Thinking and Writing About the Disabled: Courageous or Burdened?

Mary Johnson’s article in the Indiana University School of Journalism website titled “The ‘Super-Crip’ Stereotype—Press Victimization of Disabled People” raises an interesting ethical issue which may extend beyond the way the news media may describe the disabled but perhaps is only a reflection of the way the general public themselves may look at them. Do the reporters and the public think of the disabled more in terms of their wonderful and “courageous ” accomplishments rather than what burdens every disabled person, to one degree or another, is bearing every day? It did take a long, long while for for the burdens and prejudices suffered by the disabled to be recognized and finally signed into a law, the now almost 18 year old “Americans with Disability Act” in the United States, to attempt to help mitigate them.

The author concludes:

Disability rights is not a heartwarming feature story and disabled individuals should not be used for inspirational sagas. If they’re newsmakers, they should be covered like anyone else - the disability noted matter-of-factly only when its relevant to the story. If they’re not newsmakers, why are they being covered? Because their lives are unusual? If so, we should ask why, looking for the real story behind the "unusual." Typically, it’s lack of opportunity, barriers, or discrimination. Those are stories. And they should be investigated and reported as they are for any other minority.

In considering the significance of Mary Johnson’s view, one would wonder whether the disabled, themselves, want to be identified primarily by what they can do rather than what they can’t?

Read her article and then let’s hear from you what you think about the way the press and public may look at the disabled. ..Maurice.

Graphic: Photograph I took 5-29-2008 of Edouard Manet's painting "The Rue Mosnier with Flags" (1878) at the Getty Museum, Los Angeles, California.

ADDENDUM 6-1-2008: To read from a blog written by a disabled person go to "Bad Cripple"

For Children: A Kiss on the Forehead vs A Placebo Pill

The New York Times article yesterday (one time registration required)
tells the story of a newly developed product, a candy flavored sugar "placebo pill" (called "Obecalp"-placebo spelled backwards) for distressed mothers to give to their distressed children instead of the child being given a pharmaceutical product over the counter or by prescription for only the drug's placebo effect. As you will see from the article, the ethicists including Howard Brody have entered the discussion about it's ethics of use.

Now that a pill that looks, to a child, like medicine but is only sugar is going to be available to all mothers and fathers who are responsible for the care of their child but also the need to maintain some peaceful environment in the home, should parents offer the pill to their child? Is it ethical and honest to give the child a pill, a placebo, knowing it contains no active ingredient in hopes of "doing something" to settle the child? What are the implications regarding conditioning the child into thinking that a "pill" will solve all problems? Should children be given placebo pills if a kiss on the forehead just doesn't do the job? ..Maurice.

GRAPHIC: Photograph courtesy of Arrow Photography.co.uk

Are Insurance Companies the Dodder of the United States Medical Care System?

Dodder is a plant parasite (See the Addendum below for details.)


The suggested analogy to Dodder is mine, but according to Jonathan Kellerman's Opinion piece in the Wall Street Journal April 14, 2008; Page A15

The health insurance model is closest to the parasitic relationship imposed by the Mafia and the like. Insurance companies provide nothing other than an ambiguous, shifty notion of “protection.” But even the Mafia doesn’t stick its nose into the process; once the monthly skim is set, Don Whoever stays out of the picture, but for occasional “cost of doing business” increases. When insurance companies insinuate themselves into the system, their first step is figuring out how to increase the skim by harming the people they are allegedly protecting through reduced service. …

Once they affix themselves to the host – in this case dual hosts, both doctor and patient – they systematically suck the lifeblood out of the supply chain with obstructive strategies. For that reason, the consequences of any insurance-based health-care model, be it privately run, or a government entitlement, are painfully easy to predict. There will be progressively draconian rationing using denial of authorization and steadily rising co-payments on the patient end; massive paperwork and other bureaucratic hurdles, and steadily diminishing fee-recovery on the doctor end.

Go to the Wall Street Journal Health Blog April 14, 2008 to read from the visitors there a most interesting and educational discussion of the Kellerman opinion. Then come back and express your own opinions here. ..Maurice.

Photograph taken by me 5-26-2008 Omelveny Park, San Fernando Valley, California.

ADDENDUM: From Colorado State University Extension Website:

Dodder (Cuscuta and Grammica), is a twining yellow or orange plant sometimes tinged with purple or red. Occasionally it is almost white. The stems can be very thin and thread-like or relatively stout (a species characteristic). …Dodder is classified as a member of the Morning-Glory Family (Convolvulaceae) in older references, and as a member of the Dodder Family (Cuscutaceae) in the more recent publications. …Dodder produces seed that drops to the ground and germinate the next growing season if a suitable host is present. If no suitable host is present, the seed may remain dormant for five years.
Dodder seedlings must attach to a suitable host within a few days of germinating or they die. The young seedling is sensitive to touch and yellowish stem gropes in the air until it makes contact with a plant. The contact is made firm by one or more coils about the stem. If this plant happens to contain foods suitable to the dodder then a secondary stimulus is aroused which causes root-like branches (haustoria) to form and penetrate the stem. The basal part of the parasite soon shrivels away so that no soil connection exists.

Patient Modesty: Volume 3

SINCE MAY 14 2008, NONE OF THE COMMENTS SUBMITTED AND APPROVED BY ME FOR POSTING HAVE ACTUALLY BEEN POSTED ON THE COMMENT PAGE OF "PATIENT MODESTY VOLUME 2". AGAIN, THIS APPEARS TO BE A QUIRK OF THE BLOGGER.COM SYSTEM. ALL THE POSTINGS CAN BE VIEWED THERE BY CLICKING ON "NEWEST" ON THE POSTING PAGE BUT NONE ARE PUBLISHED ON THE COMMENT PAGE.

I WILL CONTINUE THE DISCUSSION BY POSTING BELOW ALL THE COMMENTS THAT WERE NOT PUBLISHED IN "VOLUME 2". AS OF JUNE 26 2008 THIS THREAD WILL BE CLOSED FOR ALL COMMENTS. PLEASE GO TO "PATIENT MODESTY: VOLUME 4" TO CONTINUE COMMENTS.

gve said..

JD, the porblem with your "Pyramid selling" tactic is that men are embarrassed about discussing this issue at all, whether it be with friends, family or the "so called" medical "professionals".

