Doctors and Nurses and the Problem of Their Disruptive Behavior

One group of nurses banded together to try to get a physician unfairly disciplined, while another encouraged fellow nurses to disobey doctors' orders outright. A surgeon told his staff that monkeys could be trained to do what scrub nurses do, while another doctor told a patient that the nurse in the room didn't know what she was doing.
A nurse witnessed the onset of complications in an intensive care patient but refused to contact the on-call physician for fear of his temper -- a delay at least one observer thought contributed to the patient's death.

This excerpt is from November 16, 2009 American Medical Association News, amednews.com




The article is all about what is happening now in hospitals, clinics and other healthcare facilities around the United States. It is all about disruptive and intimidating behavior of physicians and nurses which has been going on for years but now, starting about a year ago, the Joint Commission which certifies hospitals and other institutions for government reimbursement in the interest of patient safety declared that these institutions must present evidence of “zero-tolerance” for these unprofessional behaviors which potentially can impact negatively on the care and safety of the patients. However, there still is a lot still missing in institutional and personal compliance to the Joint Commission’s order.

A 2009 study of behaviors "Bad Blood: Doctor-Nurse Behavior Problems Impact Patient Care," American College of Physician Executives 2009 Doctor-Nurse Behavior Survey,Physician Executive Journal, November/December showed the following:degrading comments and insults comprised 84.5% of the behaviors followed by yelling 73.3%,cursing 49.4%, inappropriate joking 45.5%, refusing to work with colleague 38.4%, refusing to speak to colleague 34.3%, trying to get someone unjustly disciplined 32.3%, throwing objects 18.9%, trying to get someone unjustly fired 18.6%, spreading malicious rumors 17.1%, sexual harassment 13.4%, physical assault 2.8% and others 10%.


However, what is happening is that there seems to be a difficulty in separating disruptive speech and actions from honest attempts in certain situations to protect patients and to disclose to hospital administration of weaknesses in the hospital’s healthcare system or in the harmful behavior of certain physicians or nurses—that is, “whistle blowing”. Unfortunately, these actions may be considered disruptive, not constructive and behavior which must be suppressed to keep to the Joint Commission’s rule and it is the “whistle blower” who is accused of being disruptive. Further, staff may be reluctant to report on behavior of superiors or other colleagues in fear for personal repercussions.


Obviously, much more has to be done besides hospitals simply writing a policy about these matters. Read the full article and the linked references there and return and give your opinion about the issue and any disruptive behavior you have witnessed, but please give no names. ..Maurice.

Graphic: Photograph, taken by me, of a painting ("Self-portrait, Yawning, Joseph H. Ducreux, 1783 from the Getty Museum, Los Angeles)but modified with Picasa3. Basis for selection of this graphic for this thread: Somehow, the painting looked to me like a disruptive yelling rather than a benign yawn. What do you think?

Violation of the Patient’s Autonomy?: Is that Ethical?

Patient autonomy is the ethical principle which represents that a patient who has the capacity to understand their medical condition and the risks and benefits of some action upon them, has the ethical right, under most circumstances, to make that decision for themselves and expect the physician to abide with their request.


But that is “under most circumstances”. I want to present two scenarios where a patient has stated “stop! I don’t want…” The question I pose to my visitors is whether a physician can ignore that request in each of the scenarios and if so why or why not should the patient’s request be followed or not followed. When do standards of medical practice trump a patient’s request? Standards of medical or surgical practice are specific behaviors, based on scientific literature but also based on the consensus of physicians about certain diagnostic or therapeutic actions and also on common behaviors or actions of doctors where they practice and which the profession of medicine place upon physicians as the physicians carries out their care of their patients. In this regard, if there is a difference between the two cases, what is the difference? ..Maurice.


Scenario 1:
Brain surgery of lesions is often performed on conscious patients to establish safe dissection around motor and sensory areas. A patient with skull opened and brain exposed demanded the surgeon to stop the operation at once despite understanding the consequences of fully terminating the surgery at this point and leaving the skull open. Instead of stopping, the surgeon had the patient anesthetized to allow proper closure of the skull thus was violating the patient's demand. Is what the surgeon did ethical?


Scenario 2:
An adult Jehovah’s Witness patient because of acute massive bleeding which cannot be rapidly stopped requires life saving blood transfusion but is awake and refuses blood transfusions based on the patient’s religion. The patient is informed that with the transfusion, the patient will live and the underlying bleeding problem can be resolved with no long term medical consequences. Without the transfusion, the patient could most likely die. The patient still refuses but the physician, as the patient is beginning to lose consciousness, violates the patient’s autonomous demand and begins the blood transfusions. Is what the physician did ethical?

Patient Modesty: Volume 27

Yes, throughout these threads on patient modesty, it does appear that often what is missing and what should be corrected is the lack of communication on this issue both on the part of the patient but also on the part of the various healthcare providers, clinics and hospitals. It may be that many of both parties display modesty in communication by not speaking out or asking out about modesty. Hopefully, this issue of modesty in communication can be eliminated on both sides and that the concerns of patients in physical modesty can be resolved.

Continue writing.. ..Maurice.

Graphic: A photograph taken by myself at a local clinic and modified with Picasa3.

A Medical Student’s Anatomic Gift: There is More Involved than Dissection

From a medical student to the student’s group human cadaver:


“You are an exponential gift, from one man to eight future doctors to hundreds of patients to the multitudes that make up their family and friends ... You gave us access to the wonder that is human life and challenged us to discover all the intricate parts working together to make one man.”


To read the whole story of the Boston University School of Medicine’s anatomical gift program and its manager and anatomy lab director, Robert Bouchie, go to this link. There you will find a find a fine video about the program but importantly read about the ethics and consideration given to the donated bodies but also to the deceased person’s family. Very inspiring. Do you want to donate your body to a medical school like Boston U.? ..Maurice.

The Elderly and the Four Ethical Principles

With more and more people living longer, attributed to various factors including advances in medical treatments, there are more and more elderly now present in the population.

But, first, what is the definition of an older person or the elderly? One definition included in a World Health Organization online document regarding the elderly and old age is by M. Gorman: "The ageing process is of course a biological reality which has its own dynamic, largely beyond human control. However, it is also subject to the constructions by which each society makes sense of old age. In the developed world, chronological time plays a paramount role. The age of 60 or 65, roughly equivalent to retirement ages in most developed countries, is said to be the beginning of old age. In many parts of the developing world, chronological time has little or no importance in the meaning of old age. Other socially constructed meanings of age are more significant such as the roles assigned to older people; in some cases it is the loss of roles accompanying physical decline which is significant in defining old age. Thus, in contrast to the chronological milestones which mark life stages in the developed world, old age in many developing countries is seen to begin at the point when active contribution is no longer possible."


There are the four ethical principles which should be considered and which can apply to the medical care of the elderly. The principles are beneficence, non-maleficence, autonomy and justice. How can they apply? I think that others might give different examples, however the following are the ones that come to my mind presently.


