A Distortion and a “Disservice”?: Stem Cell Research and the Words of President Bush

President Bush’s view on the use of embryos for stem cell research is well known including his limiting of federal funding for research using stem cells other than those already created at the time of his 2001 decision. At that time, it was accepted in the scientific community that the lines available were limiting for research and may have been unacceptably contaminated. It appeared that Bush’s decision represented the imposition on the American public of a moral and an obviously political decision rather than one based on science. However, Bush’s order stuck and attempts were started by states to fund their own stem cell research beyond those initial lines. A successful attempt occurred in California when the state’s voters approved a 3 billion dollar funding program for stem cell research. The funding organization known as The California Institute of Regenerative Medicine (CIRM) provides the following history: “CIRM was established in 2004 with the passage of Proposition 71, the California Stem Cell Research and Cures Act. The statewide ballot measure, which provided $3 billion in funding for stem cell research at California universities and research institutions, was overwhelmingly approved by voters, and called for the establishment of an entity to make grants and provide loans for stem cell research, research facilities, and other vital research opportunities. To date, the CIRM governing board has approved 156 research grants totaling almost $260 million, making CIRM the largest source of funding for human embryonic stem cell research in the world. For more information, please visit www.cirm.ca.gov.”

However CIRM is unhappy with President Bush’s State of the Union Speech last night when he said:

“On matters of life and science, we must trust in the innovative spirit of medical researchers and empower them to discover new treatments while respecting moral boundaries. In November, we witnessed a landmark achievement when scientists discovered a way to reprogram adult skin cells to act like embryonic stem cells. This breakthrough has the potential to move us beyond the divisive debates of the past by extending the frontiers of medicine without the destruction of human life. So we are expanding funding for this type of ethical medical research. And as we explore promising avenues of research, we must also ensure that all life is treated with the dignity it deserves. So I call on the Congress to pass legislation that bans unethical practices such as the buying, selling, patenting, or cloning of human life.”

In response to the speech, CIRM promptly published the following statement:

CIRM DISAGREES WITH PRESIDENT BUSH’S MISLEADING POSITION
ON STEM CELL RESEARCH


SAN FRANCISCO, Calif., January 28, 2008 –

The California Institute of Regenerative Medicine (CIRM) issued the following statement in response to President Bush’s State of the Union address:

Tonight, in his State of the Union address, President Bush distorted the scientific facts on stem cell research and did a disservice to the millions of patients suffering from chronic disease and injury for whom stem cell research holds great promise for future therapies and cures.

The stem cell research community is united in the position that human embryonic stem cells clearly remain the gold standard for research into pluripotent cells – cells that have the capacity to form all tissues of the body. Human embryonic stem cells are also the model against which all other potentially pluripotent cells need to be compared. The President’s proposals to further limit medical research in this area fail to take into account the intricate realities of the state of stem cell research. Indeed, the recent advances in which skin cells were induced to become pluripotent would not have been possible without research involving human embryonic stem cells. Furthermore, induced pluripotency is a technology still in its infancy. Though this technology offers great hope and promise, it will not, for the foreseeable future, be suitable for clinical studies in humans because of safety concerns.

Therefore it is critical that all avenues of stem cell research be aggressively advanced. To do otherwise would increase the already devastating restrictions that have burdened Federal support of stem cell research and patients who are depending upon it. This Administration’s position on stem cell research has already cost years in lost research productivity. Further restrictions would result in more lost time in developing stem cell based therapies and cures that hold great promise to alleviate suffering for the most destructive and costly diseases such as spinal injury, loss of sight, heart muscle injury, Parkinson’s Disease, ALS and diabetes.

CIRM supports and applauds any programs the White House advances that accelerate NIH funding for research on induced pluripotency. There is much work to be done on all cell types, including this highly promising but early stage technology. CIRM looks forward to engaging with NIH and other state and federal organizations in accelerating the progress of stem cell therapies to the clinic.

CIRM also strongly opposes reproductive cloning.

Melissa King
California Institute for Regenerative Medicine
210 King Street
San Francisco, CA 94107
Desk: 415-396-9119
FAX: 415-396-9141
www.cirm.ca.gov

I wonder how my visitors look at the embryonic stem cell controversy and whether, for example, President Bush is still not telling the American people the realistic scientific facts, either in 2001 or 2008. Or what do you think about CIRM’s argument regarding distortion and “disservice” as a fair judgment of President Bush’s communication to his fellow citizens? ..Maurice.

Graphic: Photograph of 8 cell human embryo (from Wikipedia).

ADDENDUM (2-2-2008): To get a better understanding of the technology and biology behind embryonic cloned cell and the reprogrammed skin cell (also called iPS "induced pluripotent stem" cell) so that one can intellectually tackle the differing expressed moral views on these two approaches toward therapeutic goals, please read the following contrasting articles published in the Bioethics Forum: Embryonic Ethics and Getting Clear on the Ethics of iPS Cells. Our President has failed to explain to us why he finds, based on the scientific differences and similarities, iPS as morally acceptable compared with the use of embryonic stem cells.

