The Placebo:Lying to the Patient-A Skillful Use of Reassurance and Encouragement?

The American Medical Association (AMA) has a policy regarding the use of placebos in clinical practice and here it is:

H-140.869 Placebo Use in Clinical Practice


A placebo is a substance provided to a patient that the physician believes has no specific pharmacological effect upon the condition being treated. In the clinical setting, the use of a placebo without the patient’s knowledge may undermine trust, compromise the patient-physician relationship, and result in medical harm to the patient.

Physicians may use placebos for diagnosis or treatment only if the patient is informed of and agrees to its use. A placebo may still be effective if the patient knows it will be used but cannot identify it and does not know the precise timing of its use. A physician should enlist the patient’s cooperation by explaining that a better understanding of the medical condition could be achieved by evaluating the effects of different medications, including the placebo. The physician need neither identify the placebo nor seek specific consent before its administration. In this way, the physician respects the patient’s autonomy and fosters a trusting relationship, while the patient still may benefit from the placebo effect.

A placebo must not be given merely to mollify a difficult patient, because doing so serves the convenience of the physician more than it promotes the patient’s welfare. Physicians can avoid using a placebo, yet produce a placebo-like effect through the skillful use of reassurance and encouragement. In this way, the physician builds respect and trust, promotes the patient-physician relationship, and improves health outcomes. (CEJA Rep. 2, I-06)

Thoughtful and empathetic communication from the physician to the ill patient is a therapeutic tool. In fact from the above AMA policy: "Physicians can avoid using a placebo, yet produce a placebo-like effect through the skillful use of reassurance and encouragement. In this way, the physician builds respect and trust, promotes the patient-physician relationship, and improves health outcomes."

My question: What if the reassurance and encouragement is to the physician clinically unrealistic? However this is unknown to the patient. Nevertheless, to the physician, at this point, such reassurance would be considered as theraputic and beneficent. Would that misrepresenation to the patient of the patient's clinical condition be considered "a placebo of a 'placebo-like' effect"? A placebo of a placebo? Does lying to the patient represent "skillful use" of reassurance and encouragement? And is that consistent with AMA's ethics policies? ..Maurice.

Medical Challenges: Jumping to Conclusions and Medical Uncertainty

"A DOG'S STORY
The man dressed all in white quickly raised the dogs over the flames. Fortunately they were neither burned nor damaged. Covered with the yellow emoliment, he bedded them to rest for now but not for long. Every dog lover must know that
Nathan's on the Coney Island boardwalk is famous for their dogs."

When you read A Dog's Story, you are presented the perfect example of what all physicians face when confronted with a patient's medical story without sufficient time because of scheduling or where an action must be taken quickly and that is--jumping to conclusions and, in fact, the wrong conclusion.

And if the challenge of "conclusion jumping" is not enough for the physician there is also the "fog of medicine", the certainty that there is uncertainty in medicine.
Patients may unrealistically expect their doctors to uniformly overcome these challenges. But it really is difficult. Robert Lowes writes about this issue in the October 24 2003 Medical Economics: "In fact, The doctor-on-a-pedestal model of medicine also makes it hard for doctors to voice their doubts. Patients naturally prefer comfort and reassurance to any talk about percentages. Many physicians assume that anything less than supreme certitude on their part will discourage them and set back their progress. In the end, doctors have no choice but to live with unease."

How do you expect your doctor to respond to these challenges? How would you feel if your physician expresses personal doubt about his or her diagnosis or prediction of the outcome of any treatment? Would you be willing to face the uncertainty together or would you expect to be transferred to another physician who would be able to provide you with all the answers to the questions you are asking? But is there such an "other physician"? ..Maurice.

Should The Mentally Ill Deserve Assisted Suicide?

Although physician assisted suicide is legal, with restrictions, in but one U.S. state, Oregon, it is practiced in other countries. One such country is Switzerland, which allowed assisted suicide since 1918 and not requiring physician involvement and not requiring the patient to be a resident. A recent decision by the Swiss Federal Supreme Court now permits assisted suicide, under guidelines, to be available to psychiatric patients and others with mental illnesses. The issue of whether the mentally ill should have suicide rights is discussed as an Essay in the May-June 2007 issue of the "Hastings Center Report" titled "A Suicide Right for the Mentally Ill?" by Jacob M. Appel. (The link will lead you to the full text article after a free sign-in.) Read the article and then return and write about the issue. ..Maurice.

