Patient Modesty: Volume 5

Graphic: Photograph by J.Granier of ballet "The Modesty of Icebergs" by Daniel Leveillé, reproduced from the review at uncoy.com. Note: My selection of the graphic was based on the current context and tone of the conversations on these more recent threads regarding patient modesty but more directed towards male patient modesty issues and the apparent difficulty of healthcare providers recognizing this concern. The photograph shows the three male dancers avoiding frontal nudity to the viewer and in fact avoiding looking upon each other. This photographic moment in the dance seems to me to represent an expression of physical modesty of these men. Though review of graphics is not the purpose of this thread, I would be interested to read if my visitors find my interpretation in error or something more or less related to male patient modesty in the photograph. ..Maurice.

AS OF OCTOBER 4 2008 THIS THREAD WILL BE CLOSED FOR ALL NEW COMMENTS. PLEASE GO TO "PATIENT MODESTY: VOLUME 6" TO CONTINUE COMMENTS.

Maurice Bernstein, M.D.: Bioethics on Google Knol

Yesterday, I began the first of a series of Knols on Google Knol titled "My Bioethical Opinion is...". My intent is to have readers there ask me bioethical questions (ethics dealing with medicine and medical practice) and, if I feel I have the capacity to do so, will try to answer the questions with a Knol for each question. (There will be a Comment section for each Knol so that the readers can respond to my answer and I can respond to their response.)

The format is entirely different than this bioethics discussion blog. Here I pose an issue to my visitors and await an expression of their views. I rarely express here my own views since I don't want to bias the visitors responses. On Knol, it is just the opposite: the readers will be asking me questions for me to answer.

I know many of the visitors to this blog have ethical issue questions which I have as yet not thought of or created a thread. This will be the chance to ask. I may migrate some of the questions back to this blog as new threads here. I hope some of my visitors here will meet me on Google Knol. Thanks for your attention. ..Maurice.

The Patient Patient: Tolerating Symptoms and Palliative Care

I pay you money to try and fix my head
I lie on your couch reveal what’s in my bed
You scribble in your pad
'Patient feels sad'
"Just take this medication
And if it fails to work
Then try a razor"


Well, the doctor-patient relationship need not go the way of the Val Emmich’s lyrics in the “Patient Patient”. But all patients should know that there are times when there is no cure and the patient has to patiently tolerate their symptoms. This does not mean there is no treatment. It does mean that there is presently no cure but it also should mean that palliative treatment is available. Palliative treatment represents “comfort care”, providing a systematic attempt to reduce the discomfort and the debility of one or more symptoms by medications but also by providing physical therapy, psychologic and spiritual support. Palliative treatment need not be confined to end-of-life terminal illnesses or hospice care. Palliative treatment can be extended to patients with symptoms of chronic diseases or even acute processes where definitive and curing treatments themselves are not available or where the use of such treatments pose a risk greater than the consequences of the illness. Patients should be informed and recognize that unfortunately even palliative treatments may not necessarily relieve all the symptoms completely, particularly if there is medical need or patient’s request not to be so deeply sedated that the patient is put into a coma. So.. patients may have to patiently, but with medical assistance, tolerate their symptoms

The “no cure” outcome is a difficult result for physicians to manage. In the past, from experience in childhood and the training in medical school, the goal of treating illness is cure. In the past, very little was taught about how to manage the patient’s symptoms when there was no cure. When a physician, after many attempts to cure his or her patient, without successful results, the issue in the doctor’s mind is “what’s next?” Would “next” be reexamining the whole illness and trying to establish another diagnosis? Would it be to do more tests or try out more treatments? Would it be to refer the patient to some specialist for diagnosis and treatment, thus also relieving the physician‘s intellectual and emotional burden? (The referring probably should have been done much earlier.) Or just to continue the doctor-patient relationship with the tone of “there is no cure but try to tolerate your symptoms.”--and hopefully not with Emmich’s words “..then try a razor.”


Though the concept of palliation was part of the management of patients in years past, it was untaught, informal and not a consistent medical practice. In recent years, with the development of the hospice end-of-life management, palliation has become virtually a science and medical specialty with a duty to spread the knowledge and guidance to all physicians. For more about palliative care, read the Wikipedia article on the subject.

What makes a “good doctor”? What makes a "bad doctor"? I think the answer would come from the patient about how he or she was treated when there was no cure. ..Maurice.

"Being Alive vs Having a Life"

Ethicist Erich Loewy challenges me with the following:

"You are standing in front of a building which is on fire and two things are trapped in it: the one a happy carpenter with three children and the other a Petridish with developing stem cells. You can only rescue one. What would you do?"

