Bioethics and Dealing with the COVID-19 Pandemic
Graphic: : St Roch Ministering to Plague Victims,
by Jacopo Tintoretto (Italian, 1518-1594)
Yes, there is science. Yes, there are politics. Yes, there are laws to obey. Yes, there is religious doctrine. Yes, there is public opinion. And yes, there is the ethics--the concept of fulfilling all these domains fairly, logically and yet in the direction of "doing good".
In the dealing with the Covid-19 pandemic, ethical issues are fully present and ethical issues cannot be ignored if it is the goal to proceed to a better and safe and healthy society despite our current handicaps.
To get a quick idea of the scope of the consideration of ethics and its role in this present pandemic, simply go to the website of a major ethics institution, the Hastings Center and learn what was of already being considered in March of this year.
At the time of initiating this blog thread in May, a lot has happened since March and in so many ways the ethics of what has happened and what is considered to happen in the months ahead require our understanding and consideration. ..Maurice.
posted by Maurice Bernstein, M.D. @ 11:12:00 AM
109 comments
109 Comments:
The topic is not strictly dealing with patient modesty or patient dignity but with the ethical, philosophical, civil and legal approaches to the management of this dominant world-wide problem. What is needed from the public is an understanding of the many elements of such a pandemic and approaches to limits its trauma, utilizing for example the 4 principles of ethics:autonomy, justice, beneficence, and non-maleficence. There are potentially productive and potentially destructive results which could be identified as of value or of no value or destructive in any political policy. The goal of the public in this world-wide disaster is to sort out one from the other and follow and contribute to the path to safety and health for all. ..Maurice.
Let us look at one action which we understand has been happening in many hospitals when a patient is admitted for COVID-19 infection and serious symptoms or perhaps may have advanced to the ICU and is on a respirator to maintain life or may be on the verge of dying..and family members are not allowed, by hospital policy, to visit the patient. The emotional need by both the patient and the family is to be together at this critical and emotional time of their lives. Do you see an example of unethical behavior by the medical institution?
Let's discuss this one simple example with regard to the ethical principles. Are there two sides to this decision? Which do you feel or find is the most ethical? Remember, one ethical principle may trump another and yet reach an ethical behavior...but an explanation of that conclusion is always necessary. ..Maurice.
Let's first look at what is happening in the medical and social world specifically in terms of the 4 commonly accepted principles of medical ethics: autonomy, justice, beneficence and non-maleficence.
Here are the brief description of each as written in web.stanford.edu and edited by me for this presentation.
What are the Basic Principles of
Medical Ethics?
Bioethicists often refer to the four basic principles of health care ethics when evaluating the merits and difficulties of medical procedures. Ideally, for a medical practice to be considered "ethical", it must respect all four of these principles: autonomy, justice, beneficence, and non-maleficence.
Autonomy
Requires that the patient have autonomy of thought, intention, and action when making decisions regarding health care
procedures. Therefore, the decision-making process must be free of coercion or coaxing. In order for a patient to
make a fully informed decision, she/he must understand all risks and benefits of the procedure and the likelihood of
success.
Justice
The idea that the burdens and benefits of new or experimental treatments must be distributed equally among all groups in
society. Requires that procedures uphold the spirit of existing laws and are fair to all players involved. The health care provider must consider four main areas when evaluating justice: fair distribution of scarce resources, competing needs, rights and obligations, and potential conflicts with established legislation.
Beneficence
Requires that the procedure be provided with the intent of doing good for the patient involved. Demands that health care providers develop and maintain skills and knowledge, continually update training, consider individual circumstances of all patients, and strive for net benefit.
Non-maleficence
Requires that a procedure does not harm the patient involved or others in society.
Let's consider how each principle is applicable to what we understand is occurring in the current pandemic. ..Maurice.
Please excuse me for a bit of disorganization of the commentaries above. Now that all 4 ethical principles have been identified and a bit defined, lets move on to the analysis of the example issue I presented dealing with keeping a hospitalized patient and family apart. ..Maurice.
The most common complaint I have heard is family members being unable to be with their loved one while hospitalized, sometimes including end-of-life. I experienced this myself to a small degree when my wife was an inpatient for a non-coivd-19 matter when these new policies were being implemented. As things were rapidly unfolding, each day as I left the hospital I didn't know if I'd be allowed back in the next day, and then the day arrived that I couldn't. Her condition was sufficiently fragile that had she gotten the virus she likely wouldn't have survived and so rather than be upset with the new policy I thought what took them so long.
If preserving the life of the patient trumps all other concerns, then in an environment with limited PPE, limited staffing (the hospital in question was short staffed when the schools and daycares closed and some parents had to stay home with the kids), and limited ICU capacity, removing me from the list of things they needed to be concerned with was the right move for my wife and all the other patients. I don't see what they did as violating any of the pillars of medical ethics.
What did violate medical ethics hugely was the policy of some States to force nursing homes to take in infected patients who were not sick enough to remain in the hospital. One does not need a medical degree or training in infection control to know such a policy would end badly, and it did in neighboring NY with thousands dead as a result. Here in my State (VT) most nursing homes shut down visitors and instituted rigid infection control protocols weeks before the State started shutting things down, and we have not had the problems seen in NY. NY knowingly put fragile nursing home patients in harms way which fails the Justice, Beneficence, and Non-maleficence tests.
The last piece of this that I will comment on is the most controversial. This is resuscitation of covid-19 patients. Not having proper infection control PPE for staff forced some to decide between attempting to save the patient vs protecting themselves and possibly their own families. I posit that it was an ethical lapse on the part of federal & state govts for not being even minimally prepared for a pandemic in this regard but also to the hospitals themselves for not be prepared not only with adequate supplies but also with policies and training that wouldn't have left the staff bearing the burden of this decision-making. This was not a black swan event but one that was known would happen sooner or later. The only missing elements was when would it occur and how severe would it be. As an ethical choice I don't think medical staff should potentially sacrifice their lives in order to save mine and as such were I the patient and there wasn't adequate PPE to protect the staff, I'd of said let me go. This too breaches the Justice, Beneficience, and Non-malificience tests.
JF speaking.
I kinda wonder if going to a hospital for a Corona Virus patient is the best option at all! We hear different things on the internet about what MIGHT help and maybe not. One theory that I have heard is that the ventilators themselves are dangerous. And that patients that are put on them often don't make it.
That could mean two conflicting things, either the ventilators are harming the patients or the patients are already critical when the patients are put on those ventilators.
So far as Im aware, nobody I know has been infected with Covid 19. I also heard recently that not every country has suffered a breakdown in their economies. I sure don't know what to think about all this!
Reginald, wrote the following today on the long running blog thread topic "Preserving Patient Dignity (Formerly Patient Modesty)j Volume 111:
Hello,
I submit to you the URL of a doctor who understands empathy.
Reginald
https://suneeldhand.com/2020/05/19/how-doctors-should-communicate-over-the-phone-during-covid-19/
Yet, such behavior on the part of the physician represents more than personal understanding of the patient's physical suffering (empathy) but also the patient's concerns and the patient's need for family emotional support. The physician, taking time and communicating with the appropriate family member is in fact supporting the patient's autonomy (desire by the patient to have communication with his or her family member). The physician is also promoting beneficence ("doing a good for the patient involved and the family").
Think about the emotional disturbance of members of the family of a patient who can't communicate with them and their presence is not allowed. Yes, the subject of a doctor-patient relationship is, of course, the patient. But a physician has a responsibility as needed and legal to provide support in varying degrees to members of the patient's family. The clinical-social consequences of the COVID-19 pandemic puts extra-emphasis on following the ethical principles. ..Maurice.
In the management of the COVID-19 crisis, it is important that all recommendations to the public meet the ethical principle of non-maleficence in that the recommendation has been adequately investigated and has been found to be appropriate for the situation and will not lead to harm to those who follow the recommendation.
Sometimes, a recommendation has not been fully evaluated to guarantee to the recipient that such harmlessness is proven. If that is the case, this deficiency in evaluation must directly be made aware to the recipient. The recipient must be made aware of the harm but also the limits available to investigate and deal with the harm. Ignorance by the recipient of some decision or action and the rationale should never be considered as ethically acceptable. ..Maurice.
A very current ethical principle issue as we deal with the Corona-19 pandemic is what does society think and do about those who have been sentenced to prison for their criminal actions and are now imprisoned in close quarter prison institutions exposed to a much higher degree of risk for acquiring and dying from the virus infection. The ethical issues involved is, of course, justice and non-maleficence .
If prisoners cannot be protected from the very high risk of infection and death as compared with the general population not imprisoned, is the ethical principle of justice being observed and served by continuing to keep all prisoners of varying history for their imprisonment together and not released to a safer health environment?
And then we have to consider the ethical principle of non-maleficence--to do no harm. If we know that keeping masses of prisoners in close quarters with no means of separation except removing some out of prison to safer environments, then society is failing in this ethical principle in preventing sickness and death for those imprisoned and even for the guards who attend the prisoners.
Where does society meet the ethical balance between punishment for prior acts by those imprisoned and yet attending to preventing the likely illegal harming of those imprisoned as a consequence of this pandemic? ..Maurice.
Dr. Bernstein, we as a society should be able to do more than one thing at a time, but at present how we are managing nursing homes leaves much to be desired in at least some States such as NY & NJ. We as well have yet to assure that front line healthcare staff have the PPE and training to do their jobs safely. Not to be harsh but nursing home patients and front line healthcare staff are a higher priority for me than prisoners. If we can't do the first two (nursing homes & healthcare staff), then let's not focus our efforts and resources on the third (prisoners).
That said, I don't object to moving the lowest risk (to the public) prisoners out of prisons if it can be done with minimal risk to the public. Sometimes the choices people make have unforeseen consequences and the risk of covid-19 does not give anyone the right to an early release from prison. Move the non-violent type ones into alternative facilities if we can, but the violent ones need to stay where they are.
Biker, ..And how about the individuals held within the prison awaiting trial and as yet have never had the opportunity of a trial to be found guilty? These specific folks provide a particularly difficult ethical and legal dilemma when we are faced with the matter of increased danger even to the potentially legally innocent? It would be wonderful for society not to have been faced with this dilemma. ..Maurice.
I think the zero-visitor policy at hospitals across America is very unethical and ridiculous.
Here are my thoughts:
As founder of Medical Patient Modesty, a non-profit organization that works to educate patients about their rights to dignity, privacy, and freedom from abuse in medical settings, I am very concerned about the zero-visitor policy at many hospitals in America due to COVID-19.
The zero-visitor policy is too extreme and it is a violation of patient rights. While I understand the important undertaking which has fallen on hospital administrators to help control the spread of COVID-19, they fail to understand two important things.
1.) It is ethically imperative that all patients have access to someone who is physically and exclusively present on their behalf—someone who is not subject to the conflict of interest that exists when caregivers are employed by someone other than the person needing medical services. In addition, it is impossible for even the best medical professionals to give personalized attention to each patient since they have to devote time to other patients also. Every patient must have the right to have a chosen person with him/her at all times. Technology cannot substitute for in-person interaction, respectful advocacy, and the protection from abuse which (despite even best efforts by hospitals) can only be guaranteed by the constant presence of a loved one.
2.) Most asymptomatic family members are much less likely than the hospital employees to have COVID-19. Medical professionals are seemingly at a higher risk of contracting COVID-19 than the average person because they regularly interact with numerous sick patients.