Pharmaceutical Testing in the Incompetent Patient

The issue of the ethics involved in the pharmaceutical testing of the mentally incompetent patient (one who does not have the capacity to make medical decisions for himself or herself) was presented on my now inactive "Bioethics Discussion Pages". As with other topics on the "Pages", I would like to migrate them here to the blog and read what my current visitors might comment on them.

I recently got an e-mail from L.R. Booth (boteone@yahoo.com) who does not believe any surrogate has the right to make a decision for a mentally ill patient to participate in a drug experiment and believes that there are patients who could eventually make their own decision. He writes:

" I do not feel you can use the terms incompetent and mentally ill interchangeably. Someone who is incompetent cannot give consent, therefore, it is unethical.
I do not believe anyone has the right to make that decision for the Pt. It's a shame that too many DPOA's and legal guardians do not have the Pt.'s best interests at heart. If the Pt. has outlined this tx in the form of a Advanced Directive then it would be ethical. If someone is suffering from a mental illness that does not mean they are incompetent. Mental illness includes a wide variety of disease processes; depression, bi-polar etc. If treated properly these Pt.'s can make a informed decision on experimental drug txs"

I should explain my understanding of mental illness and capacity to make medical decision. Not every mentally ill patient has lost capacity to make their own medical decision. The loss of capacity must be determined by careful testing by the physician. It can be done successfully. A patient can have the capacity to make a medical decision in one context and not in another, so the testing should include the context in which the patient may be involved. Does the patient understand what drugs are and what they do, for what they are used, by whom and how drugs are developed and how they are tested, for what are they tested and upon whom they are tested? Does the patient understand that the patient might not get to take the drug that is being tested and might get another drug or a sugar pill? Does the patient understand that the drug being investigated might not be any more useful than a sugar pill or another drug? Does the patient understand that the patient might suffer complications from the testing either by bad effects of the drug or by the fact that their usual medication may have to be discontinued? If the patient passes all these questions by demonstrating understanding, then I would think the patient would have the mental capacity to make their own self-decision whether or not to participate in the study regardless of their established psychiatric diagnosis. For those who have no capacity to understand and give consent, the main question of this post is whether someone else should. But unlike surrogates giving consent for treatments that are not experimental and are known to be effective, balanced against the risks, in the case of experimental drugs tha effectiveness is unknown and the risks may only be partially known. Is the altruistic properties of being a subject in a test that might help oneself and many others sufficient to override the inability of the patient to understand and agree with the surrogate's decision?

In the comments below, the oldest replies are at the bottom of the posting. ..Maurice.




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Pharmaceutical companies must test new drugs for the treatment of mental illness on patients with the illnesses for which the drugs were developed to treat. This seems a very clear statement. The ethical concern is how can these patients who may have lost the capacity to understand the purpose, nature, risks, benefits and alternatives (including nonparticipation) of the research, to make a decision about participation? Should a family member or other surrogate make the decision for such a patient? Ordinarily, surrogate medical decisions deal with therapeutic issues. In the case of drug testing, the testing itself may not prove to be therapeutic, may be painful or even harmful for the patient. Should surrogates be given the power to allow the patient to be subjected to medications which have not been proven therapeutic but may be harmful? If there is no surrogate, who should make the decision or should the patient be eliminated as a candidate for the study?


Here are the questions:

How can the patient's rights be protected and still provide for necessary testing of drugs in the mentally ill? Who, if anyone, should make the decision for an incompetent patient regarding participation in a drug testing experiment?







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Date: Tue, Mar 9, 2004 7:06 PM From: khmaio@earthlink.net To: DoktorMo@aol.com
Please do not employ the term, "the" mentally ill. No group is generic.How to obtain informed consent when a person is not capable of giving it? Stop.If I know someone is not competent, proceeding is unethical. Only greed motivates past knowing the person cannot consent. The greed for an answer or for a recognition.More the latter than the former. Harold A. Maio


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Date: Wed, Jan 21, 2004 11:20 AM From: khmaio@earthlink.net To: DoktorMo@aol.com
How can the patient's rights be protected and still provide for necessary testing of drugs in the mentally ill? Who, if anyone, should make the decision for an incompetent patient regarding participation in a drug testing experiment?

