Patient Modesty: Volume 18

NOTICE: AS OF TODAY JUNE 14, 2009 "PATIENT MODESTY: VOLUME 18" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 19.

Continuing on with the discussions of patient modesty, I want to add to the mix the consideration, as expressed in the above graphic, of whether there is such a thing as a "false modesty", a path which if followed could lead to late or inadequate diagnosis and treatment and misery, if not debility and death. On the other path, the direction is that of "good health" ignoring modesty and leading to the goal of "happiness". Just something to think about, put in a graphic form. ..Maurice.


Graphic: "Which Way Will You Choose", an illustration from an old sex hygiene manual, taken from Wikipedia and modified by me with ArtRage. Instead of the path "sex hygiene" I substituted the words "Good Health".

An Ethical Argument Against Same-Sex Marriage: The Outcome of Marriages

First, from the United States Centers for Disease Control and Prevention
2007 statistics:
• Number of marriages: 2,197,000
• Marriage rate: 7.3 per 1,000 total population
• Divorce rate: 3.6 per 1,000 population (46 reporting States and D.C.)

Second, I recently received an e-mail from a visitor to this blog which included the following comment:

"I have often wondered, with the dismal success rate of marriage in the western world, why gay people would want to emulate that most dysfunctional of co-habitations.....the desire for total equality, I suppose."

Third, I have nothing further to write to this thread except await your responses. ..Maurice.

Graphic: Customary wedding rings. Photograph from Wikipedia.

Painting Groups with the Same Brush as Outliers: Is That Ethical?

I, unfortunately, though some may consider it fortunate, have created a series of topic threads which has stimulated some of my visitors to make negative and derogatory comments seemingly referring to members of an entire class rather than those outliers who might well deserve these comments. Example threads where you can read the comments to which I refer deal with infant male circumcision, hysterectomies, patient modesty and also a probably unfortunate title in this context, “I Hate Doctors”.

As having been a patient myself, I can understand and even empathize with those who have experienced instances in medical practice which could be the basis of and promote negative comments. However, my point is that these comments should refer to specific individuals of a class and not necessarily to the entire class itself.

On the other hand, extending this issue to the “bad apple” analogy, should one or two “bad apples” in the basket cause all the apples to turn "bad" and that there is a responsibility of every class of healthcare providers in medical practice to be responsible for their “bad apples”? If they are not carrying out this responsibility to get rid of them then shame on the entire group and thus the painting of the group with the same brush.

I would be most interested in my visitors’ opinion. ..Maurice.

Graphic: Photographs composed and modified digitally by me using ArtRage.

Ethical?: The Child in a Study and Parent is the Investigator

There is a challenging ethical question that is posed in an article in the current Journal of the American Medical Association May 27 2009 titled "Parent-Investigators A Dilemma" by David B. Resnick, JD, PhD. It's about whether medical investigators or those investigators who do research in social science should be permitted to use their own children in their studies or trials. I present an excerpt from the beginning of the article below. Unfortunately, the article cannot be accessed online except by subscription.

A recent news story reported that some psychologists and neuroscientists have used their children as study participants.1 In one case, a neurology professor had 3 of his children undergo a brain scan with magnetic resonance imaging. In a language development study, a psychologist videotaped 70% of his son's waking hours for the first 3 years of his life.1 Other investigators have also conducted research on their own children, including Edward Jenner,2 who tested his smallpox vaccine on his 11-month-old son; Jonas Salk, who tested his polio vaccine on his own children; and psychologist Jean Piaget, who constructed his theories of child development based on studies of his own children.

Should investigators conduct research on their own children? Federal research regulations3 do not address this issue and regulatory agencies, such as the Office of Human Research Protections,4 have no policies dealing with it. Other research guidelines, such as the Nuremberg Code5 and the Helsinki Declaration,6 also do not address the issue of parent-investigators. When laws and professional codes do not provide guidance concerning human research, investigators and committees that oversee research, such as institutional review boards (IRBs), must rely on their ethical judgment to decide.7

So, do you find any conflict of interest and how would you express it? If the parent is the surrogate decision-maker for a young child, how can the parent make an unbiased decision about the risks and benefit for the child participating in the study if the parent is also the investigator? Might the presence of the child, cause the parent to change the protocol of the study? What is any benefit for the child to be part of the study? Would it make any difference if the investigation was a medical one where the child might be exposed to a drug or procedure as compared with a social-science study where the child is asked questions or behavior is being observed? Should official committees that rule on the ethics of a scientific investigation be notified by the investigator that his or her child is within the study? I would be most interested to read the views of my visitors on this issue. ..Maurice.

