Does the Fertilized Egg Equals Legal Person?

From today's New York Times:

"A constitutional amendment facing voters in Mississippi on Nov. 8, and similar initiatives brewing in half a dozen other states including Florida and Ohio, would declare a fertilized human egg to be a legal person, effectively branding abortion and some forms of birth control as murder. With this far-reaching anti-abortion strategy, the proponents of what they call personhood amendments hope to reshape the national debate."

By the time most of my visitors will have read this thread, the voters in Mississippi will have voted and the constitutional amendment will have passed with all its potential consequences or simply defeated and with some folks in Mississippi unsatisfied. Read the article describing the significance of this vote and return and discuss here what you think would be the consequences of such an amendment passing in other states or even become part of the United States Constitution. Should a fertilized human egg be a legal person and the intentional destruction of that person be consider a crime such as a homicide (murder)? ..Maurice.

Medical Bloopers 3: A Medical Communications Defect

The following medical charting errors may appear funny to the casual reader but if they or their cousins are written in medical charts, they not only appear ambiguous but may in some cases be harmful for the safe and effective medical management of patients. These "bloopers" are the results of rushed notations with no rereading by the writer of what was actually written.

This is actually the third in a series of such charting errors (the second in this series was an addition of 6 "bloopers" added to the original 19 and may be found at this link). There may be a few repeated from that second listing in this current presentation. Enjoy. ..Maurice.

Note: These "bloopers" come from a variety of sources and I don't know who to acknowledge for them.

By the time he was admitted, his rapid heart had stopped, and he was feeling better.

Patient has chest pain if she lies on her left side for over a year.

On the second day the knee was better and on the third day it had completely disappeared.

She has had no rigors or shaking chills, but her husband said she was very hot in bed last night.

The patient has been depressed ever since she began seeing me in 1986.

Patient was released to outpatient department without dressing.I have suggested that he loosen his pants before standing, and then when he stands with the help of his wife, they should fall to the floor.

The patient is tearful and crying constantly. She also appears to be depressed.

Discharge status: Alive but without permission.

The patient will need disposition, and therefore we will get Dr. Shapiro to dispose of him.

Healthy appearing decrepit 67 year old male, mentally alert, but forgetful.

The patient refused an autopsy.

The patient has no past history of suicides.

The patient expired on the floor uneventfully.

Patient has left his white blood cells at another hospital.

The patient's past medical history has been remarkably insignificant with only a 45 pound weight gain in the past three days.

She slipped on the ice and apparently her legs went in separate directions in early January.

The patient experienced sudden onset of severe shortness of breath with a picture of acute pulmonary edema at home while having sex which gradually deteriorated in the emergency room.

The patient had waffles for breakfast and anorexia for lunch.

Between you and me, we ought to be able to get this lady pregnant.

The patient was in his usual state of good health until his airplane ran out of gas and crashed.

Since she can't get pregnant with her husband, I thought you would like to work her up.

She is numb from her toes down.

While in the ER, she was examined, X-rated and sent home.

The skin was moist and dry.

Occasional, constant, infrequent headaches.

Coming from New York, this man has no children.

Patient was alert and unresponsive.

When she fainted, her eyes rolled around the room.

Malpractice vs Involuntary Manslaughter: What is the Distinction?

The current legal case being tried in court regarding the death of Michael Jackson by the alleged acts of Dr. Conrad Murray as involuntary manslaughter in contrast to the death being an act of malpractice brings up the question: what is the difference in legal terms between medical malpractice and involuntary manslaughter. And, perhaps, what is the difference in ethical terms? If the physician is found guilty, the physician is punished financially in the first case but by prison time in the second. An excellent article written by Eisenberg and Berlin in the American Journal of Radiology in August 2002 gives case examples and may tend to answer to the question posed in the title of my thread. An excerpt from the article follows:

The circumstances under which a physician's error of medical judgment triggers criminal prosecution are not totally clear. An English court of appeals ruled that to justify a criminal conviction, it must be proven that a physician acted with “gross negligence,” which is characterized by any or all of the following elements: indifference to an obvious risk of injury to health; actual foresight of the risk coupled with the determination nevertheless to run it; an appreciation of the risk coupled with a high degree of negligence in the attempt to avoid it; and inattention or failure to avert a serious risk.

A person whose behavior is “grossly negligent” may be liable for involuntary manslaughter if his or her conduct results in the accidental death of another person. Most jurisdictions hold that something more than ordinary negligence must be proven before the defendant can be found guilty of involuntary manslaughter. This usually requires that there be a substantial danger not only of bodily harm, but also of “serious bodily harm or death.” The defendant must have acted “recklessly,” a term defined as a “gross deviation from the standard of conduct that a law-abiding person would observe” in the same situation The court must consider all the circumstances surrounding the incident, including the social utility of any objective the defendant is trying to fulfill.

