Developing an Ethics Topic By Looking at a Picture

This is the last day of the year 2008 and I have posted 650 threads on this bioethics blog in the past 4 ½ years. Most of them are more or less unique from each other on subjects regarding ethics in medical practice and medical education. I have been asked how I think of a new subject to write about. My answer is that much is based on my own experiences as long time chair of a hospital ethics committee and long time physician and teacher of medical students. I find some topics in medical journals, ethics journals and the news media. Some topics I get from what is being discussed on a bioethics listserv to which I subscribe. Since publishing photographs on this blog was made practical, I have tried to relate the subject I have written about with a particular graphic, hopefully to emphasize a point. However, another way that I use graphics is to start with a graphic and then think out what ethical issue that graphic might instill in me to write about. This approach is much more stimulating and represents, perhaps, an important way of looking at the world around us in terms of ethics.

So for this thread, I would like to perform a bit of an exercise or experiment in thinking about bioethics. I present the graphic below for my visitors to look at carefully, think and then come up with what they feel would be the best ethical issue that the graphic might illustrate. Perhaps, the issue might be one of the hundreds I have on this blog or perhaps it might be a totally new topic. If you take me up on this challenge, write a bit about what contributed to your decision.

And since is a discussion blog, if you disagree with the conclusion by a former visitor, explain your disagreement.
..Maurice.

Return of Research Results: Would You Really Want to Know?

Pretend that you are part of a medical research study. If you are now really part of medical research study, your consideration and response to this thread should be even more significant. Pretend that you are part of a study to detect the frequency of a gene within a population that can cause a severe and fatal neurologic disease if you have that particular gene. Somehow, the researchers found that you are part of a population of people that they would like to study. And they ask you to participate. It would take only a few drops of your blood and only a few minutes of your time and you would get a participant button to wear on your coat. By being a participant in this genetic study, you would be doing an altruistic thing by contributing to the knowledge about the disease, specifically how common the genetic abnormality is present. Sounds simple enough, doesn’t it? Want to be a participant? It’s free.

By the way, you do understand that you are a participant, not really a subject since you are not needed for the study after the blood is taken and actually after a few demographic details are obtained you can leave. The results obtained from your blood will be part of pool of 4999 other participants and will be published in the genetic literature as the percentage of participants with the gene abnormality in that 5000 participant population. Still sounds simple? No muss. No fuss. No risk? Risk? Maybe.. what if you just happened to be one of the 0.5% whose blood was found to contain that gene that might cause you to develop a severe neurologic disease in the next dozen years. Would you have wanted to know the results of your own blood test as to whether you had that abnormal gene? Would you want to know whether you had a risk for a disease you really don’t know much about? Would you want to know the result of your blood test if what you do know is that the disease may occur in family members? Would you want to know the results if it was required that you report them to your medical or life insurance companies? Would you want to know if you also knew that there was no current treatment for the disease and is always fatal after a year or so of symptoms?

Would your decision to know the result be affected by knowing that it would cost time and money to the research program to locate the results of your test amongst the 5000, to be sure the results were valid, by retesting, and then by providing professional counseling for you when the results of your test are revealed?

Finally, let’s suppose nobody asked you to participate. Your blood had been already taken years ago for some medical problem or other and was held without your knowledge in a blood bank storage for later research or whatever and was pooled with hundreds of thousand others tubes of blood and now used for this genetic survey. Your blood is out there and has been tested for the gene and some technician found the result, knows the result but you are virtually anonymous and you will never know. If you never knew that your blood was tested for the gene, there would be no reason for you to want the result. Right?

These questions are not philosophic rambling but actually current practical ethical concern in these days of research into the genetic basis for many of the known disorders such as Parkinson’s Disease, Huntington’s Chorea and other neurologic and non-neurologic diseases. How much should a participant or a subject patient in a clinical trial be informed about their own test results or the final results of the clinical trial? This issue is discussed in a series of articles in the November 2008 American Journal of Bioethics. But let’s begin a discussion here about your views since it will be the public’s input that will set the ethical criteria for these research studies. ..Maurice.

Partially Misplaced Sympathy: Should the Doctor Get a Little?

