Are Physicians to Serve as Moral Gatekeepers?
What have you been reading, hearing or TV viewing that has provoked some feelings of comfort or concern about what is happening in the world of medicine, medical care, treatment or science? Ethics is all about doing the right thing. Are you aware of any issues in medicine or biologic science which are being done right, could be improved or in fact represent totally unethical behavior? Write about them here.. and I will too! ..Maurice (DoktorMo@aol.com)
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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”
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.
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.
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.
“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.