Bioethics Discussion Blog: November 2008





Sunday, November 30, 2008

South Dakota Abortion Law: Informed Consent or Political Manipulation?

Read the graphic above (click to enlarge) and then read the free full
Perspective article in the November 20 2008 issue of the New England Journal of Medicine, where the graphic was extracted. In addition, here is another extract from the article explaining the history of the law:

Under a law that went into effect in July, physicians in South Dakota must tell any woman seeking an abortion that she is terminating the life of "a whole, separate, unique, living human being" with whom she has an "existing relationship," that her relationship "enjoys protection under the United States Constitution and under the laws of South Dakota," and that abortion terminates that relationship along with "her existing constitutional rights with regards to that relationship."1 The "informed-consent" law was passed in 2005 but was immediately suspended by an injunction sought by Planned Parenthood, which operates the only South Dakota clinic providing abortions. On June 27, 2008, in Planned Parenthood Minnesota v. Rounds, a divided Eighth Circuit Court of Appeals lifted the injunction, clearing the way for implementation.

The article,describing the law,tells us what is unique, arbitrary, undocumented, and what I think is potentially and unnecessarily stressful for both the woman and the physician. The law itself, as written, shows us how politicians can change the informed consent function of the doctor-patient relationship into informed state moral policy. Instead of taking the proper route of challenging Roe vs Wade as unconstitutional and overturning the previous Supreme Court decision by a vote of the United States public, the politicians are attempting to subvert something which, at present, is constitutional by creating a purposely heavy burden for the physician to bear and the woman to accept in order for an abortion to be carried out. It puts the interests of outsiders wrongly into the doctor-patient relationship. This is my opinion. Read the article and come back and let's read yours. ..Maurice.

Thursday, November 27, 2008

Ethical Reflection and the Caterpillar Who Thinks

“The caterpillar who thinks about how its legs work falls on its chin, the story goes.” The issue is all about reflection and its role in ethics. The quote is taken from an interesting blog thread titled “The Caterpillar Effect in Ethical Reflection” found on The Splintered Mind blog November 19 2007.

This issue raises questions as to whether there are some aspects of life and behavior that we really shouldn’t analyze potential acts or alternatives too closely and we would do better to simply follow our own natural impulses or follow along what others have decided to do. Can unbridled introspection and reflection slow necessary responses and lead to wrong rather than good decisions? Are there not certain decisions that we must make, such as driving our automobile, where we must allow our learned automatic responses to respond rather than reflecting on the implications of what we intend to do as we are driving? Cannot this analogy be similarly applied to making ethical decisions? In clinical ethics, there is the doctrine or principle of the “double effect”, permitting a bad consequence in order to obtain a good effect. You can read all about it at Stanford Encyclopedia of Philosophy website.

An example would be to the treating of pain in a terminally ill cancer patient with morphine with a dose to relieve the pain which might in this patient accelerate the patient’s death. This principle has been expressed in various ways and there have been significant criticisms about the logic or interpretation of the principle.

My question is that when a physician is attempting to relieve the suffering of the patient such as described above, should the physician begin an introspective analysis or reflection of whether the motivations leading to his or her decision is fully in keeping with the principle of “double effect” or if there was the slightest intent to bring the patient’s suffering to a permanent end, rather than simply relieving the pain at the moment. If the latter, would that mean that the morphine should not be administered because the criteria for permissibility of the “double effect” would not have been attained. One can think of other examples of problems in ethical reflection.

I would like to know what my visitors think about reflection and its role in ethics. Is reflection always a good or like the thinking caterpillar simply inhibit doing something necessary? ..Maurice.

Graphic: Photograph taken by me today of clouds and mountains reflected in a puddle of rain water on a muddy path in Towsley Canyon, Santa Clarita, California.

Thanksgiving and the Myopia of Bioethics

Steve Miles, the physician ethicist who has often written to this blog and who certainly isn't myopic reminded a bioethics listserv today with the following truism. I probably am just as guilty as all the rest as I gave thanks today. ..Maurice.

It is Thanksgiving.