The deliberate conspiracy of silence which men face is not accidental. Female staff will simply ignore your request and certainly will not raise it "up the food chain" because all they care about is protecting their jobs. The comfort of male patients is NOT an issue, we are compliant and quiet, what more could they want?
They rely on the embarrassment factor to stop men "going public" with the issue, have you EVER seen this as an issue in a large circulation newspaper or news channel?
The ONLY answer is individual refusal to go along with what i feel constitutes "abuse".
Men need to start saying no and keep on saying no.
WHY is it even remotely deemed appropriate to have cystoscopy performed by females on men, let alone the issue of female "spectators".
The person who said that doctors are choosing to employ females so as to negate the need for a chaperone was absolutely right, until we men complain, it will not only stay this way, it will get worse!
Why not email your friends the URL of this site and let them see for themselves how others feel, it has certainly empowered me!

Wednesday, May 14, 2008 1:52:00 PM

Anonymous said...
Men's Restroom- Women's Restroom
Men's Lockeroom-Women's Lockeroom
Healthcare-?
Just really makes you wonder?
Justin.

Wednesday, May 14, 2008 2:08:00 PM

Anonymous said...
chuck mcp you made good points but where are you deriving your figures from? 1/3, 1/3, 1/3?

I wonder if 1/3 of men care about this? I also wonder if ANY males ever apply to work in a doctors' office? Most of these positions are very low paying, so most men would probably want more compensation than what is offered as an office assistant. There is a good deal of turn-over as well.

It is odd that some "men" feel a male nurse must be gay, when most are not. I wonder if women should assume that the female nurse working on them is a lesbian? Then, following suit, women patients should request and prefer male nurses.

It is also being stated here on this site that women in general have no understanding of how men feel to have opposite gender care. Maybe many nurses don't have any compassion for this issue but I do think many wives would MUCH prefer their husbands be cared for by males when it comes to genital & personal care and they certainly do understand this issue.

Wednesday, May 14, 2008 5:27:00 PM


Anonymous said...
I don't like to see that word modesty. It's not an issue of
modesty. It's an issue of double
standard. Somehow that men are
less of a human being than women,
therefore we don't count!


pt

Wednesday, May 14, 2008 10:22:00 PM

Elaine said...
I am a 49-year-old woman who has a fresh (albeit apparently unpopular) view on the issue of gender and medical care. I cringe at the thought of another woman performing any form of exam on me. Three years back we moved to a small town in another state, and I chose a male gyne whom I had been told by many women was very reputable. It was true-- the man was purely professional during every part of the visit. However, when it came time for the pelvic exam, in came miss bouncy-happy-nurse to stand between my legs and "chaperone." When I said that I didn't want her there, the doctor explained that it was required to have a chaperone present. So I said no problem, my husband can come in and chaperone. I was then told that wasn't good enough, it had to be a female. This made NO sense to me. Who is more likely to protect a woman's best interests? The man she's been married to for 30 years? Or some stranger who works for the doctor? They suggested that could have my husband come in along with the nurse, but that would have been worse for me-- the more people in the room, the more embarrassing. In the end, I refused the exam, put on my clothes and left. I have since called every doctor within a reasonable radius of our town, and they all require that their own chaperones be present. As a result, I have not had medical care of a female nature in 3 years, nor do I intend to. I have since met a few other women in town who have the same view as mine-- one hasn't been to a gyne in 8 years!

I have heard several doctors complain about how many women they see with advanced cancer who would have been fine if they'd "just come for their yearlys." I say that those doctors can shoulder some of the blame themselves. If more doctors gave the women a choice as to EXACTLY who they were willing to have present during intimate exams, a lot fewer women would skip them.

And here is a very interesting thing. Most of the offices I called suggested that I go to a female gynecologist because they don't require chaperones at all. WHY the double standard? Have they ever heard of homosexuality? My very reason for not liking female medical staff is, when I was quite a bit younger, I overheard 2 female nurses discussing in great detail what "beautiful boobs" the woman in the room next to mine had. It made me sick. People have to wake up and realize that this is a new day and age, and just having people have same-sex medical staff isn't going to fix everything, and may even make things worse (think about it-- if a doctor *did* do something untoward to you, would it be easier to live with if they were the same sex as you?) For me, the answer is no, and this is why I prefer male doctors.
But I know many people feel differently. I have 3 daughters, and from the time they were old enough to understand the question, I always asked if they wanted to go to a girl doctor or a boy. Two of them now go to females, one goes to a male. It's a very personal choice, and one that should be given to every patient of any age-- by the parents, and by the medical staff.
The ultimate answer is in giving the patient the right to choose who they want present at all times in all situations, be it during tests, exams or surgeries.
As for the modesty issue, why can't the doctor simply inform the patient exactly what needs to be done and let them (the patient) set the standards regarding their own modesty? Some people are more embarrassed wearing flimsy gowns than being nude. Others need to be as clothed as possible at all times. We're all wired differently, so the medical profession needs to stop trying to find a golden "standard" to treat everyone by.

Thursday, May 22, 2008 11:19:00 PM

AS OF JUNE 26 2008 THIS THREAD WILL BE CLOSED FOR ALL COMMENTS. PLEASE GO TO "PATIENT MODESTY: VOLUME 4" TO CONTINUE COMMENTS.

AMA Report (5) Sedation to Unconsciousness in End-of-Life Care

I have recently already covered this topic in a March 2008 posting. This type of sedation, particularly its use in terminally ill patients, has been open to criticism as either a form of physician-assisted suicide or euthanasia. However, as with much of the rationalizations in medicine (and I guess politics), the results of an act are defined more by intent than by outcome. To get a fuller understanding of the arguments please read the full report which can be accessed through the link below.


The subject Report 5 Sedation to Unconsciousness in End-of-Life Care, is one of a series of 8 Reports of the Council of Ethical and Judicial Affairs (CEJA) of the American Medical Association and is the last of the series to be posted here. The previous seven have now all been posted. These reports have not yet been adopted as AMA policy; they will be discussed and debated in June 2008. If they receive the support of the majority of the delegates from the state and specialty societies, they will become policy. Anyone, including the general public, can provide testimony on CEJA reports either in person at the meeting or by writing to ceja@ama-assn.org.