Beneficence is the principle “to do good”. Non-maleficence is the principle “to do no harm”. We, as physicians, are required, as part of our profession, to adhere to these two principles as we proceed in the care of our patients. The question arises as to whether at some point in the life cycle, what these two principles mean in practice is different between the elderly and those who are younger. And then who is to characterize the actions: the doctor, the patient, the profession or society?


For example, is there a point in the care of an elderly patient who has symptomatic cancer where administration of classic or novel cancer chemotherapy with its significant side-effects might no longer be considered a beneficent act but actually a harmful act? Would this point be considered as readily in a patient who is significantly younger? Would the use of a cancer drug in an elderly patient, which by statistics would only prolong the patient’s life by a few months but with continued suffering from the underlying disease be considered a non-beneficent act on the part of the physician? Would the consideration that a new drug might come out during that extra time of life that would be more effective rationalize the current management? Would this issue be the same in a patient who was considerably younger? Should the decision as to whether a treatment represents a “good” or a “not good” be one of the physician based on knowledge and experience or should such decisions be left only to the patient who is the one who has the burdens of the illness, the symptoms, the costs and the effects on the patient’s ways of life and goals?


The third principle, the principle of autonomy, the right of the patients to speak for themselves as to how they want their illnesses to be treated, plays a important role in how beneficence and non-maleficence is judged. As one grows older, some patients may lose their capacity to make their own medical decisions and, without an Advance Directive or legal surrogate to help, the bearing of responsibility for defining the physician’s actions as beneficent and non-maleficent or “wanted” vs “unwanted” in terms of the patient’s own desires may be placed more on the physician’s shoulders or others. Is the principle of autonomy just as valid an ethical principle in the elderly as in the younger patient?


And finally, comes the principle of justice. One reads about the tremendous amount of money spent on disease management within the United States just during the last months of a person’s life. Is that fair? is that spending a fair act to other patients who are sick but have the potential of many more years of life ahead and where the money might be put to use which is more constructive to society? Isn’t the issue of justice most pertinent about the medical care which is given to the elderly? Or is bedside rationing against the elderly an unethical and abhorrent concept?


Many, many questions and mostly about whether the elderly should have the four ethical principles applied differently than to those who are younger . However, I look to my visitors for the answers. ..Maurice.

Graphic: Photograph of the elderly walking in a city park in Southern California by me 11-4-2009.

The Hospital Ethics Committee: Was it of Help?: Tell Your Story

I have been the chair person of two hospital ethics committees over the past 23 years and my current committee continues to do its assigned job. The role of the committee includes being the educator, being the facilitator, being the mediator when an ethical issue appears as a patient is being treated and one or more stakeholders in the issue request help from our committee. We sort out the issues and explain to the stakeholders the possible ethical and legal courses but we don’t make the final decisions. We, as members, hope that our education, facilitation and mediation has been beneficial to all those who look to us for help and, of course, particularly the patient.


In my own experience, the grades of our performance as given to us by the stakeholders have been good. It does seem that our committee fills a need. But that is only by my personal experience. In all these over 700 threads on ethics, I have never asked my visitors about their experiences with hospital ethics committees. I strongly suspect that most of the patients and their families who have had a hospital experience never had any interaction with that hospital’s ethics committee. In fact, there may be many visitors here who didn’t even know that there was such a resource available in your hospital.


But to those who do know and had the experience, usually as a family member of the sick patient or even that of the patient, I would be interested to read about that experience and whether you felt that the interaction with the committee was to the good of the patient and a beneficial experience. If you tell your stories, tell them anonymously and don’t name names, for reasons of privacy to the patient and fairness to the hospital. Tell us what was the issue and in which way the hospital ethics committee itself helped or didn’t help. As I suggested, I am not expecting a large number of replies but I still wanted to provide a means for the public to grade these committees. ..Maurice.

“One Who Becomes Compassionate to the Cruel will Ultimately Become Cruel to the Compassionate”: Should Terrorists be given Medical Treatment?

This is the ethical issue that has, as yet, not been fully answered by international law or by consensus ethics. And yet the issue is certainly not hypothetical. If the journal is available to you, you must read the Target Article in the American Journal of Bioethics, October 2009 titled “Medical Care for Terrorists—To Treat or Not to Treat” by Gesundheit, Ash, Blazer and Rivkind. (It is followed by a series of comment articles by other ethicists). In the article, the authors, from Hadassah University Hospital (G, R), Rambaum Medical Center(B) and Israeli Defense Forces (A) present two cases for discussion, both Hamas terrorists, both severely injured and both given immediate and extensive medical and surgical treatment in the Israeli hospitals over 20 days and a year respectively with the costs borne by the hospitals.

The physicians and caregivers provided excellent management despite whatever their own feelings or views were regarding what these terrorists had already done to the public. The ethical principles of autonomy, beneficence and non-maleficence was observed and practiced in the care of these men. An ethical question which might now be raised is whether the fourth principle of justice was observed. In the triage of these critically ill terrorists to provide emergency management, there were other patients, civilians, who needed prompt attention for whom attention to them may have been delayed. Also, in terms of justice, shouldn’t the great financial cost of caring for both terrorists have been used instead to the care of non-terrorist sick civilians? There may be a debate as to the definition of “terrorist” and some may say that they were simply “criminals” but wouldn’t the indiscriminate killing of civilians for no specific purpose but only to terrorize the population be an adequate description. Both terrorists when recovered were handed over to the government, tried and convicted.


So should all the humanistic, professional and ethical standards which physicians take from their Hippocratic Oath and their profession be set aside when it comes to medical care for a terrorist? And should the medical profession bear in mind what was written in the Ecclesiastes Rabba 7:16 “One who becomes compassionate to the cruel will ultimately become cruel to the compassionate”?
What do you think? ..Maurice.

The Muslim Faith and Ethical Issues: Questions to My Muslim Visitors

I would like to pose the following questions to my visitors and who come to this blog from Muslim countries so that we all can learn and understand how bioethical issues are looked upon by people in their countries who are of Muslim faith. Muslim visitors to my blog who lives within the United States are also certainly welcome to write but also tell us how you see your views as similar or different from those of your faith in other countries. I assume that some of the views taken for granted within the American bioethics may be quite different in other countries. I think those of us not of the Muslim faith would like to know. ..Maurice.


SOME QUESTIONS (answer any or all):

1) What is the view of stem cell research and human cloning? How about simply animal cloning? How about the manipulating the genes of plants used for food?

2) How is invitro fertilization looked upon: taking the egg of a woman and mixing it with the husband’s sperm and then inserting it into that woman’s womb so that a child might be created in a couple who otherwise were unable to normally have a child? What if the husband was sterile and the woman was fertilized by a sperm of another man to create a child for the husband and wife?

