"Good People Doing Bad Things for Good Reasons": Revision

The following original article which I wrote and was published today at the bioethics.net website is reproduced here with permission.  ..Maurice

05/28/2013

GOOD PEOPLE DOING BAD THINGS FOR GOOD REASONS

Maurice Bernstein, MD

What is ethical or not is often in the eye of the beholder. That is why often the ethics of decisions or acts that we deal with in medicine is established through the process of consensus. And I don’t necessarily mean consensus by only scholars, lawyers or ethicists or even physicians. I think in ethical consensus the many voices of society should be included. I think that an understanding of reason for the divergent views that may occur in ethical analysis can be expressed by what Marcia Angell, former editor-in-chief of the New England Journal of Medicine has said in the past. Perhaps you have already have heard it.“Ethical violations are usually not a case of bad people doing bad things for no good reason, it is usually the case of good people doing bad things for good reasons.” If it were bad people, bad things and bad reasons, there would be no ethical conflicts. The question is whether the acts of those good people carried out for those good reasons best meet the principles of ethics for that particular issue.
Many times in clinical ethics, we find that all of the stakeholders of an issue have meritorious reasons to base their suggested actions. There also may be a meeting of an ethical principle for each action so that there is no strictly unethical violation. The problem arises when one action is inconsistent with another action and we have to decide which act and its ethics trumps another. But trumping may mean that some stakeholders may lose. Therefore, those of us who perform the responsibilities of the hospital ethics committee must remember that we are dealing with good people who have good reasons and perhaps their intended actions are not even that bad except in light of the context of the issue.

Three members of a hospital ethics committee met with 4 family members and two physicians of the patient to come to a decision about the patient’s further management. The patient, a 67- year-old diabetic male who had been a heavy smoker for most of his life, three weeks earlier had suffered a massive stroke which left him unconscious and unresponsive but able to breathe.  Supplemental oxygen by nasal catheter had to be replaced by continuous ventilator breathing support within the Intensive Care Unit when after a week bilateral pneumonia developed and adequate spontaneous breathing ceased.  His course was further complicated by signs of progressive renal failure and gastro-intestinal bleeding of unknown cause, which was significant enough to require repeated blood transfusions to maintain a minimally satisfactory blood count. The patient’s mental state remained unchanged.

The attending physician and neurologist presented to the family and the ethics committee a conclusion to terminate energetic treatment because the patient’s condition was progressively worsening despite intensive medical management, the patient would be unable to tolerate exploratory surgery for the bleeding and the neurologic prognosis was that significant recovery was unlikely. The ethics committee reminded the meeting that the repeated blood use was utilizing a particularly scarce resource.  The son and two daughters agreed with the physicians’ conclusion but the wife who was the legal surrogate stated that she was told by the nursing staff, confirmed by the physician, that the patient had begun triggering the ventilator and that she felt that this was a good sign and that her husband would have wanted treatments to continue.

One of the tools the ethics committee has in this case is compromise. Sometimes compromise mitigates the conflict if even only temporarily. Though it may be only a band-aid in making an ethical solution, it often permits time to get the parties together on a final decision. If, as an example, the issue is end-of-life decision-making and family members are in conflict as to whether enough time on treatment has elapsed to be assured that the patient will not recover, a compromise can be often reached.

In the case presented, at the suggestion of the ethics committee members, the family and physicians agreed to seven more days of current management and then meeting again to re-evaluate the situation and if there was no improvement to then agreed to provide solely comfort care rather than the current attempts to cure.  While the ethics committee agreed with the physicians’ initial conclusions along with that of the children, the committee recognized that the wife, as the surrogate, had some basis for her initial rejection and that compromise with the wife was appropriate.

Those of us “doing ethics” should always temper our dogmatic views, if we carry them, to realize that generally we are dealing with good people and their good reasons. And the “bad” things they may want to do is often just “relatively bad.”.