Soured on the Cost, Service and Value of Medical Care? Look to Mc Allen, Texas vs Grand Junction, Colorado

Yes, with the current increasing interest and need in improving medical care within the United States along with making it less expensive, less wasteful and more easily available to all the people, this article in the New Yorker by surgeon Atul Gawande “The Cost Conundrum: What a Texas Town can Teach Us about Healthcare” provides an excellent perspective into this important issue. Click on the above link, read the article, then come back and share your views. ..Maurice.

Graphic: Photograph composed and taken by me and digitally modified with Picasa3.

A New Years Poem for Memorial Day

Today is not New Years Day and the poem by Lord Alfred Tennyson “In Memoriam, [Ring out, wild bells]” may seem inappropriate for today’s Memorial Day in America. Yet, thinking about Memorial Day and what it represents may make this poem appropriate. We are remembering those who we have lost in battles to protect America and preserve the ideals and those fine realities that made up and defined a good life in America. Some have found these ideals and fine realities tarnished in recent years and with the new Administration, the American public is now looking forward toward the “ringing out the old and ringing in the new” and the changes as characterized in Tennyson’s poem. Unfortunately ringing “out the thousand wars of old and ring in the thousand years of peace” is going to be a challenge for this new Administration and those that follow and unfortunately there will be more Americans lost in battle to memorialize. ..Maurice.

In Memoriam, [Ring out, wild bells]

by Lord Alfred Tennyson

Ring out, wild bells, to the wild sky,
The flying cloud, the frosty light:
The year is dying in the night;
Ring out, wild bells, and let him die.

Ring out the old, ring in the new,
Ring, happy bells, across the snow:
The year is going, let him go;
Ring out the false, ring in the true.

Ring out the grief that saps the mind
For those that here we see no more;
Ring out the feud of rich and poor,
Ring in redress to all mankind.

Ring out a slowly dying cause,
And ancient forms of party strife;
Ring in the nobler modes of life,
With sweeter manners, purer laws.

Ring out the want, the care, the sin,
The faithless coldness of the times;
Ring out, ring out my mournful rhymes
But ring the fuller minstrel in.

Ring out false pride in place and blood,
The civic slander and the spite;
Ring in the love of truth and right,
Ring in the common love of good.

Ring out old shapes of foul disease;
Ring out the narrowing lust of gold;
Ring out the thousand wars of old,
Ring in the thousand years of peace.

Ring in the valiant man and free,
The larger heart, the kindlier hand;
Ring out the darkness of the land,
Ring in the Christ that is to be.

When Should Doctors Retire?

My visitors may have varying opinions regarding the answer to the question "When Should Doctors Retire?". If so, please write your opinions here. However, here is the opinion from a physician, Thomas Percival, who lived throughout the latter half of the 18th Century and published a notable book of medical ethics a year before he died in 1804. What follows is a quotation from Chapter 2 Section XXXII from that book "Medical Ethics".

The commencement of that period of senescence, when it becomes incumbent on a physician to decline the offices of his profession, it is not easy to ascertain; and the decision on so nice a point must be left to the moral discretion of the individual. For, one grown old in the useful and honourable exercise of the healing art, may continue to enjoy, and justly to enjoy, the unabated confidence of the public. And whilst exempt, in a considerable degree, from the privations and infirmities of age, he is under indispensable obliga¬tions to apply his knowledge and experience, in the most efficient way, to the benefit of mankind.

For the possession of powers is a clear indication of the will of our Creator, concerning their practical direction. But in the ordinary course of nature, the bodily and mental vigour must be expected to decay progressively, though perhaps slowly, after the meridian of life is past. As age advances, therefore, a physician should, from time to time, scrutinize impartially, the state of his faculties; that he may determine, bona fide, the precise degree in which he is qualified to execute the active and multifarious offices of his profession. And whenever he becomes conscious that his memory presents to him, with faintness, those analogies, on which medical reasoning and the treatment of diseases are founded; that diffidence of the measures to be pursued perplexes his judgment; that, from a deficiency in the acuteness of his senses, he finds himself less able to distinguish signs, or to prognosticate events; he should at once resolve, though others perceive not the changes which have taken place, to sacrifice every consideration of fame or fortune, and to retire from the engagements of business. To the surgeon under similar circumstances, this rule of conduct is still more necessary. For the energy of the understanding often subsists much longer than the quickness of eye-sight, delicacy of touch, and steadiness of hand, which arc essential to the skilful performance of operations. Let both the physician and surgeon never forget, that their professions are public trusts, properly rendered lucrative whilst they fulfil them; but which they are bound, by honour and probity, to relinquish, as soon as they find themselves unequal to their adequate and faithful execution.