It is very encouraging that most hospitals allow pediatric and obstetrical patients to have at least one visitor with them and that other hospitals in the nation have already abandoned the zero visitor policy. The truth is that all patients deserve to be treated in a similarly ethical manner.
Screening patient’s visitors such as taking temperatures, special questionnaires to determine exposure to COVID-19, and requiring masks and protective clothing would be a better solution.
The inability for patients to have a family member present with them as they recover has many consequences which hinders the overall recovery. Some of the consequences are: loneliness, lack of comfort, no one to advocate for patients’ wishes for modesty and numerous other issues, etc. Numerous patients prefer that their family member (especially spouse) to help them with personal care such as bathing and dressing. Those patients should always have their wishes honored.
Too many patients have been forced to recover, or even die, without one family member present due to this policy.
Here are a few examples of sad cases affected by the zero-visitor policy:
1.) A man had an accident at work that seriously injured his hand and he required surgery. He was required to stay in the hospital for a few days and his wife could not visit him at all. She did not have COVID-19 at all.
2.) A man had a massive heart attack and spent over a month in the hospital before dying. The zero-visitor policy went into effect a few weeks later and his family could not visit him much at all. Sadly, he passed away alone without the presence of his wife and his two daughters who did not have COVID-19.
Misty
Misty, you definitely bring up an important unethical behavior of the medical system as the system fights against the COVID-19 pandemic.
I look at this unethical issue related to the ethical principles of Justice and Autonomy and ignorance of Beneficence. Justice: Where is the attention to obligations to both the patient and family? Autonomy: Where is the response to the patient's request. Finally Beneficence: Where is the attention to the "doing good" to the patient and to the family?
Is the lack of protective equipment to be applied to both the staff and to the family visitor the excuse to prevent attendance? Is the anticipated legal issue to be of concern to the hospital if the visitor becomes a victim of the viral infection, related to the hospital visit? Do we really know?
Here is a link to a current article by NPR on this very topic: https://www.npr.org/2020/05/17/857531789/federal-government-asked-to-tell-hospitals-modify-visit-bans
I wonder if the hospital management really understands the ethics and the therapeutic and humanistic aspects of patient or family's request for attendance. ..Maurice.
Dr. Bernstein, I understand the "presumed innocent until proven guilty" aspect of this but one needs only look to NYC's new "no bail" policy that immediately puts offenders back onto the streets on that presumed innocence theory. The results have been disastrous with the ensuing crimes committed while awaiting trial for the first crime. If the police and courts cannot reasonably assure the public that they will be safe from further crimes when releasing these arrestees during the covid-19 period, then they shouldn't be released. It can't be a one way street where we only worry about the interests of the arrestees.
My covid-19 solution for the presumed innocent arrestees would be the same as for low risk prisoners, put them is a secure but safer setting until trial, assuming they don't otherwise qualify for bail.
Here is the link to a detailed current article on the issue of prisoner release related to the current COVID-19 pandemic:
https://www.nbcnews.com/news/us-news/early-release-cohen-manafort-shows-how-unfair-prison-system-experts-n1212001
Of course, in everyday life, prior to the current pandemic, there has always have been ethics vs justice conflicts. One commonly brought to mind is the use of the death penalty . For those interested, here is the link to the issue against the death penalty from Markkula Center for Applied Ethics at Santa Clara University, California<. ..Maurice.
Hello Dr. Bernstein,
I question whether medical ethics is considered by any hospital in the US today until a “situation” occurs. I would submit that, in the hospital setting, medical ethics is only approached ex post facto. I welcome your considered criticism of the following.
The typical scenario of hospitalization requires signing an informed consent form and, subsequent admission to the facility. If the (usually electronic) consent form is not signed in toto, one is not admitted (I know this from personal experience.). I submit that justice has been denied in this circumstance. Once one objects to any aspect of the form (allowing pictures, filming, presence of students, etc.), one is denied services. Medical help is not given to this individual. The proper approach would be to interview the individual in an attempt to offer accommodations. (How can we justly satisfy your needs within hospital parameters?) Typically, wishing to amend (line-out) portions of the consent form will bring referral to a supervisor who will mechanically reiterate the policy. Again, if one does not sign the form “as is”, one is denied admission. Of course, there are reasons for this policy. The form is essentially “boilerplate”. It’s created by lawyers to protect the hospital. An attempt is made to account for all possible eventualities which would create “problems” (i.e. lawsuits) FOR THE HOSPITAL. The form is really a misnomer. It IS NOT a form in which one gives informed consent. There is no mention in the form of what procedures one will be undergoing or, anything which is specific to the individual. It’s a generic form in which the hospital is informing you of that to which YOU WILL consent. This is not informed consent. This might, more aptly, be termed informed coercion. If one does not sign the form, one is turned away and denied JUSTICE (an equitable access to the potential benefits of medical treatment). If one signs the form, (wishing to change it but, knowing the aforementioned consequences), one compromises AUTONOMY. S(H)e has not FREELY agreed. The agreement was made solely to avoid the negative consequences of objecting. This seems to be an ethical dilemma. If one objects to any element of the consent form, that individual either will be denied JUSTICE (not admitted) or denied AUTONOMY (unfreely signing). Beneficence and Non-maleficence can be left for another day.
There are remedies to the above situation. This problem could be addressed in a particular setting. That setting might be an in-depth Medical Ethics Committee Study to rectify the so-called informed consent form. Why has this not been undertaken? Others have commented regarding the farce of the informed consent form. A first semester Ethics 101 student could recognize the above dilemma. Why hasn’t the initial step in the medical encounter been addressed in an ethical manner? How can one ponder the lofty questions of life and death, if the first step is not considered? Where is the august Medical Ethics Committee? (This question is rhetorical. I realize that ethics has acquiesced to legalism. The doctors have acceded to the lawyers.)
Would it be incorrect to say that, aside from being what might be termed a perfunctory disquisition, medical ethics, in the hospital setting, is considered ex post facto?
Reginald
Reginald, within the hospital to which I am a member of the clinical ethics committee and previously chairman, I am not aware of the current administrative ethics committee or equivalent issues being considered with regard to your point. I know that in our clinical ethics committee we have never discussed in detail the construction of hospital admission form itself, nor was that our assignment. I strongly suspect, as you do, that the anatomy of the form is greatly structured by lawyers since one might say that "hospitals are businesses" and as businesses certain issues of "self-protection" ("prophylaxes" might be a medical term) would be felt to be appropriate. But thanks to you and Misty for bringing up the issue. ..Maurice.
There is a specific ethical dilemma that faces all states in the United States as well as countries around the world. That dilemma is the preservation of the ethical principle of Non-Maleficence. This dilemma becomes political since both opening closed businesses and effective control of the pandemic can represent an immediate conflict of hazard and value of which there may not be of uniform agreement by the affected populations.
Non-maleficence (to do no harm) sets the two needs at conflict. And this conflict may perplex the state or country governing authority in setting rules which are fair to the different geographic locations where conflicts may easily appear. Here is an example of the current perplexity facing a United States governor and the affected population in the state of California.
Anyone on this blog thread would like to be Governor at this time a face the dilemma of providing non-maleficence to each and everyone under his or her public responsibility during this pandemic? ..Maurice.
Dr. Bernstein, I wouldn't want to be a Governor right now because I would find it too frustrating to be battling an entrenched bureaucracy and those others trying to use the pandemic to gain political advantage. Never let a crisis go to waste and all that. I would insist on science based solutions and common sense, and there is no room for either in modern political arenas. Essential vs non-essential is nonsense at a scientific level nor has the making of those designations demonstrated much common sense.
The decision-making variables should have been based on infection transmission and control. Pertinent variables include PPE, social distancing, disinfecting protocols, HVAC systems, and the like, not on the nature of the goods and services being sold, yet for the most part they focused on the nature of the goods and services being sold.
In NJ they knowingly sent infected patients from hospitals into nursing homes and then banned two large tulip farms from having people take driving tours through the farm, never leaving their car, and having bought their tickets online. Where was the science behind that, let alone common sense? In Michigan you could go out on a lake or pond to fish if you did so in a canoe or a sailboat, but not if your boat had a motor. In Wisconsin I think it is a restaurant can now have up to 50 people dining outdoors but a church can only have 10 people listening to a service outdoors. How is eating food multiple times more safe than praying? Such examples abound and now they're wondering why social unrest is growing and people are starting to ignore their mandates?
So no, I wouldn't want to be a Governor because the public service unions and civil service laws wouldn't allow me to fire people as quickly and extensively as I would need to do in order to manage the pandemic response using science and common sense.
Dr. Bernstein,
It’s heart breaking that the lady with Down’s Syndrome had to die by herself. I cannot believe that they would not allow her family members to be present with her.
The truth is the zero-visitor policy has a bad effect on medical professionals. There is just no way they can give specialized attention to patients that their family members could. Good family members help medical professionals by making sure they give right medicines and treatments. For example, think about how some patients may be allergic to certain medications and their family members can give that information. Even the best and most compassionate medical professionals can never help patients like their family members can.
There are many consequences of a patient not being able to have their family members present. A family member can help to play a role in making sure their loved one is given the right medicine. Nurses are often overworked and it’s hard for them to remember everything for all patients they have to take care of. Many years ago, I noticed my grandfather was overmedicated in a hospital and I went to ask them to take him off the medicines. He was much more alert and better when they stopped giving him some sedatives.
Think about patients who have dementia who cannot advocate for themselves. Some patients with dementia who may need assistance with feeding may refuse to eat for a staff member, but will eat for a family member.
The zero-visitor policy is not patient centered at all. There is also a concern that this could be implemented for other contagious illnesses in the future.
Here’s my response to your questions:
Is the lack of protective equipment to be applied to both the staff and to the family visitor the excuse to prevent attendance? Is the anticipated legal issue to be of concern to the hospital if the visitor becomes a victim of the viral infection, related to the hospital visit? Do we really know?
No, this should not be an excuse. Hospitals should work to have enough protective equipment for both staff and family members. I believe that all family members (visitors) should be required to sign a form agreeing that they will not hold the hospital liable if they contract the virus. The truth is anytime you go in a hospital, you risk getting a viral or bacterial infection since there are germs in hospitals. As you know, medical professionals and hospital staff members are at high risk of getting coronavirus. One of my cousins who is a radiologist contracted coronavirus a few months ago and he thinks he got it from the doctors’ lounge. Thankfully, he has recovered and is doing well.
I believe it is very important to reduce risk of spreading coronavirus, but the no-visitor policy is too extreme. I do agree that they should not let children under 12 visit since some children especially toddlers touch everything and put their hands in their mouths and eyes. I believe only adult family members who are willing to take precautions such as wearing gloves, mask, and washing their hands should be allowed to visit patients.
Misty
Misty, pertinent to your last presentation here, there is a short 2018 article written by a 3rd year medical student and reviewed by a physician editor which supports your comments and appears a reasonable summary to me regarding the value of family "in with the patient".
By the way, I want to emphasize that this issue of family visitation as requested by the patient meets the ethical principles of autonomy and beneficence ..Maurice.
I agree that families should be able to visit and that hospitals should have the necessary PPE for that to occur safely, but the reality is this pandemic caught federal, state, & city governments w/o actual pandemic response plans and it similarly caught hospital systems w/o actual pandemic response plans.
