Does Donation After Cardiac Death (DCD) Break the Dead Donor Rule?

Alex Tang wrote me a question in my "My Opinion is.." ethics Google Knol which I subsequently answered. Specifically with regard to "donation after cardiac death" (DCD), I thought that his concern that "doctors are allowing the patient to die so that organ harvesting can take place" needs to be responded to. I feel visitors to this bioethics blog should also read Alex's concern and my answer, so I have copied the texts below. In addition, I have included the following link to the New England Journal of Medicine Video Round Table discussion of the issue regarding organ donation after cardiac death with Atul Gawande as moderator and discussants, ethicists George Annas, Arthur Caplan and Robert Truog. ..Maurice.

Here is the question:
Cardiac Death and Organ Harvesting
The normal procedure for organ harvesting is from patients who has been certified brain death. In the United States, the Uniform Determination of Death Act (UDDA) set two criteria for death; (1) sustained irreversible of circulatory and respiratory function, and (2) all function of the brain including the brain stem is considered non-existent.

In recent years, there is a movement to harvest organs when the heart stops but brain function is still present. This is usually in patients that are severely ill and are going to die. This is termed "Non-Heart-Beating" or "Cardiac Death" organ donation. The University of Pittsburgh Medical Centre allocated 2 minutes after the heart stops before organ harvesting can begin. There is some uncertainty about this and the Institute of Medicine (IOM) extended the time to 5 minutes. However there have been documented cases of "autoresuscitation" i.e. the heart restarts after 10 minutes of no heart beats. The University of Zurich allows 10 minutes. This is a scary development because doctors are allowing patients to die so that organ harvesting can take place.

Dr Mark M Boucek reported the first heart transplants in three children after cardiac failure rather than brain death in August 14, 2008 issue of the New England Journal of Medicine. The transplants were done in Denver's Children Hospital in Denver. The time between the heart stops and organ harvesting is...75 seconds.

This is a scary development because the ends has justified the means. While it cannot be denied that there is a need for human organs, these organs must be harvested from patients who are already brain dead, not those allowed to die.

What do you think? Alex Tang

Here is my answer:
The moment of death for legal purposes has always been pronounced by a person who has the legal responsibility and capacity to pronounce death. It should be the same (and is the same) whether organs are to be procured or not. The pronouncement of death of a patient in whom no attempt will be made for cardio-vascular-pulmonary resuscitation should occur when it is known by clinical experience that full return of non-assisted cardio-vacular-pulmonary system function spontaneously is unlikely or if it should occur the period of anoxia of the brain would be long enough to cause brain function to meet brain death criteria. The pronouncement of death can also be made in a patient who may still have cardio-vascular system function but meets the clinical criteria for brain death. The pronouncement of death, if not by neurologic criteria, was made not because the heart was "dead" but because of the permanent pathophysiologic failure of the cardio-vascular-pulmonary system, no longer providing oxygen or other substances to the brain and the other body organs and with no intention to attempt artificial resusitation. I believe it should be clarified that The Dead Donor Rule (that the patient should be dead at the time the organs are removed) is satisfied by a legal pronouncement of death, There is no other way to define death since it is known that the cells throughout the human body don't all die at the same instant. There is nothing inconsistent with the Dead Donor Rule that the donated heart has resumed beating in the recipient. This event is not pertinent to the pronouncement of death of the donor since it was the entire cardio-vascular-pulmonary physiologic system that "died" and not the heart.. Patients have the ethical and legal right to voluntarily withdraw unwanted life support and the legal right to give permission for their organs to be removed for donation when the patient is pronounced dead. I would disagree that "doctors are allowing patients to die so that organ harvesting can take place" since the physicians, supported by the law and ethics, are following the requests of the patient. As long as society maintains strict attention regarding the validity of these patient permissions, the act of organ procurement for transplant is an ethical and humanistic procedure. ..Maurice.

“Normalized Deviance” in Bioethics: It’s Normal to Pretend to be a Bioethicist

What is the sociologic definition of the expression “normalization of deviance” which is applied to human behavior? The expression was invented by a sociologist Diane Vaughan and represents when individuals in a system, over time, change the rules of what has been found an appropriate and safe behavior to one which is less appropriate and less safe because each individual finds that other individuals are changing the rules in the same way. So that behavior which is deviating from the established rules is now being made normal and common by this phenomenon.