There is no generic "the" mentally ill. There is however a commodity, "the" mentally ill, which is widely exploited. There have been many such "commodities" in history. Once one has retreated to an abstract "the", societies seem to offer that group to be expolited. Generally the exploited group has no political power, ergo the Tuskegee "study". Even the Salk vaccine was tested on people unable to consent.

If one is a "patient" are there not already ethics in place, or is the term just a convenient empty metaphor?

Should a person unable to consent be forced to participate? No. Whatever term someone wishes to employ, it amounts to force since consent cannot be obtained. Florida law accepts that infomed consent has been obtained when "sufficient" explanation has been given. "Sufficient" is a metaphor of force, since it will be defined by the person intent on forcing, not by the person forced.

Harold A. Maio,Consulting Editor Psychiatric Rehabilitation Journal Boston University


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Date: Tue, Apr 8, 2003 3:52 PM From: bpspiper@msn.com To: DoktorMo@aol.com
I believe that it is wrong to conduct experimental testing for unapproved drugs on the mentally ill without express consent from a legal guardian, power of attorney, or judgment of the state. As a nursing student we have been taught that our highest priority is to protect the rights of our patients. Through education we can help the families and guardians come to a better understanding of how pharmaceutical companies work to improve and or create new drugs that could better serve the people. With this education now comes the power of the families and guardians to decide what is in the best interest of the patient. We cannot arbitrarily stand by while others decide our fate. We have to stand up for the rights of those who cannot stand up for themselves. If we don't who will stand up for us if the time comes?

Becki Price


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Date: Mon, Oct 22, 2001 8:52 AM From: CBlades@JPMC.ORG To: DoktorMo@aol.com
Not all mentally ill people are incompetent. I think that has to be determined before you can make a blanket statement as to who can make the decision for their participation in a drug trial. Many mentally ill patients would welcome the chance even during stable periods, if it meant decreasing the effects that their illness has on their lives. Look at the Clozaril trials for instance...while there are great risks associated with this medication the benefits for the majority of the patients outweighed the risk. I believe we allow the patient to make the choice unless the court has declared them incompetent and if that is the case, give the information to the legal guardian and assist them in make the appropriate decision as needed.


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Date: Thu, Jan 11, 2001 5:46 PM From: mlammers3@home.com To: DoktorMo@aol.com
Using experimental drugs on persons who are mentally incompetent because of illness is not a clear cut issue. However, if the drugs are being designed to specifically treat their disease or disorder, and this disease or disorder often or always leads to mental incompetence, the treating physicians are really left with no choice but to test the drugs on these people. Certainly the drugs cannot be used on healthy people. I think the decision of whether or not these patients should be used in experimental drug testing should be left up to their relatives, who will hopefully act in the best interest of the patient.


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Date: Tue, May 19, 1998 3:44 PM From: sheilac@kalama.doe.Hawaii.Edu To: DoktorMo@aol.com
Pharmaceutical testing in the incompetent patients? This is a really tough issue. It's like a gamble, you test the drug on a person like a guinea pig, if it lives and does its purpose it works, but if the patient gets worse or dies it's a failure and you loose. I say let a family member make the decision for him or her. Discuss the drugs purpose and whats expected to happen, Also explain it's risk and possible side effects. Also explain what the patient may feel physically and mentally.


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Date: Sat, Jul 26, 1997 1:35 PM From: DocReading@sprintmail.com To: DoktorMo@aol.com
Mentally ill patients are not by definition incompetent to consent to drug testing. Many mentally ill patients do not lack the capacity to understand the purpose, nature, risks, benefits, and alternatives of the research. As a matter of fact, I have many patients (I am a Psychiatrist) who are more altruistic than their non-mentally ill designated counterparts. If a drug can be tested on willing and factually competent individuals, it should. Only if it can be proved that an illness renders all people who contract it incompetent to consent then legislation could be enacted to appoint a committee to decide based on the individual's premorbid preferences if possible whether or not to allow the person into the study. The principle of autonomy should rule whenever possible.