Both articles come to the conclusion that further research and development using embryonic stem cells is necessary in spite of current skin cell reprogramming effort.

Putting Doctors on a List:Good Idea or Bad To Fool Around with Human Nature?

The idea is how to develop even better and less expensive medical care than what we already have. We have discussed this issue previously on a thread titled “Pay for Performance: Doctors, Hospitals and Pills” . I wrote “Would you like to see all doctors and hospitals required to follow protocols and achieve benchmarks for the results of treatments based on evidence based medicine studies or statistically achievable norms? Should their report cards be made public regarding how well they are following the rules and how well they are doing?

Would you like to select from a list of doctors and hospitals who are better than others and know which doctors and hospitals one should avoid? Should doctors and hospitals be paid by patients, insurance companies and the government based on where on the list of acceptable performance they are located?”

Well, the State of New York has been preparing lists, available to the public, that deal with the results of the treatment by cardiologists and surgeons for heart attacks. But perhaps there is something about human nature that has to do with discomfort with lists and so some doctors will attempt to see to it that they do not end up near the bottom of the list by manipulating selection of their patients, such as not taking on high risk patients, rather than taking on all patients who need treatment and simply try their best to do a good job.

Here are the results of a study regarding the New York state listing which was published in the February 2008 issue of the American Heart Journal by A.P. Apolito and others titled “Impact of the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System on the management of patients with acute myocardial infarction complicated by cardiogenic shock.” Patients who have heart attacks and whose blood pressure has fallen due to the heart attack are at greatest risk of dying irrespective of the treatment. The conclusion: “New York patients with acute myocardial infarction and cardiogenic shock were less likely to undergo coronary angiography [dye visualization of the arteries of the heart] and PCI [opening of the blocked coronary artery with a catheter] and waited significantly longer to receive CABG [bypass graft heart surgery] than their non-New York counterparts. These findings suggest that state-required reporting to the New York State Cardiac Surgery and Percutaneous Coronary Intervention Reporting System may result in the reluctance to revascularize the highest-risk cardiac patients.”

After all, its human nature to try not to be a loser, perhaps even amongst doctors. Does this study, confirming previous studies and if further confirmed with other surveys, tell us something about the idea to make lists or also something about the medical profession?

Autonomy: But Whose Autonomy?

Autonomy is an ethical principle the definition of which includes the person’s ability to make personal and independent choices. In medical practice, it is the right of a patient to make their own medical decisions based, in part, on information provided by the patient’s physician. It is the responsibility of the physician to provide the patient with all the risks, benefits and alternatives regarding the medical issue. If at the time of a needed decision, the patient is unconscious or doesn’t demonstrate the capacity to make such decisions, then what they have expressed in the past by writing or communication with others or through the assignment of surrogates may be sufficient to establish a decision. Sometimes, in medicine, there is a question of whether the patient actually has the capacity to make a medical decision even when the patient is conscious. It is the responsibility of the attending physician to finally answer that question. If there are no prior writings, communications or surrogates available as there often may be with a patient brought into the emergency room of a hospital, it becomes the additional responsibility of the physician to not only decide on the patient’s mental capacity but if decided as incapacitated to make the medical decision for the patient. The physician’s decision must be made only in the patient’s best interest.

A case that is currently in the news and which will be going to trial shortly is that of a patient who while being attended in a hospital emergency room for an injury strongly refused a rectal exam but was evaluated by the doctor as not having the capacity to make his own decision and since there were no surrogates available to speak for the patient, the patient was allegedly then held down and later sedated despite the patient’s continued protestations. The story is documented in a New York Times Blog article along with a great number of readers’ commentaries. All the facts are not known to the public and hopefully will come out in the upcoming trial of a lawsuit by the patient.

Of interest to our blog is how patient autonomy, to make one’s own decision, is affected by the situation, an alleged emergency medical evaluation for a potential harmful injury in which a patient refuses what the physician believes is an essential examination. In this situation, does the physician’s autonomous professional decision (in the past called “paternalism”) regarding the patient’s mental capacity to make decisions trump the patient’s own right to autonomy? Or another way of putting it, should all patients who enter an emergency room know that it is possible that the doctor will decide that the patient is unable to make an informed consent decision for a procedure and that the doctor will perform the procedure even with the expressed refusal of the patient? ..Maurice.

Graphic: Painting "Judith Beheading Holofernes" by Artemisia Gentileschi ca 1620

Adolescent Sexual Activity as a Pervasive Culture: What View Should Doctors Hold and Advise the Teen?