For my US colleagues, friends, students, teachers and lurkers on this list,
take the day off. Our musings on

dead brains,
stem cells,
Jehovah's Witnesses,
sperm from dead guys,
and caring people of either gender trying to eek out a living on Gilligan's

should pause so that we may reflect on the significance that our water is so
predictably and universally clean and available from indoor taps at any
temperature we desire that we do not even include it in our thanks or our

A billion people do not have potable water, let alone hot and cold indoor
2.5 million people die every year for want.

Steven Miles, MD

Method to Arrive at an Ethical Decision

On 5-24-2001 I put the following summary up on my now inactive "Bioethics Discussion Pages". As with other postings which I have migrated from the "Pages" to this blog, I add this one. ..Maurice.

The Method to Arrive at an Ethical Decision

This presentation is based in part on a handout by Susan Rubin, Ph.D. and Laurie Zoloth, Ph.D. for a session at the 3rd Annual Meeting of the American Society for Bioethics and Humanities October 26,2000 titled "The Theory and Practice of Clinical Ethics: Charting a Course for Effective Consultation"

In a message dated 4/15/01 7:25:36 AM, wrote me the following: "What do you think are the questions that should come to mind when confronted with a ethical or moral question?"

Since I am involved in hospital ethics committee consultations what he requests is something which also must be of concern to me performing this activity. The questions he asks about are steps in a method for decision-making for ethical issues. Obviously, the method need not only be applied to clinical hospital ethical dilemmas and conflicts but can be used for many other bioethical issues. I wrote him back the following answer to his request:

1) What is the question? Define clearly the question or issue-We should make sure we understand exactly what is asked or what is the conflict.

2) What are the facts related to the question?- This is the most important element and often incompletely obtained.

3) What ethical or moral principles are involved? Consider:

Beneficence-the commitment to do good and promote well being

Nonmaleficience-the commitment to avoid or minimize harm

Autonomy-the commitment to respect the capacity and right of individuals to choose their own values and goals and to decide for themselves what happens to their body and their lives

Justice-the commitment to fairness, to giving each individual his due and to equitably allocate collective resources

Veracity-the commitment to truth telling

Fidelity-the commitment to promise keeping

Community- the commitment of taking into account the needs, interests, contribution and role of the community and acknowledging the way in which individuals are embedded to varous degrees in complicated relationships and broader connections which might not be readily apparent

4) What are the options? What are the answers or actions to take in order to resolve the question?

5) In order to resolve the ethical or moral question and selecting an option of action we must decide which principle, on balance, will result in the more good compared with competing principles. But in making this decision one must also consider the following concerns:

Consequences-the likely impact of each option on all parties involved

Rights-establishing whether basic rights are at stake and considering the correlative obligations

Duties-essential obligations we have for one another

Respect for Persons-value certain actions which lead to human flourishing and to value people who have the potential for such actions

Virtues-which include integrity, compassion, honesty and fidelity

Cost-Effectiveness and Justice-consideration of fairness to be taken into account in weighing the distribution and balance of the benefits and burdens of each option

6) Finally, the decision of the better option can be assisted by utilizing casuistry-Is this ethical question similar to one which a consensus has previously been obtained and therefore should we use that decision in the present question? Or the narrative approach-use of foundational stories to understand the nature of the ethical dilemma and the role and perspective of each stakeholder.

It is important to remember that the answer or option worked out by this method may not be final or absolute but may have to be revisited as time goes on and the facts change.

Monday, November 24, 2008

Anonymity in Blog Publishing: Is It Ethical, Is It Necessary?

The issue I want to present is whether it is ethical to post a comment to a blog as an anonymous writer. Shouldn’t the commenter show the strength of their convictions by taking full responsibility for what the commenter writes? Shouldn’t the reader be provided with a real full name? How else can the reader have the necessary information about the writer to establish whether the writer has changed or modified views from previous commentaries and judge from those earlier commentaries or by public history whether or not the commentator has conflicts of interest which should be considered? And then there is the matter of the tendency toward unethical or illegal ad hominem remarks or libel which is more likely to be written by anonymous writers.

I have found an interesting article about the history of anonymity in the publishing business, it’s rejection in later years and then it’s return as the information media has turned to the internet. The essay “Time to Get Tough: Managing Anonymous Reader Comments” by Vin Crosbie posted 1-26-2006 in the Knight Digital Media Center.