I have presented each Report as a separate thread on this blog. By clicking on the link above, you can gain access to the specific wording of this particular Report. 1 through 6 are to be Amendments to the Constitution and Bylaws of the American Medical Association. Reports 7 and 8 are for Informational purposes . Why should the public be interested in these reports? They are part of the ethics of the system of medicine in the United States and may be reflected elsewhere in the world. Through the practice of medicine by all physicians, the rules presented in these reports can be applied to and may affect all patients. You may write directly your comments to CEJA at the e-mail address above and, of course, you are certainly welcome to post your comments on this particular Report here.

Here is the Conclusion and Recommendations of the Report:

CONCLUSION

Palliative sedation to unconsciousness is an important tool in the armamentarium of palliative medicine. For patients whose illnesses are terminal and end stage, palliative sedation to unconsciousness can ameliorate such intractable symptoms as delirium, pain, dyspnea, nausea, and vomiting. It is medically and ethically acceptable under specific, relatively rare circumstances. Because palliative sedation to unconsciousness is intended to be maintained until the patient’s death, it should be used only as a therapy of last resort for relief of severe, unrelenting clinical symptoms after the failure of other aggressive interventions, including psycho-social support.7 It is important to ensure that patients are indeed at the end stage of a terminal illness and that other forms of symptom-specific treatment are not effective. It is most appropriate as part of a multi-disciplinary mode of palliative care that addresses the whole patient in the context of that patient’s family system, spiritual beliefs and values. It is not appropriate for suffering that is mainly existential.

RECOMMENDATION

The Council on Ethical and Judicial Affairs recommends that the following be adopted and that the remainder of this report be filed.

The duty to relieve pain and suffering is central to the physician’s role as healer and is an obligation physicians have to their patients. Palliative sedation to unconsciousness is the administration of sedative medication to the point of unconsciousness in a terminally ill patient. It is an intervention of last resort to reduce severe, refractory pain or other distressing clinical symptoms that do not respond to aggressive symptom-specific palliation. It is an accepted and appropriate component of end-of-life care under specific, relatively rare circumstances. When symptoms cannot be diminished through all other means of palliation, including symptom-specific treatments, it is the ethical obligation of a physician to offer palliative sedation to unconsciousness as an option for the relief of intractable symptoms. When considering the use of palliative sedation, the following ethical guidelines are recommended:

(1) Patients may be offered palliative sedation when they are in the final stages of terminal illness. The rationale for all palliative care measures should be documented in the medical record.

(2) Palliative sedation to unconsciousness may be considered for those terminally ill patients whose clinical symptoms have been unresponsive to aggressive, symptom-specific treatments.

(3) Physicians should ensure that the patient and/or the patient’s surrogate have given informed consent for palliative sedation to unconsciousness.

(4) Physicians should consult with a multidisciplinary team, including an expert in the field of palliative care, to ensure that symptom-specific treatments have been sufficiently employed and that palliative sedation to unconsciousness is now the most appropriate course of treatment.

(5) Physicians should discuss with their patients considering palliative sedation the care plan relative to degree and length (intermittent or constant) of sedation, and the specific expectations for continuing, withdrawing or withholding future life-sustaining treatments.

(6) Once palliative sedation is begun, a process must be implemented to monitor for appropriate care.

(7) Palliative sedation is not an appropriate response to suffering that is primarily existential, defined as the experience of agony and distress that may arise from such issues as death anxiety, isolation and loss of control. Existential suffering is better addressed by other interventions. For example, palliative sedation is not the way to address suffering created by social isolation and loneliness; such suffering should be addressed by providing the patient with needed social support.

(8) Palliative sedation must never be used to intentionally cause a patient’s death.

Recommendation 5 states “Physicians should discuss with their patients considering palliative sedation the care plan relative to degree and length (intermittent or constant) of sedation, and the specific expectations for continuing, withdrawing or withholding future life-sustaining treatments.”
I think, what is missing from the Recommendations but should be emphasized is that the withholding or withdrawal of life-supporting treatments, including hydration and nutrition is not and should not be considered part of the act of palliative or terminal sedation itself. ..Maurice.

AMA Report (6) Expedited Partner Therapy

What the heck is “expedited partner therapy”?

Do you have any idea what “expedited partner therapy” is all about? It sounds like a kind of cut and dried, straightforward administrative action. But it isn’t!! It is all about the treatment and prevention of sexually transmitted diseases through the use of identified patients with the disease to personally go to their single or various partners and presumably inform them about the patient’s diagnosed condition, to educate them about the necessity to be seen in a medical clinic for medical evaluation and treatment as necessary. However, if the partners are unwilling to go, the patient is to educate them about the nature of the disease, the treatment and the risks involved in taking the treatment. Then, the patient will have been provided with the medication to give to the partner to take. Under this “expedited” medical care, partners of the infected patient will be treated, completely without a professional medical diagnosis based on history, physical and laboratory tests, without direct education by the physician and provided with a medication, as either as prophylaxis or treatment, without a diagnosis and without any formal professional supervision. I have included the conclusion and recommendations of the report below but I would suggest that the visitor go to the link below and read the entire report including further description of the “expedited partner therapy”, the history and rationale and the ethical and legal issues involved.

The subject Report 6 Expedited Partner Therapy is one of a series of 8 Reports of the Council of Ethical and Judicial Affairs (CEJA) of the American Medical Association. These reports have not yet been adopted as AMA policy; they will be discussed and debated in June 2008. If they receive the support of the majority of the delegates from the state and specialty societies, they will become policy. Anyone, including the general public, can provide testimony on CEJA reports either in person at the meeting or by writing to ceja@ama-assn.org.

I am presenting each Report as a separate thread on this blog. By clicking on the link above, you can gain access to the specific wording of the Reports, 1 through 6 are to be Amendments to the Constitution and Bylaws of the American Medical Association. Reports 7 and 8 are for Informational purposes. Why should the public be interested in these reports? They are part of the ethics of the system of medicine in the United States and may be reflected elsewhere in the world. Through the practice of medicine by all physicians, the rules presented in these reports can be applied to and may affect all patients. You may write directly your comments to CEJA at the e-mail address above and, of course, you are certainly welcome to post your comments on this particular Report here.

