Bioethicists and Activism: Should They Rock the Boat?

We are all bioethicists because we all have views and opinions about things bioethical in our country and world. And with these opinions we set our behavior about those things. But there are bioethicists and there are bioethicists. There are bioethicists who have studied philosophy and ethics and are actively participating within the discipline of bioethics through consultation and teaching. It is with regard to these people who spend their lives immersed in bioethical thought and investigation that I find something missing in their role and goals.

That missing function is the lack of a spirit of activism. Activism represents the need and desire, not just to sit and contemplate but to act on their ethical conclusions. If a bioethicist finds that his or her view is the ethical path for change that would benefit both the individual and/or society, that ethicist should join others with like views and actively try to change things in the most appropriate and effective manner. What things are going on in the world that should be considered? How about inadequate healthcare in the United States and other countries, inadequate nutrition and water for people in many parts of the world, misuse of resources, pollution, torture and many more?

But is that happening in bioethics? No. Why not? I think it is because the discipline is still relatively new and I guess bioethics has been derived from a more academic, sedentary, introspective discipline of philosophy and bioethicists are still caught in that environment.. think things out, give advice but don’t rock the boat. On the other hand, maybe the true value of a bioethicist’s conclusion is, along with others, to rock the boat.
What do you think? ..Maurice.

Looking Ahead at The Road of Life

The topic of this thread is very simple. How should a person look at and anticipate their life? Is one’s life like moving on down a road? Does one need a map or directions from others? Is progression by walking or riding? What should one expect is the condition of the road, paved or full of rocks and potholes? Has anyone any way to smooth the path or is pain, suffering, ill health and uncertainty to be expected as one traverses the road? Is life diminished in value or significance if none of these occur and the ride is smooth and secure? And how does the road end, as a road to glory or, without warning, as a dead end? Maybe I was wrong. The topic may not be simple. However, I suspect that how one looks at and anticipates their life is how one sets their moral and ethical views and behavior. ..Maurice.

Addendum: Graphic is a photograph taken by me on a trail in Placerita Canyon Park in Southern California, December 23, 2007.

Advice to the Doctor Thread: What is Your Advice to Doctors and Medical Practice?

Throughout these over 500 different threads on this blog, there have been plenty of topics which provided the opportunity for visitors to comment about their doctor’s personal behavior and practice. Many visitors did express their good and bad experiences with their physicians, their pleasure and their disgust with their doctor or the profession. Notwithstanding the opportunity my visitors were given to tell their stories within those threads, I thought it would be a good idea if I put up a thread that dealt solely with general but constructive advice which patients would give to doctors perhaps in the form of some guidelines or guideposts to improve the quality of care that is expected. Doctors, as part of their work are always giving advice to their patients. I think that a blog such as mine should give patients the opportunity to return advice. Hopefully I, myself and other physicians who come and visit this blog will learn and consider seriously the advice given. For the purpose of clarity, keep the advice short and succinct but do include an explanation of the basis for giving such advice. Remember, advice is more easily accepted if it is constructive, civil and understandable. If one visitor agrees or disagrees with the advice presented by another, this can also be expressed. Now go to it.. I am listening. ..Maurice.

Patient Modesty: Volume 2

With over 700 Comments written to the thread "Patient Modesty: A More Significant Issue?"started on May 11 2006, one of my visitors, js md, suggested that I start another volume on the topic to promote easier access to the comments for reading and writing. This posting here is to follow up on that suggestion which I thought was appropriate.


NOW..ON TO A NEW ISSUE OF THE PATIENT MODESTY DISCUSSION--
All the discussion regarding patient modesty had to do with issues of the modesty of adults in the medical environment. No visitor, none, have discussed at what age a patient's modesty must be considered and whether all this discussion of modesty applies to infants, small children or up to what age. And, if modesty applies to infants and children WHOSE modesty does the concern represent? Is it the modesty of the parents? If so, is this one of the responsibilites of parenthood? And if so, from what are the parents protecting the child? Is it fair for the parents to project their biases on the healthcare of their children? Is modesty purely an issue for those humans who have passed through the period of puberty or does modesty have nothing to do with the development of secondary sex characteristics or the maturing of emotional sexuality in the developing human of either gender? I think answers to these questions would help develop more of an understanding of the whole issue of patient modesty. Any ideas? Remember, post this new discussion HERE. ..Maurice.