3) How does the Muslim faith look at the possibility of adoption of a child?

4) How about organ donation to a needy patient from a live donor? How about organ donation to a needy patient from a newly deceased donor?

5) Should hydration and nutrition be continued in a patient who is in a permanent vegetative state (permanently in a unconscious state, apparently unaware and not reactive to the external environment)?

6) Should a conscious patient who understands his or her medical condition have the right to order that life-sustaining treatment (like a mechanical ventilator) be turned off even though it will cause the death of the patient)?

7) Is euthanasia (physician, responding to a patient’s request and causing the patient to die) permissible? Is suicide permissible? Would physician assisted suicide as practiced in Oregon and Washington (physician writing a prescription for a lethal dose of drug which the patient can fill and take if they desire at their own time) be allowed by the Muslim faith?

8) Is medical research using animals which may be killed for the research studies permissible? Are certain animals protected from such use?

9) Is it ethical for a physician and a patient to have a romantic relationship while the patient is still under the physician’s care?

10) Should the doctor tell “bad news” to the patient (such as cancer or a fatal illness)? If not, to whom? A family member?

Yes, The House of Medicine is Haunted! Boo!

Haunting ahead.. just follow me:

It is still Halloween 2009 in the United States and still time to retell a scary story of, well, ghost writers. Yes, ghost writers. Oh! They don’t write ghost stories. Doctors are grabbed, yes grabbed in their busy offices and convinced that for a bit of money slipped to them from a pharmaceutical company they can write a journal article to educate other doctors and the public about their own experiences with a drug the pharmaceutical company would love to promote and promote.

Ah! That’s where the ghost writers come in. Without any scientific studies but with some flourishing words, they take the bits of experience from these doctors and come up with a beautiful article which could be published and, in fact, have been published. It’s all so simple and a little money paid out by the pharmaceutical company gets an article.. oh, not titled with the name of the ghost writer.. but the name of the grabbed doctor..it makes it oh so much more official and well, professinal. But remember, it is all part of a haunting ghostly experience and one that can raise a few more million bucks for the drug company. You know, I changed my mind: Maybe what they write are truly “ghost stories”.

Want to read more? Read the article by ethicist-physician Howard Brody in his “Hooked: Ethics, Medicine and Pharma” blog August 24, 2009 titled “Friendly Ghosts--Why Should Academic Docs Get All the Credit?”





Boo! ..Maurice.

Graphics: Photographs of student Halloween projects located at the Lombardi Farm Halloween Pumpkin Festival, Santa Clarita, California by me today..Halloween 2009.

What is a "Good Death"?

What is a “good death”?


That is a question that every living person must eventually contemplate. Is a quick death, a sudden demise by a heart attack, some accident or by violence or intent, such as a self-inflicted gun shot to the head really a good death? Or is death which is delayed long enough to allow one to have the life issues settled and to see and relate to family for the last time good? Or is a death which comes on painless and without the burden of discomfort and anxiety also a good death? Each person may have a different view. Certainly, physicians should have the goal to understand and attempt to provide a good death for their patients when it comes. It is their professional obligation to the patient. But is a “good death” something that the doctor can define or must it come from the patient’s own lips? Often, physicians are unaware of how their patient might set the definition.


Tony Back, MD writing in the Ethics of Medicine End-of-Life Issues of the University of Washington School of Medicine sets some guidance for medical students and physicians. Amongst other advice he suggests:


In caring for a person who is dying, knowing what would make the experience of dying "good" is an important goal for physicians and other members of the care team. I find it doesn't take fancy techniques-you just need to be sincere and patient and interested. Listen more and talk less. Try asking something like, "Knowing that all of us have to think about dying at some point, what would be a good death for you?" What people choose when they think about a good death for themselves is often beyond what medicine can provide-for instance, an affirmation of love, a completion of important work, or a last visit with an important person. As a physician, I can't always make those things happen. But I can help the dying person get ready-and in this way, contribute to a death that is decent.

What is your view of what would constitute a good death for you?

I would like to end this introduction with another way of looking at a “good death” but looking at death after one dies. It comes in the form of the lyrics of a song written by Lee Hays of the Weavers, famously sung by Pete Singer and immortalized by a film by that name. ..Maurice.


Dead Earnest

If I should die before I wake
All my bone and sinew take
Put them in the compost pile
To decompose a little while

Sun, rain and worms will have their way
Reducing me to common clay
All that I am will feed the trees
And little fishes in the seas

When corn and radishes you munch
You may be having me for lunch
Then excrete me with a grin
Chortling, There goes Lee again

'Twill be my happiest destiny
To die and live eternally

Lee Hays, 1981

Disappearing Diseases: When Benefit Leads to a Dilemma

An interesting dilemma is raised in a Perspective article in the October 22, 2009 issue of the New England Journal of Medicine. The article titled “When Diseases Disappear-The Case of Familial Dyautonomia” by Barron H. Lerner M.D.,Ph.D.


Dr. Lerner writes “The success of genetic-screening programs raises an intriguing possibility: some dread diseases of the 20th century may soon become history. A representative example is familial dysautonomia, a severe neurologic condition, the incidence of which has decreased precipitously since population screening began in 2001. By giving prospective parents the option of terminating affected pregnancies, screening is doing exactly as was intended, but the disappearance of diseases such as familial dysautonomia should also give us pause. On a practical level, will interest and funding shift away from these conditions, leaving affected adults without advocates or the possibility of scientific breakthroughs? And philosophically, is the disappearance of a disease always an unmitigated good? What does it say about — and to — people currently living with a severe genetic disease when prospective parents would rather abort than bear a child with the same condition?”


Well, what are your answers to Dr. Lerner’s pertinent questions? ..Maurice

Patient Modesty: Volume 26

The issue of patient modesty and healthcare provider gender selection and provision is as most of my followers of this topic know a multifaceted complex issue. We can't learn enough about the topic simply by reading the comments of those patients who have found the issue affecting them personally and medically burdensome. We needed to have input from other views but, unfortunately, such visitors with other views are rare here. Nevertheless, we have to able to have a naturist, CSM, in past Volumes and who has returned briefly in Volume 25. We have had a male nude art model, Edo, who is back and with us. And now, we have a female physician urologist, Lisa who is providing us with the insight of the issue in a specialty in which the issue is particularly pertinent.

With this introduction, let's go on with the discussion.. ..Maurice.

Graphic: Physician Performing a Cystoscopy. The original image from the United States National Institutes of Health, modified by me with Picasa3.

AS OF TODAY NOVEMBER 11, 2009 "PATIENT MODESTY: VOLUME 26" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 27.

One Embryo at a Time: A Suggestion or a Law?