Here are extracts of the essay which emphasizes the need for human intervention in the maintenance of thoughtful and ethical commentary on the Internet and under what requirements anonymity might be used.

Although the technologies of this medium evolve with the speed of "Moore's Law," the actual laws and liabilities governing the technologies evolve about as fast as the eponymous Gordon Moore can walk (he celebrated his 77th birthday this month). That is because the mechanical topic of technology and the human topic of ethics seemingly aren't related to each other. Although we may strive to offer bulletin boards and commentary fields where people might provide thoughtful and ethical comments without scatology, obscenity, or libel, we cannot and will not achieve that through technology alone.

Crosbie also writes:

If you're going to let someone publish something in your publication, whether in print or online, know their identity and read their submission before its publication. If they truly are willing to stand behind their words, then they must be willing to withstand identification by the publisher who has legal responsibility for the publication of their words.
If they request that the publisher disguise or omit their identity in publication, let them first provide the publisher with a cogent reason. (The publisher should state somewhere on the page's boilerplate that a writer's name may be withheld for reasons but only after prior identification.)

What do you think about whether anonymity by visitor commentators or even blog owners is appropriate in blogs generally, in medical blogs specifically or particularly on my bioethics blog where there has been extensive ventilation within topics of concern by my visitors? ..Maurice Bernstein, M.D.

Sunday, November 23, 2008

U.S. Doctors: Getting Paid the Old Way-- by the Patient

Dr.S.Smiley Thakur writing in the November 21, 2008 Seattle Post Intelligencer sets the tone for the column titled "Why Doctors Can't See You Now" with:

Physicians have been keeping a secret from you: The practice of medicine simply isn't a viable business. This reality affects not only the availability of doctors to care for patients, but also the quality of delivered care. After 10 years in full-time clinical practice, I decided to stop accepting Medicare and all private insurance. Such a move seems illogical to physicians and patients, but was made to preserve patient access to quality care. Physicians who don't come to the same conclusion risk going out of business.

Read the column and then come back and let us know your opinion, whether you think that Dr. Thakur is on the right track regarding the facts and consequences or that government and insurance companies should continue to play a role in the financing of medical care and the doctors should continue to participate with these systems.

Do you think that doctors should go back to the old days where each patient was responsible to pay the doctor out of his or her pocket and the doctor was beholding to nobody except the patient? ..Maurice.

Graphic: Digital photograph by my wife 11-24-2008.

Friday, November 21, 2008

Thriving vs Surviving: Should One Trump the Other?

“Thriving vs surviving", it all comes down to the issue as to whether the patient’s life is worth living (thriving) in the view of the patient. Take for example the scenario I posted in October 2006 which was based on a real case.

After 4 years on the ventilator, the 34 year old quadriplegic finds nothing to encourage him to live longer in his current condition. He lost his girl friend and no longer can be a motorcycle officer and is fully dependent on others to care for him. He is requesting that the physicians withdraw his life supporting ventilator treatment. The decision seems clear when the patient is conscious and has the capacity to make his own medical decision. But is not always accepted by the physicians as what occurred in the scenario presented.

Hospital ethics committee experience is that the decision is much more difficult to establish when the patient is unconscious and may never awaken to tell the physicians what “thriving” means to the patient’s own life and whether life supportive treatment should be continued or discontinued. The committee must look to family members or friends who know the patient and may report on what their sense is of the values in life for the patient so that some decision can be made.

On the other hand, do you think that under all circumstances including even the conscious patient but especially when the patient is unable to communicate, that the morally correct decision would be that surviving always trumps any consideration of thriving? ..Maurice.

Graphic: Digital photograph taken by me today.

Thursday, November 20, 2008

The Ethics of Refusal: Well, Should They?

From the New York Times, November 17, 2008: "WASHINGTON — A last-minute Bush administration plan to grant sweeping new protections to health care providers who oppose abortion and other procedures on religious or moral grounds has provoked a torrent of objections, including a strenuous protest from the government agency that enforces job discrimination laws.

The proposed rule would prohibit recipients of federal money from discriminating against doctors, nurses and other health care workers who refuse to perform or to assist in the performance of abortions or sterilization procedures because of their “religious beliefs or moral convictions.”