Patient Modesty: Volume 55

As we move on to Volume 55 of this thread on Patient Modesty there appears to be more discussion about ways to educate physicians, nurses and other healthcare providers regarding the personal feelings and concerns and particularly related to physical modesty.  Scripting responses for the medical staff to communicate to the patients or families is being currently discussed. It may well be that appropriate scripting by administrators in humanistic terms and attention to see that the staff apply this technique properly and consistently may well help in preventing some of the conflicts described on these threads.  Today, I posted on Volume 54 the following in this regard: Here is a wonderful example of "scripting" for the employees if this wasn't (as I suspect)only a public advertisement for the Cleveland Clinic. Maybe more videos of this kind (demonstrating to the staff what is going through the minds of patients) would help toward diminishing the conflicts and emotional trauma as described on our blog thread.
As I have written previously, this thread has had virtually 8 years of descriptions, some quite detailed, of the visitors' experiences and concerns.  What is needed are descriptions of approaches to provide change in the medical system along with changes in the approaches by the patients which will provide an interaction between healthcare providers and patients which is comfortable and valuable to all. ..Maurice.

Graphic: From Google Images and modified by me with Picasa 3.

NOTICE: AS OF TODAY JULY 6,2013  "PATIENT MODESTY: VOLUME 55" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 56.

Smelling the Unethical: Can You? Should You?

The question arises as to how the average person can "smell" (suspect without documentation) that some act or behavior of an individual or individuals is unethical. An often used expression is: "It smells fishy to me." Is everything which determines what we suspect really set down in the past by our "ethics education" through reading or listening to the views of philosophers, ethicists, our religious or grade-school teachers or parents or the outcomes of our own experiences? On the other hand, is what "smells" unethical simply based on individual personal preferences and not some theory or rule developed by others. Then again, perhaps there is some genetically constructed mechanism or instinct which provides every individual with the capacity to establish that suspicion about what might be an ethical "bad" and not an ethical "good". An important point to consider is whether you can fully explain the reason that the action "smells unethical". If you can't, then maybe this would point to the decision as an instinct mechanism.

Beyond considering the mechanism of the this use of smell, is the question as to whether use of this "olfactory" function is of personal or social value. Will it prevent the individual to enter into unethical actions which might be harmful toward ones self or harmful toward others?

Whether you can or cannot "smell the unethical", I would like to express my personal view. I want to emphasize that all ethical decision making (what is a "good" vs what is a "bad") should be made on carefully obtaining and evaluating the facts of the action or behavior and weighing them on the ethical principles and ethical consensus and law with the understanding sufficient to explain the decision, if necessary, to others. I think that whatever the mechanism is for "smelling the ethics" and whatever its "odor" ,ad hoc or premature decision making about an ethical matter, which. by the way is not uncommon, is itself unethical.

Any comments?  ..Maurice.

Graphic: A Mephitidae ("skunk") photographed by me May 26 2013 Whitney Canyon, Southern California.

Patient to Physician Confidentiality: Under All Circumstances?

Within the May 10 2013 issue of the New York Times comes the following concern from a physician:

I am a physician. Years ago, I saw a young patient with headaches, who disclosed — reluctantly — that he had committed a serious crime and that somebody else took the fall for it. I believe he was telling me the truth (his headaches soon resolved after the confession). Before his admission, I assured him that whatever he told me would not leave the room. Later, without giving specifics, I consulted our hospital lawyer, who told me that we were under no obligation to report the incident, because the patient wasn’t in danger of hurting himself or others. But the future of an innocent man hinges on two people’s consciences, my patient’s and my own. I feel like a coward, hiding behind the Hippocratic oath, doing nothing. NAME WITHHELD

Well, if you were going to give advice to this physician..what would you say? If the doctor had initially given the patient assurance of confidentiality, should that promise be kept under any circumstance that arose in further communication? What is your opinion? ..Maurice.

Graphic: From Google Images

A Medical Student and YOU: The "Hidden Curriculum"

Another in a series of threads regarding the ethical/professional issues that could involve a medical student and you or a family member as a patient. This thread is based on the book Professionalism in Medicine : A Case-Based Guide for Medical Students. Cambridge:Cambridge University Press; 2010 and  from the website "Professionalism in Medicine" prepared by Jefferson Medical College in Philadelphia Pennsylvania. This thread begins with a video dramatization of a vignette which is followed by a faculty member perspective commentary.First go to the following link, read, view and then return and present the visitors to this thread your own view of the particular professional issue from the perspective of the patient:Commitment to Professional Competence

A STARTING COMMENT FROM ME:


Being competent as a physician requires proper education and experience. Much of the basic education in diagnosis and the treatment of the patient's disease actually occurs during the first two years of medical school. It is there where the theory and also the scientific basis for accomplishing these responsibiities are presented. What happens as part of the student, intern or resident's professional development after these two years is a learning activity which can be distorted by various suspected or realistic practicalities and clinical habits of those performing the instruction. This later teaching regarding the profession of medicine has been called the "hidden curriculum". Often this "hidden curriculum" while perhaps assumed to facilitate certain clinical actions and certain doctor-patient relationships may, in fact, pose unnecessary patient cost and unnecessary patient harm and may even go against medical professional code of ethics. Though it is doubtful that the "hidden curriculum" in medical education and behavior will ever be eliminated, however knowing about this phenomenon should provide patients with a reason to retain a touch of attention and indeed a bit of skepticism with regard to the behavior and decisions of their physicians. ..Maurice.

A Medical Student and YOU: Like to Know Who is Closing the Incision?

I am putting up a series of excellent discussions about ethical/professional issues that could involve a medical student and you or a family member as a patient. Each discussion as a separate thread is based on the book Professionalism in Medicine : A Case-Based Guide for Medical Students. Cambridge:Cambridge University Press; 2010 and  from the website "Professionalism in Medicine" prepared by Jefferson Medical College in Philadelphia Pennsylvania.  Each issue at the website is begun with a brief vignette, and then a brief video dramatization of the vignette and then followed by perspective commentaries by a medical student and followed by that of a faculty member. First go to the following link, read, view and then return and present the visitors to this thread your own view of the particular professional issue from the perspective of the patient: Principle of Patient Autonomy.  

A STARTING COMMENT FROM ME:

In the case of surgery, informed consent for a procedure means that the patient understands the need for the surgery, the risks and in general how and specifically who is performing the surgery. By becoming informed and then agreeing, the patient's autonomy is maintained. To intentionally fail to inform the patient beforehand as to who is part of the surgical team, except in the case of an emergent switch of surgeons, defeats the validity of informed consent. Patients expect the best of surgical skills and to have a novice involved without informing the patient and receiving patient consent for that novice is unethical and fails professional standards regardless of the necessity for novice (student) education. ..Maurice.

A Medical Student and YOU:Patient Confidentiality

I am putting up a series of excellent discussions about ethical/professional issues that could involve a medical student and you or a family member as a patient. Each discussion as a separate thread is based on the book Professionalism in Medicine : A Case-Based Guide for Medical Students. Cambridge:Cambridge University Press; 2010 and  from the website "Professionalism in Medicine" prepared by Jefferson Medical College in Philadelphia Pennsylvania.  Each issue at the website is begun with a brief vignette, and then a brief video dramatization of the vignette and then followed by perspective commentaries by a medical student and followed by that of a faculty member. First go to the following link, read, view and then return and present the visitors to this thread your own view of the particular professional issue from the perspective of the patient: Commitment to Patient Confidentiality.

A STARTING COMMENT FROM ME:

It's all about the "need to know". Comments about an individual patient's medical or psycho-social condition have to be guarded and away from those individuals who have "NO need to know" where the need is to provide diagnosis, therapy, financial or other specific benefit to the patient unless otherwise specifically requested by the patient. That is why,in the United States, we have the HIPAA regulations which penalizes those who violate the "need to know" dictum.

One could argue that, if the information is unidentifiable regarding any specific patient such release of information is safe. Unfortunately, in these days of mass communication and the internet with search engines, specific patient identification is easier and unidentifiable can be a "wishful thinking" concept. ..Maurice.

 

  ..Maurice.

A Medical Student and YOU: The Matter of Honesty

I am putting up a series of excellent discussions about ethical/professional issues that could involve a medical student and you or a family member as a patient. Each discussion as a separate thread is based on the book Professionalism in Medicine : A Case-Based Guide for Medical Students. Cambridge:Cambridge University Press; 2010 and  from the website "Professionalism in Medicine" prepared by Jefferson Medical College in Philadelphia Pennsylvania.  Each issue at the website is begun with a brief vignette, and then a brief video dramatization of the vignette and then followed by perspective commentaries by a medical student and followed by that of a faculty member. First go to the following link, read, view and then return and present the visitors to this thread your own view of the particular professional issue from the perspective of the patient: Commitment to Honesty with Patients.