Normalized deviance can be found in a number of systems including government, business, technology and medicine. Marshall Allen writing in the Las Vegas Sun for August 14 2008 gives examples of such behavior affecting medical care in Las Vegas. He starts out with a technological example of normalized deviance which was identified by Vaughan in the Challenger disaster. The cause of the incident was due to O-ring failure and where O-rings were known to be brittle in the cold environment to which they were exposed. Yet, according to Allen “Politics and a culture of compliance led decision-makers to determine it was an acceptable risk. ‘They redefined evidence that deviated from an acceptable standard so that it became the standard,’ Vaughn wrote.”

I think that in the bioethics discipline we also have an example which could be termed “normalized deviance”. Medical (or so-called "clinical") bioethics is a consultative activity which in the case of medical bioethics deals with the ethics of medical research and the ethics of medical care and treatment as applied to individual patients and to society. Individuals calling themselves “bioethicists” are examining patient’s charts, talking with patients, family, physicians and other healthcare providers and then discussing with all an ethical viewpoint in the form of a professional consultation. There is nothing wrong with that as it stands in the form of a professional consultation except for the fact normalized deviance is present and therefore it is not clear that medical bioethicsts are practitioners of a formal profession.

We know that in other consultative professions, medicine, law, engineering and more, there are formalized methods of accreditation of institutions teaching the knowledge and skills of the profession, there is a formalized certification of the student on completion of the course of study and finally there is a code of ethics for the profession. Why is this necessary? Because the professions need practitioners who have demonstrated knowledge and skills to handle complex problems and where effective consultation is a goal and where client safety (physical, financial or other) is at risk. It is also important that rules are followed so that the consultations are ethically handled fairly and without, for example, personal conflicts of interest. What have we got for medical bioethics? None of the above. Why? This deviance from what is considered acceptable for all such professions has for most been itself considered with the view "bioethics has been doing business for more than 25 years and it has all worked out well so that status quo is acceptable"--thus, normalized deviance from the established requirements of a consultative profession.

There are now stirrings to the creation and development of a true profession of medical bioethics which will lead the former activity away deviance and toward an accepted normalization of what it takes to be a professional. ..Maurice.

Medical Blogs: Who are They Good For?:My Answer on AMA News

There are a host of medical blogs on this internet blogosphere and a question one may reasonably ask is "Who are they good for?" Well, I was asked to provide my answer by the staff of the American Medical Association News, a publication which is said to be read by over 200,000 physicians. I did so and it was published in the Ethics Forum column of the September 1 2008 edition. I think that medical blogs can provide important education to the public but also to the physicians themselves. My multiple threads on patient modesty along with other patient concerns issues should awaken physicians to these patient issues and hopefully the patient concerns can be effectively mitigated.

Here is the link to the ethics column containing my writing but which also includes another article, the description of what the Healthcare Blogger Code of Ethics is and why it was needed, as written by one of its authors, Rob Lamberts, M.D. The link to AMA News, currently is available, however since after 90 days the link may no longer be available to non-AMA members, I have been given permission by AMA News to publish my entire article on my blog. Write here any general comments pertinent to this thread particularly regarding educating physicians about the needs and concerns of patients but return to the most recent Patient Modesty Volume to write about the patient modesty issue itself. ..Maurice.

Scenario: Can physician-written blogs meet legal and ethical professionalism standards?

Many medical blogs are anonymous and unedited, few contain reference sources for their authors' statements, and most are open to comments from patients. With these limitations on oversight and reliability, can medical blogs offer genuine benefits to the public and the profession?

Response:

Medical blogs can provide two benefits for the public. They can offer timely and accurate medical information as a supplement to what is available through other media. Perhaps more importantly, they enable members of the public -- often patients -- to express concerns about their health care experiences and to receive feedback from the bloggers and visitors who read their comments.

Writers to the blog can express their concerns fully because they are allowed to remain anonymous. Although many blog visitors comment on experiences they have had or anticipate having with their physician or physician's staff, most of them have not shared what they write about with their physicians, and, for their part, physicians rarely give patients the opportunity to talk about such matters.

There is no doubt that a lack of time and real and imagined power differences between physicians and patients, among other factors, contribute to inadequate communication. Medical blogs help compensate for the poor communication -- the anonymity, time and space to ask and say whatever one wants and the availability of immediate responses to one's comments make medical blogs a means of much-needed ventilation for many.