In addition, "It would also prevent hospitals, clinics, doctors’ offices and drugstores from requiring employees with religious or moral objections to 'assist in the performance of any part of a health service program or research activity' financed by the Department of Health and Human Services."

This rule has stimulated much bioethical discussion. Steve Miles, physician ethicist who has contributed frequently to my blog answers the following questions with his own questions:

Should physicians and other medical professionals be required to perform
procedures they view as morally problematic or prohibited?

Should physicians and other medical professionals be protected from employer
dismissal, sanction, or other disciplinary action if they refuse to perform
procedures they view as morally problematic or prohibited?

Doctor Miles wrote:

"And I add five more (and in the way of not privileging the conscience of

Should Islamic cab drivers be forced to take someone from an airport if the
fare is carrying alcohol purchased in Barbados.

Should a Seventh Day Adventist be allowed to work in a lab facility and
selectively refuse to type blood for transfusions?

Should a Hassidic Jew be allowed to be a grocery cashier and selectively
refuse to handle, scan and ring up sales of pork chops?

Should a Mormon be allowed to wait tables in a restaurant and refuse to
carry hot coffee to patrons or bus coffee cups from tables?

Should a Baptist Creationist be compelled to teach Darwin?"

Does any visitor here want to answer the first two questions or any of Steve's questions? ..Maurice.

ADDENDUM; 11-21-2008 Steven Miles would like to add two more questions to his list of five posted above. Here they are:

Should an anti abortion banker be allowed to refuse to process payroll checks from a Planned Parenthood clinic?

Should a Quaker family be allowed to refuse to pay the portion of their taxes that go for war?!

What Medical Students Should Learn and Doctors Should Know about Ethics and Professionalism in Medicine

Behaving in an ethical and professional manner should begin in medical school and continue uninterrupted into active practice as a physician. Understanding each other, healthcare providers and students in the medical profession and understanding the concerns and views of patients and their families is an essential requirement to make decisions which are good, in the best interest of the patient and avoid unneeded conflicts.

I have created a list of what I think are important issues and terms that students should learn and physicians should also know and consider. Many of these issues and terms I have already incorporated into threads which discuss them. (Enter the term or issue into the Search field at the top of the page to get to the thread.) Some of my visitors may come up with other issues which they feel are important for doctors to be aware of and act upon them.

As a student or as a physician we should, as we care for or attend to our patients:

1) Be aware and consider the clinical situation from the viewpoints of all the stakeholders in the medical care of the patient: medical student, intern/resident, attending physician, patient, patient’s family, nurses and hospital administration. What are the healthcare interests of each and specifically the self-interests of the healthcare providers and the families?
Each will have different interests and interact differently with each other. Also consider what are the power inequalities between the stakeholders and how would this affect communication and decision-making.

2) In medical training institutions, all participants should be made aware of ethical issues within the training hierarchy. As examples, the “hidden curriculum” (teaching by superiors of their own view of professional behavior). Another is the need for humanistic behavior such as the identification of patients by including their name and not simply their disease or room number, attention to the patient as a subject and not an object when making rounds with the need for communication with the patient, caution about group discussions in front of the patient and attention to patient modesty. In addition there should be humanistic treatment of the medical student as a colleague in the healthcare team and the prevention of medical student abuse.

3) Distinguishing between withholding life support and withdrawal of life support, killing vs letting die, patient autonomy vs physician paternalism, capacity to make medical decisions vs competency. With regard to the latter, understand how a patient’s capacity to make their own medical decision is determined and by whom.

4) Consider examples of unsatisfactory communication between physicians and their patients, patients’ families, physicians and nurses and between physicians themselves which could lead to misunderstanding and conflict.
Students and physicians should also be alert to and identify “mixed messages” sent by consultants (consultants each giving conflicting prognoses) to the patient or the family.

5) All stakeholders including patients and their families should be able to distinguish between a Living Will, Advance Directive, Durable Power of Attorney for Healthcare and in states where it is law POLST (physicians Order regarding Life Sustaining Treatment).

6) All stakeholders should understand the role of the hospital ethics committee including what the committee can do and what the committee shouldn’t do.

7) All stakeholders but particularly students and healthcare providers should be watching to pickup instances which would suggest that a pro-active request for clinical ethics consultation would be appropriate instead of waiting until the management course leads to a climatic conflict.

