force when it is ratified by 20 countries. One of the issues that concern disability activists is the “forced sterilization of girls and women because of their disability, forced institutionalization and substitute decision making.”

It is my understanding that governmental ordered (forced) permanent sterilization of mentally disabled women in the United States has been abolished in the past several decades. Sterilization, to prevent pregnancy, of a woman who is mentally unable to provide informed consent varies in the different states but can be performed only on the direct request of a legal guardian with physician recommendation and/or court approval. The obvious medical rationale for performing such a procedure would be to prevent harm if further pregnancy or delivery would endanger the life or health of the mother. However, if this is not the case, the social rationale would be to prevent harm to the child if the mother is mentally unable to provide appropriate care or as a consequence of the pregnancy an unnecessary burden placed on society or the guardian with regard to the financial or other responsibilities to care for the child. Another social argument would be to prevent any genetic basis for the mental handicap to be passed on to future generations—eugenics. The latter argument for mandatory sterilization, as originally approved by the Supreme Court in 1927, was overturned in 1942 by the Court.

Here is the ethical issue to my visitors: Do you find any excuse for the permanent sterilization of a mentally disabled woman ethical on the basis of a decision by others without the woman’s own personal and informed consent? How about non-surgical, non-permanent contraceptive medication use without consent? ..Maurice.

Saturday, December 09, 2006

“Grains of Truth” vs Evidence-Based Medicine”

For the layman, “old wifes’ tales” (“a wisdom much like an urban legend, supposedly passed down by old wives to a younger generation. It is so named for the alleged lack of sophistication of old wives.”) often deal with sex, pregnancy, puberty, nutrition and health issues. Most of the tales have no basis in fact but occasionally a few have, as quoted from the Wikipedia article, “... grains of truth, the veracity is likely coincidental.”

In medicine, physicians have carried along the professional version of “old wives’ tales” through the years, the veracity of which was mainly based on a physician’s own personal experiences in practice, the reports of other physicians experiences or just theories. Some of these tales dealt with issues of diagnosis or illness outcomes and others dealt with therapeutic benefit of drugs or procedures.

In the last decade or so, out of concern for providing the best in medical care but also because of concerns relating to the financing of medical care that the medical profession and others have looked to providing physicians and their patients the results of “evidence-based medicine” which defined by the Centre for Evidence Based Medicine as quoted in the Wikipedia article “is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients." And continuing from the Wikipedia article “Using techniques from science, engineering and statistics, such as meta-analysis of scientific literature, risk-benefit analysis, and randomized controlled trials, it aims for the ideal that healthcare professionals should make ‘conscientious, explicit, and judicious use of current best evidence’ in their everyday practice.”

What has all of this to do with medical ethics? It has to do with the physician’s duty to be trustworthy to the patient and to aim to do good and not produce harm to the patient. Informing the patient, unless some patient rejects being informed, is also duty of the physician and is part of the consent to treatment process. It should be a standard of medical practice that the patient understand what portions of the physician’s decisions regarding diagnosis, prognosis or treatment is based on reliable evidence and which is based on hearsay or simply statistically not verified experience. But do most physicians have the time or skill to explain to the patient on what basis their decisions were made? Further, do most physicians even know which of the “facts” they are using have not been rigorously proven? Unfortunately, even with the best of physician attention to educate themselves on the evidence and to explain this to the patients, there is much in medical care that will remain “old tales” either because there is not sufficient interest to provide the time and expense to do scientific studies or realistically because some studies just can’t be accomplished because of technical or ethical issues. Fortunately,for both the patient and the physician, many decisions the physician makes do have incidentally those “grains of truth” and are luckily followed by successful outcomes. ..Maurice.

Monday, December 04, 2006

Being “Culturally Competent” vs Caring for a Patient’s Concerns

“A medical anthropologist is asked by a pediatrician in California to consult in the care of a Mexican man who is HIV positive. The man's wife had died of AIDS one year ago. He has a four-year-old son who is HIV positive, but he has not been bringing the child in regularly for care. The explanation given by the clinicians assumed that the problem turned on a radically different cultural understanding. What the anthropologist found, though, was to the contrary. This man had a near complete understanding of HIV/AIDS and its treatment—largely through the support of a local nonprofit organization aimed at supporting Mexican-American patients with HIV. However, he was a very-low-paid bus driver, often working late-night shifts, and he had no time to take his son to the clinic to receive care for him as regularly as his doctors requested. His failure to attend was not because of cultural differences, but rather his practical, socioeconomic situation.”

The medical profession is being encouraged to engage in becoming culturally competent. That is, for the medical profession to be able to understand and behave constructively towards patients’ cultural backgrounds in hopes of providing more compassionate and effective care. But as the above story from the article “Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It” by Arthur Kleinman and Peter Benson in PloS Medicine, an online open-access journal, suggest and the authors explain, making cultural assumptions may not be valid in a particular case and actually hinder practical understanding. In their story they conclude, in place of stereotyping the patient,“talking with him and taking into account his ‘local world’ were more useful than positing radically different Mexican health beliefs.”

The authors give another example story where therapy didn’t fully work, the example emphasizing the importance of using “culturally appropriate terms to explain people’s life stories” rather than terms usual in medical culture..

The authors give healthcare workers six steps in dealing with a patient of another culture, however they conclude by writing that “If we were to reduce the six steps of culturally informed care to one activity that even the busiest clinician should be able to find time to do, it would be to routinely ask patients (and where appropriate family members) what matters most to them in the experience of illness and treatment. The clinicians can then use that crucial information in thinking through treatment decisions and negotiating with patients.”

This, the authors feel “is much different than cultural competency. Finding out what matters most to another person is not a technical skill. It is an elective affinity to the patient. This orientation becomes part of the practitioner's sense of self, and interpersonal skills become an important part of the practitioner's clinical resources. It is what Franz Kafka said 'a born doctor' has: 'a hunger for people'. And its main thrust is to focus on the patient as an individual, not a stereotype; as a human being facing danger and uncertainty, not merely a case; as an opportunity for the doctor to engage in an essential moral task, not an issue in cost-accounting.”

Please click on the link above and read the entire article with the references (not included in the extracts above) and let me know what you think. Have you and your physician come from different cultures (besides the obvious medical culture) and how was your relationship with the physician handled? ..Maurice.