Patient Modesty: Volume 24

The discussion continues by my visitors with their personal experiences and understandings about the issue of patient modesty. However, the discussion also continues to develop mechanisms of how to change the medical system and permit patient expression of their concerns but also the system acting in the patient's favor on them. ..Maurice.

Graphic: An old illustration of a religious scroll but modified by me with ArtRage and Picasa 3.


NOTICE: AS OF TODAY OCTOBER 11, 2009 "PATIENT MODESTY: VOLUME 24" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 25.

A Child by IVF vs Adoption:: Ethical Defining of "Want" vs "Need"

The issue is simply or perhaps not so simply the addition of a member to the family where there is an infertility problem of the couple. Should the couple "want their own kid", a child of their own genetic background, to carry on the family's genes by attempting an expensive and with some risk the invitro fertilization (IVF) and implantation of the embryo into the mother? Or would it be less expensive and more ethical in a societal sense to adopt a child who needs parents and a home? What is the ethical difference between need and want?

Physician-ethicist Erich Loewy wrote a response about "need" and "want" to a bioethics listserv dealing with this issue about the "wants" of infertile couples. He has given me permission to reproduce his comments here.

"Want their own kids" or want their own anything is the disease we in
Capitalist societies have, the "I need" is equated with I want. I
need food, water, shelter, the opportunity to get educated (no
comment please---I know it is too late!!) and to have health care. I
want is substantially different. I want to see the Great Chinese Wall
but if I don't, so what. I (actually) wanted to become a conductor
but lack perfect pitch which a first rate conductor needs. So, I
changed my want to something else. If I am terribly thirsty I need
water (same for hunger--and I do not mean appetite) and if I do not
get it I will die.

Having your own child may be a want but it surely is not a need. We
have (and I will not cite statistics once again) myriads of children
that need a home. Yes---they need it because there is more to a
child's surviving than what I have called "first order needs" (see
above). The problem is that many children who are homeless in today's
splendid Capitalist society happen to be Afro-American and (horor of
horrors!, I should have a Black, Jewish or Hispanic child!!!). So
instead of the needy glut we spend perhaps billions to artifically
satisfy somebodies want and let the need of others slide. Further,
this society is as full of racism (although the fraud of PC covers it
with a veneer of probity) as Austria, Germany and, yes, the US had of
anti-Semitism after the first war and, alas has today but again
hidden by a veneer of PC.

If a person is sterile (and I remember several classmates who would
have liked to be!!) that is unfortunate. If I lack perfect
pitch--that is unfortunate. Engelhardt woud claim that if I am ill,
that is unfortunate or unlucky. It however puts no obligation on
anyone to help me. But you see that is an entirely different one. My
"wanting" medical care is not a want---it is a need and it is
therefore that a decent society would provide single tiered
(everybody gets the same and no one can buy more of those things that
are "wants"---private rooms, TV in the room, nicer curtains, etc.
which do not affect outcome, However, the same physicians, staffing
with nurses, diagnostic or therapeutic means, waiting time, etc which
do affect outcome.

Being unable to have my own child is no more a "need" than is my
having perfect pitch is. It seems perverse to me that a society and a
world which already have more than it can take care of (or is willing
to take of!!!) goes out and with great effort and the use of many
resources tries to make more of what we already have but neglect severely.

Erich

Dr Erich H. Loewy
Professor of Medicine and Founding Chair of Bioethics (emeritus)
Associate in Philosophy
University of California, Davis
E-mail: ehloewy@ucdavis.edu



How do you look at this "want" vs "need" decision of infertile couples? ..Maurice.

The Language of Bioethics: Nuances in Use Lead to Ethical Dilemmas

In contrast to the “Thai Dictionary of Medical Ethics” which appears to be a “tongue-in-cheek” description of terms used in bioethics, for those who would like the more established definitions, I suggest you go to this link which is to the “Language of Bioethics” by the Medical College of Georgia. Many terms are tossed around these days by doctors, ethicists, politicians and others and it is worthwhile to understand what is the current consensus of meaning of the terms.

Futility is a word often used but often misused since in medical practice using the word futility or futile alone is misleading. That is because one has to describe in what sense the term futile or futility is being used. Often the expression is used: “further treatment is futile”. It is this misuse that has caused some ethicists to declare that this term should not be used as a medical descriptor. So, from the “Language of Bioethics” what should we know about the term “futility”?