One of the areas of medical practice which are introduced to first and second year medical students is how to behave and communicate if a patient is an adolescent. Providing medical care for an adolescent is in some ways more complex than caring for an adult. The doctor is dealing with a patient who is old enough to give assent and even in some jurisdictions able to give consent to various procedures and treatments but still is under the legal and ethical responsibilities of parents. The doctor, therefore, has to be involved not only with the adolescent but also the parents. Also the adolescent is in the dynamic process of maturing, emotionally, physically and intellectually with variations of the degree of maturation based on age, genetic factors and environment. There will be views of the adolescent which will be overturned by the individual when the person is no longer an adolescent.

One of the areas of medical interest regarding adolescents is their understanding of sexuality and their resultant sexual behavior. I received a communication from a medical school teacher who has been involved in teaching medical students about adolescents. She poses the issue as to whether, communicating to teen patients, there was a rationale for physicians to make a point opposing sexual activity by teens. The teacher wrote:

“A student approached me feeling strongly that her classmates and professors were all making comments/jokes about talking to teens about their sexuality and “everyone already has premarital sex anyway" and was there a place for a physician to express a different viewpoint in a society so pervasive with sexuality. How to make a stance for abstinence with a young teen? How should doctors reconcile their own religious and moral beliefs about sexuality if they are different from the pervasive culture?”

In the terms of sexual behavior, do you think it is right to teach medical students that physicians should go against the “pervasive culture” or go with the tide? How would you feel as a teenager if your doctor told you to avoid all sexual contact when you know all your fellow students are engaging in sex? ..Maurice.

A Disease Named After a Doctor: What’s in a Name?

Since the beginning of my medical career I have known about the rare blood vessel inflammatory disease called Wegener’s granulomatosis, named after Dr. Frederick Wegener, a German pathologist who first identified the disease. I also have long known about Reiter’s syndrome, a form of arthritis, named after Dr. Hans Conrad Reiter, who wrote about that disease. Years later, Dr. Reiter became a senior Nazi official with “a trail of war crimes”. Dr. Wegener had joined the Nazi party to become a high official and may have participated in experiments on concentration camp inmates.

In recent years, these doctors’ affiliation and participation in Nazi activities have become known as described in an article appearing today in the New York Times.

In view of what is now known about their participation in crimes during the Nazi era, there has been an attempt to remove their names from the diseases they described. Their names however have been solidly ingrained into the medical terminology and we use them regularly in medical student education and communication between physicians and also between doctors and patients. The ethical issue is whether it is ethically right to continue using their names applied to those diseases now that we suspect what crimes they committed. Or is it more useful to clarity in the practice of medicine to retain these classic names, representing simply the disease and not the person? ..Maurice.

Doctors' Bad Doctoring and the Their Penalty

Many visitors on my blog have been concerned that doctors' bad behavior or incompetency may be missed by state licensing boards or that doctors simply get a slap on the wrist by those boards as punishment. I can’t speak for medical boards outside of California. I thought it might be informative to present here some of the publicly published administrative actions by the Medical Board of California during the period of August 1, 2007 to October 21, 2007. To be fair and not appear selective, I decided to present every 5th case which had been documented in alphabetical order of the physician’s last name in the January 2008 quarterly Medical Board of California Newsletter. As you may note some of California’s actions are taken because of the actions taken by other states. For a pdf file of the entire Newsletter so that you can read all the administrative actions, just click on this link. Go to the link and read more cases and responses of the Board and let me know if you think that the bad doctors are getting, in a fair and proportionate manner, what they deserve. ..Maurice.



Explanation of Some of the Disciplinary Language:
Date at the bottom of summary means the date the disciplinary decision goes into action.
Gross Negligence-Extreme deviation from the standard of practice
Incompetence-Lack of knowledge or skills in discharging professional obligations.
Judicial Review Pending- Action is being challenged through the court system.
Public Letter of Reprimand- The licensee is discipline in the form of a public letter.
Revoked-The licence is canceled, voided, annulled, and rescinded. The right to practice is ended.
Stayed-the revocation of license is postponed. Professional practice may continue as long as licensee complies with specific probationary terms and conditions. Violation of probation may result in revocation.
Stipulated Decision- A form of plea bargaining. The case is formally negotiated and settled prior to trial.
Suspension from Practice-The licensee is prohibited from practicing for a specific length of time.



Example Cases:
5. Committed acts of repeated negligence in his case and treatment of a cosmetic surgery patient, and failed to maintain adequate and accurate medical records for 3 patients. Revoked, stayed placed on 3 years probation with terms and conditions including, but not limited to completing a clinical training program and a medical record keeping course. September 26, 2007. Judicial review pending.

10. Failed to maintain adequate and accurate medical records in the care and treatment of a patient. Physician completed a medical record keeping course and a physician-patient communication course. Reprimand. August 24 2007.

15. Stipulated Decision. Disciplined by Florida for practicing medicine while impaired or under influence of drugs or alcohol. Revoked, stayed, placed on 5 years probation with terms and conditions including, but not limited to, abstaining from the personal use or possession of controlled substances and alcohol, and submitting to biological fluid testing.