CONCLUSION

Expedited partner therapy has been demonstrated to be a clinically effective strategy for the treatment and limitation of spread of a limited number of sexually transmitted infections. As such, physicians should recognize the practice as a valid tool for promoting public health when appropriately indicated. However, EPT in the absence of a traditional patient-physician relationship creates distinct ethical concerns pertaining to informed consent, confidentiality, and patient safety. Physicians should therefore emphasize to patients that medical care within a patient-physician relationship is preferred. Only in circumstances when this is impossible or unlikely should EPT be considered. While it may be ethical to use EPT to minimize the negative health consequences of sexually-transmitted diseases, physicians should make reasonable efforts to refer the partners of their patients to appropriate health care professionals.

RECOMMENDATION

The Council on Ethical and Judicial Affairs recommends that the following be adopted and the remainder of the report be filed:

Expedited Partner Therapy (EPT) is the practice of treating the sex partners of patients with sexually transmitted diseases via patient-delivered partner therapy without the partner receiving a medical evaluation or professional prevention counseling. While this practice is presently recommended by the Centers for Disease Control and Prevention for use in very limited circumstances (for gonorrhea or chlamydial infection in heterosexual men and women), EPT may be recommended for additional applications in the future.

Although EPT has been demonstrated to be effective at reducing the burden of certain diseases, it also has ethical implications. EPT potentially abrogates the standard informed consent process, compromises continuity of care for patients’ partners, encroaches upon the privacy of patients and their partners, increases the possibility of harm by a medical or allergic reaction, leaves other diseases or complications undiagnosed, and may violate state practice laws. The following guidelines are offered for use in establishing whether EPT is appropriate:

(1) Physicians should determine the need for EPT by engaging in open discussions with patients to ascertain their partners’ abilities to access medical services. Only if the physician reasonably believes that a patient’s partner(s) will be unwilling or unable to seek treatment within the context of a traditional patient-physician relationship should the use of EPT be considered.

(2) Prior to initiating EPT, physicians are advised to seek the guidance of public health officials, as well as determine the legal status of EPT in their state.

(3) If the physician chooses to initiate EPT, he or she must provide patients with appropriate instructions regarding EPT and its accompanying medications and answers to any questions that they may have.

(4) Physicians must provide patients with educational material to share with their partners that encourages the partners to consult a physician as a preferred alternative to EPT, and that discloses the risk of potential adverse drug reactions and the possibility of dangerous interactions between the patient-delivered therapy and other medications that the partner may be taking. The partner should also be informed that he or she may be affected by other STDs that may be left untreated by the delivered medicine.

(5) The treating physician should also make reasonable efforts to refer a patient’s partner(s) to appropriate health care professionals.

What do you think about expedited partner therapy and especially if it is approved for application beyond the current limited diagnoses of gonorrhea or chlamydial infection in heterosexual men and women? Write us about your opinion on this interesting twist of medical care and prevention. ..Maurice.

Should Physicians “Bear Their All”? (AMA Report #7)

Report #7 Protection of Medical Staff Members’ Personal Proprietary Financial Information is an informational document describing a resolution in which American Medical Association (AMA) delegates wanted their Council of Ethical and Judicial Affairs (CEJA) to add to the prior CEJA Opinion regarding medical records and computers which begins:"the utmost effort and care must be taken to protect the confidentiality of all medical records, including computerized medical records” to also include the confidentiality of medical staff members personal proprietary financial information.

The concern of the resolution was that of the possibility of inappropriate disclosure and use of physician financial information and the extent to which that information may be used to demonstrate a conflict of interest. The inappropriate use might include the granting, denying, or termination of hospital staff privileges. The CEJA concluded that such a change was inappropriate to include in the Opinion on all medical records but the resolution was already covered in an established Opinion regarding Staff Privileges:

Decisions regarding hospital privileges should be based upon the training, experience, and demonstrated competence of candidates, taking into consideration the availability of facilities and the overall medical needs of the community, the hospital, and especially patients. Privileges should not be based on numbers of patients admitted to the facility or the economic or insurance status of the patient. Personal friendships, antagonisms, jurisdictional disputes, or fear of competition should not play a role in making these decisions. Physicians who are involved in the granting, denying, or termination of hospital privileges have an ethical responsibility to be guided primarily by concern for the welfare and best interests of patients in discharging this responsibility.

Read the entire Report at the link above. However, this concern by AMA delegates raises more general issues of how much should anyone (including patients themselves or hospital staff) except, of course, the IRS and also,by current consensus, the journals to which the doctor writes, know the financial status and investments of the doctor? Would it make any difference to you, as a patient, to have available the personal financial information about your doctor? Would such knowledge make a difference in whether to select the doctor as one’s personal physician or the one to perform that surgical operation? What would the information mean to you?

Is this information more pertinent to your selection than, for example, the doctor’s marital status, sexual preferences, religion, political preferences? How much should doctors be expected to "bare their all" in the interest of the betterment of patient care? Any ideas? ..Maurice.

The Surgeon's Schedule: Cutting on More Than One Patient at the Same Time: It's Done but Is It Ethical? (AMA Report 8)

I thought I would move on to an informational report in this series of reports by the the Council on Ethical and Judicial Affairs (CEJA) of the American Medical Association.(See the last 4 threads.) It is Report #8-Surgeon’s Attendance During Surgery

It seems that it is common surgical practice for surgeons, especially in teaching institutions, to schedule more than one surgery under their name and all at the same time but to participate not fully in any of them. The Report states:

At its 2007 Annual Meeting, the American Medical Association (AMA) House of Delegates adopted Resolution 16, “Surgeons’ Attendance During Surgery.” This resolution asks that the AMA design policy that requires operating surgeons to “post their surgical cases so that they are actually physically present in the operating room performing or supervising their surgical cases during the majority of the case and during all crucial or essential phases of the surgical procedure.” After discussion with the sponsors of the resolution (the District of Columbia Delegation) and for reasons set forth below, the Council on Ethical and Judicial Affairs (CEJA) has decided that its current policy addresses the issues raised by the resolution.

The resolution is primarily concerned with the effect on the patient-physician relationship when a physician has 2 or more cases posted at the same time. Clearly, the physician cannot be present for the entirety of both cases. The absence of the surgeon from portions or all of a procedure without a patient’s knowledge and consent may have a negative impact on patient trust as well as safety.