Real plans would have taken into account that in a global pandemic, standard just-in-time procurement systems would fail overnight. And they did fail which meant PPE given to family members would have been all the less available for staff. Hospital system plans would have taken into account that the feds & states did not have plans and did not have adequate stockpiles and that the hospital systems needed to create their own stockpiles. But they didn't have plans and they didn't have stockpiles enough for staff let alone family members.
There was never a question in the public health community that there would be a pandemic. The questions were only when it would come and how severe it would be. This was not a black swan event but rather one that they could have been prepared for. But they didn't plan for it and the need to keep family members out of the hospitals was one of the prices that had to be paid.
Biker, as the current patient population of COVID-19 cases actually comes down (at least hopefully not temporarily but "permanently") shouldn't one expect that family members would be allowed to be present? Or do you think there are factors involved in hospital decisions not related to PPE resources and use but other legal concerns which would put an additional burden on the management of a hospital? For example, to protect against a visitor from making an argument that the visitor's subsequent COVID illness was really the hospital itself as the source. Should hospitals now require all visitors to sign a legal document before visiting any patient taking full responsibility for a subsequent personal COVID-19 infection? Would this support the ethical principle of justice toward the visitor? ..Maurice.
At this point we probably are in a position to begin allowing family members back into hospitals, perhaps with mandatory wearing of masks, screening at the door, and restrictions on where they can go. In areas of the hospital with actual covid-19 patients, the hospital itself would have to provide the required PPE being it is more than simply wearing a mask.
A few days ago I had to bring a urine sample to the lab for my wife. I was required to wear a mask and was screened at the door with a series of questions and my temp being taken. It all made sense. My guess is that the lawyers haven't fully caught up with the risk to visitors aspect of this but they likely will for the reasons you indicate and some form of public notice or formal consent will be required. My guess is they'll go with public notices being posted given the logistical problems with doing actual consents.
I'll throw in an interesting twist to the discussion. Can or should hospitals prohibit visitors who come from out-of-state? Both the local hospital and where I get my scheduled care at in NH want to know if you have been out-of-state in recent weeks. VT is OK with you having been in NH and NH is OK with you having been in VT given we have very low levels of the virus relative to our populations, but our neighbors MA & NY have bungled their response badly with disastrous results, as did their neighbors NJ & CT. Would it be OK right here and now to not allow visitors from MA/NY/CT/NJ and those who admit to having traveled to those States while allowing visitors who have only been in VT & NH?
Bear in mind that though we have had very little in the way of cases here, a good share of what we have had came from people fleeing Metro NYC. Roughly 1 in 7 homes in this State are 2nd homes and many did high taui
I think what JF wrote on the Preserving Patient Dignity Volume 111 and my response to her is worthy of reproduction here on this topic. ..Maurice.
At Tuesday, May 26, 2020 7:18:00 AM, Anonymous JF said...
Dr B, WHY do you think you couldn't self diagnose? You could probably be approximately as accurate as another doctor doing it for you. Maybe if the college was a more responsible wage we could have many more doctors and there'd be more accountability from them. I kind of think more self treatment MIGHT be the way to go if people could force themselves to study up. At least to the point where doctors need patients as much as patients need doctors. Without that kind of equality we can always be mistreated by the medical staff who desires to mistreat us.
At Tuesday, May 26, 2020 8:26:00 AM, Blogger Maurice Bernstein, M.D. said...
JF, if you look at the current medical news and journals at this time of the COVID-19 pandemic, you will read that doctors do need patients for their financial and mental health. With some loosening up in parts of the United States and clinic or hospitalization for elective procedures are beginning to be permitted, for example, more routine visits with your doctor may be coming but with return soon of ongoing COVID flareups divorce between patient and doctor may still be an ongoing reality.
And yes, that means that patients for the foreseeable future may require self-medical education more than previously and self-treatment.
What I wrote above is real and is happening now. However, self-education and self-treatments will always have limits even with methods of self-electronic diagnosis and self-treatments. There is a reason why medical school education to become a physician is a 4 year exercise and even after 4 years more knowledge and experience is necessary before a physician becomes fully educated in medicine. But who knows what the future may bring in this upset and dangerous world and perhaps this respite from everyday professional care to self-diagnosis and management may be what will be a major public behavior in the future or even near future. COVID-19 is now known to attack and damage many bodily organs beyond the respiratory tree and even attack the healthcare providers in their work or at home and therefore it will end up with any "mistreatment" if present as exercised by the now "medically-educated" patients themselves. ..Maurice.
Not sure what happened with my last post but the final paragraph was supposed to be:
Bear in mind that though we have had very little in the way of cases here, a good share of what we have had came from people fleeing Metro NYC. Roughly 1 in 7 homes in this State are 2nd homes and many did high tail it up here to their 2nd homes.
I want to emphasize that the topic which JF and I was currently covering actually deals with the bioethical principle of patient autonomy and the degree to which it can be practiced in the matter of the health of the patient involved but also with regard to the health of those humans who are in the vicinity or are being affected in other ways by the decisions and actions of that patient.
Patient autonomy in medicine should be an ethical principle with decision-making by the patient but should not be primarily directed to cause ethical or physical harm to others. Repeating: A wrong autonomous intent or final decision by a patient should not lead to the ethical error of maleficence toward others. So patient autonomy should be utilized by the patient with education and care. Does anyone here disagree? ..Maurice.
As a followup to my last posting regarding patient autonomy..there is a current (today) interesting article in the American Medical Association website regarding the ethics about rushing to give cardio-pulmonary resuscitation (CPR) to Covid-19 patients. This issue has also been a topic discussed on the medical ethics listservs to which I subscribe. In many cases related to managing a Covid-19 patient there is a matter of the clinicians weighing benefit vs risk and, unfortunately, the infection risk to the doctors and nurses are is on the scale to weigh. ..Maurice.
Okay, let me get this straight. Saving a person who has COVID it not important as they must give the germ to the medical worker but when a normal patient declines/refuses a gold standard treatment than the medical worker has the right to force that treatment on the patient? It is funny how such a double standard can exist? Using this logic why do firemen rush into burning buildings at risk of their lives? Why do any of the jobs that put the job holder at risk still do those jobs? What about the military--should they be able to say it is too risky and not doing it? It didn't work for those during the years of the draft. For those who do things that put them at risk such as a mountain climber, does this now mean there will be no rescue operation because their careless, selfish actions could/may put the rescue team in danger? Does this mean because someone smokes cigarettes and set their bed on fire that firemen will not have to put their lives at risk to save them or put out the fire? How far does this go and to what "special" people does this apply to?
As far as patient autonomy, patients really only have autonomy on paper and not in practice. For a patient to have real autonomy, they must avoid medical care because at any time the medical community will take away the paper granted autonomy. I have personally witnessed this happen. The medical community made a decision that lead towards maleficence toward my husband but yet because he didn't die because of it, it is viewed as being okay. His decision to refuse invasive treatment did no harm to any of the medical people involved but yet they forced their gold standard of treatment on him. Where or at what circumstances will a patient be allowed autonomy? When is the convenient time for medical personnel to allow patient autonomy? So does this include anyone with flu symptoms from getting treatment because the flu can kill hundreds of thousands? Why can EMTs ignore DNR orders from a patient but yet can chose not to give CPR to a COVID patient? Does a person's DNR wishes not matter in the big scheme of things if the medical community sees it as not mattering for whatever reason?
This rule book is very confusing and is bound to be very thick. Will it be written in a language us non-educated common people can comprehend or do we need to rely on the medical community's superiority to dole out the instructions?
Why would a COVID infected individual even go to a hospital is my question? You are isolated and die alone. You may be abused but they now have immunity. They may put you on a ventilator which ultimately will probably kill you as it has done so many. You are drugged and get very little human interaction as all within your sight are like space invaders. They may or may not have to give you care as it might be too dangerous for them. Okay, I'll just stay at home and die and will do it more cheaper.
JR, I think that patient autonomy is a complex "freedom of self-decision making" and is even more complex when injury to others is an obvious issue. Here is a worthy article to click here and read regarding limits to patient's autonomy.
And let's then discuss this bioethics principle here since this is an important aspect of medical ethics and actions in this COVID-19 pandemic. ..Maurice.
JR makes some good points. To clarify my earlier remarks, if the hospital staff did not have proper PPE as has sometimes been the case, and I was a covid-19 patient, I would not want them taking undue risks to resuscitate me. I don't want to live at the cost of some much younger nurse, tech, or doctor possibly losing their life. To me this would be me expressing my personal autonomy. I am not advocating that as the correct solution for everyone, nor what choices those nurses, techs, and doctors should be making for themselves in such a situation. I'm just saying I don't expect them to put me before themselves in such a situation w/o proper PPE.
My role model for autonomy is my grandfather. He had been a longshoreman back in the days before machines did all the work and I can recall seeing him w/o a shirt at about age 75. He still had a physique most men never had. Other than a pacemaker he was still in pretty good health at 85 when diagnosed with stomach cancer. The doctor recommended surgery which at his age certainly presented risks and possibly a long recovery. My grandfather refused any treatment, had another good year living his life as normal, became ill and passed at home at 87 with my grandmother having been his primary caregiver during his illness.
Going through that article you referenced, I have many points to add. I am painting w/ a broad stroke so I know there are exceptions.
The two concepts--the first being well-informed to make a decision. This is a problem area bc many drs don't want their patients to be well-informed as they feel threatened by patients w/ knowledge. True informed consent doesn't exist in most circumstances as most drs will gravitate towards the special procedure they are proficient in so they generally do not present the options or if they do, not in a favorable light. W/ the Internet, many more pts are becoming knowledgeable of options which seem to displease the medical community who thinks bc they have spent long yrs in getting education, we should bow to them.
It is the obligation of the dr to provide the info but many choose not to as they think pts don't really need to know but rather should rely on their judgment.
The extent of autonomy by this article should be limited if "its exercise causes harm to someone else or may harm the patient". This is totally BS. While their autonomy should not seek to harm others, they do have the right to decide their treatment options or no treatment at all. That is fully within their rights. A patient has the full right to refuse any treatment they do not wish to have. No has the right to force treatment on them. But the issue is, if a medical member disagrees they will merely call the person incompetent or unreasonable and do treatment against that person's desire or belief. But in saying the paragraph goes on to say "autonomy is limited when its exercise violates the physician's/healthcare team's medical conscience". So in other words, medical personnel are the only ones allowed to have beliefs or conscience. Wow! What a total double standard. I thought medical people left their personal feelings at the door such as sexual desires, racism, discrimination, etc. Apparently not but then I already knew that.
I totally agree that a dr does not have to provide treatment for giving antibiotics for a cold, etc. but that does not mean the medical team can force treatment upon a patient. They can deny treatments that are not medically needed but cannot force treatment especially if a patient says NO.
Just because a patient like Biker's grandfather declined the gold standard treatment does not make them incapable or mentally unbalanced. It means they have the right to control their fate. Doing an unneeded mental assessment on a patient just because their views of medical treatment is different is totally immoral and unethical. The thing about living is knowing that in the end you will die. Some choose to accept a more natural approach than others and no one has the right to disallow that.
My issue is medical people are said to not let personal feelings intrude into their professional conduct but it is and does. That is why many patients are denied basic patient rights such as dignity, respect, and autonomy.
While no one should purposely harm others, some jobs and professions are riskier than others. That is a fact of life. No one makes anyone become a member of the more riskier professions as of yet but that may come as politics change. But right now there is the freedom to choose. Doctors/nurses have always faced a certain amount of danger given they do deal with diseases that can kill if they are infected with them. It is a risk of their job just like it is for police, firepeople, military, bank tellers, convenience store clerks, etc. If you want a less riskier job, then you are free to choose that job.