20. Stipulated Decision. Physician has a condition affecting his ability to practice medicine safely; and, misdemeanor conviction for battery related to domestic abuse. Surrender of license. October 26, 2007.

25. Criminal conviction for having sexual relations with a patient. Revoked, stayed, placed on 7 years probation with terms and conditions including, but not limited to, completing an ethics course, an educational course in addition to required CME and must have a third party chaperone present while consulting, examining or treating female patients. October 10, 2007.

30. Stipulated Decision. Convicted of driving under the influence of alcohol on 4 different occasions between September 2005 and November 2006. Revoked, stayed and placed on 7 years probation with terms and conditions including, but not limited to, 1 year of actual suspension, abstain from the use of controlled substances and alcohol, submit to biologic fluid testing, successful participation in ethics course, and complete the Board’s Diversion Program on her license will be automatically revoked effective October 12, 2007. License was automatically revoked effective October 17, 2007 when she was terminated from the Board’s Diversion Program for non-compliance.

35. Stipulated Decision. Disciplined by Florida for failure to practice within the standard of care and failure to maintain adequate medical records related to her care of a patient. Disciplined by New York for failure to evaluate and document her evaluation of 5 patients during their colonoscopies. Physician must complete a medical record keeping course. Public Reprimand. September 12,2007.

40. Violated the terms and conditions of his board-ordered probation by being convicted of a felony for knowingly, intentionally and unlawfully distributing and dispensing controlled substances. Revoked August 1, 2007.

45. Stipulated Decision. Disciplined by Washington related to the performance of spinal surgery on 3 patients. The physician, a board-certified anesthesiologist, failed to disclose that he was not qualified professionally to perform these procedures, and failed to inform the patients of the potential risks involved with each procedure. Revoked, stayed, placed on 3 years probation with terms and conditions including, but not limited to, must complete a clinical training program, obtain a practice monitor, and complete an ethics course and an educational course in addition to required CME. September 26, 2007.

50. Stipulated Decision. Committed an act of dishonesty by signing a certification under penalty of perjury that he had attended 65 hours of lectures at a conference where in fact he had only attended 1 day of the 5 day seminar and had returned to California to treat patients. Physician must complete an ethics course. Public Reprimand. September 26, 2007.

55. Stipulated Decision. No admission but charged with gross negligence and failing to maintain adequate and accurate medical records in his care and treatment of a patient. Physician must complete a medical record keeping course. Public Reprimand. October 25, 2007.

60. Engaged in unprofessional conduct by failing to timely comply with the board’s request for a patient’s medical records and failing to comply with an administrative citation and fine related to the failure to produce the requested medical records. Revoked, stayed, placed on 3 years probation with terms and conditions including, but not limited to, paying a civil penalty of $ 244,000. September 28, 2007. Judicial review pending.

65. Stipulated Decision. Committed acts of repeated negligence, gross negligence, incompetence and aided and abetted the unlicensed practice of medicine by allowing medical assistants and physician assistants to engage in unlicensed practice beyond their scope. Revoked, stayed, place on 2 years probation with terms and conditions including, but not limited to, completing an ethics course. September 4, 2007.

70. Disciplined by Florida for failure to practice medicine within minimal acceptable standards in the care and treatment of a patient. Public Letter of Reprimand. September 7,2007.

75. Committed acts of repeated negligence by continuing to prescribe controlled substances for 3 individuals after his employment with the county public health department was terminated and they were no longer his patients. Breached the terms of a prior Stipulated Decision by failing to complete a clinical training program. Revoked, stayed and placed on 3 years probation with terms and conditions including, but not limited to, completing a clinical training program, obtaining a practice monitor and maintaining a log of all controlled substances ordered, prescribed, dispensed or administered. October 18, 2007.

80. Stipulated Decision. Failed to maintain adequate and accurate medical records in the care and treatment of a patient. Physician completed a medical record keeping course. Public Reprimand. August 28, 2007.

85, Discipline by Florida for providing substandard care to a patient who presented with chest pain, shortness or breath and nausea. Public Letter of Reprimand. September 7, 2007.

90. Stipulated Decision. Aided and abetted the unlicensed practice of medicine by working for an unlicensed person at a weight control clinic, and dispensed prescription drugs in improperly labeled containers. Revoked, stayed, place on 4 years probation with terms and conditions, including but not limited to, completing a prescribing practices course and an ethics course and obtaining a practice monitor. October 4, 2007.

95. Committed acts of gross negligence in the care and treatment of a patient and failed to maintain adequate and accurate medical records in the care and treatment of 4 patients. Revoked, stayed, placed on 5 years probation with terms and conditions including, but not limited to, completing a medical record keeping course and obtaining a practice monitor. September 14, 2007.