However, current CEJA Opinion E-8.16, “Substitution of Surgeon without Patient’s Knowledge or Consent,” addresses these concerns. This policy states that “a surgeon who allows a substitute to operate on his or her patient without the patient’s knowledge and consent is deceitful.” In general, a physician should provide participatory supervision if aspects of the procedure are delegated to residents or other physicians. If a resident or other physician performs the procedure under non-participatory supervision, the patient should be fully informed of this fact.

It is unethical for physicians to post 2 or more cases (ie, not fully participate in any of the cases) without the informed consent of the patient. The Council believes that this Opinion fully answers the directive of the resolution and sees no need for additional ethics policy on this matter.

Well, are all my visitors, all being potential surgical patients, satisfied with the Council’s conclusion? ..Maurice.

AMA Report (4) Peers as Patients

The subject 4 Peers as Patients is one of a series of 8 Reports of the Council of Ethical and Judicial Affairs (CEJA) of the American Medical Association. These reports have not yet been adopted as AMA policy; they will be discussed and debated in June 2008. If they receive the support of the majority of the delegates from the state and specialty societies, they will become policy. Anyone, including the general public, can provide testimony on CEJA reports either in person at the meeting or by writing to ceja@ama-assn.org.

I am presenting each Report as a separate thread on this blog. By clicking on the link above, you can gain access to the specific wording of the Reports, 1 through 6 are to be Amendments to the Constitution and Bylaws of the American Medical Association. Reports 7 and 8 are for Informational purposes. Why should the public be interested in these reports? They are part of the ethics of the system of medicine in the United States and may be reflected elsewhere in the world. Through the practice of medicine by all physicians, the rules presented in these reports can be applied to and may affect all patients. You may write directly your comments to CEJA at the e-mail address above and, of course, you are certainly welcome to post your comments on this particular Report here.

The issue of peers as patients is one where a physician is responsible for the management and care of another physician who may be unknown to the treating doctor or who may be a colleague in the same office, same hospital or a known physician in the same or different specialty. It could also involve a resident in training being cared for by or actually treating the resident’s supervisory physician. In fact, it may be that a medical student might be involved in the team caring for another medical student or a resident. In virtually all of these relationships, there are factors both emotional and practical and professional which make the therapeutic relationship different than that related to the usual non-peer patient. (Similar factors are involved if a physician attempts to treat a close member of his or her own family.)

The Report notes 4 areas of ethical concern which are extracted here:

Clinical Objectivity. Treating a physician-patient who is a also a close personal friend raises concerns… notably the possibility that the treating physician’s professional objectivity and medical judgment may be affected by his or her emotional ties to the patient, thereby interfering with the care delivered. Moreover, as this Opinion also notes, when the patient is a colleague, physicians may fail to probe sensitive areas in taking the medical history or may fail to perform intimate parts of the physical examination. Fairness is also a consideration in making treatment recommendations or providing care to a professional peer. When preferential treatment that other patients do not standardly receive for the same clinical indications is given to—or expected by the physician-patient—it may result in an uncomfortable and confusing situation.4 Although it is human nature to treat differently someone you know personally or feel a professional kinship to, physician-patients should not receive disproportionate attention and resources beyond what is appropriate to meet their medical needs.

Informational and Physical Privacy.
Concerns about the privacy of their personal health information have been cited as a reason physicians delay seeking medical attention.4 Physician-patients may be uncomfortable disclosing sensitive information, much in the way friends or family members of the treating physician might react. …Respecting modesty and physical privacy is important for any patient. When the patient is a professional colleague, particularly one who works in the same health care setting, special attention may be required to ensure that his or her physical privacy is respected

Informed Decision Making.

When physicians undertake the care of a colleague they may assume that the physician-patient has a good medical knowledge base and that they need not fully explain the condition or plan of treatment.4 It is important that an open dialogue take place in which a physician-patient and the treating physician discuss the condition at hand. The treating physician should keep in mind the physician-patient’s general medical background but make no assumptions on the depth of his or her knowledge about a particular disease, especially one outside the physician-patient’s specialty area.

Effects on Professional Relationships

Providing medical care for a peer may also lead to tensions in a physician’s professional relationship with that individual. For example, a negative medical outcome or disagreement over best course of treatment may have disruptive effects on the parties’ working and personal relationships with one another.

The Report makes the following Recommendations:

(1) Physicians who provide care to a peer should be alerted to the possibility that their professional relationship with the patient may affect their ability to exercise objective professional judgment and make unbiased treatment recommendations. They must also recognize that the physician-patient may be reluctant to disclose sensitive information or permit an intimate examination.

(2) Physicians providing care to a professional colleague have an obligation to respect informational and physical privacy of physician-patients as they would for any patient. Treating physicians should consider, and possibly discuss with the physician-patient, how to respond appropriately to the inquiries about the physician-patient’s medical care from other physicians or medical staff. Treating physicians should also recognize that special measures may be required to ensure that the physician-patient’s physical privacy is respected.

(3) Physicians providing care to a colleague should respect the physician-patient’s right to participate in informed decision making. Treating physicians should make no assumptions about the physician-patient’s knowledge about her or his medical condition and should provide information to enable the physician-patient to make voluntary, fully informed decisions about care.

(4) Physicians in training and medical students face unique challenges when asked to provide or participate in care for peers given the circumstances of their roles in medical schools and residency programs. Except in emergency situations or when other care is not available, physicians in training should not be required to care for fellow trainees, faculty members, or attending physicians if they are reluctant to do so.

In what other ways do you think doctors treating other doctors might affect their therapeutic relationship and even affect how the doctor at the time treats his or her non-peer usual patient? Go to the link above to read the full Report. ..Maurice.

AMA Report (3) Secret Shopper “Patients”

The subject 3 Secret Shopper "Patients" is one of a series of 8 Reports of the Council of Ethical and Judicial Affairs (CEJA) of the American Medical Association. These reports have not yet been adopted as AMA policy; they will be discussed and debated in June 2008. If they receive the support of the majority of the delegates from the state and specialty societies, they will become policy. Anyone, including the general public, can provide testimony on CEJA reports either in person at the meeting or by writing to ceja@ama-assn.org.

