Ethical Injustice of Medical Care: Possible Cure in California

Ability to obtain medical care is ethically unjust in the United States because of the fact that 44 million people are uninsured and have no access to medical care other than going to and waiting in hospital emergency rooms for all illnesses. It is also bad in my state of California. Uninsured in California estimates based on the Census Bureau's March 2005 and 2006 Current Population Survey as published at Kaiser statehealthfacts.org reveal 6,598,940 Californians or 18% of the state population have no medical insurance and are not covered by any state or federal or private plans.
California Governor Arnold Schwarzenegger spoke to the California Medical Association sponsored Legislative Leadership Conference meeting earlier this week and guaranteed health care reform for California this year. Over 500 physicians, medical students, residents, and medical executives from throughout the state gathered in Sacramento for the conference. The governor was confident in his prediction of health care reform this year,in fact he stated "I guarantee it."

In view of the way our governor has been moving California to lead the nation in a number of important societal issues through working with both political parties, I find it reasonable to suspect that his promise will likely come to fruition soon. You may want to watch the approximately 17 minute speech courtesy of the California Medical Association. I think that the states should get into the act rather than wait for the federal government to finally do something about this injustice. ..Maurice.

"Being sick is no fun. But you can have fun while you’re sick"

Film critic Roger Ebert, faced with the fact that his salivary gland cancer has spread to his right lower jaw, previous surgeries were unsuccessful and needs additional surgery and also has a tracheostomy to breathe, is planning to attend a film festival despite his visually uncomfortable physical appearance and his disabilities. If what Roger writes in today's Chicago Sun Times column, truely represents his honest feelings about himself and his illness, his broadcasting of these feelings should provide a great uplift and support to others who are disabled by their difficult illness both physically and emotionally. If he is sick and doesn't appear as the usually recognized Roger Ebert, why is he going to the festival and exposing himself with his illness to the public? He responds: "We spend too much time hiding illness. There is an assumption that I must always look the same. I hope to look better than I look now. But I’m not going to miss my festival." ... "Being sick is no fun. But you can have fun while you're sick.I wouldn’t miss the festival for anything!" ..Maurice.

Ethical Loss of Prisoner Medical Human Rights in the "Fog of War": Documentation Resource

I have written on previous posts about the ethical conflicts which can exist by the "wearing of two hats" by medical professionals when they are part of the military. Steven Miles, a physician and ethicist from the University of Minnesota, has looked carefully into this subject and has written about the recent and current medical treatment of prisoners who are held in various locations by the United States in the current "war on terror" and wars in Iraq and Afghanistan. He would like to make everyone aware of a resource for documentation regarding what is happening in the prisons where those individuals are being held. Here is his announcement of the website resource. ..Maurice.


U of M’s Center for Bioethics and
Human Rights Library post online archive
of documents on prisoners of the war on terror
Documents focus on medical operations in prisons


MINNEAPOLIS / ST.PAUL (April 23, 2007) -- The University of Minnesota’s Center for Bioethics and Human Rights Center have created a comprehensive archive of government documents describing medical operations in U.S. prisoner of war facilities in Iraq, Afghanistan and Guantanamo Bay, Cuba. The archive, launched today, can be accessed from the homepage of the Human Rights Library (www.umn.edu/humanrts) or directly at www1.umn.edu/humanrts/OathBetrayed/index.html
The archive’s purpose is to enable scholars, journalists, policymakers, and interested citizens to study and understand the medical operations in these prisons. It contains more than 60,000 pages of indexed White House and Defense Department policies, prison medical records, autopsy reports, criminal investigations, sworn witness statements and e-mails involving the Armed Forces and the FBI.
This project was organized by physician-ethicist, Steven Miles, M.D., professor of medicine at the University. In articles and a book, Oath Betrayed: Torture, Medical Complicity, and the War on Terror (Random House, 2006), he has tried to answer the question, “Where were the doctors and nurses at Abu Ghraib while the notorious abuses were taking place?”
Web archivist, Leah Marks, of the Human Rights Library, built the archive.
This is not a dry compendium of documents. Examples of documents available to the public include:
White House and Defense Department policies and memoranda showing how medical and behavioral clinicians were organized to exploit prisoners’ emotional and physical vulnerabilities for interrogation.
Death files describing 148 prisoner deaths, including that of a child who died after having untreated tuberculosis.
Interrogation documents showing how medical personnel cleared prisoners, even with signs of abuse, for interrogations; how the behavioral science consultation teams operated; and, how the FBI objected to harsh Army interrogation techniques. One interrogation document tells how a pregnant prisoner's baby was delivered and sent to an orphanage or her family so that she could be interrogated.
Silence files documenting medical personnel who remained silent about abuses, failed to record injuries, or “lost” records of prisoners who made allegations of abuse.
Health documents describing the physical, sanitation, and mental care in the prisons.