Here is the story of Thomas Percival as described in Wikipedia. Please go to this link to Wikipedia to access the links to the references. ..Maurice.

Thomas Percival (1740-1804) was an English physician best known for crafting perhaps the first modern code of medical ethics. He drew up a pamphlet with the code in 1794 and wrote an expanded version in 1803, in which he reportedly coined the expression "medical ethics"[1].
He was born at Warrington at Lancashire. He lost both his parents when he was three years old, so his older sister was responsible for his early education. Once he was old enough, he was placed in a private academy in his home town. He also spent time in a free grammar-school. In 1757, he was enrolled as the first student at Warrington Academy. After achieving a good reputation in classical and theological studies, he transferred to Edinburgh in 1761. He became a fellow to the Royal Society in 1765, through a recommendation by his friend and patron Lord Willoughby de Parham, and achieved his M.D. degree the same year.[2]
Percival is also known for his early work in Occupational health. He led a group of doctors to supervise textile mills, their report influenced Robert Peel's to introduce the Health and Morals of Apprentices Act of 1802. The legislation stipulated that children could work only 12 hours per day, walls had to be washed, and visitors had to be admitted to factories so that they could make health-related suggestions.[3][4]
Percival's Medical Ethics served as a key source for American Medical Association (AMA) code, adopted in 1847. Though hyperbolic in its recognition of Percival, the AMA itself states:
The most significant contribution to Western medical ethical history subsequent to Hippocrates was made by Thomas Percival, an English physician, philosopher, and writer. In 1803, he published his Code of Medical Ethics. His personality, his interest in sociological matters, and his close association with the Manchester Infirmary led to the preparation of a scheme of professional conduct relative to hospitals and other charities from which he drafted the code that bears his name. [5]
As one expert writes, "The Percivalian code asserted the moral authority and independence of physicians in service to others, affirmed the profession's responsibility to care for the sick, and emphasized individual honor."[6]

References
1. ^ Codes of Ethics: Some History, Center for the Study of Ethics in the Professions at IIT
2. ^ Thomas, Percival (Digitized Oct 17, 2006). Percival's Medical ethics. Published 1849 John Churchill. http://books.google.com/books?id=yVUEAAAAQAAJ&printsec=frontcover&dq=medical+ethics+thomas+percival&as_brr=1#PPP4,M1.
3. ^ Dr Thomas Percival and the Beginnings of Industrial Legislation
4. ^ Environmental History Timeline (1795)
5. ^ Short history of medical ethics, AMA web site
6. ^ Bioethics - Codes, Oaths, Guidelines and Position Statements, Dal Libraries

Informed Consent for Healthy Population Medical Screening: False Positive Results, Harm and Cost

Doctors, medical organizations and the government can claim that healthy population medical screenings for various cancers are of value even if the screening test turns out negative. Of course, the value also depends on how many true positive cases of cancer are turned up and whether early detection plays any role in the overall cure of the cancer. What these medical groups don’t tell the public, because often those advising don’t really know, is what is the frequency of false positive results (detecting a “cancer” when there really is none present)and the harm produced as part of further testing or removal of what was thought to be a cancer but was not.


An advance in the knowledge regarding the frequency of false positives picked up in population screening tests and the subsequent harm is now available as an article “Cumulative Incidence of False-Positive Results in Repeated, Multimodal Cancer Screening” by Jennifer Miller Croswell, M.D. and a host of others published in the Annals of Family Medicine 7:212-222 (2009)


You must read the entire article to fully understand how the data was obtained and its significance, but to get started, here is the Abstract of the article.

PURPOSE Multiple cancer screening tests have been advocated for the general population; however, clinicians and patients are not always well-informed of screening burdens. We sought to determine the cumulative risk of a false-positive screening result and the resulting risk of a diagnostic procedure for an individual participating in a multimodal cancer screening program.
METHODS Data were analyzed from the intervention arm of the ongoing Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, a randomized controlled trial to determine the effects of prostate, lung, colorectal, and ovarian cancer screening on disease-specific mortality. The 68,436 participants, aged 55 to 74 years, were randomized to screening or usual care. Women received serial serum tests to detect cancer antigen 125 (CA-125), transvaginal sonograms, posteroanterior-view chest radiographs, and flexible sigmoidoscopies. Men received serial chest radiographs, flexible sigmoidoscopies, digital rectal examinations, and serum prostate-specific antigen tests. Fourteen screening examinations for each sex were possible during the 3-year screening period.
RESULTS After 14 tests, the cumulative risk of having at least 1 false-positive screening test is 60.4% (95% CI, 59.8%–61.0%) for men, and 48.8% (95% CI, 48.1%–49.4%) for women. The cumulative risk after 14 tests of undergoing an invasive diagnostic procedure prompted by a false-positive test is 28.5% (CI, 27.8%–29.3%) for men and 22.1% (95% CI, 21.4%–22.7%) for women.
CONCLUSIONS For an individual in a multimodal cancer screening trial, the risk of a false-positive finding is about 50% or greater by the 14th test. Physicians should educate patients about the likelihood of false positives and resulting diagnostic interventions when counseling about cancer screening.