From the Opinion section (Room for Debate-A Running Commentary of the News) of the New York Times for October 11, 2009:

Ever since in vitro fertilization became an option, there has been widespread concern about the multiple births that result from implantation of multiple embryos. Yet most doctors and patients are comfortable with implanting two or three embryos, despite the costs involved and the far higher risk of prematurity associated with twins.
Should the United States move beyond recommended guidelines for fertility treatments to impose stricter regulations on I.V.F. procedures? Should transfers be limited to one embryo at a time?

• Mark I. Evans, Fetal Medicine Foundation of America
• Robert Stillman, reproductive endocrinologist
• James A. Grifo, professor of obstetrics and gynecology
• Arthur Caplan, bioethicist, University of Pennsylvania
• Helen Richens, the Human Fertilization and Embryology Authority
• Rebecca Dresser, law professor, Washington University
• Josephine Johnstone, Hastings Center
• Zev Rosenwaks, professor of obstetrics, gynecology and reproductive medicine
• Joanne Stone, professor of reproductive science

Read the opinions of these professionals and then come back and voice your opinion. ..Maurice.

Graphic: Collage by me using Picasa 3 from a photograph on Wikipedia of an estimated 8 week old spontaneously aborted fetus.

Patient Modesty: Volume 25

To many of those posting on these Patient Modesty volumes, there appears to be something "broken" in the United States medical care system that is not really being discussed in all the current public commentary about healthcare reform issues. The broken part is what should have been an attention, concern and resolution of patient physical modesty but where, according to the posters, there is generally none or if present it is very limited. We will continue with discussion of approaches to fix this broken part. ..Maurice.

Graphic: Photograph by me of a broken pot composition.

NOTICE: AS OF TODAY OCTOBER 24, 2009 "PATIENT MODESTY: VOLUME 25" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 26

Learning More about Bioethics

Are you interesting in knowing more about bioethics? Here is a resource.

The following is a copy of a page on my inactive since July 2004 "Bioethics Discussion Pages" which was prepared by an ethicist for a university web-based Masters program in bioethics. I posted it, with the ethicist's permission, on my "Pages" in 2002 and I think the material is still of value almost 7 years later. Hopefully all the links, addresses and phone numbers are still currently accurate and active. If not, please let me know at DoktorMo@aol.com ..Maurice.

Bioethics: History & Resources
Mark G. Kuczewski, PhD.
Neiswanger Institute for Bioethics & Health Policy
Loyola University Chicago Stritch School of Medicine.

[Moderator's Note: This lecture is one in a series that is used in their Web-based MA in Bioethics and Health Policy Program. The contents below has not been edited for presentation here. See http://bioethics.lumc.edu for further details of the Program]

Objectives:

At the end of this session, participants should be able to:

1. identify several of the historical roots of contemporary bioethics
2. identify major resources for procuring information on pertinent ethical questions including major reference works, professional societies, and leading journals
3. apply these resources to a practice task and analyze how the resources can assist in meeting your personal educational objectives.

The lecture will help you to reach these objectives by identifying:

1. Key terms and their definitions including medical ethics, bioethics, and medical humanities
2. The difference between contemporary bioethics and traditional bioethics
3. Some major events that could qualify as the birthplace of contemporary bioethics
4. Journals, bibliographic resources, Web sites, and professional societies that can assist in study and research of contemporary bioethical issues.

Following the online lecture, two questions are provided (a "Quiz") that will serve as practice to gain facility in the use of these multifarious resources.


Readings: Albert R. Jonsen, "The Birth of Bioethics: The Origins of A Demi-Discipline," Medical Humanities Review, 2(1): 9-21, 1997.

Suggested Further Reading:

Albert R. Jonsen, The Birth of Bioethics, New York: Oxford University Press, 1998. ISBN: 0195103254

"The Birth of Bioethics," Special Supplement, Hastings Center Report, 23(6), 1993, Includes articles by Albert R. Jonsen, Shana Alexander, Judith P. Swazey, Warren T. Reich, Robert M. Veatch, Daniel Callahan, Tom L. Beauchamp, Stanley Hauerwas, K. Danner Clouser, David J. Rothman, Daniel M. Fox, Stanley J. Reiser, and Arthur L. Caplan.
Lecture
Terminology: Medical Ethics, Bioethics, Medical Humanities

Medical Ethics -- ethics of the physician-patient relationship, provider-patient relationship, includes all general duties a provider has to a patient, e.g., duty help the patient and avoid harming him or her, as well as specific rules of conduct, e.g., duties of confidentiality


Bioethics -- literally "life ethics." It is usually used in a way that includes medical ethics as a subset. (For this reason, you also see the term "biomedical ethics.") As the more general category, bioethics seems to include additional issues that are not necessarily a part of medical ethics, e.g., research ethics, ethical issues related to new scientific techniques such as cloning, and environmental policy. In general usage, persons may sometimes try to contrast bioethics with medical ethics by seeing the former as a more general and philosophical approach to the same issues that the latter considers from a strictly clinical case-oriented approach. For instance, we can talk about ethical issues related to abortion from a general philosophical approach, e.g., what kind of society do we become if abortion is a frequently used method of birth control? Or a clinical perspective, e.g., What right does the doctor have to impose treatment on a dying woman in order to try to bring a fetus to viability?


For our purposes, we will see bioethics as a general category of which medical ethics is a subset. When talking about issues in medical ethics, we will often use the terms interchangeably.
Medical Humanities -- A term that was initially coined to cover philosophical, literary, and humanistic approaches to problems in medicine. As such, medical humanities was thought to include bioethics since ethics is an area of study in philosophy and philosophy is in the humanities. However, the usage of the term medical humanities has become more specialized. Now it mainly refers to the use of literature, poetry, and film to increase appreciation for the humanistic, interpersonal, or empathetic aspects of medicine.
(II) When and where was bioethics "born"?

Candidates:

* 1962 Life magazine article by Shana Alexander on Seattle Artificial Kidney Program.
* 1973 Roe v. Wade- seldom cited as bioethics' birth
* 1973 Fetal Tissue debate
* 1974 The Tuskegee Syphilis Study exposed
* 1975 The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research.
* 1976 Quinlan Case

Clearly, questions of how physicians should conduct themselves toward patients were considered as early as the time of Hippocrates, several centuries before the birth of Christ. Similarly, questions of life and death, including reproductive choices such as infanticide and abortion, have been with the human race for several thousand years. Philosophers and theologians have even given systematic treatment to them in various eras, especially the Medieval period. Therefore, if we are talking about the "Birth of Bioethics" as being somewhere between 1962 and 1976, we are presupposing that contemporary bioethics is different from medical ethics as it evolved throughout the ages. What's the case for this?


Ethicist Al Jonsen's answer is that prior ages thought about medical ethics in a very traditional way, e.g., as (1) part of ethics or the (2) standard practices of the culture/craft of medicine. As a result, medical ethics was a specialized discipline that was the concern of academic philosophers and theologians or physicians. It was not necessarily a part of public discourse, a concern of the populace at large.


Jonsen terms contemporary bioethics a "demi-discipline," a half-discipline. It works within a larger picture that is public discourse or public policy.


