Patient Modesty: Volume 28

We continue on with a discussion about physicians, nurses and others in the healthcare system ignoring some patients’ modesty concerns and the need for a gender selection option offered to patients who wish to have their say in who examines and treats them. ..Maurice.

Graphic: Photograph from the Faculty of Nursing Science, Assumption University of Thailand and modified by me with Picasa3. If this was a real man and not a manikin in the photograph, some visitors to these Patient Modesty threads would find such a gathering rather disturbing.

NOTICE: AS OF TODAY DECEMBER 13, 2009 "PATIENT MODESTY: VOLUME 28 WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 29.

Doctors and Nurses and the Problem of Their Disruptive Behavior

One group of nurses banded together to try to get a physician unfairly disciplined, while another encouraged fellow nurses to disobey doctors' orders outright. A surgeon told his staff that monkeys could be trained to do what scrub nurses do, while another doctor told a patient that the nurse in the room didn't know what she was doing.
A nurse witnessed the onset of complications in an intensive care patient but refused to contact the on-call physician for fear of his temper -- a delay at least one observer thought contributed to the patient's death.

This excerpt is from November 16, 2009 American Medical Association News, amednews.com




The article is all about what is happening now in hospitals, clinics and other healthcare facilities around the United States. It is all about disruptive and intimidating behavior of physicians and nurses which has been going on for years but now, starting about a year ago, the Joint Commission which certifies hospitals and other institutions for government reimbursement in the interest of patient safety declared that these institutions must present evidence of “zero-tolerance” for these unprofessional behaviors which potentially can impact negatively on the care and safety of the patients. However, there still is a lot still missing in institutional and personal compliance to the Joint Commission’s order.

A 2009 study of behaviors "Bad Blood: Doctor-Nurse Behavior Problems Impact Patient Care," American College of Physician Executives 2009 Doctor-Nurse Behavior Survey,Physician Executive Journal, November/December showed the following:degrading comments and insults comprised 84.5% of the behaviors followed by yelling 73.3%,cursing 49.4%, inappropriate joking 45.5%, refusing to work with colleague 38.4%, refusing to speak to colleague 34.3%, trying to get someone unjustly disciplined 32.3%, throwing objects 18.9%, trying to get someone unjustly fired 18.6%, spreading malicious rumors 17.1%, sexual harassment 13.4%, physical assault 2.8% and others 10%.


However, what is happening is that there seems to be a difficulty in separating disruptive speech and actions from honest attempts in certain situations to protect patients and to disclose to hospital administration of weaknesses in the hospital’s healthcare system or in the harmful behavior of certain physicians or nurses—that is, “whistle blowing”. Unfortunately, these actions may be considered disruptive, not constructive and behavior which must be suppressed to keep to the Joint Commission’s rule and it is the “whistle blower” who is accused of being disruptive. Further, staff may be reluctant to report on behavior of superiors or other colleagues in fear for personal repercussions.


Obviously, much more has to be done besides hospitals simply writing a policy about these matters. Read the full article and the linked references there and return and give your opinion about the issue and any disruptive behavior you have witnessed, but please give no names. ..Maurice.

Graphic: Photograph, taken by me, of a painting ("Self-portrait, Yawning, Joseph H. Ducreux, 1783 from the Getty Museum, Los Angeles)but modified with Picasa3. Basis for selection of this graphic for this thread: Somehow, the painting looked to me like a disruptive yelling rather than a benign yawn. What do you think?

Violation of the Patient’s Autonomy?: Is that Ethical?

Patient autonomy is the ethical principle which represents that a patient who has the capacity to understand their medical condition and the risks and benefits of some action upon them, has the ethical right, under most circumstances, to make that decision for themselves and expect the physician to abide with their request.