ADDENDUM: Graphic-Photograph of Apollo, presumably as a child: National Museum of Antiquities of Tajikistan Southern Tajikistan, Sculpture of clay 3C-2C BC. Photograph altered by me in the interest of modesty! ..Maurice.

ADDENDUM (1-14-2008):ALL COMMENTERS WHO WISH TO SIGN ON AS ANONYMOUS NEVERTHELESS PLEASE SIGN OFF AT THE END OF YOUR COMMENTS WITH A CONSISTENT PSEUDONYM NAME OR SOME INITIALS TO HELP MAINTAIN CONTINUITY AND NOT REQUIRE RESPONDERS TO LOOK UP THE DATE AND TIME OF THE POSTING TO DEFINE WHICH ANONYMOUS SAID WHAT. Thanks. ..Maurice.

ADDENDUM (3-1-2008) THE THREAD NOTED ABOVE "Patient Modesty: A More Significant Issue?" IS NOT FUNCTIONING PROPERLY AND IS NOT POSTING COMMENTS. PLEASE DO NOT ATTEMPT TO WRITE COMMENTS TO THAT THREAD. ..Maurice.

ADDENDUM (4-17-2008) THE THREAD "Naked" is NOT FUNCTIONING PROPERLY AND IS NOT POSTING COMMENTS. PLEASE DO NOT ATTEMPT TO WRITE COMMENTS TO THAT THREAD. ..Maurice.

ADDENDUM (5-23-2008) WARNING! SINCE MAY 14 2008, NONE OF THE COMMENTS SUBMITTED AND APPROVED BY ME FOR POSTING HAVE ACTUALLY BEEN POSTED ON THE COMMENT PAGE. AGAIN, THIS APPEARS TO BE A QUIRK OF THE BLOGGER.COM SYSTEM. ALL THE POSTINGS CAN BE VIEWED HERE BY CLICKING ON "NEWEST" ON THE POSTING PAGE BUT NONE ARE PUBLISHED ON THE COMMENT PAGE. IT APPEARS TIME TO START A NEW VOLUME. I WILL BEGIN "PATIENT MODESTY VOLUME 3" AT ONCE AND INCLUDE ALL THOSE POSTINGS WHICH DID NOT PUBLISH ON THIS THREAD.

DO NOT TRY TO POST ANY MORE ON THIS THREAD SINCE IT WILL NOT BE PUBLISHED. PLEASE GO TO "PATIENT MODESTY VOLUME 3" ..Maurice.

What Matters Most in Life?

I would like to take a survey of my visitors regarding what to each visitor matters most in life. This survey is based on the things described in the Gallup-International Millennium survey of a representative sample of 50,000 people around the world. Perhaps it is best for our survey that the visitor doesn't read the results of Gallup before answering. If you respond and don't live in the United States, please note the country where you do live.

Here is the survey question by Gallup:

What matters most in Life?

Tell me only the two things that matters the very most in life?

• To have a job
• To get an education
• To be faithful to my religion
• To have a good standard of living
• To live in a country where there is not war
• To have a happy family life
• To live in freedom
• To live in a country without violence and corruption
• To have good health

Remember.. tell only two things from the list. However, I would encourage you to make a commentary about why you selected those two. ..Maurice.

A Blessing Praising Good Health After Using the Toilet

If by any chance we are really healthy, we really wouldn’t know it by all the medical information and ads in the media which seem to tell us otherwise. Therefore, if we have no aches and pains and we are at the moment not considering that we have a sleep disorder, a bowel disorder, chronic arthritis or recurrent headaches, digestive disorder or depression and have no need to call the doctor for an appointment then we should celebrate. Perhaps, give a blessing praising our good health.

As described in A Piece of My Mind section of the Journal of the American Medical Association May 28, 1997, Kenneth M. Prager, M.D. writing “For Everything a Blessing”, that he was aware of a Jewish blessing when he was a child attending a Jewish parochial school. There was a sign posted outside the bathroom there stating that a blessing must be spoken after one had “relieved oneself” (through micturition or defecation). According to the Jewish Talmud, a document of Jewish law and lore, “Abayei said, when one comes out of a privy, he should say: Blessed is He who has formed man in wisdom and created in him many orifices and many cavities. It is obvious and known before Your throne of glory that if one of them were to be ruptured or one of them blocked, it would be impossible for a man to survive and stand before You. Blessed are You who heals all flesh and does wonders.” The blessing was to be performed in Hebrew by an observant Jew and as a student in the school, Dr. Prager and the other students were always reminded by the sign.