These are my suggestions for the education of medical students and education or re-education of physicians as they move up to training ladder to and including full and independent practice of medicine. Obviously, there is much more including physician relationships to pharmaceutical companies, clinical research on patient-subjects and the ethics of "bedside rationing" and utilization of scarce resources. And as I stated, my visitors having experience as patients or families of patients may have other important issues that need the attention of students and physicians to ensure the best in ethical behavior and professionalism. ..Maurice.

Monday, November 17, 2008

Redefining Withholding and Withdrawal of Life Support: Patient Autonomy vs Jewish Religious Law

As used in clinical ethics, withholding of life support means that a treatment or procedure which could keep a patient alive who, without the treatment, would die is not given or performed. Withdrawal of life support is an expression which means that a treatment or procedure which is currently being applied to a patient and which is keeping the patient alive is stopped and not resumed. Both the withholding and withdrawal of life support have been accepted by the ethics community and by law in the United States and elsewhere in the world as ethical and legal for patients or their surrogates who have autonomously requested them. It is the consensus that both withholding and withdrawal are equally ethical. However in some religious and non-Western cultures, this may not be so.

Even in the United States, some physicians, healthcare providers, patients and families may not fully accept the absence of ethical distinction between withholding and withdrawal. Withholding is then considered a passive act and in appropriate cases and at the request of the patient is acceptable. There is also the possibility that, with some treatments or procedures, in the specific patient, the treatment/procedure might not even be life supporting in the first place. Withdrawal, on the other hand, may be considered as an active action. In this case, a treatment or procedure which has already been shown to be effective in supporting the patient’s life is being terminated with the intent and understanding that, as a consequence, the patient will die.

It is this conflict and the relationship to patient autonomy vs Jewish religious law that was written about by Vardit Ravitsky in a February 2005 issue of the British Medical Journal titled “Timers on Ventilators”. The following extract details the issue as interpreted by the Jewish religious law called the Halakha.

Within Halakhic literature, withholding treatment at the end of life, generally perceived as a permitted noninterference in the natural process of dying, is traditionally distinguished from interventions involving direct contact with the body or immediate environment of the dying person—for example, the withdrawal of treatment that has already started. This distinction stems at least in part from the religious approach that humans should not have an active role in the dying process, which should remain in the hands of God. Jewish religious law does not approach the issue from a consequentialist perspective, where the moral value inheres only in the end result. Rather, the procedure leading to the outcome has independent moral value.

The Halakhic literature reasons using a metaphor of the dying person as a "flickering candle," and the idea that one should not be "placing one's finger on the candle." In his book Alternatives in Jewish Bioethics, Noam Zohar notes that "this clearly excludes an understanding of the forbidden hastening of death in consequentialist terms: the deed's wrongness is not determined by its result—namely, the fact that the patient is dead at a certain earlier moment—but rather by its symbolic characterisation as extinguishing the candle." This means that withdrawal of treatment is perceived as forbidden even if the death of the patient at that point in time is an ethically appropriate outcome.

To resolve this issue, an Israeli committee was formed in 2000 and in 2002 came up with a proposed law with regard to life support by ventilator. It revolves around a declaration that life support should be distinguished between “not continuing discrete treatment" (treatments which are potentially intermittent) which would be considered as “withholding life support” and “not continuing continuous treatment” and which would be considered as “withdrawing life support.” By this definition, patients would be able to order the termination of discrete treatments by not resuming the next treatment (such as dialysis) but not continuous treatments such as the ventilator. However, if the continuous treatment could be established in advance as discrete by, for example, applying a timer to the treatment the treatment would now become discrete and the patient could request that when the timer expired it should not be restarted. This explains the title of the article. The proposed law, according to information I have received as I post this thread is that the law is not as yet in effect. Read the article and then come back and discuss your view of withholding and withdrawal and the Israel committee’s solution to preserve autonomy and yet hold to Jewish religious law. ..Maurice.

Friday, November 14, 2008

A Developing Reproductive Technique: Eggs from Sperm and Sperm from Eggs: Should This Technique be Available to Homosexual Partners?