What, in my opinion, seems to be missing in the accusation of a physician with a crime of involuntary manslaughter rather than a professional error of malpractice is whether the physician's intent in diagnosis and management was to ignore any attempt toward the professional goal of beneficence (doing a "good" ) to his or her patient. If one could prove that such was not the intent and goal, shouldn't that be the overriding criteria to define a death as professional malpractice and not a crime? On the other hand, I look forward toward what how others to my blog thread look at this distinction. ..Maurice.

Another Look at Medical Futility

What is medical futility? What does it mean to stop or not start some procedure or treatment because such action is futile? And what does futile mean in this context? Over the past 7 years on this blog, I have started a few threads which included this issue. Once, I presented the definition of futility as described by physician-ethicst Dr. Steven Miles in his humorous "A Thai Dictionary of Medical Ethics" in which he described an example of the use of the term "futility"as "a siphon for removing puddles of water that form far ahead on highways on hot summer days." Medical futility is a bit more complicated than that. Recently, for me, a concise description of medical futility was made by an ethicist and teacher Laurence B. McCullough, Ph.D. on a bioethics listserv and with his permission, I present his words below. But also what I would like to read from my visitors is how they look at the term "futile" or "futility" in relation to its use by doctors and whether it represents to them as patients or family members of patients a term which has meaning and should be used. ..Maurice.

In its general clinical meaning, 'futile' means that in evidence-based reasoning there is no reasonable expectation that the usually intended outcomes of a clinical intervention will occur. The roots of the concept can be found in the admonition in the Hippocratic text, The Art, against the madness of thinking that clinical intervention has unlimited power to alter the course of disease or injury. (Blackhall in "Must we always use CPR?" suggested 100% failure rate or 97-99% failure rate with high and unacceptable morbidity.)

Providing futile clinical management is not consistent with professional integrity. (See Brett AS, McCullough LB. When patients request specific interventions: defining the limits of the physician's obligation. N Engl J Med 1986; 315: 1347-1351.) Professional integrity has been a consistent, core consideration of common law on end of life care, starting with Quinlan in 1976.

This general meaning of 'futility' must be specified, to be clinically applicable. (See Jones JW, McCullough LB. Postoperative futility: a clinical algorithm for setting limits. Br J Surg 2001; 88: 1153-1154; Rabeneck L, McCullough LB, Wray NP. Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement. Lancet 1997; 349: 496-498.)

Physiologic futility: no reasonable expectation that physiologic outcome will be achieved (e.g., antibiotics for viral infection, CPR on totally decapitated human being [from international resuscitation guidelines and my favorite], artificial administration of nutrition to a patient with cancer cachexia). Physiologic futility is not discredited by a transient physiologic effect, such an occasional heartbeat during CPR.

Imminent demise futility: clinical management is expected to be physiologically effective but the patient is expected to die during current admission with no expectation of recovery of interactive capacity. (Medicine is not vitalist in any global tradition of medical ethics. See Baker RB, McCullough LB. The Cambridge World History of Medical Ethics 2009, in which'vitalism' does not appear in the index.)

Clinical or overall futility: clinical management is expected to be physiologically effective and prevent imminent death but the patient is not expected to recover interactive capacity, as in permanent vegetative state diagnosed by American Academy of Neurology guidelines. (Again, medicine is not vitalist.)

Quality of life futility: clinical management is expected to be physiologically effective, prevent imminent death, and preserve interactive capacity but the resulting functional status is not acceptable to the patient from the patient's perspective. (Quality of life is engaging in life tasks and deriving satisfaction from doing so. This concept does not apply to infants or to patients about whom too little is known to reliably identify the life tasks in which they engaged and the values by which they would make judgments about whether engaging in those life tasks with projected functional status will result in sufficient satisfaction.)

The first three specifications fall within clinical expertise; the fourth depends on clinical expertise (prognosis of functional status) but is also a function of the patient's values and beliefs.

These specifications often cannot be invoked a priori. Instead, they become the basis for stopping rules for critical care (initiated by CPR, high-risk surgery) as a trial of intervention. Explaining this concept in advance is a powerful preventive ethics response to requests to "do everything," by focusing on everything that is consistent with excellent medical care.

Race, ethnicity, and money (source of payment) are irrelevant to the conceptualization and clinical application of these specifications, which, when explained, can help address the distrust problem. If someone wants to make discussions of futility toxic, just introduce money, especially with folks of modest economic means or people of color. (Against stupidity, though, even the gods themselves rage in vain. See I Asimov, The Gods Themselves 1972.)