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Date: Wed, Apr 16, 1997 2:41 AM From: gottlieb@hp380.ist.unige.it (Prof. Alberto Gottlieb) To: DoktorMo@aol.com
The problem of consent to diagnostic and therapeutic procedures of incompetent individuals has not yet been solved adequately and you already ask about the consent relative to experimental therapy ?! It seems evident that caring for, let's say, a demented Alzheimer patient is quite easy when benefits prevail over risks by far :e.g.in case of arterial hypertension or acute appendicitis. If, on the contrary, performing diagnostic and therapeutic procedure entails a certain morbidity (annoying side effects) or mortality e.g. coronary disease, then every person deciding for the incompetent patient will be criticized , and perhaps also legally sued by relatives with conflicting interests , if things don't go straight. Deciding about new diagnostic or therapeutical procedures (namely drugs) to be applied in incompetent patients should start from the same point: the benefits either real or awaited (on serious scientific grounds)should prevail by far over risks. It must brought in mind however that only at the beginning of the dementing process, such as Alzheimer or Multiinfarctual dementia, a real benefit may be awaited from a therapy and it will be, when it will be, a stop to mental deterioration. It seems actually unbelievable to restore mental abilities that have been lost because the corresponding neuronal centers are atrophic and millions of neural cells and their fibers are absent. This stimulates drug researchers to focalize their efforts on the beginning of the dementia when the best resuls are perhaps attainable and, if attained, best measurable. But it is just the moment when patients usually are still competent and may be asked their consent about new drug treatments. I think morevover that in this period of initial restriction of mental capacity which does not intefere yet with the ability of caring about theirselves patients may be asked advanced directives about the future behaviors of the caregivers (deciding substitute) and the medical staff.


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Date: Thu, Dec 19, 1996 2:43 AM EDT From: BBrodie960@aol.com To: DoktorMo@aol.com
Society provides a surrogate decision maker for its immature and mentally incompetent members. To an extent, the rights of this unfortunate class are transferred to those close enough to them to act in a manner as similar as possible to the incompetent person. Usually, this is a family member, but it might be a friend, or even the state when that's the best society can come up with. It's not a perfect system, but more often than not, the designated decision maker acts in the incompetent individual's best interest and in a way that is reasonably similar to the way that individual would act if he or she were competent.

I think the testing of psychotropic drugs is so important that the risk of unnecessarily violating a person's right to make an informed decision is significantly outweighed by the benefit of making appropriately tested and effective drugs available to those who need them. (Not only does the mentally ill patient benefit from the drug, but society benefits from him or her taking the drug.)

I say, let the party designated to make any important healthcare decision on behalf ot the incompetent individual make the decision regarding participation in a drug study. The only exception I would make to this rule would be when the incompetent individual's guardian is the state because the state is least likely to know how the incompetent individual would act if he or she were competent.


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Sick, Unconscious and Without Family, Friends or Surrogates--What's Next?

OK..here's the deal: You are in a hospital sick..you are unconscious..you need to have a surgical procedure done to attempt to make you better to some degree but you are unable to weigh the risks and benefits or to give the surgeon permission to operate..you are unconscious. In addition..you have been homeless..you have lived on the street..different streets..you have no friends..you have no relatives..you have no one to come to the hospital to visit you or talk to your surgeon. The surgeon wants to make you better..he or she needs to operate..but there is no one..not you or anyone else to give the surgeon permission. There is no law where the hospital is located which would instruct anyone what to do under these circumstances..Should the surgeon act as a family member or legal surrogate and make the decision for you? If you really were that patient..what do you think would be legal and ethical.. what would be the fairest act for that doctor to do for your benefit? Should the surgeon make the decision for you? And what if the decision to be made was not simply to operate to attempt to make you better but involved a decision to stop all life-supportive treatment because your condition was hopeless and you would never recover. Who should make that decision? You can't..you are unconscious and you have no one to speak for you. Got the picture?

By the way, this scenario is not at all rare. It can happen every day in some hospital. Most states in the U.S. have no laws which tell doctors what to do under these circumstance. Sure, the doctor and hospital can take the problem to the courts and have a judge decide or to have a legal guardian appointed. But this takes time and there may be no time. The guardian will not be available to respond for every single medical procedure nor will the guardian be free of conflict of interest or free of pressure from the judge when it comes to terminating life-support. So the doctors and hospitals have to make up their own guidelines. But my question is ..what would you want them to do if a patient comes in with no capacity to make decisions and no friends, family or surrogates to help with a medical decision? ..Maurice.