As an example of the role of medical blogs in the discussion of patient concerns, I'll tell you about my "Bioethics Discussion Blog," which, since 2004, has developed 600 topics related to the medical system, medical professionalism, medical education and ethics.

The most popular topic among visitors to my blog has been concern over violations of patient modesty. I have been aware of the importance of respecting patient modesty throughout my 50 years of internal medicine practice and never ignored it during many years of teaching the skills of physical examination to students. Only after reading more than 1,000 comments by visitors to my blog, however, did I become fully aware of the extent and magnitude of patient concern and distress.

Unfortunately, quantitative statistical analysis of blog responses is probably not realistic, but one can easily appreciate the qualitative aspects and nuances of patient concern for modesty. There are questions about respect for both unconscious and conscious patients during surgery, office procedures and physical examinations.

Visitors ask specifically how well the modesty interests of unconscious patients are respected in the operating room. What is the gender of the attendants who perform the surgical preps? What parts of the body must be exposed? Must genitals be exposed? What opportunities do patients have to express their concerns prior to surgery, and will their wishes be honored in the operating room?

In office procedures and examinations of genitalia, can the patient request that only attendants of his or her sex be present? Will that request be honored? The argument over right to choose the gender of physicians, nurses and technicians always arises. Most people feel that women are granted that right but men are not. Male visitors to the blog state that physicians either ignore their requests with seeming surprise or simply turn them down with an economic excuse or a "take it or leave it" attitude.

My visitors also have found that hospitals are generally uninterested or unable to change policies and employment practices to accommodate respect for patient modesty. Those who can't find a resolution for their modesty concerns write about postponing or disregarding necessary procedures or examinations.

Though my blog visitors are not my patients, and quantitative statistics are absent, I believe their concerns deserve professional and institutional attention. I tell them that, although ventilating on the blogosphere may be emotionally therapeutic, they may need to become more active in bringing about the changes they desire, and I encourage them to do so. At present, writers on the blog are discussing how to present their concerns to their doctors and hospital administrations. I have suggested they form groups of like-minded patients to advocate with those who can help change what they view as violations of their modesty. I think that my contribution of such advice is a legal, ethical -- and humanistic -- response. For professionals who moderate medical blogs, offering appropriate advice goes a step beyond merely providing discussion space.

Medical blogs, moderated with attention to civil and open discussion among the visitors and following guidelines for ethical operations, make a significant contribution to the medical education of the public and, I dare say, the profession.

--Maurice Bernstein, MD, assistant clinical professor of medicine, Keck School of Medicine, University of Southern California, Los Angeles; blogger, "Bioethics Discussion Blog" (bioethicsdiscussion.blogspot.com)

HPV Vaccination: Selling the Future When the Future is Unknown

What is known and what is as yet unknown about the current human papilloma virus (HPV) vaccination program, to prevent sexually acquired HPV stimulated cervical cancer, approved by the FDA in the United States, promoted by policymakers world wide and the couple of pharmaceutical companies who make the vaccine represents a scientific and ethical challenge. The program is for 12 year old pre-adolescent girls prior to becoming sexually active to be vaccinated and a catch up program for girls and women ages 13 through 18 up to 26 years of age. Unfortunately the effect of the vaccination program, because of the slow development of HVP stimulated cancer of the cervix will not be known for decades. The editorial written in the August 21, 2008 issue of the "New England Journal of Medicine" by C.J. Haug, discussing a research article in the same journal issue, sets the questions which I have provided as an extract below. Some of my visitors may not be familiar with all the terms but I think most will be understanding of the concern expressed.

The vaccine was highly successful in reducing the incidence of precancerous cervical lesions caused by HPV-16 and HPV-18, but a number of critical questions remained unanswered.5,6 For instance, will the vaccine ultimately prevent not only cervical lesions, but also cervical cancer and death? How long will protection conferred by the vaccine last? Since most HPV infections are easily cleared by the immune system, how will vaccination affect natural immunity against HPV, and with what implications? How will the vaccine affect preadolescent girls, given that the only trials conducted in this cohort have been on the immune response? The studies with clinical end points (i.e., CIN 2/3) involved 16- to 24-year-old women. How will vaccination affect screening practices? Since the vaccines protect against only two of the oncogenic strains of HPV, women must continue to be screened for cervical lesions. Vaccinated women may feel protected from cervical cancer and may be less likely than unvaccinated women to pursue screening. How will the vaccine affect other oncogenic strains of HPV? If HPV-16 and HPV-18 are effectively suppressed, will there be selective pressure on the remaining strains of HPV? Other strains may emerge as significant oncogenic serotypes.