But it is this very real admission of "moral distress within the team" which really bothers me and would explain why some patients face harm such as sexual and medical assault as it is clear the medical team seems to think they can use their personal feelings whenever necessary. Very troubling indeed!
I am greatly impressed by the dissection of the relationship between patient and caregiver autonomy through the views of JR and Biker. The issues, particularly in the cases of firemen (for example) and their risks as described by JR and by Biker regarding hospital staff in the context of the current COVID-19 pandemic and the limitations of protection to those not as yet infected, something which should be considered at least by the family of the patients if not, at the time, by the patients themselves.
There are times, as brought out by both JR and Biker when autonomy to be fair and of value, needs more thought and reasoning than at other times. Thanks. ..Maurice.
The whole trouble with "autonomy" being at the whim of another (i.e. dr) is you have the situations of common person and celebrity. This is where the differences meet the road.
Everything is done to save someone like a George or Barbara Bush along with a Jimmy Carter. We, taxpayers, have probably paid millions to prolong their lives until it got to the point where even George and Barbara Bush said enough is enough. Jimmy Carter whose health is bad is saved at every cost even though he has co-morbidities. My father was not that lucky. His hip fractured due to Warfarin and he fell. He had Parkinsons but was functioning well. But in the ER that night, he was told he would not be saved as there was nothing they could do for him. At that point, I saw him close down instantly bc of that ER monster's words--You have no choice but to die. So they let him to linger with a broken hip unable to move for 3 weeks on hospice drugged to the max with no food or water or IV for any type of nourishment as hospice said they do not do IVs for nourishment. If he had been a Bush or Carter than it would have been different. This highlights why patients must have autonomy as there is a difference in care standards. To that ER dr., my father was unimportant but that certainly was not the case. We could have had him longer if that dr. did not feel it was within his right to pronounce for my father a death sentence. If my father had been "somebody" I am sure his "ethical" reasonings would have different. This is why I say it is dangerous to let the medical community have free reign when patients have a right to chart the course of how medical care is delivered or not. That is not to say pts have the right to have surgery just because but the same standards of care should be given to John Smith as it to Jimmy Carter.
I will stand behind that some professions have more inherent risks than others. If you do not want to have a job with risks, take another job. My job at a school wasn't suppose to have violence in it but it gradually grew to have it. I had choices though to continue or not. I continued knowing that any time a kid could commit violence and I was a victim of student violence but I accepted that risk. I knew at any time a student could stab, shot or run over me. I also knew that part of my job was to protect the other students. So with this in mind, is it okay in the minds of society for a teacher when faced with danger to abandon their students to save their own life? There was a cop at Parkland who took a lot of heat because he hesitated because of the apparent danger. Do cops like drs/nurses have the option to say not today--it is too dangerous? Do we need a flag/marker system so we know the mood of the day of whether they accept the risks on a particular day?
Do we need to know when we are going to be "allowed" rights and when the whim of someone says we do not have rights? How does that work exactly? But then that is how it works now. Sometimes we have rights at least on paper but when it comes right down to it we don't have rights bc in healthcare the medical community reigns supreme over us bc only they know what is good for us. This is why I like many others avoid healthcare. It is my body, my choice. If it works for women wanting to kill a baby bc they carelessly had sex, it should work for a responsible adult wanting to make their own healthcare decisions?
And JR, there is the ethical principle of justice that ends up as "injustice" within the medical community workers itself. Just read this current article "Nurses Disciplined, Fired for Wearing Hospital-Issued Scrubs". There is injustice all around. ..Maurice.
Hello Dr. Bernstein,
Thank you for your article from Hospital News re patient autonomy. It rekindled my remembrance of Logic 101 - from a faulty premise anything follows. I suppose that the essence of the article is the following initial line: "As they [health care workers] work with patients and families who are making healthcare decisions, the goal is to move care in the right direction." What is the "right direction"? Would this be what is most expedient for the health care "professionals"? The next statement is ridiculous. "First, to be autonomous (literally a self-lawmaker), an individual must have adequate knowledge to explore and examine all options relevant to the healthcare decision that needs to be made." NO!!! Nowhere in the definition of autonomy is there any implication of "knowledge"!!! This is why Epistemology (Theory of Knowledge) and Ethics (Theory of Morals) are separate disciplines. There's no reason to further dissect this ludicrous article. Maybe health care individuals should also be given a course in Logic before they delve into the more nuanced field of Ethics.
Reginald
Reginald,
I was much impressed at your previous post about consent forms. Well written.
Maurice,
As to autonomy, justice, beneficence, and non-maleficence, this is marketing fluff, it is NOT the law. Providers do what they want. The oath only helps to quell (what ever is left after med school of their) conscience for doing what they were taught to do.
You speak of ethics as if it is practiced in healthcare. I hate to beat this dead horse, but as long as intimate exams on anesthetized patients without proper consent continue to occur, the profession is devoid of any morality. It applies to the entire profession, because if one is not part of the solution, then they are part of the problem.
What this pandemic has shown is how tight the leash society has put on providers really is. It still needs to be tighter and they need to be muzzled as well.
Now the pandemic is pushing us to realize what is really necessary and what is not. Hands on physicals are being replaced by video chats.
I see the larger picture. The providers are losing.
-- Banterings
There is so much concern now about how long it would take to obtain a proven effective vaccine for the prevention of illness and death by the CORONA-19 virus infection. Well, I found a numerous cartoon related to the length of time to prove the effectiveness of an "immortality vaccine' if even one could be invented. I have used this cartoon to present an introduction to the issue of "Ethics of Immortality". To inspect and perhaps contribute a thought click here. ..Maurice.
I learned that a child whose parents were healthcare workers in my county contracted COVID-19. This shows that you are at a high risk of contracting coronavirus from a healthcare worker. The zero-visitor policy is ridiculous because many hospital employees are more likely to be exposed to COVID-19 since they are required to interact with sick patients who may have the virus.
Check out this article,
Are heart attack patients avoiding hospitals because of coronavirus? Some Chicago doctors think so. I had heard on the news that some patients are avoiding the hospital because they are afraid of contracting coronavirus. I also know some people do not want to go to the hospital because they do not want to recover alone.
One of my friends shared this with me last week: I know a man (not personally, he is a relative of a friend) who is in his 80s and chose not to go to the hospital when he contracted COVID because he didn't want to die there alone without family. Miraculously he survived--but nobody should have to make such a terrible decision. Even if hospitals converted rooms with windows into negative pressure rooms (that is where the air in the room cannot escape into the rest of the hospital and is instead pumped outside), so that a family member could monitor the patient from the window, that would be better than nothing. She encouraged me to check out this video showing how normal rooms can be converted into negative pressure rooms and how one hospital has done this in a short amount of time: https://www.youtube.com/watch?v=5FRBv3S252Q.
Misty
It is also very heartbreaking that family members have not been allowed to visit their family members who are in nursing homes since March. The truth is coronavirus has been a problem in nursing homes because staff members or residents have spread it. Some nursing homes do not take putting COVID-19 patients in a separate area seriously. I feel the governor in New York made a big mistake by forcing nursing homes to accept COVID-19 patients. It would have been best for them to remain in the hospital or another facility devoted to taking care of COVID-19 patients.
It is important for a family member to be able to visit their loved ones (especially those with dementia) in a nursing home on a regular basis to prevent them from being neglected or abused,. For example, bed sores and falls have killed many nursing home residents. Check out this web site about nursing home falls. According to CDC, at least 1,800 nursing home residents die from falls. I think with this pandemic, the rate of nursing home falls will go even higher because most nursing homes are understaffed and it is harder for staff members to monitor residents without their family members involved.
Misty
Misty, I fully agree that family members do play an important role in the protection of their loved ones in nursing homes. But I have found, in many ways, family members play that role for patients in hospitals. Certainly, JR writing in the Preserving Patient Dignity blog thread is such an example regarding her husband as a patient within a hospital environment. ..Maurice.
EXPANDING EUTHANASIA DURING THE PANDEMIC is a worthy reading in Public Discourse June 7 2020, the Journal of the Witherspoon Institute. It is about what has been going on in Canada for the past 4 years, legalizing euthanasia, and how the ongoing COVID-19 pandemic has set varying interest in that now legal Canadian euthanasia rulings.
My question: should threat of further spread of COVID infection within the medical community itself or visitors of COVID patients and repeat of inadequate respiratory equipment availability make legalized euthanasia, as now Canadian law, a rational and ethical approach to the pandemic? Or should we just let "nature take its course" ..Maurice.
Doctor Bernstein,
I wish to make a distinction regarding your last post. What you refer to "euthanasia" is more accurately described in Canada as "Medical Aid In Dying" (or MAID). The legislation is there to allow individuals who have met the qualifying criterias to choose to end their lives when they cannot do so themselves. The criterias are as follows:
1. be eligible for health services funded by the federal government, or a province or territory (or during the applicable minimum period of residence or waiting period for eligibility).
Generally, visitors to Canada are not eligible for medical assistance in dying
2. be at least 18 years old and mentally competent. This means being capable of making health care decisions for yourself.
3. have a grievous and irremediable medical condition
4. make a voluntary request for medical assistance in dying that is not the result of outside pressure or influence
5. give informed consent to receive medical assistance in dying
More information can be found at this website : https://www.canada.ca/en/health-canada/services/medical-assistance-dying.html
Dany
Dany, what is your understanding of the C-7 Canadian bill which would provide physician-assisted suicide. Would the passage of such a bill be of significance in the current and ongoing pandemic? ..Maurice.
Hopefully, all my visitors here have so far avoided COVID-19 infection.
A question: With the COVID-19 documented infection levels in many parts of the United States, what do you think is the motivation of those citizens who disregard using face coverings and distancing when interacting with others outside of the citizen's household? Is this something political or simply fatigue or disinterest in continuing this "unusual" public behavior? ..Maurice.
Because they made it into a joke. First, masks wouldn't help then they would then it has flip flopped again. We must using the offensive term "social distance." Then we can't visit nursing homes but they can send COVID patients there to kill the residents. People can't go to church or have funerals but then we can have riots, looting, and a mass funeral but still church isn't save for the ordinary citizens. Apparently COVID germs do not spread during riots but can spread at county fairs. It is a political ploy is how I view it. Yes, it can spread but so does flu and nothing much is done about it. Enough is enough. If they want to change the government then every four years they have that option. They don't feel they can win even with everything they have done in the past 3 years so now it is COVID they are using. And no, I am a MAGA person but I can see what is happening and it is scary that it has been allowed to go to this extreme. Local people know we can get COVID just was we can get the flu even with the vaccine but there is no point in all this stupidity that is being forced on us to punish us for having Trump as President. COVID should have come during the Bush and O'Bama years because I objected to both of them. Normal people should now riot just because and we should decide what laws we will follow and what laws we won't. Shouldn't that be the new normal? People see the rioters getting back with murder, stealing and whatever else they want so why should we be forced to hide, wear masks, and just quit living so we won't die? Enough is enough. If I have offended, from what I see on tv, just consider me a rioter or a social justice warrior and everything will be okay. Society has allowed some to take an issue about the killing of a man by police and turn it into something it should never have allowed to become just as COVID was done. If I get COVID and die then it will happen as we all die someday. I will be getting any medical harm during my dying process. They aren't my heroes as they are great social injustices within the system that society as a whole doesn't care to address. Maybe the rioter should take up medical harm as their cause?
