The Ethics of Smoking

From the Centers of Disease Control and Prevention here are the current statistics about the prevalence of smoking cigarettes.

Current Cigarette Smoking
In 2007, the median prevalence of adult current smoking in the 50 states and DC was 19.8% Among states, current smoking prevalence was highest in Kentucky (28.3%), West Virginia (27.0%), and Oklahoma (25.8%); and lowest in Utah (11.7%), California (14.3%), and Connecticut (15.5%). Smoking prevalence was 8.7% in USVI, 12.2% in PR, and 31.1% in Guam. Median smoking prevalence among the 50 states and DC was 21.3% (range: 15.5%--28.8%) for men and 18.4% (range: 8.0%--27.8%) for women. Men had a significantly higher prevalence of smoking than women in 30 states, DC, and all three territories.

Trends in Cigarette Smoking
During 1998--2007, linear decreases were observed in 28 states, DC, and PR. Nonlinear trends were detected in 19 other states. Trends in smoking prevalence varied among these states; however, all had reached a peak prevalence before 2004 and then began to decrease. Among 16 of these 18 states, logistic regression models indicated that the prevalence decreased during 1998--2007; in the other two states no change in prevalence occurred. No change over time in smoking prevalence (quadratic or linear) was observed in Alabama, Arizona, Tennessee, and West Virginia.

The host of medical consequences of smoking is clear as can be read in the Executive Summary of the U.S. Surgeon General’s 2004 Report with studies showing damage to organs beyond the lungs and heart and the resultant personal impact in terms of chronic symptoms but also the personal and society-wide effect on productivity and medical time and financial expenditure. Further, there is the documented health effects of those exposed secondarily to a smoking environment.
The need for breaking the tobacco habit and reducing smoking within the United States is obvious. For years various approaches have been begun by the government, institutions and the medical system including ban on certain advertising, anti-smoking campaigns and public and patient education through the media and by the medical profession along with medical approaches to reduce the tobacco craving. As seen by the CDC statistics, there has been some improvement in reduction of smoking but has not reached hoped for goal of about 12%.

Now, what does ethics have to do with smoking? If smoking is a personal right and liberty, on what ethical argument can government restrict the citizen’s autonomy for smoking and for example restrict where a person can or can’t smoke? Autonomy can be preserved unless through the action of an individual there is potential harm to others. Philosopher Thaddus M. Pope has written a paper for the University of Pittsburg Law Review which dissects the ethics involved. If you are a smoker, how do you feel about the restrictions put on you on where you can smoke and which limit your autonomy to smoke? Do you think you should be “your brother’s keeper”?..Maurice.

Patient Modesty: Volume 15

NOTICE: AS OF TODAY MAY 3, 2009 "PATIENT MODESTY: VOLUME 15" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 16.

More and more discussion on the issue of patient bodily modesty, the attention and inattention or even violation by healthcare providers in the many environments where patients go for medical attention.





PLEASE NOTE: Since there is a lot of back and forth discussion between those who write here, it would be important for clarity and continuity to identify who writes what. Therefore, each writer if desiring to remain anonymous should at least use a consistent pseudonym or initials at the end of their posting or even log on to Blogger with that pseudonym so your posting will be identified at the outset. Thank you. ..Maurice.


GRAPHIC: Photograph from the United States Defense Department and titled by me with Picasa 3. A member of the U.S. Army's 947th Forward Surgical Team (FST), Newington, Conn., grabs surgical instruments for the doctors during an appendectomy operation on a soldier. The 22-member FST is based out of Bagram Air Base in Afghanistan. Photo by Staff Sgt. Jeremy T. Lock, USAF

Dying in Belgium: The Euthanasia Way

In Europe, the second country to legalize active euthanasia is Belgium. The Netherlands was first and more recently Luxembourg made the same political decision. Active euthanasia as legalized is for a physician to provide and carry out the means to end the life of a patient at the request of the patient who usually has an incurable condition, in great pain and discomfort which cannot otherwise be managed to the patient's relief. The details of the criteria and process may vary between countries. Philosopher and ethicist and Professor and Chair, University of Hull, Raphael Cohen-Almagor, D.Phil.has written an educational and insightful article in the Issues in Law & Medicine, Volume 24, Number 3, 2009 titled "Euthanasia Policy Practice in Belgium:Critical Observations and Suggestions for Improvement." It is available as a pdf file by going to this link.

The article is very readable and provides, as I said, insight into potential weaknesses or uncertainties in policy and law which is still pertinent to euthanasia in Belgium but also should be considered by other countries considering euthanasia.
After reading the article, come back and voice your opinions about the good and bad of euthanasia. ..Maurice.