Read the free full text at the link above and then return and perhaps write about your concerns, if any, regarding a large scale vaccination program where the answers regarding the overall benefit to countries where pap smear detection of pre-cancerous abnormalities with their early removal is commonplace. Does this vaccination program really promote benefit or will it simply encourage early sexual activity or in later years avoidance of necessary pap smear screening? ..Maurice.

The Answering of Rick Warren’s Questions: Ethics and the Presidency

There already has been much discussion about tonight’s separate TV interviews of the presidential candidates by the Reverend Rick Warren. (Read this link to the New York Times Politics Blog) There seems to be some consensus that, in response to the same questions posed, McCain spoke briefly but more directly and forcefully than Obama whose answers were longer, more analytical and more nuanced but less forceful and seemingly less emphatic. Some feel that, beyond the answers themselves, the way the candidates answered the questions reflects on how they may handle other questions and issues when they become President. Is this a realistic conclusion? If so, what approach, makes a better President (better, for example for this blog, in terms of identifying and mitigating ethical issues), one who acts more directly and forcefully on problems that arise or one who is more analytical and nuanced and less direct and less emphatic? To what extent do ethics play a role in the performance of the President or issues in governing? On the other hand, do you think this distinction is unnecessary since all Presidents don’t apply just one approach but actually handle problems with a mixture of both approaches depending on the situation? ..Maurice.

Hospital Doctors and Staff Must Now Squelch Disruptive Behavior!

The Joint Commission, an organization in the United States which officially accredits and certifies all hospitals for participation in the Medicare program, has recently issued a new requirement to ensure patient safety in hospitals: squelch disruptive behaviors by physicians and other non-physicians on the hospital staff. The “why” and “what” of this requirement is explained in detail, with references, on the Joint Commission’s website and is contained in this extract:

Intimidating and disruptive behaviors can foster medical errors contribute to poor patient satisfaction and to preventable adverse outcomes increase the cost of care and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team.

Intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. Intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions. Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients. All intimidating and disruptive behaviors are unprofessional and should not be tolerated

The Commission requires that by January 2009, every hospital has in place a code of conduct that defines acceptable and disruptive and inappropriate behaviors and that hospital leaders create and implement a process for managing disruptive and inappropriate behavior. Some of the suggestions by the Commission includes: educate all team members regarding appropriate professional behavior, hold all team members accountable despite seniority or specialty and enforce the code of conduct by repeated reminders and punishment, zero tolerance for assault or criminal acts, protecting those who report unprofessional behavior and establish how and when to begin disciplinary actions. Go to the above link and read the entire requirement description.

Obviously, the establishment of what is disruptive and what is not may be difficult to define in some cases but hospitals are going to have to follow these requirements to pass accreditation inspections. I am sure some of my visitors have experienced actively disruptive (vocal or worse) or even passively disruptive (unwilling to answer phone calls or respond to a request) unprofessional behavior on the part of physicians or other hospital staff. There is no doubt that the efficiency and patient safety with regard to the diagnosis and treatment and care of all patients along with attention to their family’s concerns would be improved if “we could all get along.” ..Maurice.

Participating in Torture?:California Doctors Now Beware

Here is a News Release, August 14, 2008,from American Friends Service Committee :

CALIFORNIA BECOMES FIRST STATE

TO CONDEMN USE OF TORTURE IN ‘WAR ON TERROR’

SACRAMENTO, CA – The California Legislature today adopted a resolution aimed at preventing California health professionals from engaging in coercive interrogations of detainees at Guantánamo and other U.S. military prisons.



Senate Joint Resolution 19 instructs the state’s licensing boards to inform California doctors, psychologists and other health professionals of their obligations under national and international law relating to torture. The boards will warn the licensees that they may one day be subject to prosecution if they participate in interrogations that do not conform to international standards of treatment of prisoners.



“The resolution calls attention to the intolerable dilemma that torture presents when those who are supposed to be the healers in our society are involved in the abuse of prisoners,” said Eisha Mason, associate regional director for the American Friends Service Committee, one of the organizations that sponsored the resolution.