I am presenting each Report as a separate thread on this blog. By clicking on the link above, you can gain access to the specific wording of the Reports, 1 through 6 are to be Amendments to the Constitution and Bylaws of the American Medical Association. Reports 7 and 8 are for Informational purposes. Why should the public be interested in these reports? They are part of the ethics of the system of medicine in the United States and may be reflected elsewhere in the world. Through the practice of medicine by all physicians, the rules presented in these reports can be applied to and may affect all patients. You may write directly your comments to CEJA at the e-mail address above and, of course, you are certainly welcome to post your comments on this particular Report here.

Have you any idea what is a “Secret Shopper ‘Patient’? Actually, to demonstrate how ignorant I have been about such matters (and probably I am not the only physician to say this), I had no idea that such a “patient” could be part of my patient population until I read this Report. The Report explains:

Secret shopper “patients” are modeled on quality improvement tools developed in nonclinical service domains. The secret shopper industry has been used for decades to evaluate practices in the retail and hotel industries, primarily in the area of customer service. As of 2004 the health care industry was responsible for just 2% of all secret shopper revenue, although this represented a twofold increase over the preceding year.

They are individuals hired to act as patients to monitor service quality. The activities of a secret shopper “patient” will vary depending on what type of feedback is desired. Secret shoppers have been used to evaluate most of the steps of the patient experience, from the ease of making an appointment over the phone, to the environment and flow of patients in the waiting room, to the encounter with the physician. Secret shoppers usually record general observations and may use a checklist to record whether pre-identified service criteria are met.

There are ethical issues that are related to the use of such “patients”. The Report describes the following:

…ethical concerns can arise when secret shoppers are sent into practice settings, especially when they may interact or interfere with the care of bona fide patients or are used specifically to assess clinical skills. Some examples of ethical unease include concern that the use of secret shoppers wastes scarce health care resources, is a deceptive practice, raises privacy issues,and is not well validated as a methodology for assessing clinical performance.

Their presence in hospital emergency rooms could delay and interfere with the treatment of critically ill patients.

The Report sets forth the following recommendations:

Physicians have an ethical responsibility to engage in activities that contribute to continual improvements in patient care. One method for promoting such quality improvement is through the use of secret shopper “patients” who have been appropriately trained to provide feedback about physician performance in the clinical setting. A sound secret shopper program should include the following elements:

(1) All relevant parties, especially those to whom secret shoppers will be making unannounced visits, should be notified that this mechanism is being implemented in their practice setting.

(2) The information collected by secret shoppers should be used only to identify areas of improvement and not as a basis for punitive actions. Third parties should not have access to information collected by secret shoppers that includes personally identifying data.

(3) Feedback from secret shopper “patients” should not be relied on as the sole source of data for evaluating clinical performance.

(4) The use of secret shopper “patients” should not be implemented in a manner that adversely affects access to medical care by legitimate patients. For example, the need for urgent care (such as in the emergency department setting) must always take precedence over secret shopper “patients.”

So what do you think about a “patient” who enters a doctor’s office or clinic or hospital emergency room at the request of some party who wants information about how patients are managed there? Do you think that by following the recommendations presented, the results will be a fair compromise concerning further utilization of these “patients”? ..Maurice.

AMA Report (2): Physicians' Self-Referral

The subject 2 Physicians’ Self-Referral is one of a series of 8 Reports of the Council of Ethical and Judicial Affairs (CEJA) of the American Medical Association. These reports have not yet been adopted as AMA policy; they will be discussed and debated in June 2008. If they receive the support of the majority of the delegates from the state and specialty societies, they will become policy. Anyone, including the general public, can provide testimony on CEJA reports either in person at the meeting or by writing to ceja@ama-assn.org.

I am presenting each Report as a separate thread on this blog. By clicking on the link above, you can gain access to the specific wording of the Reports, 1 through 6 are to be Amendments to the Constitution and Bylaws of the American Medical Association. Reports 7 and 8 are for Informational purposes. Why should the public be interested in these reports? They are part of the ethics of the system of medicine in the United States and may be reflected elsewhere in the world. Through the practice of medicine by all physicians, the rules presented in these reports can be applied to and may affect all patients. You may write directly your comments to CEJA at the e-mail address above and, of course, you are certainly welcome to post your comments on this particular Report here.

Should physicians refer patients to their own privately financed laboratories or services? Here is the Report’s discussion of a conflict of interest issue in such referrals:

SELF-REFERRAL: CREATING CONDITIONS FOR CONFLICT OF INTEREST

Physicians may lawfully enter into a variety of commercial and other relationships that can benefit both their patients and their own financial situation. , Physician ownership of specialty hospitals, for example, can ensure that patients have access to services that would not otherwise be available, thus also benefiting the wider community.1 Similarly, physician arrangements with diagnostic services, physical therapy or home care providers, opticians, or pharmacies can help ensure quality care and provide patient convenience while generating income for the physician. However, if such self-referral arrangements create conditions that do not promote the best interests of patients, they create an intolerable conflict. Hence the need for ethical scrutiny and guidance.

A conflict of interest is “a set of conditions in which professional judgment concerning a primary interest (such as a patient’s welfare or the validity of research) tends to be unduly influenced by a secondary interest (such as financial gain).” Primary interests are determined by the professional duties of the physician and are understood by the profession to be “the primary considerations in any professional decision . . . .”10 Secondary interests, financial or otherwise, are present to some degree in virtually every treatment decision a physician makes. Such interests are not necessarily illegitimate themselves and may even be desirable—provided that professional duties are the primary consideration. Because it can be difficult to recognize when secondary interests become inappropriate, both ethics and the law provide guidance.

The Report concludes with the following recommendations:

Business arrangements among physicians that encourage self-referral can benefit patients by enhancing access to health care services. However, these arrangements are ethically challenging because they create situations in which patients’ medical interests can be in tension with physicians’ financial interests. Such conflict-creating arrangements can have adverse consequences for patients and can undermine a robust commitment to professionalism in medicine. Physicians should generally avoid entering into such arrangements unless they provide definable benefits for patients.

Physicians who enter into legally permissible contractual relationships—including acquisition of ownership or leasehold interests in health facilities, products, or equipment; or contracts for service in group practices—are expected to uphold their responsibilities to patients first. When physicians enter into arrangements that provide opportunities for self-referral they must:

(1) Ensure that referrals are based on objective, medically relevant criteria.