100. Stipulated Decision. Discipline by Arizona for his care and treatment of a patient for failing to order further diagnostic studies and failure to diagnose a malignant breast mass. Physician completed a clinical training program. Public Reprimand. October 11, 2007.

105. Disciplined by Ohio for failing to disclose on his Ohio licensing application that the Florida Department of Health, Board of Medicine had issued a Uniform Non-Disciplinary Citation for failing to fulfill continuing education requirements. Public Letter of Reprimand. Oct 11, 2007

A Little Charity Volunteerism and a Little Malpractice Protection

In order to encourage volunteerism in the United States so that federal, state and community charity services can continue their important functions in our society, on June 18, 1997 President Clinton signed into law the “Volunteer Protection Act”. This Act is “to provide certain protections to volunteers, nonprofit organizations, and governmental entities in lawsuits based on the activities of volunteers.” The protection is described as

“no volunteer of a nonprofit organization or governmental entity shall be liable for harm caused by an act or omission of the volunteer on behalf of the organization or entity

if the volunteer was acting within the scope of the volunteer's responsibilities in the nonprofit organization or governmental entity at the time of the act or omission;

if appropriate or required, the volunteer was properly licensed, certified, or authorized by the appropriate authorities for the activities or practice in the State in which the harm occurred, where the activities were or practice was undertaken within the scope of the volunteer's responsibilities in the nonprofit organization or governmental entity;

the harm was not caused by willful or criminal misconduct, gross negligence, reckless misconduct, or a conscious, flagrant indifference to the rights or safety of the individual harmed by the volunteer.” Exceptions are detailed in the law.

In terms of protection of physicians who volunteer to work in charity, free medical clinics, 43 states and the District of Columbia have various charity immunity legislation and 12 of the states specifically refer to retired physicians in their law. 24 states have raised the negligence standard. Alaska, California, Massachusetts, Nebraska, New Mexico, New York and Vermont have no laws, hence only the federal law would apply.

What does this all mean? It means that malpractice suits against doctors who volunteer to care for patients who are cared for in charity clinics will be limited to apply in many states only to those physicians whose acts represent gross negligence or are criminal acts. It means it will be more difficult or impossible for patients to win lawsuits against charity clinics or their physician volunteers.

As a volunteer unpaid physician, myself. participating in a local free clinic whose patients have no insurance or money to pay for healthcare, I wonder if my professional standards, responsibilities and risks should be less than a doctor who gets paid outside of charity care? I see no ethical explanation of why it should be different but I would be interested in reading what my visitors think about this subject. Is the argument for state and federal government to support volunteerism to charity a good enough rationale for these laws? If malpractice law suits are currently excessive, frivolous and at times unfair shouldn’t the goal be to change the regulations in general regarding how tort claims are filed and ajudicated but not to simply excuse the doctors who volunteer. ..Maurice

"In Every New and Smart Disease, From Housemaid's Knee to Heart Disease, She Recognized the Symptoms as Her Own!"

One of the challenges facing a physician when first encountering a patient with multiple symptoms is to establish by history and later by physical examination whether a patient has one active disease which accounts for all the symptoms or whether the patient has two or more separate diseases. And finally there arises in the doctor’s mind the possibility of hypochondria, that the symptoms are derived not from a physical disease but from a fear disorder that some disease or diseases must be present and a later diagnosis of the disease by the doctor is anticipated. The patient has a symptom corresponding to that disease and will not accept the conclusion of the doctor that no disease actually can be found. The challenge with this diagnosis is how the doctor can maintain trust and confidence by the patient and how to provide support and initiate effective treatment. It is difficult to tell a patient and have a patient accept that it is an emotional illness that is present. Since physicians may not have full confidence in their assumption of hypochondria and in order to attempt to placate the patient and indeed the doctor’s own uncertainty, expensive and unnecessary tests may be ordered. Patients may argue that hypochondria is diagnosed in error too frequently and important diseases are missed or specific treatment for them is delayed.

Have any of my readers had a diagnosis of hypochondria made that turned out to be in error? If you have an interesting history, you might tell us here. No names please.

The first part of the poem “How Jack Found That Beans May Go Back on a Chap” by Guy Wetmore Carryl amusingly describes a lady that fits the topic of this thread. ..Maurice.

(ADDENDUM: Illustration by Honore Daumier for an edition of Moliere's "La Malade Imaginaire" ca 1850)

HOW JACK FOUND THAT BEANS MAY GO BACK ON A CHAP
by Guy Wetmore Carryl (1873-1904)

Without the slightest basis
For hypochondriasis
A widow had forebodings
which a cloud around her flung,
And with expression cynical
For half the day a clinical
Thermometer she held
beneath her tongue.

Whene’er she read the papers
She suffered from the vapors,
At every tale of malady
or accident she’d groan.
In every new and smart disease,
From housemaid’s knee to heart disease,
She recognized the symptoms
as her own!