Is there merit to bless our good luck that we have not as yet experienced blockage of our urinary tract, our gastro-intestinal tract, our coronary arteries or a ruptured appendix, spleen or aortic aneurism? I think so. Who knows, maybe performing the blessing as one leaves the bathroom might even be prophylactic, preventing future troubles and would be inexpensive and without side effects. Just a thought. ..Maurice.

You Know You Are A Bioethicist When...

If you wondered whether you possess the criteria for being a bioethicist, here is a little sample of conditions which would suggest the occupation. An ethicist, Timothy F. Murphy wrote this to a bioethics listserv and gave me permission to post it here. To be frank with my visitors, in order to fully understand the nuance of some of the criteria, you really have to be a bioethicist in the first place. By the way, the graphic on this thread is my tinkering with a photo of Rodin's "The Thinker" statue at the Musee Rodin, Paris.


You Know You’re a Bioethicist when:

As you exercise on the treadmill, you wonder about the ethical,
legal, and social effects of prolonging your own life.

You meet an acquaintance in the supermarket. She asks after your
mother who is in the hospital. You phrase your answer so as not to
violate HIPPA standards.

At a university banquet in your honor, you ask if the chicken has
been genetically modified or been given genetically modified feed.

The waiter at your local restaurant describes the fish of the day but
forgets to mention that the recipe contains chervil. You decry the
restaurant’s failure of informed consent.

Your teenage daughter wants angel wing tattoos on her shoulder blades.
Your teenage son wants scarified rings on his back. You suggest that
they consider whether rule-utilitarianism, act utilitarianism, or preference
utilitarianism will help them make better decisions about body modification.

You see a pregnant neighbor and ask whether her child will be a boy,
a girl, or a clone.

A reporter calls to ask you about a breaking case you know nothing about,
but you nevertheless express an opinion.

Your spouse asks why you were later coming home last night than anticipated.
You advise that you’ll have to get an ethics consultation before making any
further statements.

When arrested for driving under the influence, you breathe a sigh of relief
that federal regulations prohibit most experimentation on prisoners.

Someone at the White House asks you to serve on the President’s Council on
Bioethics. You protest that you have no qualifications as a bioethicist.
The President appoints you anyway.


Timothy F. Murphy
Chicago, November 2007

"The Best is to have Never Been Born" or...?

Read the Oxford University Press description of their book by the author David Benatar titled "Better Never to Have Been. The Harm of Coming into Existence":

Most people believe that they were either benefited or at least not harmed by being brought into existence. Thus, if they ever do reflect on whether they should bring others into existence--rather than having children without even thinking about whether they should--they presume that they do them no harm. Better Never to Have Been challenges these assumptions. David Benatar argues that coming into existence is always a serious harm. Although the good things in one's life make one's life go better than it otherwise would have gone, one could not have been deprived by their absence if one had not existed. Those who never exist cannot be deprived. However, by coming into existence one does suffer quite serious harms that could not have befallen one had one not come into existence. Drawing on the relevant psychological literature, the author shows that there are a number of well-documented features of human psychology that explain why people systematically overestimate the quality of their lives and why they are thus resistant to the suggestion that they were seriously harmed by being brought into existence. The author then argues for the "anti-natal" view--that it is always wrong to have children--and he shows that combining the anti-natal view with common pro-choice views about fetal moral status yield a "pro-death" view about abortion (at the earlier stages of gestation). Anti-natalism also implies that it would be better if humanity became extinct. Although counter-intuitive for many, that implication is defended, not least by showing that it solves many conundrums of moral theory about population.

An ethicist on a bioethics listserv in response to this topic provided this added bit of historic philosophic writing:

In his 1835-1846 poem, Morphine, the German-Jewish poet Heinrich Heine (1797-1856) wrote:

Gut ist der Schlaf, der Tod ist besser - freilich
Das beste wäre, nie geboren sein.

Freely translated:

Sleep is good.
Death is better,
but
the best is to have never been born.

Obviously all my visitors are existing for the present at least. What do you think about the virtue of non-existance? ..Maurice.