Some surrogate decision makers are not willing or are not able to engage in evidence-based, deliberative discourse. This is a rare but real phenomenon. Education and persuasion end in failure. The remedy becomes the exercise of professional and organizational power, which, in Texas, is sanctioned by our advance directives act. Elsewhere, local healthcare organizations need to agree on a futility policy, so that, when it is enforced by one organization, the others will be in support. (See Halevy A, Brody BA. A multi-institution collaborative policy on medical futility. JAMA 1996; 275: 571-574.)

Laurence B. McCullough, Ph.D.

 Dalton Tomlin Chair in Medical Ethics and Health Policy

 Center for Medical Ethics and Health Policy

 Baylor College of Medicine

 Houston, Texas

Contemporary Art and Education of Medical Students: Beauty and Truth

Diagnosing and treating a patient's illness is many times a challenge which is not easily solved with a snap judgment but requires the doctor's attention to a sequence of important considerations and actions. There is importantly the observation followed by the interpretation of what has been collected in terms of the patient's history, the physical examination of the patient and the diagnostic tests performed. Sometimes, this collection of data is complex, intertwined and frankly ambiguous and confusing. But there may appear after further contemplation and perhaps after consulting with other professionals a pattern which will direct the doctor to make the correct diagnosis and follow with the appropriate treatment. But how is the detection of patterns taught to medical students and physicians?

What is going on in a number of medical schools including the school at which I teach is to give the students an opportunity to look at and think about and discuss among themselves and their instructors contemporary art. Yes, like many illnesses themselves, the art work at first glance may appear wildly confusing but with attention to details, contemplation and discussion with others, the meaning of the painting to the student and perhaps also the meaning of the painting which the painter was attempting to express becomes more clear and definitive.

Schaff, Iskin and Tager writing in the October 2011 issue of Academic Medicine describe that teaching technique using contemporary art. The following is an Abstract of that article.

Many medical schools have incorporated experiences with representational or figurative art into the curriculum in an effort to improve learners' powers of observation, visual diagnostic skills, and pattern recognition skills or to enhance communication skills, foster teamwork, and/or improve empathy. The Keck School of Medicine of the University of Southern California has partnered with Los Angeles' Museum of Contemporary Art to design an educational experience with the goal of honing students' abilities to observe, describe, and interpret complex information. The authors discovered that through a constructivist approach to viewing and discussing nonrepresentational, contemporary art, students were able not only to apply their observational and interpretive skills in a safe, nonclinical setting but also to accept the facts that ambiguity is inherent to art, life, and clinical experience and that there can be more than one answer to many questions. This intervention, entailing extensive guided inquiry, collaborative thinking, and process work, has allowed students and faculty to reflect on the parallel processes at work in clinical practice and art interpretation. In patient encounters, physicians (and physicians-in-training) begin with attention and observation, continue with multiple interpretations of that which they observe, move to sorting through often ambiguous evidence, proceed to collaboration within a community of observers, and finally move to consensus and direction for action. In the worlds of both art and medicine, individuals imagine experiences beyond their own and test hypotheses by integrating their own prior knowledge and intuition and by comparing their evidence with that of others

Another way of looking at the value of such teaching is from the philosophical point of view and consider aesthetics, the beauty of a painting as a reflection of some truth. By analyzing the painting and exploring its beauty, the truth will most likely be apparent. When treating a patient, the doctor should always look for the truth. Isn't that a truism? ..Maurice.

Graphic: "Astigmatism" created by me using ArtRage 10-4-2011.

"I am a nurse but I am also a doctor": Conflicting Identities to the Patient?

Should a nurse with a doctorate degree in nursing identify herself as a doctor to a patient? Here are excerpts from the current New York Times article on this question:

"Doctorates are popping up all over the health professions, and the result is a quiet battle over not only the title “doctor,” but also the money, power and prestige that often comes with it. ...

As more nurses, pharmacists and physical therapists claim this honorific, physicians are fighting back. For nurses, getting doctorates can help them land a top administrative job at a hospital, improve their standing at a university and win them more respect from colleagues and patients. ...

So physicians and their allies are pushing legislative efforts to restrict who gets to use the title of doctor. A bill proposed in the New York State Senate would bar nurses from advertising themselves as doctors, no matter their degree. A law proposed in Congress would bar people from misrepresenting their education or license to practice. And laws already in effect in Arizona, Delaware and other states forbid nurses, pharmacists and others to use the title “doctor” unless they immediately identify their profession."

What do you think? Should M.D.s be identified to the patients as "doctors" and nurses with a doctorate degree be indentified as "nurses"? ..Maurice.