She had a yearning chronic
To try each novel tonic,
Elixir, panacea, lotion,
opiate, and balm;
And from a homeopathist
Would change to an hydropathist,
And back again,
with stupefying calm!

The closets of her villa
Were full of sarsaparilla,
Ammonia, digitalis,
bronchial troches, soda mint,
Restoratives hirsutical,
And soaps to clean the cuticle,
And iodine, and
peptonoids, and lint.

She was nervous, cataleptic,
And anemic, and dispeptic:
Though not convinced of apoplexy,
yet she had her fears.
She dwelt with force fanatical
Upon a twinge rheumatical,
And said she had a
buzzing in her ears!...

Is It OK for Doctors to Lie?

If, after reading the title of this thread by those visitors to my blog who are NOT doctors, may well respond with "that is the dumbest question I ever heard! Of course, it's NOT OK for doctors to lie!". Well, perhaps it would be educational for that visitor to take a little quiz and see the issue of lying with the eyes of a doctor who has a trusting and therapeutic relationship with a patient.

This quiz (which was modified slightly by myself) was written by Martin Donohoe, MD, FACP who is adjunct lecturer in the Department of Community Health at Portland State University and a hospitalist at Kaiser Permanente Sunnyside Hospital. He serves on the Board of Advisors of Oregon Physicians for Social Responsibility (PSR) and is Chief Scientific Advisor to Oregon PSR’s Campaign for Safe Foods. His website is "Public Health and Social Justice" bears the text of the original quiz and many more tools for public and professional education about the medical issues covered by the website title. Please go there by clicking on the link. You will find the site expansive in terms of issues covered (from food and safety to women's health and women's rights). It is a valuable resource.

BUT FIRST, before you go. TAKE THIS QUIZ. But pretend you are a DOCTOR. Consider the nuances regarding lying which a doctor might have to face. And then write your answers as comments to this thread. This quiz is not as simple as it might at first appear. ..Maurice.


THE ART OF MEDICINE:

TRUTH-TELLING IN MEDICINE
============

AS A PHYSICIAN:

I. Would you “lie” in the following situations?:

1. A 26 year old male presents to the ER after suffering a radial fracture in an auto accident in which he was driving. He appears intoxicated, and a blood alcohol level is 0.17. When he sobers up, he asks you not to report him to the DMV, as he is afraid of losing his license. Do you report him?

- yes?

- no?

- only if he hit another vehicle, rather than, say a lightpost?

- only if someone else was injured in the accident?

- if he’s a bus driver, would that influence your decision?

- if he’s a pizza delivery guy, and needs the job to support his sick infant?

2. A 33 year old female is admitted to the ICU with severe pneumonia. Evaluation is consistent with PCP pneumonia, and an HIV test is positive. She dies after 3 days. Her parents request that you leave the diagnoses of AIDS and PCP off of the death certificate. Do you accede to their request?

- yes?

- no?

- if she is a celebrity or public figure, and the media may find out and inform the public?

- if the parents are fundamentalist Christians, and were the obituary to read AIDS, they tell you that they might be ostracized from their church?

3. A 45 year old licensed Nurse Practitioner at University Hospital comes to your office with symptoms of major depression. She requests that you do not include any information on her mental illness on the chart. She is afraid that one of her colleagues may access the computerized medical record and discover she is taking antidepressants, and that this could lead to her being ostracized or even losing her job. How would you handle this situation?



II. Would you lie in any of the following situations?

- diagnosis of cancer (at patient’s family’s request)

- STD (sexually transmitted disease) (at patient’s request)?

-“fudging” date of disease onset to avoid patient’s being classified as having a pre-existing condition?

- assuring an anxious patient that the surgeon he’s chosen is well-qualified, if you know her to be shaky? unsafe? alcoholic?

-Record the degree service provided as less than what occurred for the visits for self-pay patients?

- Record the degree service provided as greater than what occurred for the visits for well-insured patients?

III.. Finally, Is it OK for doctors to lie?

- always?

- never?

- sometimes? (If so, when? who decides?)

Should Physicians Provide Information so Patients can Hasten Dying?

"Should Physicians Provide Information so Patients can Hasten Dying?" That is the question posed to me by Dr. Stanley Terman as a suggested title for a new blog thread. I thought it was an appropriate subject and invited him to write up the topic for posting. Stanley A. Terman, PhD, M.D . is a psychiatrist and Medical Director of Caring Advocates, an organization whose staff provides advice on creating and implementing Living Wills and Proxy Directives, advocating voluntary refusal of food and fluid, also providing advice on how to treat symptoms of dry mouth. His discussion of the issue follows, including an excerpt from his book entitled "The Best Way to Say Goodbye, A Legal and Peaceful Choice at the End of Life" written with Ronald B. Miller, MD, and Attorney Michael S. Evans.