More on the Issue of Killing vs Letting Die

Back on October 14 2006, I had a posting about a case of a quadriplegic who required the ventilator for survival but finally wanted it turned off. The issue was if the physicians or others turned off the ventilator would this represent a killing or letting the patient die of his underlying paralysis. Patients have a legal and ethical right to terminate unwanted treatment.

I wanted today to present another killing vs letting die situation for consideration. Cardiac pacemakers are inserted into patients whose heart cannot beat without electrical assistance or on its own beats so slowly that the patient is very symptomatic and if not improved the patient may die from stroke or heart failure.

There are two case scenarios discussed at the American Medical Association’s Virtual Mentor (link 1, link 2) which deal with the issue of the ethics involved in turning off cardiac pacemakers. Read them, return and indicate whether you feel that removing a device attached to preserve the life of a patient who would otherwise die is an intentional killing act such as euthanasia or murder. ..Maurice.

XDR TBC and the Fallacy of a Moat

Steven Miles, physician and ethicist from the University of Minnesota has given me permission to post here his retelling of a classical story and his challenging commentary to his colleagues which he sent to a bioethics listserv.

With admiration from Edgar Allen Poe:
THE "Red Death" had long devastated the country. No pestilence had ever been so fatal, or so hideous. Blood was its Avatar and its seal -- the redness and the horror of blood. There were sharp pains, and sudden dizziness, and then profuse bleeding at the pores, with dissolution. The scarlet stains upon the body and especially upon the face of the victim, were the pest ban which shut him out from the aid and from the sympathy of his fellow-men. And the whole seizure, progress and termination of the disease, were the incidents of half an hour.
But the Prince Prospero was happy and dauntless and sagacious. When his dominions were half depopulated, he summoned to his presence a thousand hale and light-hearted friends from among the knights and dames of his court, and with these retired to the deep seclusion of one of his castellated abbeys. This was an extensive and magnificent structure, the creation of the prince's own eccentric yet august taste. A strong and lofty wall girdled it in. This wall had gates of iron. The courtiers, having entered, brought furnaces and massy hammers and welded the bolts. They resolved to leave means neither of ingress or egress to the sudden impulses of despair or of frenzy from within. The abbey was amply provisioned. With such precautions the courtiers might bid defiance to contagion. The external world could take care of itself. In the meantime it was folly to grieve, or to think. The prince had provided all the appliances of pleasure. There were buffoons, there were improvisatori, there were ballet-dancers, there were musicians, there was Beauty, there was wine. All these and security were within. Without was the "Red Death."
It was toward the close of the fifth or sixth month of his seclusion, and while the pestilence raged most furiously abroad, that the Prince Prospero entertained his thousand friends at a masked ball of the most unusual magnificence. ... And now was acknowledged the presence of the Red Death. He had come like a thief in the night. And one by one dropped the revelers in the blood-bedewed halls of their revel, and died each in the despairing posture of his fall. ...
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XDR TB is not a new act of bacterial creationism, it is a killing automaton which we have made as a living testament to our failure to detect and treat TB. It is not hard to treat TB, $25/cure suffices in developing countries. We locked ourselves in game rooms to fret about face transplants, reality television, and fantasy sports. Globally TB treatment is in shambles, few cases are found, fewer than 30% of those found complete therapy. International agreements, like the bioethics ignored TRIPS, have put the cost of routine treatment out of reach of those most likely to be infected.
XDR TB is in 37 countries at least. Now a telegenic and selfish yuppie couple, one of Prince Prospero's favored guests, show the fallacy and porousness of our "castellated abbey."
An idiotic press and pithed congressmen demand to know why we did not build a better moat so that our slumber party could proceed without being so rudely disturbed.
Will the bioethicists say "Here! Here!" ?

I suggested to Steve that it was my impression that our current U.S. administration was, perhaps until recently, presenting the issue of greenhouse gasses leading to global warming with the same "moat-like" defense. He replied "On global warming, the US has acted the same way, ie Kyoto protocol, although the problem is much more complex and less amenable to rectification. TB treatment is especially infuriating because TB treatment was available, affordable. TB eradication was recognized as needed; it was proposed and it was possible. XDR-TB was the predictable alternative outcome."

