Are Physicians to Serve as Moral Gatekeepers?

Are physicians to serve as moral gatekeepers? This question is nicely dissected, particularly in reference to the actions of cosmetic surgeons, in an article in the May 2010 issue of the Virtual Mentor by Jordan Amadio who by now has received his Doctor of Medicine degree from Harvard Medical School.   Go to the link and read the article.

Beyond the individual patient for whom the patient’s physician has the fiduciary responsibility to attend and provide the patient the best and most beneficent advice and skills, there looms society. Society is the medium in which the physician must live and flourish along with his or her patient and which can have profound effects on both.  And the question arises, when a physician attends the patient should the physician also consider the impact of what he or she is advising or doing upon society both in moral, practical and financial impacts?  The latter two has recently been of concern because of the limits of resources and funding.

The moral aspect of what the physician decides and does has also  important social implications.  The matter of cosmetic surgery is considered in the article as, in many cases, a way the physician is reshaping societal views of what is considered normal, unpleasant, beautiful in personal appearance.  And, perhaps, to make the ethical issue worse, physicians have become complicit (and being paid by the patient to be complicit) in resetting the societal views.  Other areas of moral impact on society involves contraception, abortion, assisted reproduction, homosexuality, sexual identification as well as other non-reproductive or sexual areas such as gun control, death penalty, relations between physicians and suspected terrorists,  end-of-life issues, physician-assisted suicide and organ transplantation, genetic screening and genetic mutation of plants, animals and perhaps humans.  The question arises, as to how energetic or activistic should physicians become in their moral views and through their actions.

Moral and political views may merge.  A recent example, written up in the national news, of a physician becoming almost a literal gatekeeper was that of a Florida urologist, Jack Cassell, who posted a sign on his office door allegedly reading, "If you voted for Obama ... seek urologic care elsewhere. Changes to your health care begin right now, not in four years."

What are your thoughts about personal gatekeeper roles of physicians in their position as professionals and by their voices and actions regarding moral issues and altering the way society looks at itself and behaves? Or should, ideally, physicians  simply attend to the personal needs of their patients, suppressing moral concerns and dismiss worries regarding the effect on society in general?  ..Maurice.

Futility of Treatments: Should an Ethics Committee Decide?

On  May 14 2010 the Practical Bioethics Blog had an issue posted by Rosemary  Flannigan asking the question “Ethics Committee as Decision Makers?”  She wrote: 

In New Jersey we have the case of the 73 year old man in a persistent vegetative state for nearly a year, hooked up to a ventilator, dialysis machine and feeding tube because the patient’s daughter did not agree to the futility conclusion reached by the medical staff and who sued—and won—when the hospital placed a “do not resuscitate” sign on his bed and halted dialysis. Oh, we are getting good at endorsing family’s determination about “extraordinary” means—but we are not so good when family won’t agree to our clinical conclusions. So a group of physicians and “bioethics experts” in New Jersey are advocating “for an independent ethics committee to help resolve end-of-life disputes between families and hospitals.”WHOA!! Aren’t we jumping the gun here? Aren’t ethics committees designed to help OTHERS make good decisions? Haven’t we long held the conviction that “ethics committees are not decision-makers”? I see the need for help here, but let’s call it BY ANOTHER NAME.Agree? Disagree? I’m all ears!!! Link: New Jersey needs independent panel to resolve disputes over end-of-life care,Editorial, New Jersey Star-Ledger, May 12, 2010”

I wrote back the following response:

It's all a matter of who's "futility". What is the definition of futility which is being used by the various parties who are alive and contemplating? From the context of physiologic futility, if that is the basis for the physician's and hospital's definition they are fully mistaken. The ventilator, dialysis and feeding tube was, in fact, keeping the patient alive and with that definition the treatments were certainly not futile. Ah! but if the physicians and hospital were basing their decision on quality of life, the conclusion of futility of the treatments could be appropriate---but only if this was the quality of life that the patient DIDN'T want or to be maintained. But who would know what the patient really wanted? Why, of course, it might be the daughter..if she had engaged her father in a discussion of his desires about life if he was ever incapacitated. He may have told her that he didn't want to be kept alive but forever unconscious and not able to participate in life. The daughter says that the treatment is not futile but does that represent her own view or the view of the father? If it is her own personal conclusion it is not what should be considered since if she is acting as a surrogate for her father. It must be her father's view of what he wanted as a quality of life that she should be disclosing. Even if he never talked to her about quality of life, if he was a robust and active man as she might describe him, one might assume that he would want to return to some reasonable degree of awareness and participation in life. Based on the length of debility and the systemic chronic complications this will likely not happen. Would he have wanted his body functions, color, temperature and heart beat to be maintained indefinitely for the benefit of his family? If the daughter knows that this would be what her father wanted, then she was speaking for her father by denying futility. But I would doubt it. The role of the ethics committee in all this? Well, it would be simply to explain everything I wrote above to all the stakeholders: family, physicians and hospital. Unfortunately, the patient would be one stakeholder which will not be informed. Once this is done, it is up to the stakeholders to come to a decision. At that point, the ethics committee in their classic role, can either agree or disagree with the parties and make their view known. The ethics committee will make no final decision, should not make any final decision that will be acted upon. The decision is up to the stakeholders with the daughter speaking for her father. No other named or unnamed committee is necessary.