I encourage my visitors to think about and perhaps write about the title's general question in terms of professional medical ethics but also consider the other more specific questions that Dr. Terman asks. ..Maurice.

Dr. Terman's Post to this Thread:


Physician Assisted Suicide (PAS) is illegal in the United States except in the state of Oregon. There, under strict guidelines, at the request of the terminally ill patient, the doctor can write a prescription for a lethal dose of a drug. Then, if the patient's suffering becomes unbearable, s/he can decide to ingest the medication (without help from others) to cause a peaceful dying. The physician would then have performed the act of writing a prescription, but would not be involved in administering the drug. Since writing the prescription is the legal proximate act that made hastening dying possible, people argue whether this act is ethical.

Since it is legally possible to hasten dying by Voluntary Refusal of Food & Fluid, this question arises: is it ethical for a physician to "inform" patients who would otherwise not be aware that it can be peaceful, especially if the physician provides Comfort Care to reduce the symptoms of dry mouth? The method suggested in the book is one of voluntary refusal of food and fluid, which mainly through dehydration will cause a peaceful death in a couple of weeks.

Suppose a patient is terminally ill, has no hope of recovery, and wants relief from prolonged pain and suffering.Suppose further the physician informs the patient that it will not be uncomfortable to refuse food and fluid since A) hunger is generally not a problem, and B) thirst is a symptom that can be treated. Suppose finally that divulging this knowledge tips the patient's decision who otherwise would NOT have done anything active to hasten the process of dying, but now will passively voluntarily refuse food and fluid.

Questions: Does the physician's act of informing the patient have the same moral effect as prescribing a lethal dose of pills, so this is really morally the same as physician-assisted suicide?Would withholding of this information be an example of "moral paternalism," and make the physician culpable for lack of informed consent and cruel for not giving the patient the choice to relieve his/her suffering when it was possible to do so?

Excerpt from pages 61-63 of The BEST WAY to Say Goodbye: A Legal Peaceful Choice at the End of Life:

Why might physicians be reluctant to educate and inform the public? In part,because of the controversy stirred by a few vocal doctors over whether or not it is morally right to inform patients of this option. Jansen and Sulmasy argued [2002] that if the patient or the physician believes that physician-assisted suicide is morally wrong, then it is also morally wrong for anyone to collaborate on any action that has an equivalent result. These authors also wrote it was morally wrong for doctors to inform patients about Voluntary Refusal of Food &Fluid (if the doctor thought it was morally wrong). Their article stimulated vehement disagreement in several letters subsequently published in the same journal.

Dr. Erich Loewy went one step further in 2001. He wrote that he could accept the practice of physicians who agreed to continue to care for patients who decided on their own to ask for Voluntary Refusal of Food & Fluid. But he used the word, "macabre," to describe informing patients about Voluntary Refusal of Food & Fluid when they "ask for help in ending their lives." His reason: that would be tantamount to "advising them to starve themselves," which he termed "physician-stimulated self-starvation." He argued that its real purpose was solely to "let health care professionals off the legal hook." To support his opinion, Loewy briefly reviewed the cultural benefits of food by noting it "symbolically representsour social acceptance and is an integral part of marriage, burial, and other social practices." He concluded that informing patients about Voluntary Refusal of Food & Fluid is "encouraging them to commit social suicide." Even worse: "To encourage them to stop eating and drinking before they truly wish to do so seems a cruel act of rejection." {Emphasis added.}

Certainly, Loewy is correct about the issue of timing: some patients do ask about Refusing Food & Fluid "before they truly wish to do so." Yet once informed, patients may feel reassurance in knowing they have the option to end their suffering at any future point in time. Obviously, they do NOT need to stop eating and drinking immediately after their doctors provide this information. In fact, one advantage of this method of dying is that patients can even decide to change their mind even after they stop eating and drinking by resuming intake.On the other hand, patients may feel abandoned by their physicians if their doctors refuse to offer information they are desperate to learn. This is especially true when patients ask about help in ending their lives.

Dr. Ira Byock [1995] wrote, "In my own practice, while I steadfastly refuse to write a prescription with lethal intent or otherwise help the patient commit suicide, I can share with the patient information that he or she already has the ability to exert control over the timing of death. Virtually any patient with far advanced illness can be assured of dying—comfortably, without any additional physical distress—within one or two weeks simply by refusing to eat or drink.This is less time than would be legally imposed by waiting periods of assisted suicide initiatives. The discussion and subsequent decision are wholly ethical and legal, requiring no mandated psychiatric evaluations,attorneys, court decisions, or legislation." {Emphasis added.}

A key question: How can people make prudent choices if they are not informed about the available options? Physicians who oppose disclosure may be worried about overly influencing their patient to choose Voluntary Refusal of Food &Fluid, which in their personal opinion, would be the "wrong" choice. But, we should ask, is not the withholding of relevant information from patients who directly request it, just one way for physicians to impose their personal values ontheir patients?

