What If?: Dealing with End-Stage Cancer and Religious Coping

What if you had end-stage cancer and you were nearing the end of your life?

What if you had been using religion to cope with your cancer and its consequences?

What if both of the above “what ifs” applied to YOU and there was intensive life-prolonging care and treatment such as mechanical ventilation and resuscitation available in the last week of your life? Would you desire and accept that treatment?

The study by Phelps, Maciejewski and others in the March 18, 2009 issue of the Journal of the American Medical Association has led to a very interesting statistically significant conclusion: “Positive religious coping in patients with advanced cancer is associated with receipt of intensive life-prolonging medical care near death” and this relationship was still statistically significant after “adjusting for other coping styles, terminal illness acknowledgment, support of spiritual needs, preference for heroics, and advance care planning (do-not-resuscitate order, living will, and health care proxy/durable power of attorney)”

Read the free complete abstract of the article at the link above and then return and give us your opinion of this research finding and how it might apply to you if you were that “what if”. If this study is valid, how would you explain how using religion in dealing with the consequences of cancer would make it more likely that a patient would want mechanical ventilation, if needed for life-support, during the last week of life? Would it be related to religion and miracles? Or what? ..Maurice.

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

Medical Decision Making: Patient Autonomy vs Physician Integrity

Patient autonomy is the right for patients to make their own personal medical decisions without these decisions being made by the patient’s physician. The professional duty of the physician is to educate the patient as best as practical considering the circumstances about the details of the illness and the diagnostic and therapeutic options which are available. The physician must explain the benefits to be expected in the procedures or treatments but also detail the risks that are also possible and to compare the options with regard to benefit vs. risks. Of course, there may be one option which cannot be left out and that is: to do nothing. The explanation must be in the form of true education, providing the patient the facts that are known and accepted and should not represent intentional physician bias to one direction or another.


Then, the patient decides and informs the physician. But does that end the decision-making process? If the patient makes, to the physician’s impartial knowledge the wrong decision, a decision that may be in the short or long term harmful to the patient, should the physician remain silent? Should the physician, having a professional duty to observe and maintain the trust that the patient must hold in the doctor for beneficence, speak out if the physician finds that the patient’s decision is wrong, inappropriate or harmful? If the physician had known from the outset that such a decision could possibly be to the patient’s detriment, should that option even have been mentioned in the first place? That option, noted above, which virtually all patients are aware and the physician might find as a wrong decision would be to do nothing. Should the physician accept that decision as was made by the patient?

Regarding any decision, should the doctor insist that the patient explain to the physician’s satisfaction, the patient’s basis for the decision? If the physician is dissatisfied with the explanation, then what? Or should the physician, in keeping with patient autonomy, accept and follow any decision made by the patient? Where does patient autonomy end and to maintain physician professional integrity degrees of physician guidance extending to decision rejection begin? That is the question I pose to my visitors. ..Maurice.

Patient Centered Healthcare Ethics: Forgetting the Family

When a medical decision for a patient is being made, is the patient the only person who should be considered? In most cases, there are more individuals who can be affected by the decision than that of the single patient. The other “patients” can be members of the family associated with the patient.
In these days of patient autonomy and patient centered healthcare where physicians, lawyers and ethicists look to the patient him or herself for personal health decision making, these professionals may forget that the patient is just one member of a social group, whose members may also be affected in one way or another by the decision or have valid reasons to be a participant in a decision.

Ethicist Hilde Lindemann writing in the Hasting’s Center Bioethics Forum looks at a case where it appears that ethicists may be forgetting that there are others whose goals also need to be considered. The case: “a family consisting of a mother, a father, and their profoundly cognitively impaired 20-year-old daughter, whom they cared for at home. Neither of the parents was capable of producing any more children, but for both cultural and personal reasons, they desperately didn’t want the family line to end with them.” And so “they asked that their daughter’s ovaries be stimulated so her eggs could be harvested for fertilization with donor sperm and the resulting embryos brought to term by a contract birth-giver. They would then rear their grandchild themselves.”

Lindemann then presents the usual reaction from ethicists who look only to the “best interest” of the daughter patient, rejecting the parent’s request thus seemingly ignoring the interest of the father and mother who have been caring for their invalided daughter all her 20 years. Shouldn’t the family’s interests be recognized and accepted?