The comprehensive nature of this archive will facilitate historical research of this prison system. For example, the thousands of pages of medical records are available, and easily searchable, for researchers who want to study prison health care.
The construction of this special archive was supported by a grant from the University of Minnesota's Office of Public Engagement. The Human Rights Center and its Human Rights Library are supported by private gifts and foundation grants. Most, but not all, of these documents were obtained and posted by the American Civil Liberties Union.
The mission of the University of Minnesota’s Center for Bioethics is to advance and disseminate knowledge concerning ethical issues in health care and the life sciences. The Center carries out this mission by conducting original interdisciplinary research, offering educational programs and courses, fostering public discussion and debate through community outreach activities, and assisting in the formulation of public policy

The Human Rights Library http://www1.umn.edu/humanrts/ houses more than twenty-five thousand human rights documents and several hundred human rights treaties and instruments and is available in eight different languages. It has more than four thousands links and a unique search engine for human rights sites. This resource is accessed by 200,000 scholars, educators, and human rights advocates from more than 150 countries every month. The Human Rights Library is a major initiative of the University of Minnesota Human Rights Center located in the Law School.

Commentary Spamming on This Blog

Because of intolerable, unethical and the cheap behavior of commentary spamming visitors to this blog, I am making all comments moderated. There will be a delay in the posting of the comment. ..Maurice.

Need for Well Regulated Civilian Militia vs Public Health

The Second Amendment reads: "A well regulated militia being necessary to the security of a free State, the right of the People to keep and bear arms shall not be infringed."



From The Huffington Post
But just when you think he can't go any lower, President Bush always finds a way to outdo himself. Today, in the wake of the incomprehensible slaughter of thirty-three students at Virginia Tech, the president sent out his spokeswoman to - first and foremost - defend the killer.

"The president believes that there is a right for people to bear arms," said Perino, in the first White House response, adding the utterly meaningless "but that all laws must be followed," thus nipping in the bud any crazy attempt to use this incident to have a discussion about gun rights in the United States.

Well, thank Heavens someone's looking out for the Second Amendment while everyone else is losing their heads.

Another comment by a politician today:

Senator John McCain said today "We have to look at what happened here, but it doesn't change my views on the Second Amendment, except to make sure that these kinds of weapons don't fall into the hands of bad people," "I do believe in the constitutional right that everyone has, in the Second Amendment to the Constitution, to carry a weapon...Obviously we have to keep guns in the hands of law-abiding citizens."

A physician ethicist wrote the following today on a bioethics listserv:
"59 millions adults in the US own a gun. 49 million households have a gun. 700,000 violent gun crimes in the US each year. Impulse killing is by far the greatest cause of gun deaths. There are 4 articles on medical ethics and guns in the last couple decades; face transplants is much more important than the proliferation of tools to blow away a face or a lovely student."

So what does this mean? Are guns and the known consequences of their use literally a public health and ethical issue and should measures be taken to change the habits of the U.S. public away from guns just as smoking habits are being changed by society's public health concerns over the primary and secondary effect of smoking?

By the way, do we still have or need a well regulated civilian militia as suggested in the Constitution? Are we still fighting the British?
..Maurice.

Arrogance, Incompetence and Cynicism: Bush and Those “Hated” Doctors

Joe Klein in the April 16th 2007 issue of Time Magazine in his Commentary section dissected the behavior (or should I say misbehavior) of President Bush and his Administration and for which Bush is solely responsible (“the buck stops here”). I was struck not only about the validity of the analysis about Bush but also that, by golly, the same analysis could be made about those “hated” physicians that my visitors are writing about in the various threads on my blog .

Klein writes that the mechanism of the collapse of the Bush Administration is centered in three qualities: arrogance (the decision to “surge” in Iraq similar to the motivation to initiate the Iraq war),incompetence (the recent Walter Reed Hospital and the long term care of the disabled American troops issue) and cynicism (in the removal of the U.S. Attorneys). Read the whole article in Time.