(2) Ensure that the arrangement:

(a) is structured effectively to provide appropriate, high quality health care services or products not otherwise available in the community;

(b) does not require the physician-owner to make referrals to the entity or otherwise generate revenues as a condition of participation; and

(c) adheres to open, fair business practices vis-à-vis the medical professional community—for example, the arrangement permits investment by nonreferring physicians.

(3) Take steps to mitigate conflicts of interest, including:

(a) ensuring that financial benefit is tied to the physician-owner’s equity interest, not volume of referrals for services or sales of products;

(b) establishing mechanisms for utilization review to monitor referral practices; and

(c) making alternate arrangements for care of the patient when conflicts cannot be appropriately managed/mitigated.

(4) Disclose their financial interest in the facility, product, or equipment to patients, inform them of available alternatives for referral, and assure them that they will not be treated differently if they choose to obtain the recommended services/products elsewhere.

(5) Disclose their financial interest to third-party payers or other stakeholders on request.

Go to the link above and read the entire Report. Do you think that these recommendations would make physician self-referral more likely to be in the best interest of the patient? ..Maurice.

AMA Report (1): Industry Support of Professional Education in Medicine

The subject 1 Industry Support of Professional Education in Medicine is one of a series of 8 Reports of the Council of Ethical and Judicial Affairs (CEJA) of the American Medical Association. These reports have not yet been adopted as AMA policy; they will be discussed and debated in June 2008. If they receive the support of the majority of the delegates from the state and specialty societies, they will become policy. Anyone, including the general public, can provide testimony on CEJA reports either in person at the meeting or by writing to ceja@ama-assn.org.

I am presenting each Report as a separate thread on this blog. By clicking on the link above, you can gain access to the specific wording of the full Reports, 1 through 6 are to be Amendments to the Constitution and Bylaws of the American Medical Association. Reports 7 and 8 are for Informational purposes. (Note: An Executive Summary of the Report is posted below.) Why should the public be interested in these reports? They are part of the ethics of the system of medicine in the United States and may be reflected elsewhere in the world. Through the practice of medicine by all physicians, the rules presented in these reports can be applied to and may affect all patients. You may write directly your comments to CEJA at the e-mail address above and, of course, you are certainly welcome to post your comments on this particular Report here.

EXECUTIVE SUMMARY

Objective: To provide ethical guidance for physicians and the profession with respect to industry support for professional education in medicine.

Methods: Literature review; ethical analysis of issues in professionalism raised by industry support for undergraduate, graduate, and continuing medical education; and feedback from key stakeholders within the AMA.

Results: Medicine’s autonomy and authority to regulate itself depends on its ability to ensure that current and future generations of physicians acquire, maintain, and apply the values, knowledge, skills, and judgment essential for quality patient care. To fulfill this obligation, medicine must ensure that the values and core commitments of the profession protect the integrity of professional education. It must strive to deliver scientifically objective and clinically relevant information to individuals across the learning continuum. To promote continued innovation and improvement in patient care, medicine must sustain ongoing, productive relationships with the pharmaceutical, biotechnology, and medical device companies. However, industry support of professional education has raised concerns that threaten the integrity of medicine’s educational function.

Conclusions: Existing mechanisms to manage potential conflicts and influences are not sufficient to address these concerns. Recognizing the profession-defining importance for medicine of achieving its educational goals, the Council recommends that:

• Individual physicians and institutions of medicine, such as medical schools, teaching hospitals, and professional organizations (including state and medical specialty societies) must not accept industry funding to support professional education activities. Exception should be made for technical training when new diagnostic or therapeutic devices and techniques are introduced. Once expertise in the use of previously new devices has developed within the professional community, continuing industry involvement in educating practitioners is no longer warranted.

• Medical schools and teaching hospitals are learning environments for future physicians at a critical, formative phase in their careers and have special responsibilities to create and foster learning and work environments that instill professional values, norms, and expectations. They must limit, to the greatest extent possible, industry marketing and promotional activities on their campuses. They have a further responsibility to educate trainees about how to interact with industry and their representatives, especially if and when trainees choose to engage industry in varying capacities after residency and fellowship training.

• The medical profession must work together to identify the most effective modes of instruction and evaluation for physician learners. It must then more efficiently develop and disseminate educational programming that serves the educational needs of all physicians. The profession must obtain more noncommercial funding of professional education activities.

So the issue is what is the role of industry, if any, in medical education and should medical educators and physicians be advised to keep any such relationship to a minimum including funding and promotions. ..Maurice.

Etiquette-Based Medicine: Should Etiquette Trump Compassion or Empathy?

Writing in the May 8 2008 issue of the New England Journal of Medicine , Michael W. Kahn, M.D., a professor of psychiatry at Harvard Medical School expressed his thoughts regarding his own doctor “’What a professional,’ and even (unexpectedly),’What a gentleman.’" Here is the extract from the article where Dr Kahn explains his conclusion.

Patients ideally deserve to have a compassionate doctor, but might they be satisfied with one who is simply well-behaved? When I hear patients complain about doctors, their criticism often has nothing to do with not feeling understood or empathized with. Instead, they object that "he just stared at his computer screen," "she never smiles," or "I had no idea who I was talking to." During my own recent hospitalization, I found the Old World manners of my European-born surgeon — and my reaction to them — revealing in this regard. Whatever he might actually have been feeling, his behavior — dress, manners, body language, eye contact — was impeccable. I wasn't left thinking, "What compassion." Instead, I found myself thinking, "What a professional," and even (unexpectedly), "What a gentleman." The impression he made was remarkably calming, and it helped to confirm my suspicion that patients may care less about whether their doctors are reflective and empathic than whether they are respectful and attentive.

I had never heard the expression “etiquette –based medicine” but it appears I have been teaching my first and second year medical students exactly that and more of what Dr. Kahn sets in the article regarding his checklist for etiquette behavior towards the patient. I find that my medical students are if not already imbibed with etiquette are easily taught and responsive. My guess is that later in their medical careers as they get more patients to care for within a limited time available and have conflicts of interests between patients and with their own personal non-professional lives, full etiquette behavior by some gets tossed aside. Unfortunately, many patients can sense this loss and this can explain why they are apprehensive or unhappy with their doctors. However, somehow I would still put compassion and empathy on the top of the list of a doctor's worthy behaviors. To me etiquette behavior is in a way “just acting a role” whereas true compassion and true empathy are not acting but feelings by the doctor and is the stuff, beyond the doctor’s skills, that makes the doctor-patient relationship most meaningful. What do you think? You can read the full free article by clicking on the above link. ..Maurice.