Here is an answer some person might give:

""I would not rescue either because they are of equal worth."

What answer would you give? Is simply being alive the same as being aware of and participating in a life? ..Maurice.

Solving the Too Many People Problem: Contraception vs. No More Practice of Medicine? Take Your Pick

Dr. Erich Loewy, a physician-ethicist, who has written to this blog in the past, wrote the following to a bioethics listserv regarding considerations for control of the progression of current and further over-population of our planet. He gave me permission to post his comment here.

I personally would claim that what has caused a large number of our problems both in the US as, and especially, in developing nations is that there are simply too many of us. China used to have a severe famine every few years. No doubt there are many causes as to why the Chinese no longer have these famines but one of the chief ones is that the birth rate was too high. Their one child policy has effectively given a chance to their people's ability not to have to face famine every few years. The argument will be made (and there is, of course, something to it) that this is an incursion in people's autonomy and "rights"--that is they have a claim to speak to a question and how it affects others and the community. However in my viewpoint it is a rather weak claim. The fact that the world is overpopulated is hardly a figment of the imagination and it undoubtedly is one of the main causes why millions of deaths per year, occur; not only in China but in large parts of the so-called developing world as well as in the industrialized west and especially in the US where 25% of the people are hungry a large part of the year, the average income of a worker is $8.50/hour (which makes it very difficult for one person and impossible for a family) to do more than fulfill its most basic needs--and often not even these. I know that this is against the avowed principles of many churches more interested to produce many babies than worrying about what to do with them after birth--sort of a "let them be baptized and starve to death" attitude. I know that this is not politically correct--an idea which has made a virtue of disassembling.

In various dictatorships of the past century the desire to have children was made into a virtue. Those who have studied this era will remember the "Lebensborn"--institutions in which blond, tall and blue-eyed Aryans could sacrifice themselves to their Führer by going to bed with blond, blue eyed and tall SS men who likewise were performing a patriotic act for their Führer.

It is deeply ingrained in us that being pregnant is a cause for congratulations. In Nazi Germany with the murder of about six-million Jews, millions of Germans and citizens of other nations it is true that a large percentage of the pre-Hitler population had died. It is one way of handling the bath-tub problem: a problem which say that when the outflow from the bath-tub equals the inflow the amount of water remains the same. If the outflow (modern medicine) is decreased at the same time (fewer deaths, longer life) that the inflow is increased the bath-tub will overflow. It is then that we shall have wars, pestilence and other natural disasters. Does decreasing the number of children by fiat violate personal autonomy? Yes, of course it does. Does allowing people to have as many children as they want violate the survival and flourishing of the community? Yes, of course it does.

Having an increasing number of people is dangerous both for those who can and cannot afford it. Is it a basic violation of autonomy and an invasion of human rights---yes, it undoubtedly is. But if the community fails to flourish and eventually perishes, there is no possibility to speak of individual autonomy--there will be few left.

If we continue to hold every fertilized egg or implantation of such an egg co-equal with a happy carpenter or college student we are comparing some very different things. In early and probably until the mid-second trimester the developing fetus is not self-aware. How do I know this? Well in a future function that lacks a substrate and is, therefore, without the possibility of self-awareness, it seems almost ridiculous to hold it co-equal with a happy, functioning human being. We have the choice: (1) encourage more people not to use contraceptives and continuing the production of ever-increasing humans many of whom will starve to death or lead terrible lives; or (2) do all that is necessary to decrease our enormous birth rate.

Do I not respect the right of religions to do all they can not to use contraception? Yes, you are right, I do not respect any institution which makes a virtue out of producing babies fated to live miserably and cause their community to fail.

We are told by experts in the field of world populations that we cannot currently feed the world if we do not become vegetarians (which I would applaud but is another matter) and that even if we do we shall be unable to do so entirely. We have only two reasonable choices: (1) give up the practice of medicine except perhaps for palliation or (2) Decrease the world population even should that interfere with people's personal morality.

Dr Erich H. Loewy
Professor of Medicine and Founding Chair of Bioethics (emeritus)
Associate in Philosophy
University of California, Davis

It may be necessary for some to rethink the moral harm of contraception and balance it against the moral harm of the suffering of starving populations and all the other consequences of over-population of this planet. On the other hand.. as Dr. Loewy suggests, give up treating disease and thereby allowing nature to reduce the population. I don't think we want to go back to the Nazi method of population reduction. What is your thoughts on this subject? Can those of you who find contraception immoral, rethink your view or suggest some other way? ..Maurice.

GRAPHIC-Photograph from CorpoAlert, modified.