In the medical profession, arrogance equals paternalism: “As your doctor, I know more about you than you do and therefore you should do what I say.”. Incompetence equals not taking time or interest to understand the patient, examine the patient adequately and perform properly other professional duties for the patient. And finally cynicism equals having distrust regarding the ethical basis for the profession of medicine and in view of that distrust therefore behaving unethically.

It seems to me that as with our President Bush, self-interest is behind all these three unproductive and destructive qualities. Bush’s arrogance may have resulted from self-interest. Klein suggests that rationale for the invasion was to payback Saddam for the attempt on his father’s life. I think it also obvious that Bush has self-interest to see that his war in Iraq is won to preserve something uplifting in his own legacy thus keep the war going until it is won. I wonder if his attempt to strengthen his own political stature and that of his party along with making an effort to preserve his relationships to his friends in the Administration caused distractions in management and supervision and the resulting incompetence and cynicism that Klein describes.

Those “hated” physicians are those who are not working for their patients but actually are working for themselves and obviously patients easily sense that attitude.. What can we do about all this? Elect a President who cares for the people more than for him/herself and find a doctor who intends to keep the patient’s trust by acting in the patient’s interest rather than his or her own. Do you think that finding a President or a physician who meets that goal is almost impossible? ..Maurice.

The “Art” of Making a Diagnosis

There truly is an art in the mental exercise of a physician making a diagnosis of the patient’s illness. In fact, I think the art really trumps the science itself in most cases. Why do I say that? It is because no two patients are the same and no two same diseases present exactly the same way nor are their courses exactly the same. It is also because lab tests are rarely or ever 100% sensitive and also 100% specific. That means that at times a lab test will miss a disease or will indicate the disease is present but actually it isn’t.

In addition to this variability, is the variability of how thoroughly the physician takes the history from a patient or the variablility of some patients who don’t remember, don’t tell or may understate or embellish their symptoms for one reason or another. Then there is the variability of how the physician performs the physical exam in terms of completeness and attention to discover and interpret pertinent physical abnormalities or lack of abnormalities. Finally, there is the variability in how the physician selects the necessary tests and how the physician interprets the results in terms of supporting or not supporting possible diagnoses. As I have suggested in previous posts, the time available to physician to do all this is also a variable. So, in fact, making a diagnosis is really an art. But it is an art that we try to teach our second year medical students before they step into their clerkship duties in the third year.

Doctors attempt to make a diagnosis through two general methods. There is the experiential “script” in which the physician has learned or by experience has observed the pattern of symptoms and physical finding that lead to a certain disease that was finally diagnosed. When the doctor sees a patient who has virtually the same pattern of symptoms, that disease is immediately brought to mind and is considered high on the list of possible diagnoses. Unfortunately, not all similar patterns represent the same disease. The other method of making the diagnosis is “analytical”. That is, moving through the symptoms and physical findings in a step wise fashion and collecting a list of diagnoses along the way, eliminating some or supporting some by additional history or physical or laboratory findings. This is a slower process than the “script” method but might end up with a more correct diagnosis.

Those who have studied the methods believe that the use of both methods together, in coming to a diagnosis of a patient, is probably the most common and more likely to produce a more rapid and correct result. The pattern of findings suggests a diagnosis that is added to the list of other diagnoses that might be developed by the analytic method and then is subjected, along with the others, to the analytic process of support or elimination.

A complication in making a diagnosis is the issue of whether the symptoms and physical findings and labs all represent a single disease or whether, in fact, the patient actually has two or several symptomatic diseases at the same time. In earlier years, a single symptomatic disease at a time was probably more common. But in the current years, where more people are living into old age when more than one ongoing disease may be present and the older people are taking more medications which have side-effects and drug interactions, the possibility of more than one illness is more likely. We teach our students to start out trying to put all the facts together in terms of one illness but they should be ready to include multiple diagnoses if all the facts don’t seem to apply to one disease and especially if the patient is elderly.

I am presenting this explanation of the diagnostic process to my blog visitors because I think it is important for them to be aware of how their physician might be thinking as their symptoms are being evaluated and what complexities from variabilities physicians face. By knowing a bit about the process, my visitors might be able to understand and judge their physicians’ behavior more realistically and see what has gone on when the doctors makes either the right or wrong diagnoses. ..Maurice.