State Senator Mark Ridley-Thomas (D-Los Angeles) introduced the resolution in response to evidence that – despite the medical oath to “first, do no harm” – some physicians, psychologists and other health personnel have been complicit in abusive interrogations of detainees by the military and the Central Intelligence Agency.



“As professional licensure and codes of ethics are regulated by states, California has the obligation to notify members of laws concerning torture that may result in their prosecution,” said Ridley-Thomas.



SJR 19 aims to protect the integrity of the health professions and individual practitioners by informing them of their legal and ethical obligations, and giving them a legal reference to remove themselves from abusive situations should they have to contravene the orders of a military superior.



A survey of medical students conducted by the Harvard Medical School, published in the October, 2007 issue of the International Journal of Health Services, found that one-third of the respondents did not know that under the Geneva Conventions, they should refrain from participating in coercive interrogations.



“This is an important advance, not just in the U.S., but internationally as well,” said Dr. Steven H. Miles, professor of medicine and bioethics at the University of Minnesota. “More doctors abet torture than treat its victims, and it is time for them to be called to the mission of medicine—not to practice torture—and to be reminded that they will be held accountable to international law.”



“No government has the authority to legalize torture,” Miles added.



The resolution further requests that the Department of Defense and the CIA remove California-licensed health professionals from participating in coercive interrogations.



“This has been an effort for almost three years,” said Dr. Jose Quiroga, himself a torture survivor and now medical director of Program for Torture Victims, a sponsor of the resolution. “The California Legislature is sending a message to the Federal Government that they are wrong, and I hope that other state legislatures will begin to do this.”



The passage of SJR 19 makes California the first state in the nation to officially condemn the use of torture since the beginning of the “War on Terror.” A measure currently under consideration by the New York State Legislature, which would prohibit the state’s health professionals from participating in the torture or improper treatment of detainees, is expected to pass later this year.



“California’s adoption of the resolution sends a clear message that we are going to live by the principles that this country is founded on,” said Martha Dina Argüello, executive director of Physicians for Social Responsibility – Los Angeles, another of the resolution’s sponsoring organizations. “We will not let fear erode our civil liberties and we will hold health professionals accountable to ethical and legal standards.”



The California State Senate gave final approval to the resolution in a 21-13 roll call vote. On Tuesday, it passed the Assembly 45-31.



“Torture is much more than a political issue,” Ridley-Thomas said. “It is an ethical, moral and spiritual issue that has not only become a shame, but it is an evil in our midst.”



The Los Angeles offices of the American Friends Service Committee, Physicians for Social Responsibility, and Program for Torture Victims coordinated the campaign in favor of SJR 19. The resolution had the additional support, through petitions and testimony, of numerous faith, human rights and medical groups including the California Medical Association.





Press Contacts



Martha Dina Argüello, Executive Director, Physicians for Social Responsibility – Los Angeles
Cell: (310) 261-0073, arguello@psrla.org



The Physicians for Social Responsibility (PSR) was founded in 1961 as a non-profit advocacy organization. Aimed at creating a peaceful and just world through the education of the medical community, PSR serves as a strong reminder of the moral and legal responsibilities of practicing physicians on a national level.





Eisha Mason, Associate Regional Director, American Friends Service Committee – Pacific Southwest

Cell: (310) 528-4229, Email: emason@afsc.org



Founded in 1917, the AFSC has established itself as a successful service oriented peace and justice organization. Founded on principles of the Quaker faith, the American Friends Service Committee has dedicated nearly a century to providing a voice for communities while confronting social injustice through peaceful activism.



Dr, Steven H. Miles, Professor of Medicine and Bioethics, University of Minnesota





Dr. Miles has been a strong advocate and leading expert on medical ethics and human rights for the entirety of his career. As a Professor of Medicine at the University of Minnesota, Dr. Miles is also a faculty member on the University of Minnesota’s Center for Bioethics. The author of three books, Dr. Miles’ Oath Betrayed: Torture, Medical Complicity, and the War on Terror (2006) served as one of the first public accounts of physician’s roles in the continuation of United States torture methods used in detainee camps. Based on meticulous research, Miles was able to unearth the truth regarding the systematic torture of detainees by US military medical practitioners. For his extensive work and commitment to ethical inquiries, Dr. Miles has received the Distinguished Service Award of the American Society of Bioethics and Humanities.