John Howard posted a comment on the thread “Ethical Analysis:Sperm and the Pregnant Dead vs The Politics of Healthcare“
But offered a new topic for discussion as he wrote the following:

I wonder if you'd be interested in discussing the ethical issue I've been obsessed with for years now: same-sex conception, using genetically modified gametes. I see this as being the core question of the marriage debate, and think that we should be considering it right now while we debate gay marriage. If we decide to allow same-sex conception (attempting to create genetic offspring from same-sex couples), then we should allow same-sex marriage, if we don't, then we shouldn't, so that marriages continue to protect the right to conceive together with the marriage's own genes.

To get deeper into the ethics of a new potential for fertilization: creating sperm from a woman’s ovaries and creating eggs from a man’s sperm and it’s implications, I found the following in the February 2 2008 issue of NewScientist discussing the matter, particularly noting that there is an amendment pending to the British law governing fertility clinics regarding permission for invitro fertilization with sperm and cells grown in the lab. However the amendment, if passed, “excludes the use of female sperm and male eggs, outlawing same-sex reproduction and discriminating against gays and lesbians.”

The ethical issue is whether it is just for there to be discrimination in the application of this developing technique, if safe, to homosexual couples? The issue is that simple.. or is it? ..Maurice.

Graphic: Visual by

Thursday, November 06, 2008

Humanism and Pathology: The Anatomy Lesson

The following essay was written by physician ethicist Steven Miles who gave me permission to post the full text here. It was originally published in Clinical Anatomy 4:456-459 (1991) and then reprinted in the APA Newsletters, Spring 1999. The essay I think presents the reader with an understanding of the humanistic significance of the pathologic examination on the deceased person as well as the ones who are still alive. Doctors are not dealing with a “lump of flesh” either in the dead or living but with a human being who while alive permits themselves to “submit to procedures which in other circumstances are assaults” and who, in death, becomes through a “family’s gift” of their loved one a source of anatomic and pathologic education but also including as Dr. Miles writes “a special honor” for those who are “just beginning to learn the profound decorum that is due those who entrust their loved ones or themselves to our gaze.”

As you see, there should be something beyond simple objectivity when physicians apply their discipline and professional skills on their human patients. ..Maurice.

The Anatomy Lesson
Steve Miles
Hennepin County Medical Center
Center for Bioethics, University of Minnesota

At first, I did not really see my cadaver’s face. It was not that I avoided the encounter; it was just that the face was so unrevealing. Preserving fluids slightly swell the tissues of the face so that wrinkles—the recorded history of expression, mood, and outlook—were stretched smooth and not so obvious to my untrained eye. Death ablates the subtle, vital expressions which we learn to read so carefully. Purple-grey paints over the clue of skin color: the tan of an outdoors man whom I would learn to approach forthrightly, the pallor of chronic illness which I would later see as an omen of wariness at yet another doctor, the blush that would call for extra attention to drapes during an examination, or the blanching at my inquiry into a mortal condition which would come to alert me that reassurance is needed and will not be heard. A face is a message that we read at a distance. If it tells us nothing, we skim by to other things.

The hands are different. We know a person’s hands by active, intimate encounter. We hold hands. We shake hands. We speak of handicraft. Thoreau and Marx both spoke of life lived by the work of hands, rather than by the rational manipulation of things or others. Action and encounter is the essence of hands; their stillness emphasized his loss.

These were middle aged hands, thick callouses showed him to be a working man. An amputated index finger suggested some danger in his work; the calloused stub showed that his manual labor did not stop simply for loss of his finger. He was a man of tools, of practical things; clinicians are practical people too. I could not help but wonder what else these hands had done in his 50 or more years: the child they had held or how they had made love. As I dissected the hands, I marveled at the intricacy of the muscles and nerves which are capable of such expressiveness but which, of themselves, express nothing.

By the time I got to the face, I could see the signs of past expression. Fillings were the work of another colleague. A tattoo said that he had been in the Navy. His teeth and his fingers were stained nicotine brown, his lungs black with carbon. The appendix was gone, fibrosis showing the handiwork of a colleague who had come here before me. His body bore no stigmata of chronic disease; death had come suddenly. Coronary artery disease was present. There were no other clues.