The demi-discipline: gathers a variety of types of persons who collect a plethora of facts, who listen to advisors and to each other, and move the debate toward closure (recommendations).


The public discourse: uses the reports and publications of those in the demi-discipline as part of the discussion that takes place in a variety of venues including law courts, legislative systems, professional societies and their committees, health-care institutions, and the media.


You can see that if contemporary bioethics is conceived as an interaction between people who make a kind of interdisciplinary study of certain issues and a process of public discourse about these issues, that bioethics genuinely was born in the second half of the twentieth century. The possible places of birth include several good candidates.


The attention the Seattle Artificial Kidney Program received certainly demonstrated that controversies involving life-saving medical technologies could command widespread public attention. However, the response to the problem of rationing such technologies based upon unwarranted social judgments was for Congress to simply allocate funds for everyone to receive this technology. No specialized groups were convened to study the problem or to contribute to the public deliberation. The demi-discipline had not yet emerged.


By the time of the famous Supreme Court decision in the case of Roe v. Wade, many academics were writing scholarly studies that were meant to contribute to the public discourse on the controversial issues such as abortion and the Supreme Court was able to draw upon several of these sources in its reasoning about this case (see especially Daniel Callahan, Abortion: Law, Choice, and Morality, New York: Macmillan, 1970.). However, few bioethicists are willing to claim the field's lineage in this controversial issue. Bioethics has often made advances by seeking issues on which people will compromise rather than to focus on such an intractable problem.


As a result, Jonsen is certainly correct in that the public debates and scandals that led up the work of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research probably are the strongest candidates for the birth of the field. In these instances, we have a public debate about controversial issues (e.g., the use of not yet dead fetuses and/or fetal tissue in experimentation) and public scandals (i.e., the Tuskegee Syphilis Study) and a call for "experts" to come together to make public policy recommendations. The way in which they proceeded has become legendary in the field and exemplifies bioethics as a demi-discipline that contributes to the public discourse. The principles the Commission enunciated in the Belmont Report and the guidelines they set forth in their succeeding reports still guide biomedical research in the U.S. And, of course, this is a beginning to which bioethicists are willing to lay claim.
(III) Resources

Bioethics is an interdisciplinary pursuit that embraces contributions from medicine, philosophy, law and other fields such as the social sciences. As a result, relevant materials are often found in the medical literature, law reviews, and some philosophical journals.
Journals: General Bioethics Journals

* Hastings Center Report -- probably the most widely read of the bioethics journals; not especially clinically oriented.
* American Journal of Bioethics (visit www.bioethics.net) - AJOB is a new and hot journal. It’s format is unique in that it typically has 2 target articles which are each followed by about 15 commentaries.
* Journal of Clinical Ethics
* Kennedy Institute of Ethics Journal
* Journal of Medicine and Philosophy
* Bioethics (Based in Australia)
* Theoretical Medicine and Bioethics (Based in the Netherlands)

Bioethics Journals for Ethics Committee Members:

* Cambridge Quarterly of Healthcare Ethics -- excellent journal but can be rather theoretical in tone.
* HEC Forum -- probably the most successful at being pitched to such an audience.

Bioethics Journals with a Legal Emphasis: (Both of the following journals are available with membership in the American Society of Law, Medicine, and Ethics (ASLME))

* Journal of Law, Medicine, & Ethics
* American Journal of Law and Medicine

Medical Journals that Frequently Feature Articles on Bioethical Issues:

* Journal of the American Medical Association (JAMA)
* New England Journal of Medicine (NEJM)
* Annals of Internal Medicine
* Archives of Internal Medicine

[Note: The American Medical Association (AMA) maintains a web-site that will allow you to search JAMA and the Archives of Internal Medicine by keyword.]

Bibliographic Resources: Internet-Based Bibliographic Sources:

* www.bioethics.net - This website is maintained by the AJOB and the University of Pennsylvania. It’s the best source of daily news related to issues in medicine, science and bioethics.

* Bioethicsline -- This is a database developed at the Kennedy Institute of Ethics, Georgetown University. Bioethicsline is part of the National Library of Medicine's MEDLARS system and online access requires that your library subscribe to this database. However, free bibliographic searches are available. One can order a printout of a search by phoning 1-800-MED-ETHX.
* NYU Literature and Medicine Database: This is especially useful to those interested in the medical humanities. A hard copy version of the database is available by sending a check or money order for $35 (U.S., $4.00 postage and handling; Foreign, $9.00) to: New York University Medical Center, Dept. of Physiology, 550 First Ave., New York, NY 10016, Attention: Dr. Felice Aull

Printed Bibliographic Materials:

* Bioethics Literature Review -- This publication reviews numerous bioethics articles from the bioethics literature and medical journals. It is published monthly. The cost is $49.00 a year and can be procured by writing to the University Publishing Group, 12 S. Market Street, Suite 300, Frederick, MD, 21701 or calling 1-800-654-8188.
* Healthcare Reform & Ethics -- This is a bimonthly review of bioethics literature. It is far less comprehensive in scope than the Bioethics Literature Review but more detailed. For subscription information, call 714-997-7907 or write PO Box 14132, Orange, CA 92863-1532.
* Each issue of the Hastings Center Report also contains a feature called "In The Literature" that abstracts recent books and articles from the bioethics and medical literature. It is distinguished from Bioethics Literature Review and Healthcare Reform & Ethics in that it's reviews include books. However, it is not as comprehensive regarding articles as the Bioethics Literature Review.
* The Kennedy Institute of Ethics also publishes a Bibliography of Bioethics. This is an annual index containing over 3,600 new citations to documents in the bioethics area. This bibliography is derived from the Bioethicsline database. The cost is $60.00 for persons in North America; $70.00 for those elsewhere. To order, call 1-800-MED-ETHX.

Encyclopedias:

* The Encyclopedia of Bioethics, Warren T. Reich (Editor), New York: Simon & Schuster Macmillan, 1995. ISBN 0-02-897355-0. Note: This is a highly regarded reference source and an excellent place to begin one's research on most topics. Most articles carry important bibliographic citations with them. (A third edition is presently in press)
* The Encyclopedia of Applied Ethics, Ruth Chadwick (Editor), Academic Press, 1997. ISBN: 0122270657. A quality source.

Listservers: (Listservers are ongoing e-mail discussion groups. Some are open to all interested parties, others require that you explain your interest and credentials.)