But that is “under most circumstances”. I want to present two scenarios where a patient has stated “stop! I don’t want…” The question I pose to my visitors is whether a physician can ignore that request in each of the scenarios and if so why or why not should the patient’s request be followed or not followed. When do standards of medical practice trump a patient’s request? Standards of medical or surgical practice are specific behaviors, based on scientific literature but also based on the consensus of physicians about certain diagnostic or therapeutic actions and also on common behaviors or actions of doctors where they practice and which the profession of medicine place upon physicians as the physicians carries out their care of their patients. In this regard, if there is a difference between the two cases, what is the difference? ..Maurice.


Scenario 1:
Brain surgery of lesions is often performed on conscious patients to establish safe dissection around motor and sensory areas. A patient with skull opened and brain exposed demanded the surgeon to stop the operation at once despite understanding the consequences of fully terminating the surgery at this point and leaving the skull open. Instead of stopping, the surgeon had the patient anesthetized to allow proper closure of the skull thus was violating the patient's demand. Is what the surgeon did ethical?


Scenario 2:
An adult Jehovah’s Witness patient because of acute massive bleeding which cannot be rapidly stopped requires life saving blood transfusion but is awake and refuses blood transfusions based on the patient’s religion. The patient is informed that with the transfusion, the patient will live and the underlying bleeding problem can be resolved with no long term medical consequences. Without the transfusion, the patient could most likely die. The patient still refuses but the physician, as the patient is beginning to lose consciousness, violates the patient’s autonomous demand and begins the blood transfusions. Is what the physician did ethical?

Patient Modesty: Volume 27

Yes, throughout these threads on patient modesty, it does appear that often what is missing and what should be corrected is the lack of communication on this issue both on the part of the patient but also on the part of the various healthcare providers, clinics and hospitals. It may be that many of both parties display modesty in communication by not speaking out or asking out about modesty. Hopefully, this issue of modesty in communication can be eliminated on both sides and that the concerns of patients in physical modesty can be resolved.

Continue writing.. ..Maurice.

Graphic: A photograph taken by myself at a local clinic and modified with Picasa3.

NOTICE: AS OF TODAY NOVEMBER 28, 2009 "PATIENT MODESTY: VOLUME 27" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 28.

A Medical Student’s Anatomic Gift: There is More Involved than Dissection

From a medical student to the student’s group human cadaver:


“You are an exponential gift, from one man to eight future doctors to hundreds of patients to the multitudes that make up their family and friends ... You gave us access to the wonder that is human life and challenged us to discover all the intricate parts working together to make one man.”


To read the whole story of the Boston University School of Medicine’s anatomical gift program and its manager and anatomy lab director, Robert Bouchie, go to this link. There you will find a find a fine video about the program but importantly read about the ethics and consideration given to the donated bodies but also to the deceased person’s family. Very inspiring. Do you want to donate your body to a medical school like Boston U.? ..Maurice.

The Elderly and the Four Ethical Principles

With more and more people living longer, attributed to various factors including advances in medical treatments, there are more and more elderly now present in the population.

But, first, what is the definition of an older person or the elderly? One definition included in a World Health Organization online document regarding the elderly and old age is by M. Gorman: "The ageing process is of course a biological reality which has its own dynamic, largely beyond human control. However, it is also subject to the constructions by which each society makes sense of old age. In the developed world, chronological time plays a paramount role. The age of 60 or 65, roughly equivalent to retirement ages in most developed countries, is said to be the beginning of old age. In many parts of the developing world, chronological time has little or no importance in the meaning of old age. Other socially constructed meanings of age are more significant such as the roles assigned to older people; in some cases it is the loss of roles accompanying physical decline which is significant in defining old age. Thus, in contrast to the chronological milestones which mark life stages in the developed world, old age in many developing countries is seen to begin at the point when active contribution is no longer possible."


There are the four ethical principles which should be considered and which can apply to the medical care of the elderly. The principles are beneficence, non-maleficence, autonomy and justice. How can they apply? I think that others might give different examples, however the following are the ones that come to my mind presently.