Physicians and Torture: AMA's Letter to the President

The following is a letter the American Medical Association (AMA) sent to President Obama on April 17 2009 regarding "reports in the national media about the involvement of health personnel,some of whom may have been physicians, with the torture of detainees held by the U.S. Central Intelligence Agency" and the AMA response to those reports. The reproduction of the letter and accompanying AMA Principles of Medical Ethics and Opinions on "Physician Participation in Interrogation" and "Torture" can be accessed as a pdf file at this link. The text of the letter is as follows:

April 17, 2009

Honorable Barack Obama
President of the United States
The White House
1600 Pennsylvania Avenue, N.W.
Washington, DC 20500

Dear Mr. President,
We are deeply troubled by reports in the national media about the involvement of health personnel,
some of whom may have been physicians, with the torture of detainees held by the U.S. Central Intelligence Agency.


Any involvement by physicians in torture is fundamentally incompatible with the physician’s role as a healer. Such involvement would violate core ethical obligations of the medical profession to “first,
do no harm” and to respect human dignity and rights.

These core principles are enshrined in the Code of Medical Ethics of the American Medical Association (AMA) and the codes of other professional medical organizations throughout the world. Our AMA Code forcefully states medicine’s opposition to torture or coercive interrogation and prohibits physician participation in such activities. Our Code calls on physicians to support victims of torture, to report the use of torture, and to strive to change situations in which torture is practiced. At stake are the rights and well-being of individuals, the integrity of medicine, and society’s trust in the profession.


As the nation’s largest association of physicians and the voice of the medical profession, the AMA stands ready to work with you to ensure that these core principles guide our nation’s physicians. Our aim is to assure that all physicians are fully aware of their ethical obligations, that physicians are not
put in ethically untenable positions, and that actions like those alleged do not ever occur under U.S.jurisdiction. We will assist you in any way possible to accomplish that goal.


Sincerely, [SIGNATURES]

Nancy H. Nielsen, MD, PhD
President

Joseph M. Heyman, MD
Chair, Board of Trustees

What is Death? (6): Is Brain Dead Dead Enough?

As you can tell by the now 6 different threads on "What is Death" ( 1, 2, 3, 4, 5)there is much to write about the topic from poetry to deep philosophic analysis. One of the currently more controversial topics deals with the concept of "brain death" or in other words "death by neurologic criteria" that entered the medical and social terminology back in 1968 and has been nurtured since then on the basis that the concept from an ethical and legal perspective allows the removal of organs from a person who is not "dead" based on the classic cardio-pulmonary criteria.

Contributing to the discussion has been the recent publication of the white paper of the President's Council on Bioethics as it deals with controversies in the determination of death, when and for what reasons a person can be considered dead. D. Alan Shewmon, writing an article "Brain Death: Can It be Resuscitated?" in the March-April 2009 issue of The Hastings Center Report takes on the white paper from both the points of view as to what it was attempting to accomplish and how it was presented but also the paper's confusing conclusions. For those interested in a kind of Philosophy 101 explanation of the issues regarding death and specifically brain death, you can have free access to the Hastings article (after registering) by clicking this link.

Come back and let us all know your view of death and whether creating the concept that a person is dead if the person is declared brain dead by the established neurologic criteria to facilitate the procurement of needed vital organs for transplant was the right thing to do. ..Maurice.

What Should Doctors Do With the Non-Compliant Patient?

A patient whom the doctor finds is "non-compliant" (essentially does not accept or follow what the doctor advises or prescribes) is particularly troublesome for some doctors who, despite this age of patient autonomy, consider themselves in a "father knows best" role. They may look at their relationship with the patient, in an era of lowered payments for the time and expertise, as a waste of time and waste of their skills. However, patients may have complex psychosocial reasons and well as biologic (related to the illness or side-effects of prescribed medication) for not following the physician's advice. With regard to adherence to a drug prescription, the patient may because of finances either not purchase the drug or reduce its dosage frequency for the bottle of pills to last longer. For a description of how another doctor looks at the non-compliant patient, read an article from the Permanente Journal Fall 2003 by Fred Kleinsinger, MD titled “Understanding Noncompliant Behavior: Definitions and Causes”

“What should doctors do with the non-compliant patient?" I would agree with Dr. Kleinsinger, first talk to the patient and begin to understand the reason for the non-compliance. Then it is up to the doctor, not to ignore an issue but to actively attempt to mitigate it. This may range from obtaining a social worker to help the patient with ways of financing the medical regimen to ways of more easily getting to the doctor’s office or it may require the doctor to do things, along with patient education, like revising a dosage plan which is simpler and more likely to be followed but yet still potentially therapeutic. But first, the doctor must take the time to talk to the patient. Yes, this takes time but if there is no attempt by the doctor to recognize and find a solution for non-compliance further time "treating" the patient may be wasted to the detriment of the patient's health.

Have any of my visitors had problems with compliance with their physician's advice and prescriptions? ..Maurice.

"Things I Don't Want to Tell My Doctor and Things My Doctor Shouldn't Have Asked!"

