MUNCHAUSEN SYNDROME BY PROXY: The Potential for Medical Profession to be Co-Participants in Child Abuse.

A father brings his young son to the doctor for prescription medications because the father suspects that the son has "classic" attention deficit/hyperactivity disorder.

The  mother relates to the hospital emergency room with  a history of multiple respiratory, gastro-intestinal and musculo-skeletal symptoms from which her child was suffering and insists that  the child be "hospitalized" for a "complete workup".  A basic workup in the emergency room discloses no disease, the child was not admitted but the mother was told to have followup with a pediatrician.  She returns to the emergency room two days later with the child and more symptoms, requesting the child's admission but having not attempted to visit a pediatrician.

A mother brings a child to the pediatrician because the child has been losing weight.  According to the mother,  multiple food allergies was suspected by the family and the child's diet was markedly reduced (starving) in order to prevent symptoms.

The mother brings a child to a pediatrician pointing at the multiple bruising over the child's body  and giving a history that the child was having recent repeated nosebleeds.  The  physician's examination finds the nasal passages to be normal and the bruises have more the appearance that they were due to trauma and not spontaneous.

What you have read are various degrees of clinical appearances of a condition known as "Munchausen Syndrome by Proxy"(MSP).  The definition of the Munchausen Syndrome itself without "proxy" is a patient's specific mental or behavioral disorder in which the individual fakes a medical illness in order to get medical attention.  In "Munchausen Syndrome by Proxy", this behavior represents medical attention directed to another (usually a child)  because of a fictional history or frank physical or mental abuse by another person usually the caregiver or parent.  Other names given to this state include "factitious disorder by proxy" or the current 2013 American Psychiatric Association title  "factitious disorder imposed by another".  Regardless of the title of this state,  it defines the unnecessary introduction of a child by a caregiver into the medical system for diagnosis and for the treating a "made up" disorder. This factitious disorder imposed by the caregiver can be related to simply the caregiver's  medical ignorance and may be to some extent unintentional, however it also can be motivated by some sort of personal gratification and may include  frank intentional physical or mental abuse of the child to create an appearance of the disorder.

 One might conclude that as a result of the inherent risks of unnecessary diagnosis and treatment the medical profession could be said to be "co-participants" in the child abuse if the healthcare providers at the outset fail to attempt to identify the syndrome  as being present.

It therefore become a duty of the initial physician consulted  to always be aware of the possibility that their child patient may be a victim of a factitious disorder imposed by another.  If that possibility is suspected,  an active attempt to confirm is essential before subjecting the child to hazards of unnecessary diagnosis and treatments.  This means taking a detailed patient history from the parent but also including the parent's medical understanding of the symptoms presented, performing a careful physical examination, communicating with the patient's prior physicians and other pertinent resources including pediatricians who specialize in MSP  as needed for assistance in confirmation. And, if Munchhausen Syndrome by Proxy is confirmed, it should be seriously evaluated as child abuse and consideration for appropriate civil/legal action to be taken for the protection of the child.  Missing to consider and investigate this diagnosis,  the physician and the medical system could be looked upon as co-participants in any damage to the child. 

For more on this topic, read the statement about this issue by the American Academy of Pediatrics and the description in Wikipedia.

After reading about this subject, can you defend the accusation that the physicians involved could be considered as co-participants in child abuse?  And another question: as personal matter, if you brought your child to a pediatrician, how would you feel if you knew the doctor was surveying you as a "by proxy" candidate? ..Maurice.

Graphic: Photo Credit: memekode on Flickr

What to Eat and How to Live: Government as Your Nanny?

It is all about the role of government is setting limits on what you eat and how you live your own life vs government being simply a teacher, an instructor of the facts and allow its public to live their own personal lives as they see fit.  The recent limit-setting regulations of food, drink and other health issues by Michael Bloomberg as the previous mayor of New York city  has provoked controversy both for and against these actions.  A series of articles in Bioethics Forum, website of  The Hastings Center, bioethics "think tank",  presents views regarding this controversy.   Lawrence O. Goslin (University Professor and Founding O’Neill Chair in Global Health Law at Georgetown University Law Center, and a Hastings Center Fellow) writes "Bloomberg's Health Legacy: Urban Innovator or Meddling Nanny", originally published in the Hastings Center Report September-October 2013,  with the following Abstract.

Michael Bloomberg assumed office as the 108th mayor of New York City on January 1, 2002. As he leaves the mayoralty—having won re—election twice-his public health legacy is bitterly contested. The public health community views him as an urban innovator—a rare political and business leader willing to fight for a built environment conducive to healthier, safer lifestyles. To his detractors, Bloomberg epitomizes a meddling nanny—an elitist dictating to largely poor and working—class people about how they ought to lead their lives. His policies have sparked intense public, corporate, and political ire—critical of sweeping mayoral power to socially engineer the city and its inhabitants.