END OF EXCERPT © Stanley A. Terman, Ph.D., M.D.
The BEST WAY to Say Goodbye: A Legal Peaceful Choice at the End of Life

Graphic: Painting "The Death of Socrates" by Jacques-Louis David (1787) from the Metropolitan Museum of Art, New York, USA. (Socrates about to drink hemlock poison to carry out his suicide punishment.)

"How come this doc barges in right when I'm still changing my clothes?": Challenging the Physician

If you read so many of the treads on this blog, you will find visitors expressing to us readers all their various trials and tribulations, concerns and upsets with their doctors and the doctor’s behaviors. But unfortunately, in many cases, the visitors admit they did not communicate their concerns to the doctor about whom they are complaining. I feel it is generally unfortunate that these patients did not take that action.

I presented this issue to a bioethics listserv and a lady ethicist wrote back two examples of the basis for challenging one’s physician: “This dang doc is always an hour late, and I'm tired of having to pay the baby sitter extra just because of this guy” and “"How come this doc barges in right when I'm still changing my clothes?"

I would like to have discussed on this thread my visitor’s views of whether or not doctors should be personally and directly challenged regarding what they say or their behavior. What are the pros and cons of such a challenge of one’s own physician?
What are the benefits and what are the risks to speaking up to the doctor? Simply ventilating to a discussion blog is one thing but wouldn’t it be more constructive toward mitigation of the concern to speak up to the very person who is creating that concern? Any suggestions about how a patient should communicate their dissatisfaction to their doctor? And perhaps, one of the reasons patients don't "speak up" is the "up" part.. an inequality in power. Lets hear about that too.

Relative to this discussion would be the opposite issue: Should physicians feel free to challenge their patients to explain and perhaps modify the patient’s behavior which the physician finds unwelcome or inappropriate?

If my visitors give examples, in either case, no names please. ..Maurice.

Use vs Abuse of Hysterectomy: Hysteria vs Realism

There are a number of topics on my blog (male infant circumcision, patient modesty as two examples), in which my visitor’s views and by implication that of others are expressed regarding patient autonomy, patient rights and what seems apparent to them the lack of interest by medical practitioners to answer all their concerns and attempt to try and meet the requests. In addition, the doctors, they feel, are attending to them with a different agenda than their own.

For this thread, I have selected another topic which is high on the concern of many patients: hysterectomy, the surgical removal of a woman’s uterus. There is an activist group which is attempting to educate women about hysterectomy. The group is called the HERS Foundation and described on their website as ”... an independent non-profit international women's health education organization. It provides full, accurate information about hysterectomy, its adverse effects and alternative treatments. “

A blog which supports the goals of HERS is hysterectomyinformation.blogspot.com and the January 1 2008 posting which critically analyzed the information provided about hysterectomy by the University of Pittsburgh Medical Center was particularly interesting.

I would encourage my visitors to go to the above links and read the views and information. The question is whether in surgical practice, there is generally insufficient information given to women regarding the need and outcomes or consequences of hysterectomies and whether too many unnecessary hysterectomies are performed suggesting actual abuse of this operation and perhaps suggesting that surgeons have a different agenda than that of the patient. What do you think? ..Maurice.

ADDENDUM 9-21-2008: GRAPHIC- Photograph taken by me today of a statue titled "Will Never Forget" located at the Los Angeles County Arboretum, Arcadia, California.
When I saw the statue, it appeared to me to represent much of what is written in the Comment section of this thread, the need for a woman to hold onto her womb and her sexuality and never forgetting what a loss of this may mean to her. If you read something different into the photograph, please write to us about it. ..Maurice.

AS OF JANUARY 27 2009 THIS THREAD WILL BE CLOSED FOR ALL COMMENTS. DO NOT ATTEMPT TO WRITE ANY FURTHER COMMENTS HERE. PLEASE GO TO "USE VS ABUSE OF HYSTERECTOMY: SECTION 2" TO CONTINUE COMMENTS. ..Maurice.

A New Year's Resolution as a Patient

Today is the day to start the New Year’s resolutions. Back on December 31, 2004 I posted here a thread titled “A Few Physician’s New Year’s Resolutions” which suggested three ways physicians might change and hopefully improve their practice and their impression on their patients.

For this year Resolution thread, how about considering what would be their own personal resolutions which my visitors might select as being important as they relate to their life experience as a patient in a doctor’s office and which they think might be reasonable to follow. Or maybe I am making an impossible request. It is hard enough to follow a resolution just dealing with yourself (like lose weight, stop smoking, keep your desk clean and orderly and so on) but maybe it is almost impossible to follow a resolution when dealing with another party, particularly a physician who has another agenda.

Anyway, let’s give it a try. As a doctor,myself, who has been and surely will be a patient again, let me resolve to talk to my doctor as a patient and not as another doctor. Do you really think I can do that? ..Maurice.