JR et al, how do we proportion the importance and the essential need to follow politics, ethics, law,religion and science when we are faced with a serious pandemic for which there is no specific and absolute prevention or absolute cure? People engulfed is this pandemic who want to die can die, refuse to dying can die and those whose political ideals are such that they want to follow can die. Which of the above five human tools are currently, within this pandemic, worthy of placing as #1 on the list to hold onto and utilize to meet their own personal and current goals regarding their lives? ..Maurice.
The pandemic is only being used a ploy to control and manipulate. Control the healthcare, control the people is something that is attributed to Hillary Clinton saying. It seems to ring true.
I think ethics is the first on the list. Was it in the best interest to quarantine the country for this? Probably not given now we hear let the rioters go on a rampage but the church people still can't go to church. If it is serious then all should have to follow one set of rules or not. I am neither a rioter (yet) or a church goer so I have no skin in the game but I see how the pandemic is being used to control. For Trump rallies, crowds are too dangerous but for other issues, crowds are fine. Control the healthcare, control the people. Covid=shutdown=bad economy=unhappy citizens=change in party. Pretty slick they think but maybe not so as people are seeing the different rules for different people.
Patients who were put on ventilators seemed to die as they were used incorrectly. Medical community got immunity from harm which they had anyhow in we are being honest. Medical harm is the 3rd leading cause of death in US but nothing is done about it. No marches. No protests. Control the healthcare, control the people again. This healthcare crisis was used as a means to control with healthcare in the driver's seat on the train to ruining an nation.
Patients had no rights in this pandemic if you sought treatment. You became isolated from your family to die alone. Hospitals called all the shots both all sense of the meanings. What little rights patients had before this crisis will most likely be lost forever.
Even the gold standard for heart attack treatment was set aside for the pandemic as during this time the treatment my husband wanted was now good enough again to use. Funny how that works but not really. It just shows a how morally and ethically corrupt the medical system really is.
And yet, JR, if you and others consider the "medical system" in its true entirety, within the United States as an example, the "medical system" really does include beyond the physicians, nurses and others including researchers, there are also state and federal agencies state and federal politicians, industries as well as the healthy citizens and the unhealthy patients. Considering the citizens and patients, that is the rationale for control of the entire system, repeatedly emphasized and expected on this entire bioethics discussion blog, to "SPEAK UP". ..Maurice.
Consider: "The Lost Art of Dying". ..Maurice.
The medical system requesting JUSTICE from the United States Government with regard to the public legal suits which are expected to be made against members of the system as a consequence of the COVID-19 pandemic. ..Maurice.
Maurice,
In regards to Are there limits to a patient’s autonomy in making health care decisions?:
There is no obligation that a patient have knowledge OR make a fully unemotional, rational decision. I have declined cancer screening, and when the doc tried to convince me by making a sales pitch (as opposed to discussing benefits and harms), I simply ask:
Will ANYTHING that you say change my right to refuse?
One can NOT put conditions on the ability of one to exercise their rights. This is akin to voting literacy tests or voting tax.
As to limiting one's rights because it causes harm to others: The US Constitution (the basis of our LAW) guarantees freedom, NOT safety.
These are 2 more instances where the profession of medicine is exempting itself from the laws of society.
2 of the 3 institutions that enjoyed exemption from the laws of society (the church and the police) have had a reckoning. How long until healthcare has its reckoning? NOT very long. Look what has happen with the first 2: their members have been made an example of, their institutions torn down. You think burnout and suicide are a problem in healthcare now? Wait until the witch hunt begins.
-- Banterings
Banterings, you present an interesting prognostication regarding the medical profession based on past experience in other venues. ..Maurice.
Hello,
Banterings, I wish I could view the future so "optimistically". The lack of a modicum of transparency will delay any medical "reform". There are no (patient) cell phones in the OR to catalog misdeeds. Anesthetized patients cannot sue for molestation. Falsified electronic medical records will be difficult to refute. Our society has lost its sense of ethics; and, medicine has lost its noble luster. I fear that change will come very slowly. A bright spot may be HSA's (health savings accounts) and disclosed medical costs. These will cause patients to "shop" for the services they desire with the concomitant need for medical providers to satisfy these patient requests. Hopefully, we'll see the inception of this in our lifetimes.
Reginald
Reginald,
Fear not. Can you think of any other institutions other than the church, the police, and medicine, that claims to be so trustworthy, deal with people at their most vulnerable, have exempted themselves from societal norms and rule (self-police), and have systematically abused so many of the people they purport to serve?
The day of reckoning has come for two of these entities. What would lead you to believe that the profession of medicine's day is NOT coming?
I see the downfall. States are passing laws that are outlawing intimate exams on anesthetized patients. Just as the police can not help themselves and use excessive force when they know that every cell phone camera will be pointed at them, so to will practitioners of the healing arts not be able to restrain themselves.
You can blow out a candle
But you can't blow out a fire
Once the flames begin to catch
The wind will blow it higher...
...And the eyes of the world are watching now, watching now -Peter Gabriel, "Biko" (1980)
When it does happen, the profession will say we did not know or see this coming. I having been warning this for years. Their hubris has rendered them blind and deaf to the expectations of society.
-- Banterings
I am optimistic. It could be that the "strain" on the medical system by the current COVID-19 pandemic may actually provide changes in medical practice and the way medical practice has treated or mistreated patients in various aspects of their attention and care.
For example the use of Telehealth--Telemedicine has increased as a part of the "stay at home" necessity as part of the COVID-19 patient-doctor interaction.
Read the NEJM Catalyst article, linked above,and tell us what you think its greater future use and value long after the pandemic itself is gone. ..Maurice.
BJTNT wrote the following today on the blog thread"Preserving Patient Dignity (Formerly Patient Modesty) Volume 111" which led to my response as published today
Reference: What is Telehealth?, NEJM Catalyst, Feruary 1, 2018.
Quote:
"They also require payers to reimburse telehealth services at the same payment rate as in-clinic services."
"Moreover, payers, like employers, may be lured by decreased medical expenditures and consumers may be motivated by the convenience and promptness of care that it offers."
Unquote:
The medical lobby is quite effective. Same payment rate + decreased medical expenditures = greater profits for medical institutions.
BJTNT
At Friday, June 19, 2020 2:36:00 PM, Blogger Maurice Bernstein, M.D. said...
BJTNT, good point. But maybe the patient will by participating "at home",outside the clinical physical environment, there will be a greater sense and actuality of patient autonomy. If, as fully described here over the years, the professional avoidance of patient autonomy can be and will be substantially reduced, perhaps it will be considered by the patient to be worth the "same payment rate".
By the way, I am not writing from personal professional knowledge since "tele.." was not yet in my professional era except for a phone call from a hospital ER at 2am informing me regarding a patient present or a patient making a phone call regarding a new symptom or request for a medication.
Times have changed and are with "tele.." changing further. ..Maurice.
Maurice.
He contracted COVID-19 from a staff member in his nursing home, developed pneumonia, and was then hospitalized at St David's.
Texas Right to Life claimed that he was refused food and treatment for coronavirus there for six days before his virus death on June 11, 2020.
Read the news story and look at the video link
The ethical part is: who sets the decision to make an attempt to save the patient's life, the wife, who knows more about the patient's wishes or a judge selected organization, who hadn't lived with the patient to make the decision? ..Maurice.
..Maurice.
This is certainly a good example of the medical community raising its godlike head and deciding who lives and who dies. They deliberatively defied the wishes of the wife who knew what her husband would have wanted. They decided his fate making the loss of him even more painful. They are soul-less creatures using hospice as a vehicle of bringing death sooner. Notice the hospital is a religious hospital who will probably identify themselves as pro-life in abortion but for adults--kill them. How twisted their logic is. And once again, the two deity communities, legal and medical united against the people to harm yet another human being.
Thanks, JR. And an ethicist writing about this case on a bioethics listserv to which I subscribe wrote in part:
I acknowledge there is much we don’t know. Who was his court appointed guardian? If not his wife, why? Why was he in a nursing home? What was his insurance status? What alternatives did he have for care with a chronic trach besides a nursing home? What was his clinical status at the point of the discussion we heard? All of it is important. There’s an important story there but not sure it changes my fundamental concern.
BUT-- I heard a doctor telling a wife that he knew more about her husband’s quality of life than she did. That the "State’s decision" overruled her judgment on this issue. Then we have the question of why was treatment not only withheld but withdrawn. IF that is indeed what happened that is unusual in my experience. Court appointed guardians usually error in favor of treatment, unless strongly recommended otherwise by health professionals. Was this based upon an assessment of futility?
So as bioethicists, I ask— are we OK with that? Even if you as a doctor are tired, overworked, etc. this is not something you say from fatigue and being overworked. This is disability bias. Not even unconscious bias but explicit bias.
I, myself, think that to actually hear the physician rationalize the patient's condition and "clinical-moral" professional decision to the patient's wife is a worthy listening experience.
I think those who haven't as yet read the news article but importantly listened to the recording of physician-patient's wife interchange should do so.
The question is in matters of immediate management of a patient's Corona virus infection sickness and the patient's previous impairments who, at present couldn't communicate desires but whose wife was a legal surrogate for the patient, why would a court take away her legal decision-making power and create another, but "commercial" surrogate who would agree with the hospital's and physician's decision? ..Maurice.
Hello,
Could it be that BECAUSE SHE DISAGREED with the medical community and the state, Mrs. Hickson (explicitly or implicitly) was considered incompetent to make decisions for her husband? Is this what we can also expect from Congress and the political establishment?
Reginald
Reginald, excellent assumption. And a "take away" from this case is the value of having available an auditory recording of the interchange between the physician (representing the hospital itself) and the patient's wife (representing an expected designation of surrogate.
JR, I really think that every family member should have a voice recording devise (a cell phone) operating during every communication with a member of the medical profession or medical system when discussing issues pertinent to the management of the patient from their family. I don't recall if you utilized a recording device when personally involved with the medical management of your husband.
If any hospital institution wants to go to court to defy the decision of a family surrogate, such a cell phone recording would be an important resource regarding decision to support or deny surrogate change. ..Maurice.
I agree that every medical encounter should be recorded but the problem with that is some states like the ever so progressive state of California says that is it illegal to record conversations without the consent of all parties. Therein lies the issue. Many medical facilities have signage saying no recordings because evidently they have something to hide. In Indiana, we only need the consent of one party and that would be the person doing the recording. And yes we carry recording devices on both of us at all times.
Reginald is correct in saying if someone disagrees with the medical community, they are labeled unreasonable or mentally incompetent. There is also another case of an elderly woman who actually had a family member appointed her guardian but that member disagreed with the hospital so the hospital went to court had them relieved of the guardianship and barred from visiting. If someone thinks a hospital will not take control and power away from a hospitalized patient/family they are very mistaken. Times have changed greatly and now the legal community usually supports the desires of the medical community.
A move in the right direction regarding how energetic to treat COVID patients while being aware of the patient's past medical or other history. About health guideline changes in Tennessee as written last week in the New York Times.
“We think this is a great model and hope other states will follow Tennessee’s lead in being comprehensive in accounting for the rights of persons with disabilities,” said Roger Severino, the director of the Office for Civil Rights at the U.S. Department of Health and Human Services, which received the complaint and worked with Tennessee to resolve it.