And how had this man come to me? Dying was not sufficient; a gifting had also occurred. Since he had died suddenly, it must have been others who knew this man of tools, who had made this gift in his memory. It has not always been so. For the larger part of the history of our profession, we learned anatomy by theft, by secret deals for stolen bodies, or from the unclaimed bodies of criminals or of persons without families who died in public places. In the 19th century, bodies began to be gifted. Learned men donated their heads for their colleagues’ urgent scrutiny; Walt Whitman’s brain was disappointingly small (Gould, 1981).

The gifting of cadavers was not simply a political reform of irregular or criminal acts. It was a social response to a remarkable event in the 19th century when we learned to see with what Foucault calls the "clinical gaze." (Foucault, 1973). Before the gaze, physical signs were just signs. Like astrology, signs were a readable phenomenon which foretold a clinical future and suggested some dismal constellation of traditional, ritual therapies. But these signs and therapies were not causally related to the morbid process. A hint of the impoverished medical view of the plague which killed a third of Europe (Gottfried, 1983), survives, as a nursery rhyme: "Ring around the rosie, pockets full of posie, ashes, ashes, we all fall down. " The dramatic invention of the clinical gaze of pathophysiology was the invention upon which modern medicine (asepsis, Koch’s postulates, and DNA probes) is based.

Ring around the rosie---Beginning with a benign appearing well-circumscribed, erythematous, carbuncle at the point of entry

Pockets full of posie---The infection quickly spreads to produce large pus-filled lymph node abscesses, leading to

Ashes---The blackish spots of embolizing infection, or perhaps

Ashes---The blue-gray pallor of peripheral cyanosis of impending shock or of the hypoxia of the pneumonic plague, until . . .

We all fall down---Death inevitably follows.1

The abscess was the focus of the most productive early research. Its wall became recognized as the remains of normal cells that had died and the start of a defensive scar that failed. New entities (Koch’s tubercles) could be seen in the debris, the abscess cavity, and within still living cells. The front of cell death spread outward, the patient unaware (without signs or symptoms) until the dying front of the abscess ruptured into a bronchus producing purulent sputum or a pulmonary artery with catastrophic hemoptysis. A hidden sequence of cause-effect, cause-effect, cause-effect preceded signs and symptoms, made them interpretable, and pointed to intervention.

Pathophysiology is the foundation of our claim to efficacy but it demanded a steep price of society and patients. To receive its benefits, patients had to surrender their own sense of the meaning of illness, and suffering and wellness to our radically abstract interpretation of their need and experience. In recognition of the value of this new invention, society made a gift of what we had previous stolen or picked up as refuse. Because pathophysiology demands such a surrender, our abstract clinical objectivity is the foundation of our efficacy but not of our honor. Our honor rests on the trust that we will hold our profound clinical objectivity accountable to the fundamental conviction that patients are persons (Kass, 1985). We may only pretend that our patients are objects or mechanisms.

Clinical objectivity is not truth. It is a temporary expedient, a tool, in service of the patients’ humanity. Our patient’s trust that we do not really believe that they are objects leads them to submit to procedures which in other circumstances are assaults (with knives), and poisonings(with carbolic acid or curare), and sexual crimes, and to questions which are beyond the most intimate family conversation. Patients become angry and frightened and even leave medical care when we forget ourselves and take our tools to be the essence of our compassion.

A family’s gift of the bodies of those it loves to the relentless objectivity of the anatomy laboratory is the highest mark of their respect. It is special honor that this gift is made to those who are just beginning to learn the profound decorum that is due those who entrust their loved ones or themselves to our gaze.

Over the months, we dissected my cadaver until little remained but sliced flesh on bones. It was hard to take his hand in mine and dissect it. I dreamt of his hands. He departed as he came: nameless in a plastic bag dropped into a gurney. It bothers me that I could not say, until now, how grateful I am.

My speculations about my cadaver’s life are only speculations. Their factualness is of no consequence. It was my way to cope with the shock of the anatomy laboratory (Penny, 1985). But, within limits, this personification of my cadaver is healthier and truer than coping with human dissection by pretending that a cadaver is merely a lump of flesh (Bertman and Marks, 1989). Pretending the cadaver is just flesh is not true. Such a pretence will not ease your disquiet and if it does, you, your patients, and our profession will be the worse for it.