Hey, Hey.. I Wanna Be a DNR

Click on this YouTube presentation below for some lyrical insight into what is going on in the "non-palliative" care and treatment of some sick patients who deserve palliative and hospice care. You may go to YouTube to read comments from professionals and others but come back and let us know what you think about this "publicizing" of Do Not Resusitate, palliation and hospice. ..Maurice.

Anonymity on the Blog: Bad, Good or of No Consequence?

After over 500 threads and probably thousands of comments by visitors, it’s about time we discussed here the topic of writer anonymity and the ethics of anonymity of those who comment on this blog. I think that the significance of writing anonymously may be different between different websites. As an example, comparing a chat room with my blog. Should one consider the purpose of the website in this regard? Would the need for identity be more or less necessary while chatting in real time on various topics and attempting to develop some sort of friendship or relationship compared with discussing one established topic with a delayed response and no intent to personally relate? Should anonymity belong in either venue or in neither?

In a blog like mine, although most of the comments have been in one form or another from anonymous writers, do you think something important is missing in the discussion by the anonymity? What is the personal harm to the visitors to this blog by fully identifying themselves including their e-mail address? What is the benefit, if any, to this blog by such identification?

Somehow, I think that the fear of self-identification on a discussion blog such as mine is an unnecessary hindrance to full expression and that an unethical consequence of anonymity is that anonymity can lead in some visitors to the development of uncivil and ad hominem laden narrative or unsubstantiated or undocumented arguments. Though, as moderator, I have the power to prevent publishing such comments, nevertheless deleting a comment, though rare, is not a duty for which I look forward.

There has been discussion on the blogs in the past year and longer on this issue of anonymity and even about a formal blogger’s Code of Ethics.

What is your take on the issue of anonymity on the Internet in general but also on this Bioethics Discussion Blog. ..Maurice.

The Truth About Cancer: No "Mission Accomplished!"

I have posted on this blog on several occasions threads that deal with the ethics involved with drug research and the role of patients as subjects in these experiments. Studies which deal with the safety and efficacy of drugs and other treatments include a number of chronic diseases including heart and other cardiovascular diseases, diabetes and rheumatologic disorders as examples. These diseases produce long term degrees of disability, complications which can lead to death. Diseases for which studies are performed include diseases where death is an ever-present consideration even in the shorter term—such as cancer. With no “cure” for cancers in general nor even certainty of a cure for the patient who has specific types of cancer, there is great motivation for doctors to recommend and patients to accept to participate as a subject in all sorts of research studies, one of which, could very well be the therapeutic answer to the patient’s cancer.

But.. does the patient and the public in general really understand, in a truly realistic sense, “cancer”? What is the benefit of screening for cancer? If the screening is positive, what does that mean in terms of the reliability of the diagnosis and the individual patient’s value of further workup and , if confirmed, subsequent treatment? There is so much misinformation and distortion of reality that has been presented to the public since when in 1971 President Nixon declared the “War on Cancer” that to many in the public, regarding subjects of cancer diagnosis and treatment, there is almost a modern-day “Mission Accomplished!” attitude. (Read the opinion “Opinion: Spinning the Losing War on Cancer” by Samuel S. Epstein and Quentin D. Young regarding the history of the “war”)

What is needed is to present to the public the perspective which most thoughtful oncologists are aware that cancer is still for the individual patient a disease where the “war” is not yet won and the “mission” is still facing many problems and uncertainties. Death from cancer is still not fully out of the picture for many types of cancer. And the concept of a “cure” should be replaced by “delay of death”.

PBS has produced a great TV program that I think presents a clear and realistic view of cancer, treatment research, cancer treatment itself and outcomes. The program is part of the “Take One Step” series and is called “The Truth About Cancer”.At the PBS website you will find the transcript of the 90 minute program and you can watch the program on-line. I think this is one documentary that everyone should watch. ..Maurice.

Ethicists and Ethics Committees: As Police, Judges or What?

Hospital ethics committees have been around now for over 30 years and are currently required for hospitals to be formally accredited in the United States. Their responsibility was to provide some judgment regarding ethical dilemmas that were developing over the recent decades primarily in view of society’s acceptance of patient autonomy and the availability of more and more treatments for the chronically and terminally ill and development of life support systems. Also the courts added to dilemmas by allowing withholding life supportive treatment or terminating life support at the request of the patient or patient’s surrogate. Meanwhile, there have been no standards of uniform practice established for hospital ethics committees. In addition, the title of “ethicist” can be used by virtually anyone since there is no school entrance requirements,no academic program that would lead to an ethicist title, no accreditation process for the school and no certification process for the individual to demonstrate the skill and knowledge to be an ethicist. Finally, if that isn’t enough, there is no formal professional organization of medical ethics to set ethical standards which ethicists should follow. In view of all this vacuum, hospital ethics committees and ethicists continue to do a job of consultations requested by physicians, patients, families and hospital staff… but however they do it and whatever they decide, how much significance should be given to their consultations and how much clout should a consultation carry? Here are some questions one can ask regarding the power of an ethicist or the hospital ethics committee.

Should medical ethicists be considered “ethics police” or “ethics judges”? Should members of an ethics committee of a hospital wander around the hospital looking into charts and trying to find either unethical behavior of the hospital staff in their relationship to patients or trying to find potential ethical conflicts before they flare up into a major conflict? In other words, should ethics committees become pro-active rather than retro-active after a conflict or issue has already developed and the committee is called upon for help by patient, family or hospital staff? If an individual is found behaving unethically, should the ethics committee confront that individual and propose change or threaten consequences if the unethical behavior is not terminated? If an ethical issue is found, should it be the hospital ethics committee who decides on the appropriate “ethical” response and will expect it to be carried out? In these instances, the ethics committee members could be looked upon as either “ethics police” or “ethics judges”.

As a member of society, what do you think should be the responsibilities and power of ethicists and hospital ethics committees? ..Maurice