Overcoming the Inevitable in Medicine: Doctors Simply Doing Their Best Under the Circumstances
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 more science provides folks techniques to manage infertility such as through invitro fertilization and then implantation and the more science also provides tools to determine before the embryo is implanted whether or not the embryo is "potentially sick" because it is carrying a serious genetic defect (preimplantation genetic diagnosis), society is faced with further ethical and legal dilemmas. Such a dilemma can be developed from the example above: should prospective parents who desire to have a child by undergoing invitro fertilization be required under law to first have their embryo diagnosed for a genetic defect and if a serious genetic defect is found, they be compelled to reject implantation? Could it be argued that such attempt at diagnosis and subsequent rejection be considered under law and ethics as in the potential child's "best interest"? And, perhaps in the best interest of the future generations if this embryo was allowed to mature, be born and survive long enough to have its own children? On the other hand, is the general ethical and legal principle of parents "acting in the best interest of their child does not mean choosing the 'best child'"? The expression in quotes is the title of a rebuttal by L.S.Flicker in response to a view set by Malek and Daar discussed in the current April 2012 issue of American Journal of Bioethics. But what is your thought on this subject? ..Maurice.
Surprisingly, after over 30 years of hospice care available for those who are terminally ill, the public and even physicians have interpreted end-of-life care, hospice and comfort care patient treatment as "murder, euthanasia and killing", Palliative medicine, treatment to relieve pain and discomfort, in patients who have no further treatment to resolve their disease is an established certified sub-specialty and yet physicians who perform this specialty are working under a cloud of such misperceptions. Read about this issue in Amednews (American Medical Association News).
When asked by the Mayor of the Munchkins about the Wicked Witch of the East (on whom Dorothy’s house fell), the local Coroner answered: She is “morally, ethically, spiritually, physically, absolutely, positively, undeniably and reliably…” as well as “really and sincerely” dead. [L. Frank Baum’s, The Wizard of Oz, 1900.] Back then in “Oz,” death simply meant the cessation of heart and lung functioning. Today, modern medical technology can prolong a person’s biologic existence after major organs are so diseased they cannot function on their own, without “life-support” or “life-sustaining treatment.” The result has led to choices and conflict about which Mr. Baum could never have dreamed.
Since 1968, we have been abiding by an ethical concept called the “Dead Donor Rule.” This means that physicians will never harvest organs from live patients. The political purpose of this rule is to give people confidence that if they cannot speak for themselves, others will not give up on them because they want to harvest their organs. Clinically, however, some physicians and ethicists consider it a fiction that patients are really “dead” by definition. They point out many ways in which such patients are still alive, although very sick, absolutely unconscious, and totally dependent on machines to remain… (yes, alive). Others argue that the neurological criteria for “brain dead” are sound in one important sense: clinical experience shows that patients who fail the test never regain consciousness.
A further problem arises if a state or an institution uses a different set of criteria, one based on the functioning of the heart rather than the brain. Here, physicians take the patient off life-support and then they wait a certain amount of time to see if -- without medical intervention -- the heart will start again by itself; that is, without medical intervention. If the heart does not re-start itself, then the process is considered irreversible so death is inevitable, and then a doctor can declare that the patient is “dead” –according to local protocol and the current local definition of death. Note: In case you didn’t know, you are “legally dead” if and when a physician declares that you are “clinically dead.”
Here are two potential problems: First, does it really make any sense to say that the patient is dead based on “irreversibility” when the heart can, and in fact may be restarted with medical interventions? The reality is that such hearts are often donated to other patients and are then restarted. Second, how long should physicians wait to see if the heart can restart itself? Some people find this part scary. There is tension here between A) waiting long enough to give the donating patient a chance to live, and B) not waiting too long so that the organs become unusable because they were deprived of oxygen. Hence, the Institute of Medicine recommends waiting 5 minutes. Yet the Children’s Hospital in Denver waits only 75 seconds. Strictly speaking, that means a patient would be “dead” in Denver but still “living” elsewhere based on this criteria. By the way, these criteria have two names: “Donation after Cardiac Death” and “Donation after Circulatory Death.”
Suppose there is a way for you to decide, to describe, and to memorialize your own criteria so that others will know at what point you would NOT want life-sustaining treatment, and would therefore be willing to die? In that case, it would be YOU -- not a state, or an institute, or a hospital (which could change its definition between now and when you become unconscious and reach this end-stage disease) -- that would determine when you would let nature takes it course so that you could die and before that, donate your organs.
Note that the decision that it is time for Natural Dying is not a decision to die, but to let the underlying disease takes it course when further treatment -- including food and fluid -- are deemed by the physician and the proxy/agent, to have become extraordinary and disproportionate. Then... if the patient passes the point of no return, why should we let his/her body dehydrate so the organs are not usable, when they could be gifts of life to several patients? From what you have learned so far:
Question 1: Would you have more confidence in your own criteria, or would you rather depend on the potentially changing criteria that others will have established, when “that time” comes? The living will that determines “WHEN” can importantly choose a way to die called “Natural Dying.” This means to stop not only stopping all life-sustaining treatment including tube feeding but also assisted feeding and assisted drinking. Of course, you would always receive all the comfort care you would need to die peacefully by medical dehydration. This includes agents to reduce your thirst. (Hunger is rarely a problem.) Most people die within two weeks.