To extend the discussion of the role of physician apology in the doctor-patient/family relationship, I would like to bring up another issue which is related.

Should all the sympathy be offered only to the patient or family who have experienced or suffered the results of a medical error or the failure, despite efforts by both the physician and the patient, to attain a cure? If so, considering the fact that the physician is an integral part of the relationship, is human, has feeling and conscience, that limiting all the sympathy to the patient or family, is in reality misplacing some of the sympathy. Shouldn’t some of it be directed toward the physician?

The public should not assume that physicians are not emotionally involved in the symptoms and course of a patient’s illness. Physicians are very much involved in the need to feel that have contributed to the patient’s well-being, to support their own feelings for professional self-confidence, to promote their own professional work to other patients, to avoid personally damaging incidents leading to malpractice suits or loss of license to practice. Even beyond these ego centered reasons, there are the humanistic feelings of empathy if not simple sympathy for their patient.

If yours or a family member’s disease did not end happily or the doctor made an error in judgment or technique, would you find that you could transfer some of the sympathy offered by others to you—to your doctor? ..Maurice.

Graphic: Photograph taken by me on 12-26-2008 at Descanso Gardens, La Cañada Flintridge, California.

"I Hate Doctors": Chapter 2

With regard to how patients size up their doctors on this thread I take no sides but I am interested to read the facts which lead to this emotional response. Ventilation is great..but as I have repeatedly noted on this blog, ventilation to blog visitors is less constructive then letting your doctor know how you feel and particularly explain to him or her why you feel this way. Remember posting to this thread--no names of doctors, nurses, hospitals, etc. No names please.

ADDENDUM 3-10-2009: I think the following Essay is of value for patients to take into consideration factors that lead to an unprofessional doctor and subsequent patient anger and what doctors ought to consider.

TEXAS MEDICAL BOARD BULLETIN
The newsletter of the Texas State Board of Medical Examiners
Fall 2004 Volume 2, No.1

On the Sagging of Medical Professionalism
by Herbert L. Fred, MD, MACP

For the past two decades, medicine has been a profession in retreat,plagued by bureaucracy,by loss of autonomy,by diminished prestige,and by deep personal dissatisfaction.' These ills would be bad enough by themselves.But another malady confronts us-the sagging of our professionalism.

Medical professionalism defies precise definition. Fundamentally, however, it boils down to service in the patient's best interest. Among its central elements are (1) commitment to excellence; (2) altruism, with service before self-interest; (3) avoidance of harm; (4)trustworthiness; (5) pursuit of truth based on scientific and humanistic criteria; (6) close cooperation with others in the health care field; and (7) humility.2

In this essay, I address our sagging professionalism and offer my thoughts on its clinical manifestations, consequences, causes, and cures.

Clinical Manifestations and Consequences

To me, the most common, and yet most subtle expression of betrayed professionalism is
serving ourselves before serving our patients. By doing so, we sacrifice the very core of doctoring humanism. And as a result, the patient-physician bond becomes weakened-or never even forms. Additional manifestations include abuse of power, arrogance, lack of conscientiousness, and conflicts of interest.3
Certain other types of behavior deserve special attention because they are sometimes
interpretable as being dishonest.4 Failure to take charge is a common example. In such cases, the attending physician shirks his or her responsibility, deferring to an army of consultants, each managing a part of the body with no one managing the whole. This buck-passing5 frequently leads to a host of ill-advised activities-more consultations,inappropriate testing, undocumented diagnoses, over-prescribing of medications, uncalled-for procedures, needlessly prolonged hospitalizations, and unnecessary office visits.The consultants in these cases commonly shirk their responsibility as well. Although ideally positioned to halt this medical merry-go-round, they ride it instead. Moreover,those with a "gimmick" use it, even when they know it isn't indicated. And let us not forget the fraudulent reimbursement claims to Medicaid and Medicare or those physicians who, attracted by remuneration and perhaps by a desire for public recognition, serve as expert witnesses even though they clearly are not qualified for the role.
Finally, most physicians simply remain silent when they know or suspect a colleague to be emotionally disturbed, a substance abuser, or just plain incompetent. This reluctance to get involved is particularly deplorable when they know or suspect that an associate is cheating or lying.