Beneficence is the principle “to do good”. Non-maleficence is the principle “to do no harm”. We, as physicians, are required, as part of our profession, to adhere to these two principles as we proceed in the care of our patients. The question arises as to whether at some point in the life cycle, what these two principles mean in practice is different between the elderly and those who are younger. And then who is to characterize the actions: the doctor, the patient, the profession or society?


For example, is there a point in the care of an elderly patient who has symptomatic cancer where administration of classic or novel cancer chemotherapy with its significant side-effects might no longer be considered a beneficent act but actually a harmful act? Would this point be considered as readily in a patient who is significantly younger? Would the use of a cancer drug in an elderly patient, which by statistics would only prolong the patient’s life by a few months but with continued suffering from the underlying disease be considered a non-beneficent act on the part of the physician? Would the consideration that a new drug might come out during that extra time of life that would be more effective rationalize the current management? Would this issue be the same in a patient who was considerably younger? Should the decision as to whether a treatment represents a “good” or a “not good” be one of the physician based on knowledge and experience or should such decisions be left only to the patient who is the one who has the burdens of the illness, the symptoms, the costs and the effects on the patient’s ways of life and goals?


The third principle, the principle of autonomy, the right of the patients to speak for themselves as to how they want their illnesses to be treated, plays a important role in how beneficence and non-maleficence is judged. As one grows older, some patients may lose their capacity to make their own medical decisions and, without an Advance Directive or legal surrogate to help, the bearing of responsibility for defining the physician’s actions as beneficent and non-maleficent or “wanted” vs “unwanted” in terms of the patient’s own desires may be placed more on the physician’s shoulders or others. Is the principle of autonomy just as valid an ethical principle in the elderly as in the younger patient?


And finally, comes the principle of justice. One reads about the tremendous amount of money spent on disease management within the United States just during the last months of a person’s life. Is that fair? is that spending a fair act to other patients who are sick but have the potential of many more years of life ahead and where the money might be put to use which is more constructive to society? Isn’t the issue of justice most pertinent about the medical care which is given to the elderly? Or is bedside rationing against the elderly an unethical and abhorrent concept?


Many, many questions and mostly about whether the elderly should have the four ethical principles applied differently than to those who are younger . However, I look to my visitors for the answers. ..Maurice.

Graphic: Photograph of the elderly walking in a city park in Southern California by me 11-4-2009.

The Hospital Ethics Committee: Was it of Help?: Tell Your Story

I have been the chair person of two hospital ethics committees over the past 23 years and my current committee continues to do its assigned job. The role of the committee includes being the educator, being the facilitator, being the mediator when an ethical issue appears as a patient is being treated and one or more stakeholders in the issue request help from our committee. We sort out the issues and explain to the stakeholders the possible ethical and legal courses but we don’t make the final decisions. We, as members, hope that our education, facilitation and mediation has been beneficial to all those who look to us for help and, of course, particularly the patient.


In my own experience, the grades of our performance as given to us by the stakeholders have been good. It does seem that our committee fills a need. But that is only by my personal experience. In all these over 700 threads on ethics, I have never asked my visitors about their experiences with hospital ethics committees. I strongly suspect that most of the patients and their families who have had a hospital experience never had any interaction with that hospital’s ethics committee. In fact, there may be many visitors here who didn’t even know that there was such a resource available in your hospital.


But to those who do know and had the experience, usually as a family member of the sick patient or even that of the patient, I would be interested to read about that experience and whether you felt that the interaction with the committee was to the good of the patient and a beneficial experience. If you tell your stories, tell them anonymously and don’t name names, for reasons of privacy to the patient and fairness to the hospital. Tell us what was the issue and in which way the hospital ethics committee itself helped or didn’t help. As I suggested, I am not expecting a large number of replies but I still wanted to provide a means for the public to grade these committees. ..Maurice.

“One Who Becomes Compassionate to the Cruel will Ultimately Become Cruel to the Compassionate”: Should Terrorists be given Medical Treatment?