With more and more publicity regarding healthy population cancer screening, particularly regarding its importance and value in early cancer detection and with more commercial patient requested imaging tests, there has been some concerns in the literature about all this. Specifically there are issues involving the safety of the screening test itself (for example, if X-ray procedures are used) or invasive screening exams (such as sigmoidoscopy or colonoscopy). There is also concern about the results of the screening. Are there a large number of false positives as outcome of the screening which lead to additional testing or more invasive procedures with their own risks? In addition, do these false positives lead to unnecessary financial costs of medical care? Is there a benefit for early detection in terms of cancer cure which trumps all the costs and harms which healthy population screening can develop? Answers to these questions within the education the public receives about the need for screening is essential if the public is to accept the screening under ethically and legally appropriate informed consent. The question for doctors, medical organizations and the government is “do we really know and understand what we are advising the public?” ..Maurice.

Graphic: "False Results" created by me using ArtRage and Picasa 3.

The Ethics of Rape Reporting and Examination

“Consider what it might be like to be a victim of sexual assault who has come to a health care facility for a medical forensic examination. Sexual assault is a crime of violence against a person’s body and will. Sex offenders use physical and/or psychological aggression to victimize, in the process often threatening a victim’s sense of privacy, safety, and well-being. Sexual assault can result in physical trauma and significant mental anguish and suffering for victims. Victims may be reluctant, however, to report the assault to law enforcement and to seek medical attention for a variety of reasons. For example, victims may blame themselves for the sexual assault and feel embarrassed. They may fear their assailants or worry about whether they will be believed. A victim may also lack easy access to services. Those who have access to services may perceive the medical forensic examination as yet another violation because of its extensive and intrusive nature in the immediate aftermath of the assault. Rather than seek assistance, a sexual assault victim may simply want to go somewhere safe, clean up, and try to forget the assault ever happened. It is our hope that this protocol will help jurisdictions to respond to sexual assault victims in the most competent, compassionate, and understanding manner possible.”

This is the first paragraph of the September 2004 “A National Protocol for Sexual Assault Medical Forensic Examinations (Adults/Adolescents)” from the United States Department of Justice Office on Violence Against Women.

The reason I started this thread on a socio-medical issue is to learn from my visitors how they look at rape and its consequences both to the victim and to society but in terms of the ethics and ethical responsibilities of both the victim and those in the medical and justice system.

For example, what ethical responsibility does the victim of rape have to herself but also to the social community to report the rape to authorities and be subjected to examination and later participate in legal proceedings against the accused? Should privacy concerns, modesty and embarrassment by the victim ever be considered to be sufficient reasons to hinder investigation of a crime or if indicated prosecution of the suspected criminal?

The Protocol sets informed consent by the victim as a basis for allowing history taking, physical examination, photography and specimen removal and testing. Is “informed consent “obtained in an atmosphere of acute emotional and physical trauma a fair and just consent? If not, what are the alternatives? Any ideas on this topic? ..Maurice.

Graphic: Illustration from U.S. Government DNA Initiative and modified by me for this topic with Picasa 3.

Patient Modesty: Volume 17

NOTICE: AS OF TODAY MAY 31 2009 "PATIENT MODESTY: VOLUME 17" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 18.


Much has been written here over the past years about how both genders feel about the knowledge and behavior of physicians and the medical system regarding patient bodily modesty. Particularly written about is the patient's need for physical privacy during exams and procedures and the provision of emotional comfort through allowing and following the patient's request for gender selection of the healthcare provider. So NOW IS THE TIME TO SPREAD THE WORD!!

..So we will begin on that theme. How can we entice physicians, nurses and others in the medical profession to visit this blog, educate themselves about the concerns and provide their opinions on these topics? How can the word of patient concerns be spread to physicians and the medical system? The words have so far been defined by the visitors here and now they should be spread! ..Maurice.

Graphic: Spreading the Word: The Street Preacher. A Photograph by Coba.


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.