The anatomy laboratory recapitulates both the history and the present moment of medicine. A person voluntarily disrobes and is objectified; insight is gained and put to the pursuit of wholeness. Thus, properly viewed, the anatomy laboratory is a clinical encounter—a doctor and a willing human being.

Bertman, S.L., and S.C. Marks. 1989. The dissection experience as a laboratory for self discovery about death and dying. Clin. Anat. 2:103-113.
Foucault, M. 1973. The Birth of the Clinic: An Archeology of Medical Perception. New York: Vintage Books.
Gottfied, R.S. 1983. The Black Death: Natural and Human Disaster in Medieval Europe. New York: Free Press, p. xiii.
Gould. S.J. 1981. The Mismeasure of Man. New York: W.W. Norton, p. 92.
Kass, L.R. 1985. "Thinking about the Body." In Toward a More Natural Science: Biology and Human Affairs. New York: Free Press, p. 276-298.
Penny, J.C. 1985. "Reactions to human dissection." J. Med. Ed., 60:58-60.

1. Like most folk literature, the origins, original working, and even meaning of this rhyme is debated. Most scholars unhappily agree that it is about the plague. "Pockers full of posie" may, however, have referred to sachers of clove and other spices that were worn over the nose to prevent infection. "Ashes, ashes" may have originally been something like "Ah-shoo, ah-shoo" or "Ti-shoo, ti-shoo" evoking the sneeze from pneumonic plague. A minority of scholars with more pleasant thoughts suggest the rhyme is a courting dance and that "all fall down" is a curtsy.

Wednesday, November 05, 2008

Without Surrogates: Who Should Give Medical Permission if the Patient Can’t?

Picture this: An elderly man is brought to the hospital by the paramedics who police found living in a large cardboard box under a freeway overpass. The patient is unconscious and a workup shows that he suffered a head injury with some brain hemorrhage. There is also some damage to a foot which may represent early gangrene. Because he is not breathing adequately on his own, in the emergency room a tube was passed down into his trachea toward his lungs and he was put on the respirator for ventilation. He has no identification found in his clothing and there were no people in the area where he was found that admitted knowing him. It is too early for the doctors to know what will be the patient’s clinical outcome and when, if ever, he will be alert enough and capable of understanding his condition or treatment to have the capacity to make medical decisions about himself.

The doctors have performed some emergency procedures including inserting IV lines and inserting the endotracheal tube but they are concerned regarding who will give them permission to perform some more routine procedures, though having some risks, such as performing a tracheotomy (surgically opening a hole in the neck and trachea) to facilitate the ventilation process and to insert a tube through the abdomen into the stomach for feeding rather than continuing intravenous feeding. Further, if the patient is to survive, it may be necessary to amputate the gangrenous foot.

The question the doctors ask the ethics committee is who is going to give permission for them to perform the tracheotomy, insert the tube for longer term feeding and to authorize the necessary amputation of the slowly progressing gangrenous foot. For patients who are unable to make their own decisions and there is no individual, representing the patient, to give permission for the surgeries. there have been no legal guidelines regularly followed in the United States to answer their question. One possibility is to request from the courts the appointment of a legal guardian that would make such decisions. That guardian would make this unfamiliar patient one of many dozens of patient cases on that person’s workload. The guardian may not have time to visit and follow the patient closely enough to make judgments which should be in the best interest of that particular patient. There also may be delays in providing a decision. Other possibilities which have been considered is for the attending doctor simply to decide for the patient alone or as has been a common practice for two physicians to agree that the procedure is necessary and should be performed. There are some suggestions that hospital ethics committees or a hospital “surrogate” committee should take the responsibility for making decisions and giving permission for patients in their hospital who have no family or legal surrogates. In all of these examples, the possible conflict of interest issue is present, even in the case of the court appointed guardian who may find that keeping the patient alive longer despite clinical futility is of personal financial value.

This issue regarding who should make medical decisions for patients without capacity to make their own decisions but also without friends, family or surrogates who know them is the issue all ethics committees have worried over and have been trying to come to a answer that would represent the best,most just and efficient decision making for such a patient.

I think that the public should help the ethics committees by providing their views of the issue. As a chairperson of a hospital ethics committee, I ask for your help. ..Maurice.