By the way, for those of my visitors who don't know to what Steve referred to as "TRIPS", the acronym stands for "Agreement on Trade=Related Aspects of Intellectual Property Rights". This was the international agreement that some felt had prevented AIDS victims in developing countries to get the best AIDS therapy.

..Maurice.

"In Sickness and In Health Till Death Do Us Part": Is This What We Ask of Our Doctors?

My threads on patients hating doctors have stirred a lot of conversation here. I am still trying to understand fully the explanations patients give as the reasons for that hate. After reading the article "A Sentimental Patient" by John Portmann in the Cambridge Quarterly of Healthcare Ethics (2000, 9, 17-22), I wonder if sentimentality is one such mechanism. Portmann defines sentimental, in the sense of the doctor-patient relationship, as "a contrived exaggeration of emotional availablility of physicians." What this means is that the patient expect more emotional and concerned feedback from the physician than what is realistic. Portmann, however, says that sentimental patients are not hateful, however they may experience the same issue: attempting to deal with their concept of an "ideal doctor" vs the doctor's response which is likely based the realities of what is facing the physician trying to care for "sick and troubled" patients. I, myself, wonder nevertheless, whether sentimentality is not a major cause for the feeling and expression of hate for one's physician or physicians in general.

It is understandable that some patients may need sentimentality if their own emotional needs are unmet and especially so during times of illness and discomfort.
They would want their doctor to be more interested in them, more comforting to them and provide them with something more than a cold and casual paper prescription, if even that. When their doctors don't meet their expectations, the patient will look at their physician as heartless and anything that the doctor accomplishes to the benefit of the patient will appear incomplete and anything not accomplished will appear what the patient expected. Portmann writes "Belief in caring generosity of physicians falsifies what we know about them by emphasizing their virtues and underplaying their other committments and motivations."

The question is whether the establishment of the doctor-patient relationship actually, to some patients, represent almost a marriage vow in terms of what medical ethicists (Quill and Cassell, 1995) by their definition of the doctor-patient relationship as "a covenantal relationship grounded in mutual respect and caring... [including]caring, fidelity, altruism and devotion...[and] the particular importance of long-term, engaged presence... [and] the promise to face the future together."

If all this is what some patients expect from their doctor beyond skill and technical knowlege and willingness to listen, try to understand and try to provide supportive empathy, then I can see displeasure and even hate if the doctor doesn't provide more.

What do you think is the role of sentimentality on the part of the patient and it's role in the expressed hate? Do you think patients expect more emotional concern or involvement by their doctor, perhaps almost in a family way, than they usually receive? ..Maurice.

"I Hate Doctors and..." A Brief Study on Google Search

On June 30 2005, I started my posting with the following:

"A visitor came today to my blog from Google with the search words “I hate doctors”. While, I don’t know the true motivation and concern of this visitor, I think that this visitor’s search terms are consistent with the ambivalent feeling people have about doctors. Whether it is fair to characterize this ambivalence in the extremes of “love” and “hate” or some more moderate terms can be considered but obviously the ambivalence is a realistic phenomenon."

Today, almost 2 years later, there are now 84 comments to that posting which I titled "I Hate Doctors" and, of course, many, many more visitors who didn't comment. This has been one of my most popular postings. I wondered whether we physicians were the most hated people who are supposed to serve the public. So I went back to Google today and entered the words "I hate..." and finished the expression with "doctors" and found there were 18,300 sites using those words. Then I replaced "doctors" with "nurses" and then a whole bunch of other jobs and below is the results I obtained. I am not sure whether this study says anything significant about the publics opinion of these different classes of activities but I thought the listing would be of interest to my visitors. So here they are:
I HATE...
Doctors 18,300
Nurses 659
Lawyers 10,100
Politicians 994
Ministers 5
Police 704
Judges 676
Actors 623
Actresses 190
Plumbers 424
Used Car Dealers 127
New Car Dealers 7
Insurance Agents 10, Insurance Companies 684
Realtors 505
and then I put in the words "I Hate Men" 70,800
and naturally I tried "I hate Women" 54,500
and finally to establish the ambivalence between to hate and to love doctors I put in "I love Doctors" and Google said there were 9,760 sites with those words, a little more than half of the hated.

