Does the Fertilized Egg Equals Legal Person?
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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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.
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.
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.
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.
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.
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
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.
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.