Hindemann concludes with “We need to stop assuming that patient-centered health care ethics is adequate to deal with any kind of morally puzzling situation that bioethicists are likely to face, and start paying closer attention to how families actually work” What do you think? ..Maurice.

Another Ethical Dilemma: To Transfuse or Not Transfuse But Is That the Bloody Question?

WK was a 14 year old male and involved in a motor vehicle accident and was brought to the nearest community trauma center. The patient’s mother also involved sustained only minor injuries and was transferred to the same trauma center. WK sustained an open femur fracture with significant intra-pelvic trauma resulting in bowel injury and hemorrhage. When the trauma surgeon informed the mother that the seriousness of the boy’s injury would require blood transfusion in order to save his life, the mother refused to consider this option as it was not compatible with their faith. The trauma surgeon emphasized to the mother the severity of the boy’s condition and explained that the alternative treatments would not be sufficient. However the mother was adamant and continued to deny permission for transfusion. Operative auto-transfusion was also discussed with the mother but also not allowed.

Despite the lack of consent for blood product transfusion, the surgeon took the boy to the operating room. At the time of the operation the patient’s blood pressure was low because of the bleeding and trauma but conscious and alert. He understood he was going to undergo an emergency surgery. He was also made aware of the surgeon’s opinion that blood product transfusions were a necessity for his survival. But in addition, he was also made aware of his mother’s refusal to consent for these transfusions. On the ride to the operating room, in the elevator, the patient asked to be given whatever blood products were necessary to save his life. The surgeon documented the conversation with the patient’s own words “do whatever it takes for me to make it “. The patient also requested the surgeon to keep his transfusion record confidential and not disclose it to his mother. The patient had significant intra-pelvic hemorrhage and was given multiple intra operative transfusions. His intra-pelvic injuries and fractures were ultimately repaired and the bleeding stopped. Postoperatively his blood pressure was normalized and stable. He made a full recovery and was discharged. At the patient’s request, the mother was never notified of the patient’s transfusions. (Or did the mother finally find out from the hospital bills?)

So here are the issues that an ethics committee might have to discuss, but of course in retrospect:

Did the mother have the final decision-making capability?

To what extent can a 14 year old, who had the mental capacity of a 14 year old, make his own medical decisions?

Should the surgeon have honored the mother’s request over that of her son?

Should there have been disclosure by the surgeon of the transfusion to the mother?

What would happen if the patient, having received the transfusions, suffered a severe transfusion reaction or developed hepatitis or AIDS? Was the surgeon to blame?

Well, if you were a member of the ethics committee, how would you answer these questions? ..Maurice.

Graphic: Blood drop image via Google Image then concocted by me using ArtRage and Picasa3.

Patient Modesty: Volume 19

Continuing on with issues of patient bodily modesty and the inequality of patients to obtain the gender selection they desire for their healthcare providers. ..Maurice.

GRAPHIC: (6-16-2009) I switched graphics on this Volume since I found this picture through Google Image to be a more direct representation the topics being discussed than the one I initially posted. This image is from "The Best of Gay New York" site and is licensed under Creative Commons.

NOTICE: AS OF TODAY JULY 8, 2009 "PATIENT MODESTY: VOLUME 19" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 20

Another Ethical Dilemma: Organ Donation and Paternity Discovery

The story is simple, not uncommon, though unfortunately the ethical dilemma which it produces has not as yet been fully resolved by ethicists, physicians, genetic counselors or transplant organizations. That is why I am presenting the dilemma here for the public to answer.

The story could be told in different ways but here is one way. A father wants to donate part of his liver to his sick daughter who needs a liver transplant promptly. The mother encourages the donation. In preparation for the donation, a blood test for genetic matching is necessary. To the consternation of the physicians, the results of the matching show that the “father” is not the biologic father of the daughter.

The dilemma of this unexpected paternity discovery is what should be done with the information the physicians have obtained? Should the father be informed? Should the daughter be informed? Should the mother, who presumably already knows the paternal relationship, give permission to inform the father and daughter? Or should the physicians keep the information to themselves and proceed with the transplant if the match is close enough for an acceptable outcome? Anyone have an answer to this dilemma? As I noted, currently even the experts can’t come to a consensus. ..Maurice.