Futility: a term dealing with the hopelessly ill and dying; at least three meanings bear consideration:

Physiologic futility–the proposed intervention or continued treatment cannot reverse a physiologic condition in the patient that is leading to death. This strict definition of futility means that the intended medical effect of the treatment is not likely to occur, as determined by scientific evidence or local medical experience.

Personal futility–the proposed intervention or continued treatment may have the desired medical effect, but the resulting benefit does not outweigh the burden of continued life. This "best interest" or "disproportionate burden" definition of futility may mean that consciousness of the patient is not restored, or he/she will not leave the ICU, or that severe suffering will persist.

Social futility–the proposed intervention or continued treatment may have the desired medical effect, and personal benefit may outweigh the burden, but the treatment is not available, as determined by the social consensus, due to scarce resources.

A question one may want to ask is which kind of futility should ethically trump the others? If a treatment does what it is supposed to do with regard to symptoms but doesn’t make the patient better in terms of extending a life that the patient desires, should that treatment be called futile and not started or discontinued? What if the treatment would save a life such as a ventilator for a critically ill elderly patient but in this catastrophic influenza pandemic, the last ventilator available at the time was instead could be used on a young critically ill patient. In that case, socially established triage criteria found that the ventilator, under these circumstances, was a socially futile treatment for that elderly patient since it prevented recovery of one much younger and perhaps, when recovered, make a longer contribution to the benefit of society. Should the possibility of social futility trump all? Or if there is no physiologic nor personal futility in the treatment then “first come, first served” should be the principle used when resources are scarce?


Look at the list for all the other bioethics terms in the “Language of Bioethics”. Unfortunately, despite clear definitions to these terms, nuances in their use add to potential ethical dilemmas. (As that list defines Dilemma: moral obligations to others exist on both sides of the choice; ethical reasons that support choosing both alternatives.) I may delve into other terms in later posts in which their meanings don’t always set clear ethical answers. ..Maurice.

Addendum: By the way, the criteria for "Personal Futility" should be set by the patient or if the patient cannot communicate and there is no surrogate to tell what is known about the patient's wishes, physicians must use the "Reasonable Person Standard" which is what a "reasonable person" would decide about their future quality of life.

Reflections in Medical Practice: Thinking Things Over

The Story of Some Doctor’s Reflection

A Poem By Maurice Bernstein, M.D.

I am some doctor and Mary is my Patient
Did I know Mary was
So Sick when I first
Saw her
Then?

She comes to me and asks for Help
Did I take the Time
To listen to the entire
Symptom Story
Completely?

There was a phone Call from Doctor Smith
Did I interrupt Mary
To take the call
As though more
Important?

Then there was time left only for a Snap Diagnosis
Did I treat Mary for the flu
With some
Antibiotic?

Of course the Diagnosis was a Blood Clot to the lung
And why shouldn’t I
Have made that
Diagnosis?
And now Mary is fighting for her Life and I Reflect.

Physicians reflect back on what has transpired with their patients, thinking about what was done well and what could have been done better. Often the reflective contemplation, thinking about the process of relating to that patient, making a diagnosis and selecting a therapy or improving skills is of benefit toward future interactions and decisions. Time is often made short for the physician, diseases are not always uniformly expressed, memory and experience is limited and mistakes and misjudgments are always possible. If time is limited, nevertheless at some point in a physician’s life, as part of the professional duty, reflection should be included. ..Maurice.

More on reflection in medicine on a previous thread.

Graphic: Photograph by me of a pool, Descanso Gardens, La Canada-Flintridge, Southern California

8 Weeks Pregnant—No! 4 weeks: A Problem in Professional Communication?

Try the following mind game scenario, which easily could be real and then tell us what should have been different in the professional communication to have made the outcome less traumatic for all. ..Maurice.

Young woman, pregnant, goes to ER for abdominal pain, accompanied by a young man. She is sent to the area that focuses on OB issues and she brings the young man in with her, saying he is the baby's father. An ultrasound is performed. The resident physician provides a running narrative what he is doing.

"Yes ... see here's the baby. The baby is about 8 weeks along ... "

Immediately the young woman says "No, that can't be. The baby is only 4weeks along."

"Nope," says the resident, "this one is a good 8 weeks ... "

"NO," the young woman insists. "You have to be wrong. That can't be." The young man is looking perplexed and perturbed. It becomes obvious he can't be the father, and he is just now finding out.

So what should the resident do now?