Biopiracy: Knowledge Stealing in Medicine

Narrowing the issue begun in my recent thread "Who Owns Science?" I would like to discuss here what has been called "biopiracy".


From Wikipedia:
Biopiracy is a negative term for the appropriation, generally by means of patents, of legal rights over indigenous knowledge - particularly indigenous biomedical knowledge - without compensation to the indigenous groups who originally developed such knowledge. A classic case is that of the Rosy Periwinkle (Madagascar Periwinkle). Research into the plant was prompted by the plant's traditional medicinal role and resulted in the discovery of a large number of biologically active chemicals, including vincristine, a lucrative agent useful during leukemia chemotherapy. A method for purifying vincristine was initially patented and marketed by Eli Lilly. It is widely reported that the country of origin did not receive any payment.

Biopiracy allegedly contributes to inequality between developing countries rich in biodiversity, and developed countries served by pharmaceutical industry exploiting those resources.

The issue is whether it is ethical for pharmaceutical companies to derive medicines and make profit from knowledge acquired from natives, but without the natives' appropriate compensation. Do you see, by this behavior, piracy or if not, what is it? ..Maurice.

GRAPHIC is from a photograph taken by me of a ship's flag and modified by me with ArtRage.

A Doctor's Touch

Touching a patient is one important act which a physician can perform. Although it is no longer performed in the manner pictured in the medical textbooks graphics of the 19th century (see Addendum below), it is an act which we teach our medical students all about as they learn to first experience the relationship with a patient previously unknown to them.

Touching the patient, perhaps at first as a handshake, provides the first connection with the patient. It can be represented as the marking of a beginning doctor-patient relationship which is hopefully to continue to the benefit of the patient. The quality of the handshake tells each party, at the onset, something about the other. As the patient relates the history of illness and his or her life experiences, the physician’s touch at a moment the patient demonstrates emotional distress, a touch of the physician’s hand on the patient’s arm or shoulder shows the physician is aware of the distress and is present to be supportive.

The act of touching continues into the physical examination where touching is termed palpation. Usually, the first touching in the physical exam occurs if the doctor, not the nurse, takes the patient’s vital signs blood pressure and pulse where touching is involved. It also may be the first time that the physician and patient are physically close to each other over a period of time and becomes a marker for what will continue throughout the examination to a more intimate professional relationship. Palpation is used extensively in the physical examination. Students are taught that it is important to attempt to create a warm hand to examine the patient, since the results of touch with a cold hand can be that of patient discomfort and erroneous findings. The doctor’s touch during the exam not only discovers areas of the body which are painful to touch but also the doctor learns about the warmth of the patient’s skin, its texture, moisture and elasticity. In addition, the touch can reveal whether there is crepitation or crackling of the tissues under the skin or in the joints which may represent pathology. Touch also reveals sound vibrations from the lungs or heart or masses within the patient’s skin, below the skin, in the boney skeleton and within the cavities of the body. A doctor’s touch continues throughout the physical exam and shouldn’t stop when the exam is over and a discussion of the findings and conclusion occurs. Here the light but continuing touch of a patient’s arm or hand, particularly while conclusions upsetting to the patient must be presented, can represent that the physician intends to remain in contact and supportive for the patient as the medical care begins or continues.

Simple touching can be emotionally touching for both the patient and even occasionally for the physician, however touching should be part of the entire professional actions where the intent by the physician is solely for the benefit of the patient. The issue of hugging is a more controversial aspect of touching and I have already devoted another thread to this subject.

In conclusion, as you can see, a doctor’s touch is an action which, if used wisely and professionally can provide a variety of benefits from psychological to diagnostic. Also, you can see that touch is missing when the doctor-patient relationship involves phone, video or e-mail communication. It is understandable why we who teach medical students stress touch as an important medical tool in its many ways. ..Maurice.

ADDENDUM: Graphic above and text below from Victoriana

Medicine in the 19th Century: The Touch

Classic illustration of a woman's medical exam by her doctor. Many 19th century medical textbooks used this illustration to show the proper manner to examine a female patient. The physician's eyes are diverted so he will not violate the woman's "modesty."

Who Owns Science?

Russell Jenkins and Mark Henderson article in the UK The Times July 5 2008 and available on the TimesOnLine comments on the letter that two Nobel laureates wrote to The Times, published the same day.

The issue, as detailed in the above links, is whether science particularly science which applies to medicine and the health of human beings should “belong” to someone and all the details of the scientific investigation, the results and the applications themselves should not be readily available to all for further investigation, development and use.