Causes

Clearly, numerous factors contribute to our sagging professionalism. Heading the list in my opinion is a change in society's overall priorities and values. Old-fashioned hard work, devotion to duty, and pursuit of excellence have taken a back seat to an emphasis on limited work hours and quests for financial and other types of personal gains. As a result, people at all levels-including many physicians-are satisfied with mediocrity. In fact, mediocrity has become the standard. Given this environment, no wonder our professionalism sags.
External forces largely beyond our control also playa role. Examples are the myriad
constraints imposed by insurance companies, the incessant pressures resulting from
federally mandated regulations, the glut of "for-profit-not-for-patient" hospital administrators,the lawsuits lurking around every corner, and the reams of paperwork
required. Attending to these various demands cuts deeply into the time we could
otherwise spend attending to our patients. And complicating the picture are human
frailties; especially ignorance, greed, fear of being wrong, and the need for
aggrandizement.

Cures

Can we remedy our sagging professionalism? Only-Insofar as we are wiflfrigto be role
models of integrity and honesty for each other. Only if we show commitment,
compassion, competence, candor, and common sense. Only if we understand and
believe that medicine is a calling, not a business. Only if we strive diligently to restore,preserve, and promote the human element in medicine. Only if we look at, listen to, and talk with our patients, working as hard and as long as it takes to ensure their welfare. Only if we always put our patients first.

Final Thought

I leave the reader with a quotation from Bela Schick (1877-1967), renowned
Hungarian pediatrician and bacteriologist: First, the patient, second the patient, third the patient, fourth the patient, fifth the patient,
and then maybe comes science. We first do everything for the patient 6

Not only do his words capture the essence of this essay, but they serve to remind us
of the ruling principle of our profession.

References
1) luger, A. Dissatisfaction with medical practice. New Engl J Med 2004; 350:69-75.
2) Bryan CS, Brett AS, Saunders DE Jr, Khushf G, Fulton, GB. Professionalism. In:
Medical Ethics and Professionalism: A Synopsis for Students and Residents. Center for
Bioethics and Medical Humanities. University of South Carolina; 2004: 13.
3) ibid, p. 14.
4) Fred HL, Robie P. Dishonesty in medicine. South MedJ 1984; 77:1221-22.
5) Fred, HL. Passing the buck. South MedJ 1982; 75:1164-65.
6) Strauss MB. Familiar Medical Quotations. Boston, Mass: Little, Brown and
Company; 1968:374.

Dr. Fred is a Professor, Department of Internal Medicine The University of Texas Health Science Center at Houston. He received the American College of Physicians
Distinguished Teacher Award for 2004. The Board thanks Dr. Fred for providing this essay.

This is Chapter 2. The first chapter can be reviewed at this link. The first chapter has reached such a number of responses that I think it is wise in order to simplify reading the commentary and not to lose comments as has happened with very large number of comments on other threads, I have now closed the first chapter to any further posting. Continue the discussions here. ..Maurice.

Graphic- An appropriate example of feelings for this thread from Ploomy.com

NOTICE: AS OF TODAY AUGUST 26, 2010 "I HATE DOCTORS: CHAPTER 2" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON “I HATE DOCTORS: CHAPTER 3."

Patient Modesty: Volume 7

To continue the topic of patient modesty, now Volume 7, I selected the graphic fresco by Masaccio from Wikipedia "The Expulsion Of Adam and Eve from Eden" (painted 1426-1428),displaying the fresco before and after restoration (ca 1980). The fig leaves were added (ca 1680)three centuries after the original fresco was painted, probably at the request of Cosimo III de' Medici in the late 17th century, who saw nudity as “disgusting”. During restoration in the 1980s the fig leaves were removed along with centuries of grime to restore the fresco to its original condition.


With this fresco, the various faces and nuances of modesty are suggested from the original painting in the different postures of Adam and that of Eve and then the reaction of Cosimo III to the nudity of the characters in the fresco. In a way, I see these different responses reflected in the different views expressed on these Patient Modesty threads. I would be most interested to read what my visitors see from these two views of the painting as related to the thread topic.