Again, what this little exercise with Google's Search Engine means, I really don't know but it does seem that doctors lead the way in expressions of hate as compared to other professions and employment. What can we do to improve our image and our behavior, if necessary? For specific comments on this question just go back to the "I Hate Doctors" posting and add to the comments. ..Maurice.

100 Years of Medicine: Some Issues Just Don't Change

There might be a truism that some things in the practice of medicine change and some don't over a period of 100 years. Certainly the treatment of heart disease and cancer has changed and so have their outcomes. But there are issues in medical practice that have lingered on. If you look at the June 6th 2007 issue of the Journal of the American Medical Association (available by subscription only) you would find reprint of two 100 year old editorials (June 1 1907).

The first, "Protecting the Fool from His Folly" (the public acceptance of "medical fakes and fakirs" and the need to protect them by laws "conservatively made and stringently enforced") expresses the concern that the newspapers are not educating the public about the fakes but infers that they are actually encouraging them since "the daily newspaper lost their sense of moral perspective in the acceptance of advertisements..." and "It seems that permission to use the daily press for fraduulent and criminally indecent purposes was restricted only by the ability to pay advertising rates." On this blog, we have discussed the direct to consumer advertising by the media and its consequences. Not that I am saying that the pharmaceutical companies are promoting "fakes" or are "fakirs", but I see the similarity of the the media "mis-education" of the public about medical potions between then and now.

The second editiorial ("A Legal Opinion of the Medical Profession") involved the report of a malpractice case from Ohio where the judge "after listening to the evidence of several local physicians, took the case from the jury and instructed the verdict for the defendant." The judge stated that never thought even for a moment that "any physician would perjure himself on the witness stand to shield another." The attorney for the plaintiff, in protest, said "that it is impossible to to make a case against a physician because members of the medical profession are under obligations to endorse each other's statements."
Golly, that is exactly what many of my visitors have been writing currently on a number of threads why they feel doctors' alleged misbehavior are getting off with no punishment and changes in standards of medical behavior are not being improved for the patient because of this "club"-like attention by the "members" toward the self-interest of the physicians.

Some issues, even in medical practice, never change. ..Maurice.

Amalia and the Greek Medical Care System

From Reuters
May 30,2007:

"Greek bloggers mourn death of medical whistleblower--ATHENS (Reuters Life!) - Greek bloggers are mourning the loss of one of their own, a young Greek cancer patient whose adventures through the Greek medical system touched thousands, and are dedicating June 1 to her memory.

Amalia Kalyvinou, who died last week at the age of 30, had attracted many to her Internet Weblog [www.fakellaki.blogspot.com] with her stories about incompetent and corrupt doctors who failed to diagnose her for years or took financial advantage of her despair."

[Moderator's note: Amalia's blog in the above link is written in Greek.]

The story of Amalia is written in a blog (written in English) devoted to Amalia and titled "This One is for Amalia" The story is reproduced below.
Obviously, I have no factual information as to how dysfunctional is the Greek medical system, however if the public uproar upon this Greek lady's death has any significance, one may wonder if there isn't some more general truth to Amalia's writings. When the United States develops its healthcare system to enable everyone to have care, attention should be taken to ensure fairness, concern about patients as individuals and that everyone in the system follows the rules. ..Maurice.

Since the age of 8, Amalia Kalyvinou started having pains. Despite her numerous visits to doctors and several admissions to hospitals, no-one managed to diagnose her in time with the benign neurinoma of her lower extremity, which was the actual diagnosis at that point. 17 years later, Amalia was told that the neurinoma had transformed by then into a malignant tumour.

For the next 5 years, Amalia not only had to fight with the cancerous disease and amputation, but also with a corrupt Greek National Health System: it ignores (by choice) the ongoing patient-to-doctor bribery and insists on time-consuming bureaucratic methods and practices. Besides radiotherapy and chemotherapy, Amalia had to face the financial exploitation by doctors that stood opposite to rather than by her side. On top of her pain, she had to endure the greediness of private clinics and the exhaustingly long waiting queues of the health insurance system, in order to get legal approval for some ridiculously low financial compensation.

Amalia passed away on Friday, May the 25th, 2007. She was just 30 years old.