Triage for the Next Pandemic: Selecting on the Basis of "Social Worth"

Here is the issue in a “nutshell” as written by Margaret R. McLean in a report prepared by Center Director of Biotechnology and Health Care Ethics for the Santa Clara County (California) Public Health Department on Ethical Preparedness for Pandemic Influenza and as excerpted by the Markkula Center for Applied Ethics at Santa Clara University, July 2007.

“...one of the most vexing questions about the just rationing of health care resources is which ethical principle ought to guide decision making—save the most lives (e.g., in fires and floods); save the sickest (e.g., in organ transplant protocols); save the most-likely to recover (e.g., in triage during war); save people who can preserve society (e.g., the Centers for Disease Control (CDC) recommendation during a pandemic).

Deciding who can best preserve society means making “social worth” distinctions, which, because they run counter to the instinct for fairness, would ordinarily be considered inappropriate criteria. In the emergency situation of pandemic flu, however, making distinctions on the basis of social worth may be necessary. The hard truth of the matter is that failure to make these sorts of distinctions (giving priority, for example, to doctors, EMS workers, law enforcement personnel, vaccine scientists, firefighters, bus drivers, and sanitation workers) could translate into a high level of injustice accompanied by social chaos, exacerbating an already complicated situation. Hence, prioritizing certain essential personnel, while unfair during non-pandemic conditions, may be the best way to minimize, and ideally avoid, further social breakdown during a flu pandemic.”

Triage (deciding because of limitation of resources, who should be energetically treated with the hope for recovery or who should be left untreated) involves medical utility (who is the most sick but also the more likely to recover with treatment) and social utility (what the treatment of a particular individual will contribute to the welfare of the community.) Medical utility is based on science and clinical evidence and the guidelines are not too controversial. Social utility is a different matter and could give rise to much discussion. Read the excellent article reviewing the matter of triage in an influenza viral pandemic prepared by the University of Pittsburgh Medical Center Pandemic Influenza Task Force.

As you will see in this article, social utility is also considered the main ethical consideration but modified by the specific medical utility of each candidate. And finally, if there are a number of eligible patient candidates for energetic treatment but not all can be accommodated because of lack of resources, then those treated and those left untreated should be selected not on the basis of unfair “first come, first served” but on the basis of a lottery.

I don’t see where the ethics of triage in an influenza pandemic and specifically the triage utilizing the criterion of “social worth” in the decisions have been presented to the public educating them that this may be what the public will experience in the next pandemic but also giving them an opportunity to express their opinions about such methods. I hope my blog thread will stimulate some discussion here. ..Maurice.

Graphic: "Balance of Social Worth in an Emergency" created, in part, by me using ArtRage and Picasa 3 tools.

Editorial: Defining “what is ‘is’”: Defining Torture by the Bush Administration

First, read the May 10 2005 “MEMO FOR JOHN A. RIZZO
SENIOR DEPUTY GENERAL COUNSEL, CENTRAL INTELLIGENCE AGENCY” written by Steven G, Bradbury, Principal Deputy Assistant Attorney General.

Reading through this document, I am absolutely disgusted with Deputy Attorney General Steven G. Bradbury, the CIA and those in the Bush administration who allowed these permissions to be carried out. This document about what is and is not torture is like an attempt to define "what is 'is' " and is clearly based on conflict of interest and secondary gain and not a scholarly and unbiased use of semantics. Moreover, since severe pain and suffering, set as the hallmarks of torture, is an experiential event and whether an act produces severe pain and suffering is or is not torture is not some philosophical exercise to be debated over a table. As an experiential event which involves ones sensations and emotions and since torture even of one individual is illegal both in the U.S. and the world, certainly "I know it when I experience it" would be the proper definition of torture.

When one is really troubled to define "severe pain" or "severe suffering", has anyone suggested an empirical approach by those who want to really know the answer? Mr. Bradbury, did you allow the interrogators to have the techniques attempted on you, yourself? How about you folks in the CIA or administration, who wanted an ethical and legal answer, did you subject yourselves to these techniques? If you did, then you would really know the answer to the how to define "severe" pain and suffering.

And taxpayers actually pay for preparing such legal nonsense--disgusting! Anyway, that is my opinion.. what is yours? ..Maurice.

Patient Modesty: Volume 16

NOTICE: AS OF TODAY MAY 13 2009 "PATIENT MODESTY: VOLUME 16" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 17.


With more women contributors to these threads, the women have expressed their concerns about modesty issues related to excessive and presumed unnecessary pelvic exams and pap smears. The men continue the discussion of their own modesty concerns which appear to be ignored by physicians. And the conversations go on.. ..Maurice.



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 of a pelvic exam on a woman circa 1896 (from Wikipedia)and, of course, modified by me using ArtRage and Picasa 3.