“People with disabilities are already more vulnerable to bad outcomes during this crisis,” Mr. Severino added. “This is a time to provide more protections, not fewer.”
The new plan allocates medical care based on how likely patients are to survive their immediate illness if they receive treatment. The previous plan considered their long-term survival prospects as well. That provision was removed because it could disproportionately penalize those who are older or have disabilities.
There is much more to read about the new Tennessee guidance changes in the article. This all represents to me a following of the ethical principle of
Justice as we battle with the COVID-19 pandemic. ..Maurice.
Check out this publication by medical providers encouraging hospitals to rethink the no visitor polices for COVID patients.
I do not believe that any patient should be forced to die or recover alone without support of a family member.
Misty
Hello,
Thank you Misty for the nicely nuanced article. It shows what is possible, if medical personnel are willing to think outside the scrubs; and, to place patients and families FIRST.
Thanks again.
Reginald
A dilemma the medical system might readily experience is what to do legally if an outpatient sitting in a physician's office waiting room with other mask wearing patients refuses to wear a mask as requested by the physician and is potentially putting other patients in the room at risk. Here is a Medscape discussion of the matter.
From an ethical point of view does the need for justice and non-maleficence for the other patients counter the issue of patient autonomy for the patient involved?
If you were a physician and told by the office staff that such a patient was sitting in the waiting room and refuses to wear a mask which you provided without charge, what would you do? ..Maurice.
Hello Dr. Bernstein,
Your question: "If you were a physician and told by the office staff that such a patient was sitting in the waiting room and refuses to wear a mask which you provided without charge, what would you do?" If not wearing a mask is considered a health risk, how about asking the non-masked individual to wait on a chair outside the office, until the doctor is ready for the individual's appointment?
Reginald
Reginald, thanks for your suggestion. Would it make any difference in your presenting this option to an established patient of yours vs a previously unseen patient? Should office practice offer a different response to each class? And as a physician what would you elect to do if the patient stated "I am short of breath and can't breathe with a mask." Where should a physician's responsibility be directed in making a decision of this nature? ..Maurice.
Hello again Dr. Bernstein,
For over 50 years pediatricians' offices have had separate entry doors for sick children. I'm not sure what the problem is. Established and new patients were treated equally. "I can't breathe" is (was) not a necessary requirement. Both physician and patient could view this as an ADA accommodation. Again, this might be the ever-present tension between conformity and creativity. Does the medical profession shun creativity?
Reginald
At times there may be a conflict between treating a patient with beneficence (to the patient's "good") and ending up with maleficence (to the patient's "not-good"--harm). Yes, the mask may interfere or harm a patient's ventilation if the patient has an ongoing chronic or acute pulmonary disease. However without a mask, perhaps transmission of the virus into the patient's body would be facilitated and add more harm to the patient's health. ..Maurice.
Here is a current book (of which anyone can download as a PDF file without charge) titled "Vulnerable
The Law, Policy and Ethics of COVID-19" and presented by University of Ottawa Press.
Here is the description of the book:
The novel coronavirus SARS-CoV-2, which causes the disease known as COVID-19, has infected people in 212 countries so far and on every continent except Antarctica.
Vast changes to our home lives, social interactions, government functioning and relations between countries have swept the world in a few months and are difficult to hold in one’s mind at one time. That is why a collaborative effort such as this edited, multidisciplinary collection is needed. This book confronts the vulnerabilities and interconnectedness made visible by the pandemic and its consequences, along with the legal, ethical and policy responses. These include vulnerabilities for people who have been harmed or will be harmed by the virus directly and those harmed by measures taken to slow its relentless march; vulnerabilities exposed in our institutions, governance and legal structures; and vulnerabilities in other countries and at the global level where persistent injustices harm us all.
Hopefully, COVID-19 will forces us to deeply reflect on how we govern and our policy priorities; to focus preparedness, precaution, and recovery to include all, not just some.
Published in English and French.
I have not as yet downloaded or read the book but I posted this availability for general information on this blog topic.
..Maurice.
In using a drug or drugs to help reduce symptoms or help a patient recover from a COVID-19 symptomatic infection, ethics are involved in what approach to testing is the right ethics: An OBSERVATIONAL study vs
RANDOMIZED CONTROLLED TRIAL (RCT). The ethical principles of beneficence and justice are principles to be considered as one considers the carrying out of either approach to a worthy but also valid goal.
To help understand which is the better research approach is an article and the numerous reader responses to the article titled "Hydroxychloroquine RCT:'Ethically the Choice is Clear'".
But as you can see by the reader responses, to some professionals the choice is NOT clear. ..Maurice.
Another professional behavior issue to brought to the public by an article published by the British Medical Journal and titled
"Covid-19: Healthcare professional is referred to regulator for delaying seeing a patient because of lack of PPE"
In consideration of this issue.. how about an analogy "should firemen be punished for not entering a building on fire if he or she has no fireman (or firewoman) self-protective dress or equipment?" Who should be punished--the agency who failed to provide firemen with appropriate dress or equipment? ..Maurice.
Another issue which is drawn into the effects of COVID-19 infection on life is with regard to continue the education of medical students. Here is the link to a presentation published this week-end title by the British Medical Journal which presents a "Manifesto for Healthcare Simulation Practice" There are ethical and practical challenges involved in continued teaching of students to become physicians while immersed within this current pandemic. ..Maurice.
Here is an issue which all medical schools are confronted with during this "unending" Covid-19 pandemic. It deals with how first and second year medical students should be taught. My years from medical resident to the present has been at USC Keck School of Medicine which next month will be celebrating its 50th year of Introduction to Clinical Medicine where these medical students were learning how to be a physician to patients (taking history and performing physical examination) on patients sick within a affiliated hospital or clinic under supervision by a teacher like I have been. Now, perplexing all medical schools who have developed programs utilizing sick patients need to make a decision because of this virus infection.
Should all teaching utilizing a live subject be limited to so-called "standardized patients" who may have some chronic physical abnormality or who can simulate an abnormality for the students to interview and examine more safely to both parties in a non-clinical environment or continue, with extreme caution to continue student interaction will true patients not actors and within a hospital environment.
This issue has not been settled in many if not most medical schools and is actually to be discussed by the professionals on an internet presentation.
Where do you see the overall risk? Immediately to the selected true patient or to the current health and experience for future patient responsibilities by the first and second year medical student.
Some decision should be made now or should medical education utilizing actual patients be terminated until the pandemic is gone? Or do you think that utilizing real and sick patients for medical education should now be thrown out and use only simulation teaching.
The current pandemic has affected virtual all of us in terms of personal activity, jobs and education of students from the very beginning to college and post-graduate career education. The challenge for medical school education currently cannot be ignored either. ..Maurice.
Dear Dr. Bernstein,
I believe that medical students can and should be encouraged to examine true patients in the hospital setting. That said, I don’t think it’s appropriate at this time for medical students to interact in-person with Covid-19 patients. Rather, medical students should have access to non-Covid-19 patients. Covid-19 tests can now be performed fairly rapidly such that the patient and medical student can be shown to be negative prior to interaction. If PPE for the medical student and a mask for the patient are provided, I believe that the risks to both parties are outweighed by the benefits to both, and non-maleficence is not a significant issue. However, as in pre-covid times, patient autonomy during the pandemic must reign supreme, with the patient/student interaction commencing only upon informed consent by the patient. Similarly, medical students with pre-existing conditions that increase their risk of severe sickness once infected with Covid-19, should be allowed to opt-out of in-person assessments. Telehealth or standardized patients should be available to these students.
The primary challenge in implementing these in-person exams is the costs associated with procuring the student’s Covid-19 test and PPE. If these costs were to be borne by the medical school/student rather than the hospital, I believe that hospitals would not balk at the continuation of this highly beneficial and essential program for medical students.
KB
KB, Maurice, et al,
There is a shortage of providers due to the influx and increase in the number of patients being seen in healthcare settings. Many other profession have historically called up their recruits to "active duty" in the wake of emergencies, most notably the military and the police.
States have laws that can compel providers to work in emergency situation suspending certain employment laws (such as shift time limits). These laws are associated with snow emergencies here in the Northeast.
Executive orders by governors or the president can also compel providers to work in emergency situations. President Trump invoked this with the meat industry so America would not starve.
I see absolutely nothing wrong with calling up students and having them on the front lines. They will learn much practical knowledge just as the hidden curriculum and clerkships teach.
-- Banterings
I found a current (September) article in the Lancet medical magazine which defines what is happening throughout the world not as a PANDEMIC but more realistically a SYNDEMIC.
And defining what is happening to the world now in that term should explain why what is happening is more complex than a highly infectious virus.
The notion of a syndemic was first conceived by Merrill Singer, an American medical anthropologist, in the 1990s. Writing in The Lancet in 2017, together with Emily Mendenhall and colleagues, Singer argued that a syndemic approach reveals biological and social interactions that are important for prognosis, treatment, and health policy. Limiting the harm caused by SARS-CoV-2 will demand far greater attention to NCDs and socioeconomic inequality than has hitherto been admitted. A syndemic is not merely a comorbidity. Syndemics are characterized by biological and social interactions between conditions and states, interactions that increase a person's susceptibility to harm or worsen their health outcomes. In the case of COVID-19, attacking NCDs will be a prerequisite for successful containment.
This relationship between a wide-spread infectious disease and the race, gender, background work and lives of each and every person facing and suffering from this infection should be emphasized since this is the potential explanation why attacking this harm to our country is much more than prescribing medications or vaccines but full national governmental entry into both the medical treatment and the actual lives of each of us. And that is why it is necessary to consider our American Constitution not purely "freedom" for all but ways (some governmental) to preserve that personal "freedom" when danger encompasses our country and all the people. The latter is my philosophy.
..Maurice.
NOTICE: In the above posting NCD represent
"Non-Communicable Diseases". ..Maurice.
I wanted encourage everyone to watch this video that I recently completed, Zero Visitor Policy During Coronavirus Pandemic. Sadly, a number of hospitals have implemented the zero visitor policy again. This is ridiculous and inhumane. The policy also makes it harder for medical professionals to be as effective because they do not have family members tell them important information about patients such as allergies to certain medications. Also, even the best medical professionals cannot give personalized attention to patients as their own support person. Every patient has the right to a support person with him/her at all times. It disturbed me to see this statement on one hospital's web site: One support person will be allowed for labor and delivery patients (to remain with patient in room), but other patients are not allowed to have a support person with them. We all must challenge this horrible policy.
One lady shared this after she watched the video:
Back in March when COVID started - Mom was in the hospital with a stroke. They kept telling me I could not stay. On two separate occasions during the night IF I had not been there she would have fallen out of the bed. The bed alarm was on, but staff could not get to her quickly enough.
I understand the importance of helping to control spread of COVID-19, but the zero visitor policy is never the answer for any pandemic. The truth is medical professionals are more likely to have COVID than the patient's support person since they are around numerous patients.
Misty
I fully agree with Misty. No doctor or nurse can learn about the views, expectations, more complete background history including medical history and other history that may be pertinent in developing a medical treatment program about which family or close friend can provide. And why can't the patient provide this information? Too sick to talk, too distracted by his or her symptoms or memory is missing. History can be as critical in developing a course of therapy as the patient's pO2. The clinical risks of family members cannot and should not override the clinical information they can provide and the special love (perhaps therapeutic) no nurse holding the patient's hand can provide.