So there it is: In this case what was important was to understand how the word “futile or futility” was used.  Then to be sure that the word was used appropriately. If futility deals with the ineffectiveness of a treatment to sustain a life and the treatment is ineffective then it is futile. If futility deals with quality of life of the patient, it is essential to remember that it is up to the patient to have expressed what quality of life the patient would have wanted.  If the patient never confided with anyone, someone who has lived with the patient and knows the patients likes and dislikes may help all come to a conclusion about the patient’s definition of “quality”.  If that quality will be absent despite the treatment then the treatment is futile.  And then what one does with a prognosis of futility..well, that should be the decision of the doctors with the patient or patient’s surrogate. But not one of an ethics committee.   ..Maurice.

Patient Modesty: Volume 34

This thread has been continuing since August 2005..approaching now 5 years. With the literally thousands of commentaries written to this topic of patient modesty on this blog, I challenge our visitors here to go beyond simply expressing their concerns here, much of which I do consider valid, and now progress to the necessary chore of broadcasting the concerns to the general public, the medical system, the politicians and the government. I would like to see evidence of such action since I am sure that this will be the only route to real change, real change that I now realize (which I hadn't prior to 5 years ago) is necessary. So "go to it!"..Maurice.

ADDENDUM 5-15-2010: Those who wish to participate in advocating to the public and the medical system your views regarding the need for more attention to patient modesty and gender selection of healthcare providers, a long time visitor to this thread, swf, has set up an advocacy blog to begin this advocacy challenge. Go there and start the process.

Graphic: from various Google sources. Thanks.

NOTICE: AS OF TODAY JULY 2, 2010 "PATIENT MODESTY: VOLUME 34" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON Volume 35.
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Female Circumcision:Nicking or Cutting: Is Either Ethical?

There is some current controversy about an April 26, 2010 statement of policy by the American Academy of Pediatrics (AAP) and published in Pediatrics which suggests to pediatricians that though ritual female circumcision should be continued to be illegal in the United States, the federal government ought to allow physicians to perform simple "nicking" of the female child's genitalia as a nominal  acceptance of the family's request for full ritual circumcision and along with education of the family regarding the immediate and long term harms of full circumcision. These actions may reduce the probability that the family will take the child overseas for full circumcision.  Read the pdf file from Pediatrics to learn all about female circumcision and the suggestions and recommendations made by the AAP. For a description of the controversy read the article in the New York Times May 6 2010 edition.

Irrespective of the United States current law against any form of a non-medical procedure on a female child's genitalia, is it ethical to disregard the request of the parents for a long established and performed ritual procedure on their daughter, particularly if the ritual circumcision is also performed on the male child? Would simple nicking of the skin be a reasonable substitute for full circumcision if permitted by the parents and  be an ethical alternative for the physician to perform?

What are the limits to acceptance of norms from other cultures when requested to be performed in the multi-cultural United States?  ..Maurice.

Is Ethical Consensus Always Ethical?

Ethical consensus often sets guidelines to society as to what approach or act is a "good" and yet should that be the way ethical decisions should be made? Yesterday, on vacation in Morro Bay on the central coast of California, I found the group of seagulls which I photographed and it struck me at the time that they were making a graphic point regarding an issue that I brought up with the discussion of ethical consensus as written in the thread “Good People Doing Bad Things for Good Reasons". The black and white birds were headed and looking one way. The single colored bird was headed and looking the other way. Could one say that the black and white birds were part of a consensus and the colored bird was not? And if so, were the black and white birds looking the "right" way and the colored bird was not?  It is just this dilemma regarding the product of a consensus particularly when the way a person or society itself is guided to either the "right" or "wrong" way based on that consensus.  Or should we consider instead the direction set by the colored bird? ..Maurice.