Here, I seek to show how Bloomberg has fundamentally changed public health policy and discourse. He has used the engine of government to make New York City a laboratory for innovation-raising the visibility of public health, testing policy effectiveness, and probing the boundaries of state power. Even though the courts have blocked some of his boldest initiatives, he has offered a paradigm for the “new public health”—reaching beyond infectious diseases to upstream risk factors in everyday life and the human habitat. I also critically probe various arguments designed to derail his policies, along with the overarching charge of unjustified paternalism.

Apparently, after much negative feedback Goslin received about the article supporting Bloomberg, he wrote his response to the Bioethics Forum titled "Bloomberg’s Health Legacy: What Inflames Consumer Passions in the Food Wars? Goslin argues for some governmental control with the following:

Making the healthy choice is exceedingly hard, with so many forces pointing in the direction of cheap, accessible, aggressively marketed food, alcohol, and tobacco. Consumers, far from having unconstrained choices under the status quo, are actually heavily influenced in their purchasing and lifestyle decisions.

In a semi-rebuttal article written to the Bioethics Forum, Ann Barnhill, an assistant professor in the Department of Medical Ethics and Health Policy in the Perelman School of Medicine at the University of Pennsylvania, states:

While I agree with this analysis, I think it is incomplete. The charge that Bloomberg is a meddling nanny reflects not just distrust with government influence on our lives; it also expresses indignation at Bloomberg’s putative attitude towards us: like little children being minded by a nanny, we can’t be trusted to make decisions for ourselves. What troubles some citizens about Bloomberg’s policies is not just the material impact of these policies on their choices and pocketbooks but also the symbolic value of these policies.

Go and read the complete short articles and then return and tell us what you think of government setting regulations regarding what we eat and what we drink and even more personal choices.   ..Maurice.

Graphic: Nanny State. Expression from Missouritenth.com and graphic created by me using ArtRage and Picasa 3.

"See one, Do one, Teach one"

 You must read the satire on the "Glorious Tradition" of the description of medical education as "See one, Do one, Teach one" in the October 1 2012 issueof  the "Daily MedicalExaminer" where a doctor K.R. Thuxston. III, MD writes an essay about the topic, presumably "tongue in cheek" but then who knows.   This concept of a medical student or intern learning a procedure  but in reality actually learning it upon a patient and often the patient unaware of the learning going on was a practice considered acceptable back in the old days of medical professional paternalism.  Ah! But then came the last generation of medical practice and education with an ethical switch from medical professional paternalism to patient autonomy.  "See one and Do one" has become a "no-no" ..well, at least not on a living patient or at least not to "do one" with minimal, if any, supervision unless it is only drawing blood from a vein.  Simulators are all the rage now in medical education.  Simulators characterized by "standardized patient" (actors playing patients)  are used for honing up on interview techniques and general physical examination techniques but particularly female breast and genital exam of both genders.  For surgical practice, the simulators can be divided into organic, a very old technique in education in which animals and fresh human cadavers are utilized and inorganic, the current and future educational tools which comprise  virtual reality simulators and synthetic bench models and who knows what other "gadgets" in the future.  These tools bearing major medical educational investment are said to be of significant educational value but there are still studies going on regarding the validity of that conclusion.   For example even the use of standardized patients to instill the skill for students to later convey satisfactory "end-of-life" communication to real patients is still under investigation (JAMA. 2013;310(21):2257-2258}.

On the other hand, what is wrong with "See one, Do one..."?  Shouldn't patients take an altruistic view of donating their living body to medical education?  And as Dr. Thuxston concluded " Post-op, patients should look down at the ragged, poorly sutured scar on their abdomen and forget about the fact that they can’t wear a swimsuit at the beach anymore.  Instead, they should beam with pride, because the misshapen scar will remind them that their body was once used to teach a budding doctor how to operate."  And you, how about you? A bit of altruism? ..Maurice.

Graphic: Ancient Greek Medicine. Wikipedia via Google Images

Patient Modesty: Volume 61

The question becomes: will changing the medical system's  "bedside manner" be what is necessary to make most of the folks who are writing to this thread more comfortable with regard to their patient modesty issues?  In other words, is it a fixable  issue and all that is needed is simply presenting the medical profession with a different communicating "script"?  Or is the patient modesty issues not just a  script but a significant underlying structural issue.  An example would be: there just are not enough male nurses to care for male patients who would desire male nursing.  Another: there is no organizational way to run an operating room effectively with restrictions on the gender of the participants and changes in protocol.  What I am getting at is that solutions to the issues discussed here may be more complex even if highly desirable.  What do you think? ..Maurice.

NOTICE: AS OF TODAY JANUARY 3, 2014  "PATIENT MODESTY: VOLUME 61" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 62

Graphic: GIF file from Google Images and American Broadcasting Company