Dr. Jose Quiroga, Medical Director and Founder, Program for Torture Victims

Cell: (818) 943-0598, Email: jquirogamd@aol.com



The Program for Torture Victims served as the pioneer of medical and social services aimed towards torture victims. The organization advocates for the advancement of anti-torture legislation, and has created a safe environment for those who are often alienated and forgotten after trauma and abuse. Dr. Quiroga was originally a cardiologist and the personal physician for Chilean President, Salvador Allende. After the military coup led by August Pinochet, Quiroga was detained and subject to horrific treatment. He managed to escape to the United States in 1977, where he founded the Program for Torture Victims.





Dr. Steven Reisner, Adjunct Professor in Clinical Psychology, Columbia University and Assistant Clinical Professor, Department of Psychology, New York University Medical Center

Cell: (646) 415-1413, Email: sreisner@psychoanalysis.net



Dr. Reisner is a psychoanalyst, a Supervisor at the International Trauma Studies Program, and a consultant to the United Nations on stress and trauma. As a leading activist calling for a ban of psychologist’s participation in interrogations at United States detention centers, Reisner is also currently running for the presidency of the American Psychological Association. He is heavily involved in socially aware theater arts programs, and is the director the Theater Arts Against Political Violence. Reisner’s active stance on socially conscious work has made him an invaluable asset to the California Campaign to Stop Torture.





State Senator Mark Ridley-Thomas

Office: (916) 651-4026, Email (Communications Advisor Fahizah Alim): fahizah.alim@sen.ca.gov



Senator Mark Ridley-Thomas was elected to the California State Senate in November, 2006 after serving two terms in the California State Assembly. Ridley-Thomas also served on the Los Angeles City Council for nearly twelve years. He attended the University of Southern California and received his doctorate in Social Ethics and Policy Analysis. He introduced SJR 19 in the California State Senate.





The American Friends Service Committee is an international peace and justice organization founded in 1917 and governed by the Religious Society of Friends (Quakers). Its programs of peace, relief, reconciliation and development are based on nonviolence and belief in the inherent goodness of all persons. In 1947, AFSC accepted the Noble Peace Prize on behalf of all Quakers worldwide. Its Pacific Southwest Regional Office is located in downtown Los Angeles.

Hopefully, the Bush administration will quickly follow the request of the California Legislature and remove California-licensed health professionals from participating in coercive interrogations." On the other hand Bush may simply ignore the request with "the United States doesn't participate in torture." ..Maurice.

The Physical Examination: Is It of Any Value?

Well, it's time again to teach our first and second year medical students the details of performing a physical exam on patients. But as we do this, there is something in the back of the teacher's mind. What are we actually accomplishing in teaching techniques of the exam? Does what we teach, in practice, provide the doctor with skills that are associated with statistical sensitivity and specificity to make a correct diagnosis? There is uncertainty in this regard, especially since most of what we teach has never been put through the rigorous statistical testing which other diagnostic procedures have undergone. In addition, modern physicians seem to be doing less "hands on" examination to establish a diagnosis and more emphasis on various testing procedures. Well, that is the issue I would like to set for this thread: is the physical exam of any value?

I found an editorial in a 2005 issue of the Medical Journal of Australia written by three physicians Brendan M Reilly, MD; Christopher A Smith, MD; Brian P Lucas, MD. all from Cook County Hospital in Chicago titled "Physical examination: bewitched, bothered and bewildered" which gives a bit of insight into this topic. You can read the entire editorial by going to the above link. The editorial starts out with the following excerpt:

Young physicians today seem confused about physical examination. In the United States, many of them do not know how to do it and do not see why they should. Asymptomatic patients do not seem to need it; the US Preventive Services Task Force found insufficient evidence to recommend periodic physical examination of the breast, prostate, heart or anything else. Sick patients do not seem to benefit much from it either, most of them tested to death regardless of their physical findings. It is hard to say which is the chicken or the egg here, but physical diagnosis instruction in many US medical schools now is either out of date (emeritus faculty members teaching useless arcana like percussion of Traube’s space), out of touch (junior faculty members making rounds in a conference room, not at the bedside), or both.

Young physicians trained outside the US are bewildered about this, too. Many of them, meticulously trained in physical examination, are appalled upon first encountering the “hands off” culture of US medicine. But they learn quickly, in the process often unlearning much of what they had learned before. The pace and clinical impact of this remarkable phenomenon is unknown because no one has studied it, a bewildering thing in itself.