This is the ethical issue that has, as yet, not been fully answered by international law or by consensus ethics. And yet the issue is certainly not hypothetical. If the journal is available to you, you must read the Target Article in the American Journal of Bioethics, October 2009 titled “Medical Care for Terrorists—To Treat or Not to Treat” by Gesundheit, Ash, Blazer and Rivkind. (It is followed by a series of comment articles by other ethicists). In the article, the authors, from Hadassah University Hospital (G, R), Rambaum Medical Center(B) and Israeli Defense Forces (A) present two cases for discussion, both Hamas terrorists, both severely injured and both given immediate and extensive medical and surgical treatment in the Israeli hospitals over 20 days and a year respectively with the costs borne by the hospitals.

The physicians and caregivers provided excellent management despite whatever their own feelings or views were regarding what these terrorists had already done to the public. The ethical principles of autonomy, beneficence and non-maleficence was observed and practiced in the care of these men. An ethical question which might now be raised is whether the fourth principle of justice was observed. In the triage of these critically ill terrorists to provide emergency management, there were other patients, civilians, who needed prompt attention for whom attention to them may have been delayed. Also, in terms of justice, shouldn’t the great financial cost of caring for both terrorists have been used instead to the care of non-terrorist sick civilians? There may be a debate as to the definition of “terrorist” and some may say that they were simply “criminals” but wouldn’t the indiscriminate killing of civilians for no specific purpose but only to terrorize the population be an adequate description. Both terrorists when recovered were handed over to the government, tried and convicted.


So should all the humanistic, professional and ethical standards which physicians take from their Hippocratic Oath and their profession be set aside when it comes to medical care for a terrorist? And should the medical profession bear in mind what was written in the Ecclesiastes Rabba 7:16 “One who becomes compassionate to the cruel will ultimately become cruel to the compassionate”?
What do you think? ..Maurice.

The Muslim Faith and Ethical Issues: Questions to My Muslim Visitors

I would like to pose the following questions to my visitors and who come to this blog from Muslim countries so that we all can learn and understand how bioethical issues are looked upon by people in their countries who are of Muslim faith. Muslim visitors to my blog who lives within the United States are also certainly welcome to write but also tell us how you see your views as similar or different from those of your faith in other countries. I assume that some of the views taken for granted within the American bioethics may be quite different in other countries. I think those of us not of the Muslim faith would like to know. ..Maurice.


SOME QUESTIONS (answer any or all):

1) What is the view of stem cell research and human cloning? How about simply animal cloning? How about the manipulating the genes of plants used for food?

2) How is invitro fertilization looked upon: taking the egg of a woman and mixing it with the husband’s sperm and then inserting it into that woman’s womb so that a child might be created in a couple who otherwise were unable to normally have a child? What if the husband was sterile and the woman was fertilized by a sperm of another man to create a child for the husband and wife?

3) How does the Muslim faith look at the possibility of adoption of a child?

4) How about organ donation to a needy patient from a live donor? How about organ donation to a needy patient from a newly deceased donor?

5) Should hydration and nutrition be continued in a patient who is in a permanent vegetative state (permanently in a unconscious state, apparently unaware and not reactive to the external environment)?

6) Should a conscious patient who understands his or her medical condition have the right to order that life-sustaining treatment (like a mechanical ventilator) be turned off even though it will cause the death of the patient)?

7) Is euthanasia (physician, responding to a patient’s request and causing the patient to die) permissible? Is suicide permissible? Would physician assisted suicide as practiced in Oregon and Washington (physician writing a prescription for a lethal dose of drug which the patient can fill and take if they desire at their own time) be allowed by the Muslim faith?

8) Is medical research using animals which may be killed for the research studies permissible? Are certain animals protected from such use?

9) Is it ethical for a physician and a patient to have a romantic relationship while the patient is still under the physician’s care?

10) Should the doctor tell “bad news” to the patient (such as cancer or a fatal illness)? If not, to whom? A family member?


ADDENDUM 12-16-2009: You may be interested in a new thread I put up today titled "Suicide: Views of Christianity and Islam".