A visitor to my thread on patient bodily modesty wrote in part the following:

"..a few months ago my male doctor brought up my periods. He was completely comfortable talking about it but I wasn't. I wasn't blushing embarrassed, but would I have preferred to talk to a female doctor about it. I'm not saying he has to experience it to know about it, but to me it is a sort of female camaraderie issue. It's hard to explain, but it really feels like an intrusion of my privacy when a doctor brings up something personal that I did not plan on discussing.
LH"


With the title of this thread and the introductory comment as stimulus to discussion, let's see what my visitors think and say about the subject.

By the way, I hope my visitors will take no offense to the above graphic. It was to communicate a visual point and in no way did I intend to imply or picture a patient as a monkey. Even monkeys may have modesty issues too. Whenever I see a monkey on a TV show, I see them in diapers!

..Maurice.

Patient Modesty: Volume 14

Here we go with Volume 14 in this apparently never ending quest by patients to find solutions regarding their bodily modesty concerns and why they feel they are being ignored by healthcare providers. Specifically, they are concerned why their right to modesty and privacy is actually being violated.

PLEASE NOTE: Since there is a lot of back and forth discussion between those who write here, it would be important for clarity and continuity to identify who writes what. Therefore, each writer if desiring to remain anonymous should at least use a consistent pseudonym or initials at the end of their posting or even log on to Blogger with that pseudonym so your posting will be identified at the outset. Thank you. ..Maurice.

Graphic: The Unconscious Patient. A photograph from Auckland District Health Board, New Zealand and modified by myself using Picasa 3.

NOTICE: AS OF TODAY APRIL 24, 2009 "PATIENT MODESTY: VOLUME 14" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 15.

The Work and Issues for Clinical Ethics Committees: Some Examples

Clinical ethics is the ethics of how medical care and treatment of patients is carried out by the various responsible professionals and others. Currently, the practice of clinical ethics is carried out in hospitals and nursing facilities by a hospital ethics committee or some committee in these other facilities. Multidisciplinary clinics may also have a committee but physicians and their patients in independent office practice have no direct consultation regarding ethical issues except hospital ethics committees may take on their requests.

The consultative component of a hospital ethics committee is made up either by a single consultant, so-called “clinical ethicist” or by consultative ethics committee made up of 3 or 4 members of the main committee.
The role of the consultation is toward reviewing the history of a case, assessing conflicts or concerns and then providing the stakeholders (physicians, nurses, patients, family members, hospital administration and other staff members) with education of the ethics and the laws applicable to the case and the ethical alternatives as the committee attempts to mediate any conflicts.
There are a host of issues that currently would be and should be considered in the domain of clinical ethics committees. Jeffrey Spike, professional ethicist and teacher, has outlined a series of 22 such issues.

1. disputes about a patient’s decision making capacity
2. choosing the right surrogate for an incapacitated patient
3. deciding surrogate decision making standards
4. interpreting advance directives
5. disagreements among staff or family members
6. questions about withholding or withdrawing treatment
7. end of life options of last resort
8. difficult and noncompliant patients
9. patients refusing beneficial treatment
10. negotiating futility (requests for non-beneficial treatment)
11. negotiating complementary and alternative medicine
12. patients’ rights for vulnerable groups (Mentally Retarded Developmentally Disabled, illegal immigrants)
13. the rights of minors as patients and the role of their family
14. issues concerning pregnancy, termination, and delivery
15. what to include in full disclosure for informed consent
16. informed consent for HIV testing and surrogate tests
17. PVS, ‘Brain Death’ and transplantation
18. disclosure of mistakes
19. ‘Quality of Life’ and Disability
20. safe discharge plans vs. right to live at home with risk
21. deciding when (or whether) to call state agencies
22. uncertainty about health law or hospital policy

There are more, nevertheless this list is good for a discussion on this thread. A number of these issues have already been discussed in one fashion or another on a number of the over 670 topics on this blog. I thought, however, I would like to put a potpourri of them on one thread and have the visitors ask questions about any of them and discuss my or others responses. Many of these issues have no absolute right or wrong solutions, some have established consensus of ethical opinion or written state or federal laws to follow. Not all these issues are fully understood by the public or by physicians. Pick one and write what your suggestion would be to an ethics committee on how the committee should handle the issue. ..Maurice.

Patient Modesty: Volume 13

Can't we all get along? The graphic adapted by me using ArtRage from an image on mdwilliams/myspace, sets the current issue being discussed on these volumes. Can't patients look at their healthcare providers as responsible and beneficent people whose profession is to help patients of all genders? Well, some visitors to this blog find that exposure or manipulation of certain "private" bodily parts demands the presence of providers of a gender requested by the patient. They find that doctors are unaware of this issue or simply ignore their requests for a specific gender. Though I, personally, am more interested in the skills and personality of my doctor, nurse or tech rather than the gender in all aspects of examination or procedure, I do appreciate the arguments that have been presented here. Come join us in the conversations. ..Maurice.

NOTICE: AS OF TODAY APRIL 11, 2009 "PATIENT MODESTY: VOLUME 13" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 14.