No “Gall Bladder Case in Room 213”: Teaching Medical Students Humanism

As I have previously noted on my threads, medical education is paying increasing attention to humanism, teaching students to remain aware that a patient with an illness is not simply an illness but is actually an individual human being who is incidentally sick. There is no “gall bladder case in room 213” but there is “Mrs. Roberta Jones, an 65 year old lady whose children live on the other side of the country and this is her first hospitalization since her husband died of pancreatic cancer a year and a half ago and when Mrs. Jones’ pain first started she began to think of the similarity to her husband’s pain and then recalled his wretched clinical course leading to his death and she thought if she has a disease like that how is she going to cope since although she was able to take care of herself in the past one and half years it was because she was healthy and vigorous and had always been able to care for herself but now with this pain she may be becoming weaker and more dependent and now she was alone and …” For students and physicians to ignore all that is going on in room 213 and pay attention simply to a pathologic gall bladder represents a true failure to fully evaluate and understand the patient as a person and not just a disease.

So..how can one educate students about humanism and keep them tuned in to this important part of being a medical professional but also an attentive and caring human being? For teaching rashes, the technique has been for the dermatology teacher to gather students in front of the sick patient to inspect the patient’s rash. Teaching pathology, students along with a pathologist gather over a large white pan bearing a severely diseased cirrhotic liver specimen, teasing the specimen open with the patient, himself, nowhere to be seen. Medical educators are now considering using the arts and literature to teach not only humanism but also stimulate skills for observation and interpretation. For example, the students gather with a teacher as facilitator in front of a painting and then, communicating together, begin dissecting the entire painting into its personal impression and its personal meanings. Hopefully, this exercise will provide training for the student, when standing in front of the patient, to look fully at the patient beyond just the rash itself and to consider, as an example, the patient’s body movements as signs of distress from the itching or burning. This is all part of looking at a patient and not just looking at a disease.

As I have stated previously, though medical education is not ignoring the importance of teaching humanistic behavior in our students, our concern is that what we teach them is preserved through their further clinical years despite the forces directed at diminishing this essential way to think and behave as a doctor.

I would be interested to read my visitors comments about what they think might be the value for students to have the arts and literature as a part of their medical education. ..Maurice.

ADDENDUM 12-16-2007: Here is an example of how we might use a painting to teach a more fuller understanding of the patient beyond simply the symptoms presented. This use might help in training the students to really look at the patient beyond the routine inspection for pathology. I presented Edward Hopper's "Room in New York" to my second year medical students and asked them to study the painting and then tell me their scenario of what is going on with the persons in the room. Their responses were varied but this led to a discussion of the views and we all learned from each other. What is your scenario? ..Maurice.

Science at Any Cost?:The Ethics of the Use of Unethically Derived But Valid Experimental Data

I think that the title of my blog thread "Science at Any Cost?:The Ethics of the Use of Unethically Derived But Valid Experimental Data" tells it all. But what is the answer? History provides examples of such experiments both in Nazi Germany and other parts of the world and in earlier years even within the United States.

Martin T Donohoe, MD, FACP, a physician-ethicist, wrote the following scenario and a series of questions to a bioethics listserv which challenges the reader to think out what would be ethical responses to the questions. Martin has given me permission to post his scenario and questions here. I am sure that we both would be interested in reading my visitors responses. ..Maurice.

You are editor of a highly prestigious, well-read medical journal. A paper is submitted from "investigators" living in a country with a horrible human rights record. The investigators deliberately gave 100 women breast cancer, and waited for metastases to form. They then used a new treatment, first tested in animals, in a placebo-controlled trial wherein 50 women received placebo and 50 received the new treatment. Only 5 of the placebo-treated patients survived after 3 years, whereas 45 of the drug-treated women survived and were confirmed disease-free. Record keeping was excellent, all scans/lab reports, path slides, etc have been submitted, and the data appear solid.

Would you publish the results?
If so, would you publish them with an editorial saying how bad this is?

Would you make the information available to the press but not publish the data?

What if that led to enormous profits for these "investigators'" clinic consequent to clinical visits, esp from desperate yet wealthy patients? (Assume the government would have no interest in cracking down on these "scientists," possibly because they could skim off the top of the enormous amounts of money that could be made)

If not, would you use the information if you or your wife or mother had breast cancer, if you could procure the drug in question?

Would it make any difference if the women in the study freely consented? Were paid an amount equal, say, to 10 times their potential lifetime earnings?