* MCW-BIOETHICS -- A closed list that discusses any issue in bioethics. The way to enroll is to address a message to the listserver . Skip the subject line and in body of message type: SUBSCRIBE MCW-BIOETHICS (without the parentheses). You should receive a reply asking for your qualifications since it is a closed list. Explaining that you are a student in MCW's distance learning program is invaluable. If you run into difficulties, you may wish to send a message directly to the list's moderator, Arthur Derse, MD, JD (aderse@mcw.edu)
* IRB Forum -- A listserver and website devoted to research ethics, particularly problems encountered by IRB administrators. Enrollment instructions for the listserver are available at www.irbforum.org

Professional Societies:

* There is now one main society in bioethics, the American Society of Bioethics and Medical Humanities (ASBH). It has a Web site with an online membership application. Or, you can contact the society through more traditional means: American Society of Bioethics and Humanities, 4700 W. Lake, Glenview, IL, 60025-1485, Phone 847/375-4745, fax 847/375-4777.

(I highly recommend that anyone interested in bioethics should become a member of this group. You receive the society's newsletter, receive discounts on registration for the annual meeting, and you are eligible for membership in any of the society's "affinity groups": Disability & Rehabilitation Ethics, Nursing, Hospice and Palliative Care Medicine, Visual Arts and Cultural Representation, Residency Interest Group, and Student Interest Group) Historical Note: The American Society for Bioethics and Humanities (ASBH) was formed from a merger of the three major bioethics societies:

* The Society for Health and Human Values (SHHV - a group that concentrated on the medical humanities)
* Society for Bioethics Consultation (SBC - a group that focused on clinical consultation)
* American Association of Bioethics (AAB - a group that focused on public policy)

There is still one group that has remained independent. It has a legal orientation: American Society for Law, Medicine and Ethics (ASLME); Web site, e-mail (aslme@bu.edu) or phone: 617-262-4990.

Ethics Networks:
Bioethics centers at academic health science centers sometimes try to provide resources for hospitals, nursing homes, and other health-care facilities in their region. These are known as ethics networks or HEC networks (Health-care ethics committee networks.). A network near you may be found by Web-surfing among bioethics centers or visiting the site of the American Society for Bioethics and Humanities, esp., http://www.asbh.org/links/cat1.html

Calendar of Events:
International Calendar of Bioethics Events, Division for Medical Humanities, University of Medicine and Dentistry of New Jersey - Robert Wood Johnson Medical School, P.O. Box 896, Piscataway, NJ 08855-0896, Russell L. McIntyre, Th.D., Director http://www2.umdnj.edu/ethicweb/upcome.htm

The ASBH also maintains a calendar at http://www.asbh.org/events/



Navigating the Available Resources:
It is important to realize that there is no comprehensive list of bioethics resources and centers of study anywhere. Because bioethics is a rapidly expanding field, any lists are quickly incomplete. You should try to become comfortable "surfing" the Web and enjoying the discovery of new resources. You might wish to start at the home page of the ASBH, www.asbh.org and use the "links" to other centers to visit their pages. You'll note that each center's page contains its own list of links that will facilitate further surfing. You should take note of pages that have resources that might prove helpful to you or are pertinent to your interests. You'll wish to use the "bookmark" function on your web browser to mark those pages for future access.

ADDENDUM 10-7-2009: A visitor brought the following link to my attention which has a listing of worthwhile humanities sites which would be good for further education and resources regarding bioethics.

To Tell and Not to Tell: The Illinois Law on HIV Disclosure

“In the name of protecting the health of all men and women, states should extend the privilege of HIV disclosure to any and all endangered third parties, not just spouses. As it stands, Illinois law uses marriage as a test of moral entitlement to public health protection in a way that works against the full value of disclosure privileges and that is ultimately inconsistent with a principled respect for all people at risk of HIV infection.”

So writes Timothy F. Murphy in the Perspective section of the September-October 2009 issue of The Hastings Center Report. As it currently stands, Illinois as other states do “gives physicians the privilege-but not the duty-to disclose an HIV infection to a patient’s spouse, even if they must override the patient’s wishes that they not do so.”


What Illinois lawmakers, however, did not extend was this privilege to a permanent couple who were not married or were simply sexual or needle-sharing partners.Thus the potential benefit, under these conditions, of informing, educating, diagnosing and initiating treatment if that other party was found to be HIV positive would be limited only to legally married couples.


What does this say about the Illinois lawmakers and their motivations to facilitate the treatment and prevention of spread of HIV and their apparently greater motivation to encourage a man to woman legal marital relationship?
Is this legislative action true public health or trying to extend a philosophical or religious bias? ..Maurice.

Use of Medical Interpreters: Facilitating Talk but Delaying Actions: Benefit vs. Annoyance

In the United States the use of medical interpreters is becoming more common in view of the influx or non-English speaking patients and state laws such as in California. But while the interpreter is valuable in obtaining the patient’s history, the patient’s concerns and may help to facilitate the physical examination and the concluding discussion, there is a time factor operating. It may take time to obtain the appropriate interpreter. It takes more time for the interpreter to translate the physician’s words, takes time to make sure the patient understands, takes time to listen to a response and then translate the response into the language understood by the physician. And a physician who has only 15 minutes for an office visit or a hospital resident physician who is simultaneously following a number of patients and/or has various surgeries scheduled throughout the day may find that the time for the use of an interpreter and the process of translation is too time consuming. The value of the interpreter, to that physician, may be simply to get the basic facts and to explain to the patient for informed consent. But beyond that the physician may be comfortable with asking “half-answered “ questions as a memorized couple word expressions and be satisfied with a partially understood patient response and never calling for an interpreter. But is this really fair for the patient who may want to talk more than a brief word or two, expecting to be able to provide the doctor with a full detail of the patient’s concerns and questions?


To help define the problem, here is the result of a study as an abstract regarding the use of interpreters by resident physicians from an article by L.C. Diamond, et al in the Journal of General Internal Medicine, Volume 24, No. 2, February 2009 titled “Getting By: Underuse of Interpreters by Resident Physicians”

Abstract
Background Language barriers complicate physician–patient communication and adversely affect healthcare quality. Research suggests that physicians underuse interpreters despite evidence of benefits and even when services are readily available. The reasons underlying the underuse of interpreters are poorly understood.
Objective To understand the decision-making process of resident physicians when communicating with patients with limited English proficiency (LEP).
Design Qualitative study using in-depth interviews.
Participants Internal medicine resident physicians (n = 20) from two urban teaching hospitals with excellent interpreter services.
Approach An interview guide was used to explore decision making about interpreter use.
Results Four recurrent themes emerged: 1) Resident physicians recognized that they underused professional interpreters, and described this phenomenon as “getting by;” 2) Resident physicians made decisions about interpreter use by weighing the perceived value of communication in clinical decision making against their own time constraints; 3) The decision to call an interpreter could be preempted by the convenience of using family members or the resident physician’s use of his/her own second language skills; 4) Resident physicians normalized the underuse of professional interpreters, despite recognition that patients with LEP are not receiving equal care.
Conclusions Although previous research has identified time constraints and lack of availability of interpreters as reasons for their underuse, our data suggest that the reasons are far more complex. Residents at the study institutions with interpreters readily available found it easier to “get by” without an interpreter, despite misgivings about negative implications for quality of care. Findings suggest that increasing interpreter use will require interventions targeted at both individual physicians and the practice environment.