Question 2: Can you imagine conditions such as untreatable, unbearable pain and suffering, or advanced dementia, or a permanent coma -- where you would opt for “Natural Dying”?
Now suppose your medical condition reached the state where you were ready for “Natural Dying,” and that, as a completely independent decision, you also decided to donate your organs.
Question 3: If you are conscious when you begin your total fast, then after several days of fasting, you will fall deeply asleep. After that point, you will not be able to change your mind to resume eating and drinking… So would you be willing to consent (in advance) to donate your organs? (Anesthesia will be provided to make sure you do not experience any pain.)
Question 4: If your end-stage condition was devastating brain trauma or Advanced Dementia, you could have previously authorized your future physician and your proxy/agent to jointly determine “WHEN” you meet your own criteria for “Natural Dying.” Once they decide, your dying will be inevitable… So would you be willing to consent (in advance) to donate your organs? (Anesthesia will be provided to make sure you do not experience any pain.)
Question 5: Overall, which set of criteria would you be more comfortable with: one established by a state, or institute or hospital… or one that you decided for yourself?
Question 6: If someone suggested that your consent to donate organs when you reach your own criteria for “Natural Dying” violates the “Dead Donor Rule,” would you agree or disagree? Could you offer an argument to support your view?
Question 7: If someone suggested that your consent to donate organs when you reach your own criteria for “Natural Dying” is a form of euthanasia, would you agree or disagree? Could you offer an argument to support your view?
Question 8: Do you have any other comments or questions?
(Note: the Natural Dying Living Will is available from a non-profit organization, whose website and email address are www.CaringAdvocates.org and CaringAdvocates.aol.com)
A physician interviewing or examining a patient may find him/herself in a professional clinical situation that the doctor had not experienced previously or even thought about and at once must decide how to respond to the situation in a manner which is ethical and professional and hopefully constructive and even of therapeutic value. I have challenged my second year medical students to a discussion about how they would handle each of the four clinical situations listed below. Now I would like to challenge my blog visitors to do the same. Pretend that you are the doctor of the scenario and suddenly faced the patient's response. What would you do next? ..Maurice.
- 1) You ask the father of a child patient whether there are guns in the household and the father becomes angry and says "it's none of your business!"
- 2) You are a male physician and your female patient of a few visits now says "I have taken a liking to you. Can we go out tonight together for supper."
- 3) You are trying to take the patient's medical history and the patient repeatedly returns to talking about different symptoms which his cousin is experiencing.
- 4) You are attempting to perform a physical exam on a young but adult patient and every time you touch the patient, the patient is repeatedly squirming around and giggling and responding "I'm very ticklish."
(A) The number of physicians in the U.S. is 700,000.
(B) Accidental deaths caused by Physicians per year are 120,000..
(C) Accidental deaths per physician is 0.171 (17%).
Statistics courtesy of U.S. Dept of Health and Human Services.
Now think about this:
(A) The number of gun owners in the U.S. is 80,000,000. (Yes, that's 80 million !)
(B) The number of accidental gun deaths per year, all age groups, is 1,500.
(C) The number of accidental deaths per gun owner is .0000188 (.00188%)
Statistics courtesy of the F.B.I.
So, statistically, doctors are approximately 9,000 times more dangerous than gun owners.
Remember, 'Guns don't kill people, doctors do.'
FACT: NOT EVERYONE HAS A GUN, BUT ALMOST EVERYONE HAS AT LEAST ONE DOCTOR.
Please alert your friends to this alarming threat. We must ban doctors before this gets completely out of hand!!!!!
P.S. - Out of concern for the public at large, I have withheld the statistics on lawyers for fear the shock would cause people to panic and seek medical attention.
Perhaps, since what is a "good" for one person may be a "bad" for another, perhaps the question why should society bother to distinguish the "good" from the "bad" in the first place? Is it essential for society to define the differences in order to set standards acceptable to society with regard to individual behavior to prevent chaos: a conflict between persons who find one behavior to be acceptable and the other persons who find it unacceptable? And yet, one might wonder whether society, perhaps through political decisions and laws, are setting too many standards, too many decisions as to what is good and what is bad, perhaps more than what is really needed. Actually, I shouldn't be blaming society in general since each individual in society may live their life with their own stereotypes of other's behavior or their own life experiences or possibilities as either good or bad. And these stereotypes may not be based on facts but more on feelings or moral beliefs. What do you think? ..Maurice.
In the past 8 years, I have covered many, many topics regarding bioethics, ethics in general and ethics specifically as related to medical education and medical practice and I have many, many visitors who have contributed to the threads I have developed. But, still, there may be a host of topics which I have not considered and which has troubled some visitor. On this thread, I would like to hear about those topics which could be further developed or started as new. Google's Knol, a site where I was attempting to answer the ethics concerns of visitors there over the last few years is now being dismantled by Google. So, let's hear from you here if you have an idea or question. ..Maurice.