FACEing the Opposition to Abortion: A Law to Protect Doctors and Patients

An Editorial in the June 7 2009 issue of the New York Times is regarding the Federal law enacted in 1994 “Freedom of Entrance to the Clinic Entrances (FACE)" and states that “reproductive rights advocates say enforcement of the clinic protection law waned in the Bush years” and indeed I think implies that the recent killing of abortion provider Dr. George Tiller in Kansas may be a reflection and result of this waning.

The law itself is interesting in that it has to walk a fine line between interfering with First Amendment Constitution rights of free speech and assembly along with local laws and yet still protecting the lawful activities of physicians and their patients. In addition, the law also protects religion under the First Amendment by requiring freedom of entrance and protection from intimidation or injury at a place of religious worship. According to the Editorial, Dr. Tiller’s alleged killer’s previous actions against the clinic were not followed up by the FBI and it is ironic that the final act of killing Dr. Tiller occurred at a church.

For those who have not read the FACE law, I have reproduced it below from the United States Department of Justice website. Isn't it curious how the law has bound freedom to have access to a place for reproductive health along with a place to be able to worship religion? ..Maurice.

Freedom of Access to Clinics Entrances (FACE) Act -- Statute
18 U.S.C. § 248


§ 248. Freedom of access to clinic entrances


(a) Prohibited activities.--Whoever--
(1) by force or threat of force or by physical obstruction, intentionally injures, intimidates or interferes with or attempts to injure, intimidate or interfere with any person because that person is or has been, or in order to intimidate such person or any other person or any class of persons from, obtaining or providing reproductive health services;
(2) by force or threat of force or by physical obstruction, intentionally injures, intimidates or interferes with or attempts to injure, intimidate or interfere with any person lawfully exercising or seeking to exercise the First Amendment right of religious freedom at a place of religious worship; or
(3) intentionally damages or destroys the property of a facility, or attempts to do so, because such facility provides reproductive health services, or intentionally damages or destroys the property of a place of religious worship,
shall be subject to the penalties provided in subsection (b) and the civil remedies provided in subsection (c), except that a parent or legal guardian of a minor shall not be subject to any penalties or civil remedies under this section for such activities insofar as they are directed exclusively at that minor.

(b) Penalties.--Whoever violates this section shall--
(1) in the case of a first offense, be fined in accordance with this title, or imprisoned not more than one year, or both; and
(2) in the case of a second or subsequent offense after a prior conviction under this section, be fined in accordance with this title, or imprisoned not more than 3 years, or both;
except that for an offense involving exclusively a nonviolent physical obstruction, the fine shall be not more than $10,000 and the length of imprisonment shall be not more than six months, or both, for the first offense; and the fine shall, notwithstanding section 3571, be not more than $25,000 and the length of imprisonment shall be not more than 18 months, or both, for a subsequent offense; and except that if bodily injury results, the length of imprisonment shall be not more than 10 years, and if death results, it shall be for any term of years or for life.