NOTICE: AS OF JANUARY 8 2009 THIS THREAD WILL BE CLOSED FOR ALL COMMENTS. DO NOT ATTEMPT TO WRITE ANY FURTHER COMMENTS HERE. PLEASE GO TO "PATIENT MODESTY: VOLUME 8" TO CONTINUE COMMENTS. ..Maurice.
..Maurice.

Medical Bloopers: A Medical Communication Defect

The problem with these hospital chart bloopers is that they represent a failing on the part of medical students or even physicians who write notes in the chart. The failing is, either because of lack of time or interest, what is written is not read by the writer after the pen touches the paper. What I keep teaching my medical students about their write-ups is to read, read, and re-read what they have just written but to read their statements as some ignorant reader who has no knowledge regarding the clinical situation and decide whether they understand what was written and whether the words make sense. Ambiguous comments in the chart may be funny to read, as many of the statements below, but their presence represents a defect in the communication system and, in some case, may lead to misinterpretation and harm to the patient.

(By the way, I had already put up Bloopers 1-19 on a thread back on June 28, 2005.But they are fun to read so in case a visitor missed those, I republished them today but with 6 more that I found.) ..Maurice.

1. The patient refused autopsy.

2. The patient has no previous history of suicides.

3. Patient has left white blood cells at another hospital.

4. She has no rigors or shaking chills, but her husband states she was very hot in bed last night.

5. Patient has chest pain if she lies on her left side for over a year.

6. On the second day the knee was better and on the third day it disappeared.

7. The patient is tearful and crying constantly. She also appears to be depressed.

8 The patient has been depressed since she began seeing me in 1993.

9. Discharge status: Alive but without permission.

10. Healthy appearing decrepit 69-year old male, mentally alert but forgetful.

11. Patient had waffles for breakfast and anorexia for lunch.

12. She is numb from her toes down.

13. While in ER, she was examined, x-rated and sent home.

14. The skin was moist and dry.

15. Occasional, constant infrequent headaches.

16. Patient was alert and unresponsive.

17. Rectal examination revealed a normal size thyroid.

18. She stated that she had been constipated for most of her life, until she got a divorce.

19 I saw your patient today, who is still under our car for physical therapy.

20. Both breasts are equal and reactive to light and accommodation.

21. Examination of genitalia reveals that he is circus sized.

22 . The lab test indicated abnormal lover function.

23. Skin: somewhat pale but present.

24. The pelvic exam will be done later on the floor.

25. Patient has two teenage children, but no other abnormalities.

Facing the Ethics of Face Transplanting

The ethics regarding the transplant of a face from a dead donor to a living person who needs an intact and functioning face to replace a face severely damaged by trauma or otherwise disfigured is one which goes beyond any ethical considerations of other bodily organ transplants, such as heart, liver or kidneys.

The procedure as 2008 is ending is still experimental and facial transplants on humans have, as yet, been only partial and perhaps only in a few publicized cases at most. The problems of full functionality and rejection has yet to be met. Beyond that is the social, psychologic and ethics involved in considering and actually carrying out such surgery.

To learn more about the details of these considerations, read the 2006 American Society for Reconstructive Microsurgery and the American Society of Plastic Surgeons Guiding Principles for facial transplantation.

Setting the discussion of the ethics of facial transplantation, the American Society for Reconstructive Microsurgery in their 2006 position paper wrote:

The ethics of facial transplantation go beyond the life and death issues common to most transplants and engage other topics that heretofore have not influenced medical decision processes. The face represents the most identifiable aspect of an individual’s physical being and is central to communication. One might expect that a facially deformed patient is markedly impaired, but most studies confirm that the severity of deformity does not necessarily correlate with distress. Most patients with facial deformity adapt quite well and accept their physical appearance as “self”. The psychology of acquiring another person’s identity is very complex; the psychology of losing that newly acquired identity can only be imagined. Similarly, the psychologic repercussions of a facial transplant on family and friends of both donor and recipient cannot be underestimated. The ethics of inflicting an untried, and potentially fatal or deforming remedy for the purposes of advancing science must be carefully weighed against the Hippocratic credo of doing no harm. Those against facial transplantation argue that the desperation of disability never justifies the infliction of a hopeless remedy. Proponents of facial transplantation argue that selected patients who seek improvement in their quality of life in certain circumstances are prepared to assume risks to achieve it. Answers to these ethical issues can be easily manipulated to comport with most viewpoints. In the final analysis, however, ethics must be regarded as a means for discussing the issues of facial transplantation and not, necessarily, for resolving them.