Before dying, she managed to document her experience and share it with us in her blog http://fakellaki.blogspot.com/. The promising literature graduate named in there each and every one of the doctors she had to bribe, praising at the same time the ones that honoured the Hippocratic Oath. Her testimony moved thousands of people that stood by her side all the way to the end.

"Amalia's main aim was to tell her story, so that she could awaken as many people and as many consciences as possible. She mainly wanted to show that there are ways to resist not only the self-regulation and authority of dishonest and heartless doctors, but also the bureaucrats of the Health System."
(Dikaia Tsavari & Georgia Kalyvinou – Amalia's mother & sister)


According to the Greek law, it is considered a major disciplinary offence for the doctors of the Greek National Health System to:

"Accept bonus and especially any compensation or property grant, for any medical service provided.”

Amalia Kalyvinou fought for things that are taken for granted in a modern European country. Unfortunately, this is not the case for Greece. Continuing Amalia’s effort where she left off, we protest in public and we demand:


* THE STATE TO TAKE IMMEDIATE ACTION TO STOP BRIBERY AND THE INEQUALITY BROUGHT IN THE TREATMENT OF PATIENTS.

* THE NATIONAL HEALTH COMMITTEE TO BE MORE FLEXIBLE SO AS PATIENTS STOP FALLING VICTIMS TO TIME-CONSUMING BUREAUCRATIC PROCESSES.

* THE DEPARTMENT OF HEALTH TO ENSURE STRICTER CONTROL ON THE RELATION OF DRUG COMPANIES – MEDICAL SERVICE.

* FULL UTILISIZATION OF CURRENTLY ABANDONED HOSPITAL INFRASTRUCTURE. CONTINUOUS AND COMPLETE SCIENTIFIC TRAINING & DEVELOPMENT FOR DOCTORS AND NURSES.

* CREATION OF A NATION-WIDE ELECTRONIC MEDICAL RECORD SYSTEM, TO SPEED UP PROMPT DIAGNOSIS AND TREATMENT

LET’S END THE HYPOCRISY OF THE ONES THAT GOVERN, WHO PREFER TO ALLOW DOCTORS TO BE BRIBED BY THEIR PATIENTS, INSTEAD OF PROVIDING THEM WITH A DECENT SALARY.

* NO MORE BRIBERY

* NO MORE BUREAUCRACY

* NO MORE LIES

WE DEMAND FREE AND EFFICACIOUS HEALTHCARE SERVICES FOR ALL.

[Moderator's note: Thanks to J.Nannou for the e-mail headsup on the story.]

Alzheimer's Disease, Advance Directive and Feeding

Back on October 29, 2005, I wrote a post describing an elderly Alzheimer's patient with no other medical complications and who was aware of her environment but who years earlier when she had the mental capacity to make decision stated that she didn't want medical nutrition and hydration. A feeding tube was placed a few years earlier because of difficulty swallowing during a prolonged respiratory infection, with the intention that it would be temporary but the feeding tube still remained in the patient. The issue was whether removal of the tube now would contribute to her death and whether it should be removed.

On this current post, I would like my visitors to consider an elderly Alzheimer's disease patient who appeared to the caregivers that she was really not aware of her environment except when food or liquid is placed between her lips she appears to accept the feeding and swallows. The ethical issue is that years ago when she had capacity to make medical decisions she wrote in an advance directive that if she had an irreversible disorder that left her unaware of her family or others and couldn't care for herself, she would not want to be fed and should be allowed to die. She is tolerating oral feedings but should they be stopped in view of her past directive?

The ethical issue in both cases is whether if a patient rejects food and fluid by tube or even by mouth under some stated conditions in an earlier advance directive, should that request be followed? Should the patient's prior directive against being give nutrition be questioned either by trying to communicate with the demented person or by following the decision of a current legal surrogate? Should there be a difference between feeding a patient by tube or feeding the patient orally, if the patient doesn't resist the feeding? If a patient in end-stage Alzheimer's now appears to accept food and fluid orally, should that behavior trump any previous directive to the contrary? Is the currently demented person the same person (in terms of personhood) who signed the original advance directive? If not, should the advance directive be ignored?

Has any of my visitors had similar issues arise in the management of their own family member with Alzheimer's? ..Maurice.