A physician’s personal experience with this issue is presented in a New York Times article.


All patients deserve beneficent attention and care by physicians despite the handicap of the inability for both to communicate in a common language. In the United States, interpreters are becoming more available to help in this communication and in some states are required by law. But the medical system is complex, not easily changed and tends to produce time limiting necessities but also physician behavioral issues that all lead to impaired doctor-patient communication and potential for errors or inadequacies of care. So what is the answer? Is it medical interpreters or something else? ..Maurice.

Graphic: Illustration by me using ArtRage and Picasa3.

Patient Modesty: Volume 24

The discussion continues by my visitors with their personal experiences and understandings about the issue of patient modesty. However, the discussion also continues to develop mechanisms of how to change the medical system and permit patient expression of their concerns but also the system acting in the patient's favor on them. ..Maurice.

Graphic: An old illustration of a religious scroll but modified by me with ArtRage and Picasa 3.


NOTICE: AS OF TODAY OCTOBER 11, 2009 "PATIENT MODESTY: VOLUME 24" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 25.

A Child by IVF vs Adoption:: Ethical Defining of "Want" vs "Need"

The issue is simply or perhaps not so simply the addition of a member to the family where there is an infertility problem of the couple. Should the couple "want their own kid", a child of their own genetic background, to carry on the family's genes by attempting an expensive and with some risk the invitro fertilization (IVF) and implantation of the embryo into the mother? Or would it be less expensive and more ethical in a societal sense to adopt a child who needs parents and a home? What is the ethical difference between need and want?

Physician-ethicist Erich Loewy wrote a response about "need" and "want" to a bioethics listserv dealing with this issue about the "wants" of infertile couples. He has given me permission to reproduce his comments here.

"Want their own kids" or want their own anything is the disease we in
Capitalist societies have, the "I need" is equated with I want. I
need food, water, shelter, the opportunity to get educated (no
comment please---I know it is too late!!) and to have health care. I
want is substantially different. I want to see the Great Chinese Wall
but if I don't, so what. I (actually) wanted to become a conductor
but lack perfect pitch which a first rate conductor needs. So, I
changed my want to something else. If I am terribly thirsty I need
water (same for hunger--and I do not mean appetite) and if I do not
get it I will die.

Having your own child may be a want but it surely is not a need. We
have (and I will not cite statistics once again) myriads of children
that need a home. Yes---they need it because there is more to a
child's surviving than what I have called "first order needs" (see
above). The problem is that many children who are homeless in today's
splendid Capitalist society happen to be Afro-American and (horor of
horrors!, I should have a Black, Jewish or Hispanic child!!!). So
instead of the needy glut we spend perhaps billions to artifically
satisfy somebodies want and let the need of others slide. Further,
this society is as full of racism (although the fraud of PC covers it
with a veneer of probity) as Austria, Germany and, yes, the US had of
anti-Semitism after the first war and, alas has today but again
hidden by a veneer of PC.

If a person is sterile (and I remember several classmates who would
have liked to be!!) that is unfortunate. If I lack perfect
pitch--that is unfortunate. Engelhardt woud claim that if I am ill,
that is unfortunate or unlucky. It however puts no obligation on
anyone to help me. But you see that is an entirely different one. My
"wanting" medical care is not a want---it is a need and it is
therefore that a decent society would provide single tiered
(everybody gets the same and no one can buy more of those things that
are "wants"---private rooms, TV in the room, nicer curtains, etc.
which do not affect outcome, However, the same physicians, staffing
with nurses, diagnostic or therapeutic means, waiting time, etc which
do affect outcome.

Being unable to have my own child is no more a "need" than is my
having perfect pitch is. It seems perverse to me that a society and a
world which already have more than it can take care of (or is willing
to take of!!!) goes out and with great effort and the use of many
resources tries to make more of what we already have but neglect severely.

Erich

Dr Erich H. Loewy
Professor of Medicine and Founding Chair of Bioethics (emeritus)
Associate in Philosophy
University of California, Davis
E-mail: ehloewy@ucdavis.edu



How do you look at this "want" vs "need" decision of infertile couples? ..Maurice.

The Language of Bioethics: Nuances in Use Lead to Ethical Dilemmas

In contrast to the “Thai Dictionary of Medical Ethics” which appears to be a “tongue-in-cheek” description of terms used in bioethics, for those who would like the more established definitions, I suggest you go to this link which is to the “Language of Bioethics” by the Medical College of Georgia. Many terms are tossed around these days by doctors, ethicists, politicians and others and it is worthwhile to understand what is the current consensus of meaning of the terms.

Futility is a word often used but often misused since in medical practice using the word futility or futile alone is misleading. That is because one has to describe in what sense the term futile or futility is being used. Often the expression is used: “further treatment is futile”. It is this misuse that has caused some ethicists to declare that this term should not be used as a medical descriptor. So, from the “Language of Bioethics” what should we know about the term “futility”?

Futility: a term dealing with the hopelessly ill and dying; at least three meanings bear consideration:

Physiologic futility–the proposed intervention or continued treatment cannot reverse a physiologic condition in the patient that is leading to death. This strict definition of futility means that the intended medical effect of the treatment is not likely to occur, as determined by scientific evidence or local medical experience.

Personal futility–the proposed intervention or continued treatment may have the desired medical effect, but the resulting benefit does not outweigh the burden of continued life. This "best interest" or "disproportionate burden" definition of futility may mean that consciousness of the patient is not restored, or he/she will not leave the ICU, or that severe suffering will persist.

Social futility–the proposed intervention or continued treatment may have the desired medical effect, and personal benefit may outweigh the burden, but the treatment is not available, as determined by the social consensus, due to scarce resources.

A question one may want to ask is which kind of futility should ethically trump the others? If a treatment does what it is supposed to do with regard to symptoms but doesn’t make the patient better in terms of extending a life that the patient desires, should that treatment be called futile and not started or discontinued? What if the treatment would save a life such as a ventilator for a critically ill elderly patient but in this catastrophic influenza pandemic, the last ventilator available at the time was instead could be used on a young critically ill patient. In that case, socially established triage criteria found that the ventilator, under these circumstances, was a socially futile treatment for that elderly patient since it prevented recovery of one much younger and perhaps, when recovered, make a longer contribution to the benefit of society. Should the possibility of social futility trump all? Or if there is no physiologic nor personal futility in the treatment then “first come, first served” should be the principle used when resources are scarce?


Look at the list for all the other bioethics terms in the “Language of Bioethics”. Unfortunately, despite clear definitions to these terms, nuances in their use add to potential ethical dilemmas. (As that list defines Dilemma: moral obligations to others exist on both sides of the choice; ethical reasons that support choosing both alternatives.) I may delve into other terms in later posts in which their meanings don’t always set clear ethical answers. ..Maurice.