..Maurice.
***Note:*** At Maurice's request, I am copying my last 3 responses from the Patient dignity thread (maybe not verbatim) because he feels that they add to this topic as well...
Maurice,
I thought about your (somewhat) snarky comment: "Ah! It's all about the basis of our Constitution: FREEDOM."
It made me reflect upon if freedom was the issue or the means. I think that people losing their businesses and homes use this legal loophole to get what they really need.
Just as I say malpractice is a means of extracting justice (punitive) for dignity violations. If a patient's dignity is violated and they cannot get justice for that, mentally they get (punitive) justice for a malpractice (with merit).
So what are public health officials, politicians, doctors and nurses (pleading for people to wear masks) doing wrong?
They are NOT practicing trauma informed care with the pandemic. They are violating one of the most important tenants of trauma informed care: they are telling, NOT asking and NOT asking permission.
Dr. Jerome Adams, the US Surgeon General saw this when he warned of rebellion over mask mandates.
As my best friend says, Americans hate to be told what to do.
The pandemic (and handling of it) has caused many people trauma: loss of job, home, business, family, friends, freedom, normality, etc. Then there are those of us traumatized by providers, so we don't trust healthcare professionals to begin with. Then then are those harmed by government: BLM was a prime example of that this year.
Just like me (and others here), we elect to drop out of the system.
As providers say we are professionals and we see providers' hypocrisy, we see the hypocrisy of our leaders who say stay at home then have dinner at the French Laundry.
Biden will be no better. He will flaunt winning the election and take credit for the vaccine. What he should do, is acknowledge that there were election irregularities that may have been orchestrated by rogue individuals, acknowledge that the quick production of the vaccine was due to the Trump administration, and lay out his plan to continue to get the vaccine out.
Instead he is going to focus on his ego and legacy. That is going to further alienate and traumatize half the country. Wait until you see the backlash over his national mask mandate.
Instead of practicing trauma informed care, putting people first, providers see a means to seize the paternalistic power with mask mandates. They are gambling at a losing game all the goodwill they have created in the pandemic.
-- Banterings
Maurice,
Your response was typical of the follow the science crowd in your response of let all the old and sick die...
We do have things that improve outcomes, HCQ + zinc, Quercetin, Vitamin C, and Vitamin D (among other things).
Read My COVID Cocktail (links to the science provided).
You also validate my point: WE DON"T KNOW. Yet, the best guess is being pawned off as science. Healthcare providers have a hubris about them because of their (supposed) learned profession and they think that the rest of society are simpletons.
With what I do professionally, I have been taught how to go into any facility and assess and recommend the appropriate PPE; and that includes industrial, medical, laboratory, and nuclear.
Doctors and nurses are NOT trained to assess this, their training is in this situation use this. I do not think that ANY medical education has taught them to fashion their own masks and wear them for ANY situation. Yet, this is shoved down our throats as science (the same way pelvic exams were).
Americans are amazing people and will step up when asked (and even when not asked). Just look at how the American people stepped up for providers during the pandemic: fashioning PPE, bringing them food, showing appreciation, etc.
When things are forced upon the American people, it becomes suspect. Asking is another form of checks and balances, ask the people to wear masks and they will, ask them to be implanted with micro chips and they will refuse.
Power corrupts; absolute power corrupts absolutely.
Freedom must be absolute. Just look at the issue of explicit consent of intimate medical exams on anesthetized patients.
The profession of medicine justifies this and it still occurs!!!
So just think what our elected officials can possibly do if be begin to give up freedoms.
As to the Fauci effect, the people applying for medical education today did not experience a time when HIV was a death sentence, when Dr. Ruth said "always wear a condom," have too look things up in a library book, etc. This is why the STI rate is on the rise. (Many 20-somethings don't use condoms for sex.) They also don't remember Fauci killing 30,000+ HIV patients by refusing to publish interim guidance on the use of Bactrim.
They are also unaware of Fauci's financial ties to AIDS research and he has not disclosed his financial relationship to Gilead Sciences or any other pharmaceutical company despite repeated calls to.
Given his position and unique power over the Remdesevir clinical trials, I believe it is Fauci's responsibility to also disclose this information. Without doing so provides for conflict of interest between NIAID, NIH, and Gilead Sciences, the antiviral developer of Remdesevir Fauci is touting. Nine of the experts on the NIH COVID-19 Panel recommending treatment options have disclosed financial support from Gilead Sciences
.
The Fauci effect would be akin to praising Dr. Josef Mengele for an uptick medical applications in Brazil.
-- Banterings
More politicizing of COVID-19
Rebekah Jones, the Florida data scientist who built the state's COVID-19 dashboard and who claimed to have been fired for refusing to manipulate data, was subject to an armed police raid. (Tallahassee Democrat)
Is this science (manipulation and intimidation)?
You cannot separate the science from the politics. Part of the problem is that mask usage has become mandated by governments. Clearly, the science is not settled about their effectiveness, so there seems to be another reason for a mask mandate apart from science, feeding conspiracy theories. Masks also affect interpersonal communication, mental health, and personal comfort, so it's not just a medical issue. This means that the mask issue is intrinsically political and social, even more so than medical.
Part of the problem is that, in the past, the sick would be quarantined and be told to wear masks, but in the current COVID crisis the healthy are also quarantined and forced to wear masks.
-- Banterings
I want to present here a general issue which stimulated me which I read on a clinical ethics listserv. It led me to consider the issue about whether employers had or should have a public health responsibility to require their employees, particularly those who interact with patients or closely with the public to accept being vaccinated with the COVID-19 vaccine or, if on their refusal being removed from their occupation. Is the employer responsible for the health of their employees and to the public who are exposed to those employees? ..Maurice.
This blog you have accessed is about BIOETHICS and it is oriented with regard to issues of how bioethics is applied to many aspects of the profession of medicine.
But bioethical decision making with regard to clinical dilemmas in the practice of medicine has limitations.
Here is a great article in the Atlantic which clearly demonstrates the uncertainties, limitations and clinical frustrations which is associated with the clinical ethicist attempting to make decisions for patients and their attending physicians. The COVID-19 pandemic providing its early clinical issues and continuing on is an example but is not the only example of limitations facing clinical ethics decision-making.
Take the time to read the Atlantic article regarding how the entry of bioethics and its consultation potential to make clinical decisions easier is not fully working out. ..Maurice.
from the December 20 2020 Wall Street Journal: Doctors are treating a new flood of critically ill coronavirus patients with treatments from before the pandemic, to keep more patients alive and send them home sooner. Last spring, with less known about the disease, doctors often pre-emptively put patients on ventilators or gave powerful sedatives largely abandoned in recent years. The aim was to save the seriously ill and protect hospital staff from Covid-19. Now hospital treatment for the most critically ill looks more like it did before the pandemic. Doctors hold off longer before placing patients on ventilators. Patients get less powerful sedatives, with doctors checking more frequently to see if they can halt the drugs entirely and dialing back how much air ventilators push into patients’ lungs with each breath. So, at the beginning era in the treatment of seriously ill COVID patients the goal included, by early use of ventilators, other non-seriously ill patients and the staff would be "protected" by a patient placed on a ventilator. The approach to therapy of the individual patient now has become more oriented to the "true" patient requirement and not simply for hopeful "protection" of others. But if this newspaper review is accurate as to clinical motivations early in this pandemic year, it would seem that the intrinsic protection of that patient who was put on the ventilator for hopeful protection of others took away that patient's dignity and with ventilator complications and inadequate other clinical approaches. This history of the treatment programs in COVID management show a separation between the ethics of public health and the ethics of the health of the specific patient under treatment. What do you think? ..Maurice.
Dr. Bernstein,
I think hospitals and doctors should do more to keep COVID-19 patients out of hospitals. I was very impressed with this one small hospital in North Carolina who provide unique services to keep patients at home.
Of course, I know some COVID-19 patients are too critical to be able to stay at home.
Misty
Misty, I read the article. One potential advantage of this service is to keep the patient potentially in contact with in-home family members who can provide, with their own infectio, protection emotional support and appropriate degrees of physical support rather than a hospitalized COVID patient who may not be able to even see his or her family at bedside. Of course, degrees of professional, in home, monitoring is essential but if this can be provided effectively, the system is a worthy one in this time of hospital "overload". The system can also be called ethically "beneficent" by the medical system to the appropriate patient, family and hospital itself. ..Maurice.
I was pleased to find this article about a doctor's daughter who asked this question: If doctors, nurses and other health care workers are safe interacting with COVID-19 patients, why aren't their families?. I love that Dr. Lane convinced the hospital administrators to allow COVID-19 patients have visitors.
Check out the article,
It's the right thing to do': Sparrow allowing visitors for COVID-19 patients
I love the below two paragraphs in the article:
Medical research has shown that the presence of a loved one can help improve a patient's condition, Lane said. When someone has a visitor, their heart rate and breathing slows and their condition can improve, she said.
“We know there’s a change that’s happening because there’s a person in the room,” she said.
I believe there would be a decrease in COVID deaths if COVID patients could have a family member present some.
Misty
I wanted to let you all know that a man, Steve Reiter whose wife died alone in a Colorado hospital started this non-profit organization, The Never Alone Project.
It's so tragic that his wife was forced to die alone. Steve even went as far as having a COVID test and it was negative, but the hospital still would not let him in.
Misty
I wanted to encourage everyone to read an article I wrote about No Visitor Policy During a Pandemic .
It is so heartbreaking that a number of hospitals in America have reinstated the no visitor policy. Most hospitals in Western North Carolina currently have this no visitor policy. I have heard horror stories of patients suffering. At one hospital, the nurses are so overworked that they cannot devote much time to patients at all and they barely have time to call family members to update.
I agree that COVID-19 is serious and we must do whatever we can to control spread of COVID-19, but the no visitor policy is not the answer. I believe that each support person should follow strict infection control measures such as wearing required masks and temperature checks.
I wanted to encourage everyone to read this excellent article by an ICU nurse in California, Nurse: Despite coronavirus pandemic, hospital patients need their loved ones at their side. I agree with this nurse. She has many excellent insights. She shared that even the most experienced RNs can make medical mistakes and how loved ones often double check medications and dosing.
Misty
Here is an issue for the US to tackle: Migrant Caravan: Thousands Move Into Guatemala, Hoping To Reach U.S..
We don't want to live in Honduras anymore, Ana Murillo told the French news agency Agence France-Presse. Standing with a group of migrants beside a busy road in southern Guatemala, she says Hondurans have been badly affected by hurricanes Eta and Iota, which slammed into the country in November. Honduras also suffers from incredibly high rates of violent crime and the pandemic has crippled the economy...
"We don't want to live in Honduras anymore," Ana Murillo told the French news agency Agence France-Presse. Standing with a group of migrants beside a busy road in southern Guatemala, she says Hondurans have been badly affected by hurricanes Eta and Iota, which slammed into the country in November. Honduras also suffers from incredibly high rates of violent crime and the pandemic has crippled the economy.
I am sure that they all will present with negative COVID tests from the last 3 days.Biden to take immediate steps to undo key Trump initiatives.
On the same day he is inaugurated into office, Joe Biden will introduce immigration legislation that will include an eight-year pathway to citizenship for nearly 11 million immigrants living in the United States without legal status.
The legislation, first reported by the Washington Post, will also include expanding refugee admissions...