What should the resident have done earlier (remember, the young woman requested that the "father" come in)?
(Scenario obtained from a bioethics listserv presented by a subscriber ethicist)

Graphic: Ultrasound image of an 8 week fetus

Patient Modesty: Volume 23

Kilroy spying on the classic DiVinci figure reflects one of the paths of current discussion on patient modesty. There is concern by patients of both genders that there are onlookers who appear in the patients' medical care environment who just don't belong there and add to the aggravation the visitors describe regarding providers ignorance of patient modesty and privacy. ..Maurice.

Graphic: My construction of Kilroy and image of DiVinci's Vitruvian Man using ArtRage.

NOTICE: AS OF TODAY SEPTEMBER 25, 2009 "PATIENT MODESTY: VOLUME 23" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 24

Intentions Regarding Turning Off the Pacemaker of Reverend G

In the “Controversies” section of the Journal of the American Medical Association for February 23, 2000 there is a viewpoint as presented by Rhymes and colleagues titled “Withdrawing Very- Low Burden Interventions in Chronically Ill Patients”. The authors present a case about a severely demented elderly Reverend G who is “abusive, aggressive and assaultive” and “hallucinating”. His mental state and behavior cannot be controlled with any drug treatment. There is, on the other hand, an approach to management of this difficult patient.


Reverend G has a cardiac pacemaker “which the wife, with agreement from their children, has asked that the patient be given treatment to keep him comfortable and they asked that his pacemaker be turned off, on the assumption that the pacemaker may prevent an otherwise natural death.” The description of the case states that Reverend G had a living will written “before his dementia became severe” however it is not clear what the will stated except “he said that he did not want to commit suicide.” The authors provide arguments which support view that the wishes of the family is based on the rationale that turning off the pacemaker will end a “burdensome life” without representing physician-assisted suicide, euthanasia or “killing” the patient.


Ethicist Ed Pellegrino in a companion article in the same section of the Journal presents a moral algorithm for “Decisions to Withdraw Life Sustaining Treatment.” In it he finally argues that the reason for turning off the pacemaker should be if the intention was to remove a futile treatment but not if the intentions of the surrogates or medical attendants “were to hasten death…or to end a life which they unilaterally judged to be of ‘no quality’”


Which view would you hold? Is the pacemaker a futile treatment? Could one argue that the pacemaker is futile treatment, not because it can’t keep the heart beating normally, but because as a life-supportive mechanism it is failing to treat the patient’s dementia and what the family believes is simply maintaining a “burdensome life”? Can one call the pacemaker’s value as futile with regard to treating the mental disorder when it was inserted to treat the heart rhythm disturbance? And whose “burdensome life”? On the other hand could the decision by the family represent a loving concern for the patient who probably in recent times experienced not only the mental burdens but also most likely the physical burdens of physical restraints? What is your take on this scenario? ..Maurice.

Primary Care Boutiques and Healthcare Reform

During these days when the issue of healthcare reform is at the table of public interest and debate within the United States and where there are almost 50 million people who do not have health insurance, there seems to be a topic in healthcare which has not been discussed or considered within the reform packages. That topic is the issue of luxury primary care practice and clinics. These are the so-called medical “boutiques” which provide for a retainer special medical and associated service which would not be available to other patients. This would include besides a more luxurious clinic environment, more ready access to a physician year round by cell phone or pager, shorter waiting times for a visit, more rapid access to specialist attention, house calls and perhaps easier access for certain vaccines or diagnostic scanning. If with the added patient loads when these 50 million people are able to be able to afford a private physician, the numbers of primary care physicians will become a limiting factor. Boutique medicine practice may only reduce the numbers of physicians available for standard care.


I suggest that visitors to this blog who are interested in learning more about “boutique medicine” should go to the thread I started May 4 2007 “Where Have All Those Doctors Gone?: Coming Back in Boutique Medicine?"
There are links on that thread to additional information on the subject. Also, here is a link to chapter titled “Family Medicine Should Encourage the Development of Luxury Practices: Negative Position” by Martin Donohoe in the book “Ideological Debates in Family Medicine”.


There have been concerns expressed beyond reduction of physicians for standard primary care practice specifically regarding the effect of these boutique practices to raise the cost of all medical care and increase exposure to unnecessary and potentially harmful screening tests simply as a service to the boutique patients.
What do you think? Hopefully, physicians who participate in these services could also participate in the discussion here. ..Maurice.