Addendum: By the way, the criteria for "Personal Futility" should be set by the patient or if the patient cannot communicate and there is no surrogate to tell what is known about the patient's wishes, physicians must use the "Reasonable Person Standard" which is what a "reasonable person" would decide about their future quality of life.

Reflections in Medical Practice: Thinking Things Over

The Story of Some Doctor’s Reflection

A Poem By Maurice Bernstein, M.D.

I am some doctor and Mary is my Patient
Did I know Mary was
So Sick when I first
Saw her
Then?

She comes to me and asks for Help
Did I take the Time
To listen to the entire
Symptom Story
Completely?

There was a phone Call from Doctor Smith
Did I interrupt Mary
To take the call
As though more
Important?

Then there was time left only for a Snap Diagnosis
Did I treat Mary for the flu
With some
Antibiotic?

Of course the Diagnosis was a Blood Clot to the lung
And why shouldn’t I
Have made that
Diagnosis?
And now Mary is fighting for her Life and I Reflect.

Physicians reflect back on what has transpired with their patients, thinking about what was done well and what could have been done better. Often the reflective contemplation, thinking about the process of relating to that patient, making a diagnosis and selecting a therapy or improving skills is of benefit toward future interactions and decisions. Time is often made short for the physician, diseases are not always uniformly expressed, memory and experience is limited and mistakes and misjudgments are always possible. If time is limited, nevertheless at some point in a physician’s life, as part of the professional duty, reflection should be included. ..Maurice.

More on reflection in medicine on a previous thread.

Graphic: Photograph by me of a pool, Descanso Gardens, La Canada-Flintridge, Southern California

8 Weeks Pregnant—No! 4 weeks: A Problem in Professional Communication?

Try the following mind game scenario, which easily could be real and then tell us what should have been different in the professional communication to have made the outcome less traumatic for all. ..Maurice.

Young woman, pregnant, goes to ER for abdominal pain, accompanied by a young man. She is sent to the area that focuses on OB issues and she brings the young man in with her, saying he is the baby's father. An ultrasound is performed. The resident physician provides a running narrative what he is doing.

"Yes ... see here's the baby. The baby is about 8 weeks along ... "

Immediately the young woman says "No, that can't be. The baby is only 4weeks along."

"Nope," says the resident, "this one is a good 8 weeks ... "

"NO," the young woman insists. "You have to be wrong. That can't be." The young man is looking perplexed and perturbed. It becomes obvious he can't be the father, and he is just now finding out.

So what should the resident do now?

What should the resident have done earlier (remember, the young woman requested that the "father" come in)?
(Scenario obtained from a bioethics listserv presented by a subscriber ethicist)

Graphic: Ultrasound image of an 8 week fetus

Patient Modesty: Volume 23

Kilroy spying on the classic DiVinci figure reflects one of the paths of current discussion on patient modesty. There is concern by patients of both genders that there are onlookers who appear in the patients' medical care environment who just don't belong there and add to the aggravation the visitors describe regarding providers ignorance of patient modesty and privacy. ..Maurice.

Graphic: My construction of Kilroy and image of DiVinci's Vitruvian Man using ArtRage.

NOTICE: AS OF TODAY SEPTEMBER 25, 2009 "PATIENT MODESTY: VOLUME 23" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 24

Intentions Regarding Turning Off the Pacemaker of Reverend G

In the “Controversies” section of the Journal of the American Medical Association for February 23, 2000 there is a viewpoint as presented by Rhymes and colleagues titled “Withdrawing Very- Low Burden Interventions in Chronically Ill Patients”. The authors present a case about a severely demented elderly Reverend G who is “abusive, aggressive and assaultive” and “hallucinating”. His mental state and behavior cannot be controlled with any drug treatment. There is, on the other hand, an approach to management of this difficult patient.


Reverend G has a cardiac pacemaker “which the wife, with agreement from their children, has asked that the patient be given treatment to keep him comfortable and they asked that his pacemaker be turned off, on the assumption that the pacemaker may prevent an otherwise natural death.” The description of the case states that Reverend G had a living will written “before his dementia became severe” however it is not clear what the will stated except “he said that he did not want to commit suicide.” The authors provide arguments which support view that the wishes of the family is based on the rationale that turning off the pacemaker will end a “burdensome life” without representing physician-assisted suicide, euthanasia or “killing” the patient.


Ethicist Ed Pellegrino in a companion article in the same section of the Journal presents a moral algorithm for “Decisions to Withdraw Life Sustaining Treatment.” In it he finally argues that the reason for turning off the pacemaker should be if the intention was to remove a futile treatment but not if the intentions of the surrogates or medical attendants “were to hasten death…or to end a life which they unilaterally judged to be of ‘no quality’”


Which view would you hold? Is the pacemaker a futile treatment? Could one argue that the pacemaker is futile treatment, not because it can’t keep the heart beating normally, but because as a life-supportive mechanism it is failing to treat the patient’s dementia and what the family believes is simply maintaining a “burdensome life”? Can one call the pacemaker’s value as futile with regard to treating the mental disorder when it was inserted to treat the heart rhythm disturbance? And whose “burdensome life”? On the other hand could the decision by the family represent a loving concern for the patient who probably in recent times experienced not only the mental burdens but also most likely the physical burdens of physical restraints? What is your take on this scenario? ..Maurice.

Primary Care Boutiques and Healthcare Reform

During these days when the issue of healthcare reform is at the table of public interest and debate within the United States and where there are almost 50 million people who do not have health insurance, there seems to be a topic in healthcare which has not been discussed or considered within the reform packages. That topic is the issue of luxury primary care practice and clinics. These are the so-called medical “boutiques” which provide for a retainer special medical and associated service which would not be available to other patients. This would include besides a more luxurious clinic environment, more ready access to a physician year round by cell phone or pager, shorter waiting times for a visit, more rapid access to specialist attention, house calls and perhaps easier access for certain vaccines or diagnostic scanning. If with the added patient loads when these 50 million people are able to be able to afford a private physician, the numbers of primary care physicians will become a limiting factor. Boutique medicine practice may only reduce the numbers of physicians available for standard care.


I suggest that visitors to this blog who are interested in learning more about “boutique medicine” should go to the thread I started May 4 2007 “Where Have All Those Doctors Gone?: Coming Back in Boutique Medicine?"
There are links on that thread to additional information on the subject. Also, here is a link to chapter titled “Family Medicine Should Encourage the Development of Luxury Practices: Negative Position” by Martin Donohoe in the book “Ideological Debates in Family Medicine”.


There have been concerns expressed beyond reduction of physicians for standard primary care practice specifically regarding the effect of these boutique practices to raise the cost of all medical care and increase exposure to unnecessary and potentially harmful screening tests simply as a service to the boutique patients.
What do you think? Hopefully, physicians who participate in these services could also participate in the discussion here. ..Maurice.