(c) Civil remedies.--
(1) Right of action.--
(A) In general.--Any person aggrieved by reason of the conduct prohibited by subsection (a) may commence a civil action for the relief set forth in subparagraph (B), except that such an action may be brought under subsection (a)(1) only by a person involved in providing or seeking to provide, or obtaining or seeking to obtain, services in a facility that provides reproductive health services, and such an action may be brought under subsection (a)(2) only by a person lawfully exercising or seeking to exercise the First Amendment right of religious freedom at a place of religious worship or by the entity that owns or operates such place of religious worship.
(B) Relief.--In any action under subparagraph (A), the court may award appropriate relief, including temporary, preliminary or permanent injunctive relief and compensatory and punitive damages, as well as the costs of suit and reasonable fees for attorneys and expert witnesses. With respect to compensatory damages, the plaintiff may elect, at any time prior to the rendering of final judgment, to recover, in lieu of actual damages, an award of statutory damages in the amount of $5,000 per violation.
(2) Action by Attorney General of the United States.--
(A) In general.--If the Attorney General of the United States has reasonable cause to believe that any person or group of persons is being, has been, or may be injured by conduct constituting a violation of this section, the Attorney General may commence a civil action in any appropriate United States District Court.
(B) Relief.--In any action under subparagraph (A), the court may award appropriate relief, including temporary, preliminary or permanent injunctive relief, and compensatory damages to persons aggrieved as described in paragraph (1)(B). The court, to vindicate the public interest, may also assess a civil penalty against each respondent--
(i) in an amount not exceeding $10,000 for a nonviolent physical obstruction and $15,000 for other first violations; and
(ii) in an amount not exceeding $15,000 for a nonviolent physical obstruction and $25,000 for any other subsequent violation.
(3) Actions by State Attorneys General.--
(A) In general.--If the Attorney General of a State has reasonable cause to believe that any person or group of persons is being, has been, or may be injured by conduct constituting a violation of this section, such Attorney General may commence a civil action in the name of such State, as parens patriae on behalf of natural persons residing in such State, in any appropriate United States District Court.
(B) Relief.--In any action under subparagraph (A), the court may award appropriate relief, including temporary, preliminary or permanent injunctive relief, compensatory damages, and civil penalties as described in paragraph (2)(B).

(d) Rules of construction.--Nothing in this section shall be construed--
(1) to prohibit any expressive conduct (including peaceful picketing or other peaceful demonstration) protected from legal prohibition by the First Amendment to the Constitution;
(2) to create new remedies for interference with activities protected by the free speech or free exercise clauses of the First Amendment to the Constitution, occurring outside a facility, regardless of the point of view expressed, or to limit any existing legal remedies for such interference;
(3) to provide exclusive criminal penalties or civil remedies with respect to the conduct prohibited by this section, or to preempt State or local laws that may provide such penalties or remedies; or
(4) to interfere with the enforcement of State or local laws regulating the performance of abortions or other reproductive health services.

(e) Definitions.--As used in this section:
(1) Facility.--The term "facility" includes a hospital, clinic, physician's office, or other facility that provides reproductive health services, and includes the building or structure in which the facility is located.
(2) Interfere with.--The term "interfere with" means to restrict a person's freedom of movement.
(3) Intimidate.--The term "intimidate" means to place a person in reasonable apprehension of bodily harm to him- or herself or to another.
(4) Physical obstruction.--The term "physical obstruction" means rendering impassable ingress to or egress from a facility that provides reproductive health services or to or from a place of religious worship, or rendering passage to or from such a facility or place of religious worship unreasonably difficult or hazardous.
(5) Reproductive health services.--The term "reproductive health services" means reproductive health services provided in a hospital, clinic, physician's office, or other facility, and includes medical, surgical, counselling or referral services relating to the human reproductive system, including services relating to pregnancy or the termination of a pregnancy.
(6) State.--The term "State" includes a State of the United States, the District of Columbia, and any commonwealth, territory, or possession of the United States.

“Two Ships Passing in the Night”: Missing Communication in Medical Practice

As I read the comments written to the threads on patient modesty, hysterectomy, “I hate doctors”, it seems to me that a basis for much of the tension and unhappiness with the medical profession is related specifically to a lack of communication between doctor and patient or the patient’s families. The patients fail to tell the doctor what are their goals and wishes and the doctor doesn’t ask and therefore may set goals or actions which appear appropriate to the clinical situation but in fact is not at all what the patient wants. It’s almost like two ships passing in the night, each going their own way, each with their own goals and experiences but not communicating with each other to warn, perhaps, about rough seas ahead or the conditions aboard ship.


This communication gap in medical practice, I think, is related to lack of time or simply ignorance or inattention on the part of the physician and the apparent power difference between the patient and doctor so that the patient may feel embarrassed, intimidated or unsure about the consequences of speaking out.


What are your ideas about the issue of doctor-patient communication? Don’t write about the specific views covered in the above threads, which can be more appropriately discussed by writing directly to those threads, but write here about your views of whether you see communication generally as a problem and what approaches you would offer to mitigate the problem. ..Maurice.

Graphic: Photograph by me of two snails passing and color modified by Picasa3.