What is your opinion regarding further research or if surgical and immunological problems can be overcome to have full facial transplant become a standard procedure for patients with facial disfigurement? ..or even for just for a simple cosmetic attempt to “look better”. Finally, what does a persons face mean to you and should it be only their own? ..Maurice.

A Bioethics Resource at Your Fingertips: Hastings Center Bioethics Briefing Book

The following is the public announcement by the Hastings Center of a new free Web resource the Center is providing for everyone's education regarding a number of issues of clinical ethics but presented in a "variety of voices and perspectives grounded in scientific and ethical fact." I know that I am going to use this resource. ..Maurice.

Bioethics Briefing Book Available Free Online!

From Birth to Death and Bench to Clinic: The Hastings Center Bioethics Briefing Book is available free online at The Hastings Center's Web site. Written by the Center's interdisciplinary scholars and Fellows, as well as other leading experts, the Bioethics Briefing Book seeks to inform debate surrounding thirty-six of the most controversial bioethics topics in the media today. Each entry is presented in clear and engaging language, sensitively presenting a variety of voices and perspectives grounded in scientific and ethical fact.

The online edition is searchable and features printable documents organized by topic. Each entry begins by framing the issue and strives to present the full range of perspectives on the issue. Phone numbers and e-mail addresses are included for contacting the experts. Recent news stories, current legislation, and links to additional reading are also found in the resource boxes for each entry.

We invite you to bookmark the Bioethics Briefing Book and utilize this free content with compliments from The Hastings Center.

Founded in 1969, The Hastings Center is the oldest independent, nonpartisan, nonprofit bioethics research institute in the world to address the fundamental ethical issues in the areas of health, medicine, and the environment as they affect individuals, communities, and societies. The Center promotes discussion of ethical issues in medicine and the life sciences.

The Hastings Center publishes IRB: Ethics & Human Research, the leading journal devoted to ethics and human subjects research, and the Hastings Center Report, a premier journal in bioethics. Bioethics Forum is a free, Web-based service that offers weekly commentary on current bioethics issues.



Contact Information

Electronic Mail: publications@thehastingscenter.org
Telephone: (845) 424-4040, ext. 234
World Wide Web: http://www.thehastingscenter.org

Apology in Medical Practice: A Changing View

Whether it is an inadvertent act of running over a family’s pet cat or a physician’s medical error, an apology is the decent and humane act to provide those suffering the result of the act.

Apology is particularly needed in the medical profession where unintended errors or errors due to carelessness or ignorance can occur with degrees of injury leading up to death of a patient. And yet, it has only been in recent years that the value of apology was stressed. In the past complications of diagnosis or treatment that were ignored, not fully explained or explained without admission of personal responsibility. In the past, apology by a physician for a consequence in medical care was considered an invitation for a malpractice lawsuit and physicians were advised by some lawyers and hospital risk-management staff to be empathetic in their response to the patient or family (“I can understand how you feel and it must be very upsetting”) but nothing further since anything suggesting an apology would be an admission of guilt if the case was brought to trial.

Recent experience with apology and an offer of helping to compensate has suggested that less malpractice legal actions are taken. The therapeutic value of an apology cannot be underestimated. It can change the uncertainties and anger of a patient or family into one of understanding and tolerance.

To read more about the benefit to all for doctor’s to apologize, you can go to the “Sorry Works Coalition” website Also read the Forward by Robert Ward for the book “On Apology” by Aaron Lazare which provides some historical background. Finally, you can read a personal response to a physician’s apology by Trisha Torrey on About.com: Patient Empowerment.

An apology is an act for one human being to offer to another which is a sign of humanism and understanding but also can be a form of therapy to the potential suffering of the other.
..Maurice.

Graphic: Digital photograph taken by me today of a neighborhood sign.