What do you think about the physical exam and your own experiences. Have you been sick but the doctor hardly did any examination? Do you think there is merit in what the editorial's authors wrote later in their editorial 'laying on of hands' improves communication and trust between doctors and patients, somehow 'connecting' them better, not just physically but otherwise." Anyway, I'll be back teaching the physicial examination to the students in a couple of days.. as usual. ..Maurice.

FAQ of Medical Ethics: Answers by AMA

Here are Frequently Asked Question in medical ethics as answered by The American Medical Association. The Answers to each question is available at this link. ..Maurice.

Questions regarding complaints

* Q: How do I file a complaint against a physician?
* Q: What if my complaint is not against a physician, but rather a hospital, health-plan, or non-physician health professional?
* Q: What can the AMA do about a physician I believe is behaving unethically or unprofessionally?
* Q: How can I find out if a physician has had complaints against him/her in the past?

AMA policy

* Q: What is the AMA’s Policy or position on a given subject?


The Code of Medical Ethics

* Q: What is the Code of Medical Ethics?
* Q: How can I order a copy of the Code of Medical Ethics?
* Q: Who does the Code of Medical Ethics apply to?
* Q: What is the difference between the Principles of Medical Ethics, the Fundamental Elements of the Patient-Physician Relationship, Opinions, and Report?

Hippocratic Oath

* Q: What obligations does a physician have under the Hippocratic Oath?

Questions regarding the AMA’s educational initiative on gifts to physicians from industry

* Q: Where can I learn more about this initiative?

Finding a physician

* Q: How can I find a good physician?

Getting medical advice

* Q: How can I find out if my physician is giving me the appropriate medical care or treatment? Can you give me a second opinion?

Returning phone calls

* Q: I have repeatedly left messages for my physician, but he/she does not return my phone calls. Is this unethical?

Medical records questions

* Q: My physician has refused to provide me with a copy of my medical records, or is stating that I will be charged for a copy of my medical records, is this ethical? What if I haven’t paid my bill?
* Q: For physicians who are retiring, leaving a practice, or deceased, what are the responsibilities in transferring medical records and notifying patients?
* Q: How long must physicians keep medical records?

Billing questions

* Q: Can my physician refuse to see me because of an unpaid bill?
* Q: What can I do about a physician who is charging too much?
* Q: What can I do about a health plan that refuses to pay my physician?

Starting and ending the patient-physician relationship

* Q: My physician has said that I will need to find a new doctor, is that ethical?
* Q: Is it ethical for a physician I have never seen before to refuse to see me?
* Q: My physician has moved, and I cannot find him/her. Can you help?

Declaration of professional responsibility

* Q: What is the Declaration of Professional Responsibility?

The Ethical Force Program

* Q: What is the Ethical Force (E-Force) Program?

Research tips

* Q: What help can you provide for students or others doing research about ethical topics?

A Walk to Visit the Doctor: More Visits, More Poverty, More Pills?

From the U.S. Centers for Disease Control and Prevention, here is the abstract of the current publication of estimate statistics of the ambulatory visits to a doctor’s office, hospital outpatient or emergency room in 2006. Read the study. You may read the entire report at this link. If these statistics are valid, what does this suggest to you about ambulatory medical care for the United States? Do you sense anything going wrong that should be corrected? ..Maurice.

Objectives—This report presents statistics on ambulatory care visits to physician offices, hospital outpatient departments (OPDs), and hospital emergency departments (EDs) in the United States in 2006. Ambulatory medical care utilization is described in terms of patient, practice, facility, and visit characteristics.


Methods—Data from the 2006 National Ambulatory Medical Care Survey
(NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) were combined to produce annual estimates of ambulatory medical care utilization.

Results—Patients in the United States made an estimated 1.1 billion visits to physician offices and hospital OPDs and EDs, a rate of 381.9 visits per 100 persons annually. The overall visit rate was not significantly different for white and black persons. However, black persons had higher visit rates than white persons to hospital OPDs and EDs and lower visit rates to office-based surgical and medical specialists. Visit distribution by ambulatory care setting differed by poverty level in the patient’s ZIP Code of residence, with higher proportions of visits to hospital OPDs and EDs as poverty levels increased.

Between 1996 and 2006, visit rates to medical specialty offices climbed overall by 29 percent, with a significant increase noted for white patients but not black patients.

The rate of OPD visits jumped from 25.4 visits per 100 persons in 1996 to 34.7 in 2006, whereas ED visits during the same period increased from 34.1 to 40.5 per 100 persons.