So let me ask, is this prudent in a time of COVID? We know where these people plan on entering the US, in California, which is already grappling with record COVID numbers. The US does not have enough vaccines for its own people, so do we offer them vaccines or is that an issue of foreign aide to be handled by the state department?
What message will it send to the world if we vaccinate illegals? What will our borders look like. What wil this do to our COVID numbers. From all the reporting that I have seen, these people are not social distancing. Where will they shelter in place?
I am sorry, an organized group of people looking to cross into our country illegally: how is this NOT an invasion of US sovereign soil?
Southern California is home to the largest illegal immigrant population in the US. California is lead the US in the COVID surge.
So the question is what do we do? I would argue that the answer is we just let them in, take their names, and let them run free in our country because that is what the majority of Americans voted for.
-- Banterings
Banterings, I see your point of view but in reality there are limits and Americans themselves are under the laws of a number of legal issues which realistically prevent any American to "run free". Oh.. even the President of the United States. ..Maurice.
Maurice,
My response that I posted to the MedScape article, Physicians Are Talking: Should Anti-Maskers Refuse COVID-19 Treatment if They Become Ill, is as follows:
Healthcare providers want to preach accountability, then let us have real accountability...
90% of physicians today have learned pelvic exams on anesthetized patients WITHOUT consent The practice still continues today. (Ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223770/ )
So what do these physicians owe patients that they sexually assaulted or the rest of society?
This practice alone, takes any moral authority away from the profession of medicine not only because it still continues to this day, because partitioners continue to defend it, but because there have been NO talk of the profession making amends for this practice.
What accountability does the profession of medicine have for billions of dollars wasted on annual physical exams that were of no benefit, but cast as an absolute must do? (Ref: https://www.health.harvard.edu/blog/a-checkup-for-the-checkup-do-you-really-need-a-yearly-physical-201510238473 )
What accountability does the profession of medicine have for using the PSA test as a tool for making money and not the way that test was created to be used? (Ref: https://www.medscape.com/viewarticle/828854 )
What about the harms from overdiagnosis, overtesting, and overtreatment of prostate cancer, breast cancer? (Ref: https://blogs.scientificamerican.com/cross-check/cancer-establishment-admits-wee28099re-getting-overtested-and-overtreated/ )
This process doesn’t promote health; it promotes disease. People suffer from more anxiety about their health, from drug side effects, from complications of surgery. A few die. And remember: these people felt fine when they entered the health care system. -- Welch, author of the excellent book Overdiagnosed: Making People Sick in the Pursuit of Health (Beacon Press, 2011)
What accountability does the profession of medicine owe for pushing pelvic exams as "necessary when the science finds them "more of a ritual than an evidence-based practice?" (Ref: https://www.theatlantic.com/health/archive/2014/07/pelvic-exams-may-not-be-helpful-but-women-will-probably-keep-getting-them/373789/ )
What accountability does the profession of medicine bear for young women STILL getting UNNECESSARY pelvic exams? (Ref: https://www.ucsf.edu/news/2020/01/416366/young-women-still-may-be-getting-unnecessary-pelvic-exams )
PHYSICIAN, HEAL THY SELF FIRST...
-- Banterings
From a recent Medscape article. If you were the employer of a healthcare worker and the employee refused to take the required COVID-19 vaccine, how would you respond to the following situations?
Is an employer exempt from paying workers' compensation to an employee who refuses to be vaccinated and then contracts the virus while on the job?
Can a prospective employer require COVID-19 vaccination as a pre-condition of employment?
Is it within a patient's rights to receive an answer to the question: Has my healthcare worker been vaccinated against COVID-19?
If a hospital allows employees to refuse vaccination and keep working, and an outbreak occurs, and it is suggested through contact tracing that unvaccinated workers infected patients, will a court hold the hospital liable for patients' damages?
And Mr. or Mrs. Employer, what would be your reaction? ..Maurice.
I am taking the Moderator's liberty to present on this blog topic, contributor Biker's response today to my above posting to which he responded from Volume 116 of Preserving Patient Dignity ..Maurice.
-------------------------------------------
At Friday, January 22, 2021 4:53:00 AM, Blogger Biker said...
"Is an employer exempt from paying workers' compensation to an employee who refuses to be vaccinated and then contracts the virus while on the job?"
No, same as employees who violate a corporate safety rule are still entitled to worker's comp if they get hurt on the job. One caveat though is the employee proving that they contracted covid-19 at work is not automatic given they could have contracted it anywhere that they were.
"Can a prospective employer require COVID-19 vaccination as a pre-condition of employment?"
Yes
"Is it within a patient's rights to receive an answer to the question: Has my healthcare worker been vaccinated against COVID-19?"
No. Patients are not entitled to staff health histories. There are endless reasons that a nosy patient might pose in order to get the personal health histories & conditions of the staff. Wanting to know about covid-19 vaccinations may be reasonable on the surface but the general topic is a slippery slope of who gets to determine what is reasonable and to what extent.
"If a hospital allows employees to refuse vaccination and keep working, and an outbreak occurs, and it is suggested through contact tracing that unvaccinated workers infected patients, will a court hold the hospital liable for patients' damages?"
Courts make reasonable and unreasonable determinations so it is anyone's guess what any given court might do. At issue is proving that this employee was the source of the patient's infection. Contact tracing is an imprecise science and relies upon a lot of assumptions. To the extent the infection can survive for a period on a surface, it could have come into the facility via a package delivery rather than an employee for example.
Maurice,
Exceptions must be made for employees who cannot be vaccinated because of disabilities or due to sincerely held religious beliefs, he added. Employers do not have to accommodate secular or medical beliefs about vaccines.
An employer-mandated vaccine is considered a part of work, so under most state laws, an adverse reaction would be covered by workers' compensation.
Workers' compensation has been the employee's only recourse for other employer-required vaccinations, and there is no reason to believe a COVID-19 vaccine would be treated differently.
If an employer merely encourages employees to obtain a vaccine, coverage under workers' compensation policies may not be available.
The Public Readiness and Emergency Preparedness Act may provide employers immunity from claims related to side effects of a vaccine or other injury at the employer's vaccination site if the employer is considered a "program planner" that supervises or administers an onsite vaccination program.
Under the PREP Act, companies like Pfizer and Moderna have total immunity from liability if something unintentionally goes wrong with their vaccines. That program rarely pays, covering just 29 claims over the last decade.
An emergency use authorization is not a license. There’s a legal question as to whether you can mandate an emergency observation. (The language in the act is somewhat unclear on that.)
-- Banterings
One note that I forgot to mention: Since the vaccine is only "emergency use authorization," if an employee has an adverse reaction to the vaccine, they can sue their employer directly for "gross negligence" (in mandating an "experimental," emergency use vaccine).
This would waive immunity for the employer under workers' compensation being "sole remedy" for workplace injury/illness.
-- Banterings
Wow! Thanks to Biker and Banterings who appear to be "in the know". ..Maurice.
I wanted to encourage everyone to take the time to read this excellent article by a doctor, It’s time for hospitals to end their no-visitation policies in The Washington Post.
The truth is all hospitals need to have enough PPE in stock at all times for another pandemic that may happen even if COVID-19 disappears.
Misty
Oops. I just realized I forgot to include the correct link for the article,It’s time for hospitals to end their no-visitation policies in The Washington Post.
Misty, maybe you can summarize the article for those of us who don't want to "sign in" to the Washington Post as requested by the newspaper. It would be of interest to know about the issues associated with the current restrictions. ..Maurice.
Here are the most immportant parts of the article:
Trisha Pasricha is a physician at Massachusetts General Hospital.
In the earliest days of the pandemic, when we were scavenging for masks and testing kits, no-visitor policies at hospitals may have been justifiable. But there is no reason to perpetuate these counterproductive, traumatic policies. It’s past time for hospitals to let patients see their loved ones.
I say this not just as a doctor but also as a casualty. In March 2020, my grandmother was admitted to a nearby hospital after a covid-19 exposure. When I rushed over, the receptionist barred me at the front door. I explained that my grandmother, who was 87 and hard of hearing, wasn’t answering her cellphone.
The receptionist was sorry. The policy made no exceptions.
Dejected, I sat in the parking lot, unsure of my next move, until finally falling sleep. Early the next morning, I got a call from my grandmother’s nurse. My grandmother had just died.
I hung up, dazed. How could she suddenly die? Was she in pain? Was she scared? Did she even have covid-19? What were her last words? I was drowning in ignorance, sitting uselessly in a hospital parking lot. Above all, I wondered, why did this woman I love die alone?
Even after her death, I never saw her again. Due to new covid-19 protocols, almost a week passed before my family could perform her cremation. After that many days, the funeral director advised us, it was better not to look at the body. And so we didn’t.
Each day at work, I saw my loss repeat itself in devastating variations: a sick wife whose partner, but not parents, could visit her. An elderly father going into surgery by himself. Patients who would vanish into thin air like my grandmother. As their physician, I often had to explain to patients the policy I found so cruel. Of every mistake we’ve made in the pandemic, there is perhaps none I regret more than having inflicted this pain on families in their darkest hours.
When the details surrounding a death are unknown, survivors’ bereavement is akin to ambiguous loss, much as when people go missing in a war. Covid-19 strips families of traditional steps toward healing, and with no-visitor policies, they are trapped in their own unresolved grief, waiting for answers that won’t come.
What exactly is the risk calculation hospitals are making with these policies? Aside from meeting patients’ psychological needs, visitors reduce length of stay and even medical errors, studies show. Seventeen percent of covid-19 patients nationwide die during hospitalization, and nearly a third of these are not in intensive care. So even when hospitals have made exceptions to their no-visitation policy for intensive care patients, they have still condemned a large percentage of people to die alone on hospital floors — amounting to more than 100,000 patients in the United States and counting. Exceptions for end-of-life patients assume that death is always careful to announce itself politely in advance. Any physician who has coded a patient in the middle of the night can tell you how wrong that notion is.
And what have hospitals gained from these policies? The few outbreaks of covid-19 in hospitals have primarily been linked to unmasked health-care workers or patients.
We can make visiting safer with a few simple lessons learned from the first wave of covid-19 cases. First, hospitals should strictly enforce universal mask policies with specially designated monitor staff. We have the capability to administer rapid-turnaround coronavirus tests in the parking lot to all visitors before entering the facility. With readily available protective equipment and training, the risk of transmission can be reduced to almost nothing.
Here is a Google Podcast of 47 minute presentation on the topic "Thinking Through the Medical Ethics of COVID-19 with Dr. Rebecca Brendel and Dr. Allen Dyer" ..Maurice.
This is a little off topic, but I issued on my social media a COVID vaccine challenge:
I am NOT going to get the vaccine, I put this out there:
If a doctor waives ALL their immunity related the COVID vaccine (COVID, vaccine, emergency use, executive orders, etc.), and accepts ALL liability for the vaccine, I will let that doctor vaccinate me.
So I am not getting the vaccine...
-- Banterings
Yesterday, I wrote the following to a bioethics listserv to which I subscribe and participate. I titled it: CDC Stepping on a "Hot Potato"?: "Off With the Mask"
Is this a medical-ethical or purely political issue? One example of published concern regarding the CDC's current "off with the mask" decision:
https://www.medpagetoday.com/infectiousdisease/covid19/92596
Should ethicists step in here?
Judge rules against hospital employees discharged because they failed to obtain COVID immunization. ..Maurice.
Post a Comment
<< Home