A STARTING COMMENT FROM ME:
Honesty with the patient or family requires that those who are called "doctors" are indeed "doctors" and not medical students who haven't graduated. As I have written on a much earlier thread, I totally disagree with the identification of the student as even a "student doctor" as I also disagree with the term "student nurse". I think all those who interact with a patient should be identified as to their role. This is part of being honest with the patient. So let's call the students what they are: "nursing student" and "medical student"--- NOT a nurse and NOT a doctor. ..Maurice.

Medical Slang Leading to Logical Fallacy: A Practice to be Avoided

The following original article which I wrote and was published today at Bioethics.Net website is reproduced here with permission.  I will put some additional comments as an Addendum at the end of the copy.  ..Maurice.

05/03/2013

MEDICAL SLANG LEADING TO LOGICAL FALLACY: A PRACTICE TO BE AVOIDED

Maurice Bernstein, M.D.

Medical slang is a form of slang used by doctors, nurses, paramedics and other hospital or medical staff. It is expressed either in informal vocabulary as words, abbreviated terms or also as acronyms (words made up of initial letters of the words the acronym represents) related to medical terms or conditions, persons or events. Presumably the basis for the use of medical slang is to communicate one’s concept or clinical finding or evaluation or diagnosis to other caregivers in a rapid and concise way. Unfortunately, the use of medical slang may lapse into derogatory expression or become ambiguous. Derogatory means that findings or persons are expressed in a disrespectful or degrading manner. Ambiguity can be related to the fact that an acronym or abbreviated word may not be sufficiently distinctive and can be used or interpreted for more than one medical term.

Examples of medical slang can be as benign as but also potentially ambiguous as the following medical transcription terms: “lytes”=electrolytes, “nitro”=nitroglycerine,”sats”=saturations, “crit”=hematocrit, “mets”=metastases, “osteo”=osteoporosis. On the other hand, medical slang can be derogatory even though amusing when applied to medical specialties. For example: “baby catcher” for obstetrician or “butchers” or “knife happy” for surgeons. Examples of medical slang as applied to patients include “dirt ball” for a patient who enters the emergency room filthy and smelling badly or “druggie” for patients known or suspected for illicit drug use or “goldbrick” for a patient who demands more attention than their (minor) condition warrants or the acronyms LOBNH for “lights on but nobody home” for a patient with suspected dementia and, of course, GOMER for “get out of my emergency room!”.

My argument is that medical slang generally can not only be or become disrespectful or ambiguous but also in the case relating to patients themselves, the derogatory descriptions may actually represent an action by the professional to create a logical fallacy. What is a logical fallacy? It is an error in reasoning that renders an argument invalid. Why attribute a medical slang expression as promoting a logical fallacy? First, a basic premise within the profession of medicine is the responsibility to obtain history and facts, if possible directly from the patient, and then to attempt to draw and present a conclusion from the facts. Drawing that conclusion is a logical exercise. Because, unlike the application of medical slang to “conditions” when this slang is applied to a person (an ad hominem), it may allow a fallacious conclusion by the healthcare provider originating the slang which rejects any argument or facts given by the patient since these arguments or facts are trumped by the provider’s own conclusion about the character or reliability of the patient. This is a logical fallacy since such a conclusion may be unwarranted. The explanation and facts provided by the patient must be logically evaluated separately for their validity and value and not invalidated by simply the provider’s personal decision regarding the patient as a person. The doctor can’t fairly make a judgment that the patient’s descriptions of pain should not be considered and reconsidered because the patient is known or suspected and described as a “druggie.” Some person on the street may say “that guy over there looks like a druggie” but that person is not required professionally to go beyond that assumption and so the statement may only be considered “unfair” or “uncouth.” My argument is that in a doctor-patient relationship such a slang expression by the doctor would represent a professional ad hominemimproperly affecting the doctor’s judgment regarding the history and facts presented by the patient.

For a number of reasons, including medico-legal, there is said to be a diminution in the general use of medical slang. Hopefully this is true and will continue to diminish. Certainly, expressions by physicians, nurses and other healthcare providers which are non-humanistic, are demeaning to the patient and indirectly to the profession itself and finally, as a consequence, allows a logical fallacy to be exercised, which distracting from and preventing proper clinical evaluation of the patient, cannot be considered of value to be continued to be used in medical communication.