The laureates, Professor Sir John Sulston and Professor Joseph Stiglitz wrote in their letter “The current system of managing research and innovation incorporates a complex body of law governing the ownership of ‘intellectual property’ — copyright and patents being the most familiar. Intellectual property rights are intended to provide incentives that encourage the advancement of science, enhance the pace of innovation, increase the derived economic benefits and provide a fair way of regulating access to these benefits. But does it really achieve these purposes? There is increasing concern that, to the contrary, it may, under some circumstances, impede innovation, lead to monopolisation, and unduly restrict access to the benefits of knowledge.”

Should medical scientific research be looked upon and treated in a way different than all other inventions or intellectual endeavors from ethical, legal and humanitarian perspectives in terms of property rights and ownership. Should the investments in time, skill and money in these projects be considered more as altruistic investments for mankind rather than the basis for future monetary rewards? What do you think? Who owns science now and who should own science? ..Maurice.

The Ideal Allergy Treatment in 54 Words

THE IDEAL ALLERGY TREATMENT

I could not breathe. It called for desperate measures. My mother took me to get allergy shots. I asked the doctor if it would hurt. No, he said, and offered to be shot as well. So I did it. My breathing has greatly improved. I seem to have no allergies here in solitary confinement.

This 54 word short, short, short story was written last year by me and together with two family members one of whom has allergies. It is an example of what can be expressed in as little as 55 words (or LESS like my story above), a yearly challenge to its readers which the San Luis Obispo (California) New Times newspaper has been supporting for many years.

The idea is to create a whole story with a beginning, middle and ending punch line in just 55 words (or less). It is fun but not as easy as one might think to develop a story line leading to an unexpected conclusion is so few words. Words are separated by spaces and the number like 55 as written as a digit is one word. Hyphenated words are not counted as one word but contractions like "shouldn't" are one word. Abbreviations such as USA or DNR are considered one word. The title doesn't count in the 55 words but can't exceed 7 words.

How about my visitors contributing to this thread their own devised 55 word stories about medicine, diseases, doctors, nurses.. you got the idea!? It is all for fun.. no prizes. But make it interesting.. especially that ending. ..Maurice.

What can Patients Do to Improve Their Medical Care?

We have touched on the subject of the patient’s contribution toward their own best medical care briefly on various threads in the past but now I would like to devote an entire thread to the issue. There has been a host of topics dealing with what physicians and other healthcare providers could be doing better. And I believe there is much validity to many of the comments about deficiencies and excesses in the medical profession and the need for change.

But what about the patients themselves? Again, believe it or not, medical diagnosis and effective treatment is a two way street. Beyond physician responsibilities, it is the responsibility of patients to provide the history, the cooperation with examinations, compliance with treatment and timely communication with doctors regarding treatment course and complications.

I don’t want to write more here myself. I do want to read comments from my visitors regarding how they look at the need for patient participation and cooperation in their own medical care. It's OK to present any personal examples but no names please. ..Maurice.

Medical Clichés :”A Taste of Your Own Medicine”

Ethicist Greg Pence writing in Newsweek comments about his experience with his college students’ writings which include clichés (tired,old expressions). He writes “When I grade written work by students, one of the phrases I hate most is ‘It goes without saying,’ in response to which I scribble on their essays, ‘Then why write it?’ Another favorite of undergraduates is ‘It's not for me to say,’ to which I jot in their blue books, ‘Then why continue writing?’"I also despise the phrase ‘Who can say?’ to which I reply, ‘You! That's who! That's the point of writing an essay!’" One may be critical of Dr Pence’s sarcastic responses, though his points about the use of clichés are valid. He describes a not uncommon confusing use of clichés in medical practice: “The language of medicine confuses patients' families when physicians write, ‘On Tuesday the patient was declared brain dead, and on Wednesday life support was removed.’ So when did the patient really die? Can people die in two ways, once when they are declared brain dead and second when their respirators are removed? Better to write, ‘Physicians declared the patient dead by neurological criteria and the next day removed his respirator.’”

Writing in clichés can make reading boring but speaking in clichés, I think is even worse, especially if the words are coming from your physician. I think most patients want clarity in what their physician says to them and clichés are often less than clear about what the physician is intending to convey. How would you feel about your doctor who, with a chuckle, tells you “an apple a day keeps the doctor away” or “an ounce of prevention is worth a pound of cure” or “time heals all wounds”? The problem with clichés are simply they have been used so much within so many different contexts that they lose their meaning and confuse the significance of what is trying to be expressed. Sometimes they can appear paternalistic or they can appear thoughtless. In medicine, clarity of thought and expression is essential and patients should not need to “read between the lines”.

For those interested in looking at a rather full listing of clichés that people use, go to ClichéSite. Have you been told any clichés as a patient in a doctor’s office? Write them to this blog. ..Maurice.