About 18.3 percent of all ambulatory care visits in 2006 were for nonillness or noninjury conditions, such as routine checkups and pregnancy exams.

Seven in ten ambulatory care visits had at least one medication provided, prescribed, or continued in 2006, for a total of 2.6 billion drugs overall. Analgesics were the most common therapeutic category, accounting for 13.6 drugs per 100 drugs prescribed, and they were most often utilized at primary care and ED visits. The percentage of visits at which medication was prescribed increased significantly in most settings between 1996 and 2006.

Hospital Deportation of Chronically Ill but Stable Illegal Immigrants: “Patient Dumping”?

This excerpt from an article by Debra Sontag in the August 3 2008 issue of the New York Times sets the ethical and legal issue. She writes:

Mr. Jiménez’s benchmark case exposes a little-known but apparently widespread practice. Many American hospitals are taking it upon themselves to repatriate seriously injured or ill immigrants because they cannot find nursing homes willing to accept them without insurance. Medicaid does not cover long-term care for illegal immigrants, or for newly arrived legal immigrants, creating a quandary for hospitals, which are obligated by federal regulation to arrange post-hospital care for patients who need it.
American immigration authorities play no role in these private repatriations, carried out by ambulance, air ambulance and commercial plane. Most hospitals say that they do not conduct cross-border transfers until patients are medically stable and that they arrange to deliver them into a physician’s care in their homeland. But the hospitals are operating in a void, without governmental assistance or oversight, leaving ample room for legal and ethical transgressions on both sides of the border.
Indeed, some advocates for immigrants see these repatriations as a kind of international patient dumping, with ambulances taking patients in the wrong direction, away from first-world hospitals to less-adequate care, if any.

The ethical question is was justice served by the U.S. government to place a burden on all hospitals, requiring them to treat all patients who enter their emergency room (including illegal aliens or the newly arrived legal immigrants) , (EMTALA law),not to transfer them until they become clinically stable for transfer to another facility but then ignoring the hospital’s dilemma when they are unable to find another facility for transfer, the patient ending up as a long term resident of the admitting hospital. There is no financial compensation to the hospital by the government for the prolonged stays and chronic treatments, once the patient is stable, if the patient is unable to pay. Of particular complexity is, as described in the article, when the patient is a citizen of another country. There are no federal regulations or state laws regarding how and under what conditions these patients can be returned to their country of origin.

My questions are: how much responsibility should hospitals be given in the final disposition of an illegal alien who has been stabilized and is ready for transfer to a facility for prolonged care but there is no facility to accept the patient since the patient may not be able to pay for such care and there is no payment by the U.S. government? Should the admitting hospital continue to care for the chronically ill but stable patient indefinitely assuming all costs? Should the hospital involved take the responsibility for deporting the patient to the country of origin? Is returning a chronically ill but stable patient to such a country that has lesser facilities for prolonged care essentially “patient dumping”? Should the U.S. government, rather than the individual hospital, be responsible for the cost of medical care and process of deportation of illegal immigrant patients? ..Maurice.

The New Language of 21st Century Medical Care

Do you think, as a patient, all the medical terms you need to know is what is a “cholecystectomy”, “CAT scan”, “CVA”, “stenting” and so on. However, as described in an article in the online Bioethics Forum by Carol Levine there is a host of “new language of healthcare" about which patients should be informed and fluent.

She writes:

What do you call a person admitted to a hospital? If you said “patient,” you’re hopelessly out of date. The person lying there awaiting surgery or recovering from a heart attack is a “consumer.” The person examining the consumer is a “provider.” Depending on the situation, she may be a “hospitalist,” “intensivist,” “proceduralist,” “surgicalist,” or other “ist.” If you’re admitted at night, the provider is a “nocturnist.” Ordinary doctors, who don’t have “ists” after their titles, are seldom seen in hospitals these days.
That’s just one example of how health care language is changing. It’s not enough to know clinical terms; you have to know the lingo of health policy and practice to navigate though the health care system.

This then followed by a test of your HPIQ. You don’t know what is HPIQ? Oh, that’s your Health Policy Information Quotient. Click on the link above and go to the Forum and take the test. If your score shows that you are “health information challenged”, you better get educated since this is now 21th century medical care. ..Maurice.

Addendum 8-4-2008: You may also be interested in reading a thread with comments published in April 2008 about patient translation and understanding of medical words.