Addendum: Beyond the issue of how derogatory medical slang may affect a physician's fair decision making  responsibilities, what do you think about medical slang in general, particularly if it was applied to you as a patient? ..Maurice.

"Incidental Finding": No Symptoms and Rarely Dangerous: Now What??

"Incidental Finding". The finding was one which was not sought for when a patient is being worked up to explain their symptoms and treat a disease, if present. The finding was not producing any symptoms. The dilemma for both the doctor and the patient is what to do if the examination or testing discloses an abnormality in the body not sought for.  And what, as is not uncommon, the abnormality is not normal as the word states but the abnormality has developed absolutely no symptoms for the patient and most of the time the abnormality does no harm to the patient if left alone and untreated.  Rarely, it may cause some symptom and rarely it would be considered dangerous, threatening the activities or life of the patient.  If the test had not been performed neither the patient nor the doctor would know about the abnormality. But yet, it was found and now what?  Just knowing may be very disturbing to the patient but also even for the doctor.  If the incidental finding was a growth, should the growth be removed despite routine procedure risks and financial costs to the patient?

The issue of the "incidental finding" in medicine was recently discussed at the Presidential Commission for the Study of Bioethical Issues and was written up in the Commission's blog, blog.bioethics.gov and a section of the discussion is reproduced below. My question to my blog visitors is how would you react and what would you want if you were told that you had such a "incidental finding".  Would you accept the risks and cost of doing something about the finding or would you go on the statistics and feel comfortable with the "incidental"
description and statistics? ..Maurice.

Incidental Findings in the Clinic: Extra Information and Extra Worry

Written by Bethany Brookshire on April 30, 2013 

During today’s meeting of The Presidential Commission for the Study of Bioethical Issues, it soon became clear that dealing with an incidental finding can involve more than just reporting to the patient impacted. As Haavi Morreim, J.D, Ph.D. Professor of Internal Medicine at The University of Tennessee Health Science Center, stated, there may be a difference between “standards by which care should be provided… and standards by which care should be assessed.”

Danielle Ofri, M.D., Ph.D., Associate Professor at the New York University School of Medicine, spoke of a patient with gastrointestinal pain. While Ofri, as her primary care physician, Ofri knew that the gastrointestinal pain was a common occurrence and probably nonthreatening. However, when her patient checked into the Emergency Room, the doctors, who did not know the patient’s history, performed a CT scan. The CT scan showed no cause of gastrointestinal pain. But it did turn up something else: “a 2 cm nodule in the right adrenal gland” or as Ofri wryly called it “The dreaded incidentaloma.”

Nodules in the adrenal glands are common, and while Ofri notes that 98% are entirely benign, in rare cases they can lead to problems such as the overproduction of hormones, or to cancer. “Nevertheless,” Ofri said, “once the incidental finding had been given life, so to speak, it was no longer incidental.”

Ofri had to refer to the standard-of-care for an adrenal incidentaloma, which involved a list of complicated tests. “As clinicians,” said Ofri, “we have a bias toward doing something, as opposed to doing nothing…Our patients, almost uniformly, want us to do something. Both doctor and patient are enthralled within this overwhelming medical imperative to act.” The tests would cost thousands of dollars, and also threatened to expend Dr. Ofri’s medical capital with her patient.

There was only so much time she had to spend with the patient, and with all of the information required to discuss the incidental finding, Ofri was obliged to skip over many other issues that the patient needed to have discussed, such as high blood pressure, cholesterol, and diabetes. These issues “…ended up with the short end of the clinical stick that day—an outcome” Ofri noted, “that is surely not incidental.”

Next, Carol Krucoff spoke of her experience as a patient who received an incidental diagnosis of a small acoustic neuroma. Even though her so-far benign neuroma has caused her significant anxiety, Krucoff stated that she would rather know about the presence of the neuroma than not. She recommended policies to help patients deal with incidental findings, including keeping patients informed in simple, direct language, training providers with communication skills to ensure both compassionate and clear communication, and to add a support person to the healthcare team, to help patients and their families process difficulty information.  And, she says “Unless it’s a necessity, don’t rush to treatment.”