Bioethics Discussion Blog: December 2004





Friday, December 31, 2004

A Few Physician's New Year's Resolutions

It’s that time of the year when it is customary that people make New Year’s resolutions. Doctors should be no exception regarding their professional behavior.

One significant defect that a number of doctors bear, either because of time constraints or their own disinterest, is failure to take into consideration the whole patient and family when evaluating a medical condition. Though medical schools try to stress to their students that there is more to a patient’s illness than simply the biologic disorder. There are also psychologic and social issues involved. Sometimes this teaching gets lost as a busy practice develops. To understand these non-biologic factors, a physician practicing in a multi-cultural environment, as many do, must also have some understanding of the way patients from different cultures and religions look at the illness, which has befallen them. This learning often comes piecemeal to the doctor.

Another resolution would be for the physician to feel and be less rushed. Rushing leads to mistakes and poor relationships with their patients. Though it is true these days that time constraints are placed on the doctor’s practice, nevertheless, often these constraints are due to improper organization of the practice system and by consultation with management specialists, the physician’s time can be better organized and more will become available.

Finally for this posting, how about a doctor’s resolution to be a health model for their patients? There are still some doctors who smoke and are grossly overweight. Could this be the resolution hardest to keep in the upcoming year?

Do you have any other suggestions as to a physician’s New Year resolutions? ..Maurice.

Monday, December 27, 2004

New Year's Resolutions to Stimulate Therapeutic Innovation

Now that it is the time for everyone to declare their New Year's Resolutions,
Dr. John Crellin writes about what he wonders might be the appropriate resolution by research institutions to reduce the barriers to therapeutic innovation. Perhaps, he suggests, it might be time to resolve to revisit the regulatory ethics paradigm and debate possible changes in order to stimulate therapeutic innovation. ..Maurice.

Thursday, December 23, 2004

Military Medical Conflicts of Interest Including Treating One’s Military “Family”

The very recent attack on a military dining facility in Mosul and the resulting deaths followed by the prompt mobilization of medical treatment for the numbers of wounded brought to me a revisiting of my thoughts about the profession of the military physician. I have been writing throughout this blog about conflicts of interest in the profession of medicine and I find this topic certainly applies to doctors in the military. It seems obvious that their conflicts of interest would be qualitatively quite different than those affecting physicians in civilian life.

One clear conflict is that of the physician’s allegedly primary duty to the military. This aspect is well described by John C. Moskop, Ph.D. whose article can be found in the Ethics and Healthcare newsletter of The Bioethics Center, University Health Systems of Eastern Carolina
Department of Medical Humanities, The Brody School of Medicine at East Carolina University Volume 7:Number 1 Spring 2004 under the title Ethics and Military Medicine: New Developments & Perennial Questions

The following is an excerpt of the Conclusion of the article:

What, then, is the underlying moral difference between military and civilian medical practice? It is, I believe, the fact that the military demands a more nearly total commitment to its goals and practices than other employers and, as a result, military physicians have less individual freedom to make their own moral choices. Some military goals, such as the protection of citizens and their way of life, are highly desirable; other possible goals, such as aggression against other nations, are highly morally suspect. Some military practices and procedures, such as strict discipline and rigorous training, are necessary and defensible means to achieving military goals; others, such as torture, genocide, and mistreatment of one’s own soldiers, prisoners of war, or civilians, are highly morally problematic. Upon entering military service, physicians assume obligations to pursue military goals and abide by military procedures, with only limited options to resist these on medical or other grounds. Thus, the decision to enter military service is a morally weighty one which demands careful reflection on the practices and regulations of the military service to which one is pledging obedience.

I have a theory that there is another conflict of interest, not described in the article, which though perhaps subtle represents a relationship with the traumatized patient, particularly during a war, which physicians in civilian life are not encouraged to encounter. It is reasonable to say that the military physician, especially during the immediate distress of battle and most especially for those physicians near the “front line”, the patients for whom the physician is responsible is part of a closely knit team of which the physician is an important part and partner. Together, they are all working to defeat the enemy. I have a feeling that the military physician might reasonably look at the team, emotionally, as his/her “family” of service people. And, if so, the physician could be in a way treating the severely injured of his/her “family”. In civilian life, physicians are discouraged from treating their own family members, certainly a severely traumatized one, because of the psychological-emotional effects which might affect proper medical judgment. And yet, this very act of treating one’s military "family member" is what is demanded of the military physician. And it is this responsibility which could be the basis for the subtle conflict of interest and its effect on professional judgment.
I really don’t have any data or other information to confirm my concerns. I don't know if military physicians look at their team emotionally as "family". I don’t know if there are more mistakes in clinical decision-making up front in Iraq or even at the military hospital in Germany than let’s say in a civilian hospital emergency room. And, if there were more mistakes on the “front-line” would other factors such as the psychological effect of potential of injury or death of the physicians or limited resources there be the important factors. This could all be my expounding an unrealistic personal idea. Do you think that there is any merit to my theory and worthy of further investigation? Let me know. ..Maurice.

Wednesday, December 22, 2004

Full Statistical Disclosure Makes Good Ethics

I write about the difficulty of the public interpreting the significance of medication risks when only the relative risks are described in the news media. An example would be the information that taking the drug “doubles the chances of getting a heart attack” than not taking it. Read it on Shrinkette, a wonderful blog expressing the views of a lady psychiatrist ..Maurice.

Monday, December 20, 2004

Physicians Making Decisions for Unconscious Patients Without Family, Friends or Surrogates (5): Ethics Committees--True Consensus?

In both of the two options involving hospital ethics committees(HEC) (see last posting) the same concern can be raised. The concern is does their final conclusion really represent a true consensus of opinions or something else? How is the final conclusion that the committee reaches developed?
Anne Griswold Peirce, RN, PhD, Associate Dean for Academic Affairs, Columbia University School of Nursing, New York writing in the Online Journal of Health Ethics, The University of Mississippi Medical Center explores some of the dynamics of decision-making by hospital ethics committees in this recent article titled “Some Considerations about Decisions and Decision-Makers in Hospital Ethics Committees”
Her cautions are well taken and are summarized by her as follows:

1. Ensure that HECs are composed of diverse professions, as well as diversity of gender and ethnicity. Diversity strengthens decisions by expanding the knowledge and opinion base (Smith, Bisanz, Kempfer, Adams, Candelari, & Blackburn, 2004).
2. Include community representation so that not all members are institutionally based. Diversity of institutional information is also important. Institutional allegiance may also influence decisions in unknown ways (DeRenzo, Silverman, Hoffman, Schwartz, & Vinicky, 2001; Deville & Hassler, 2001)
3. Make sure that the professionally powerful voices, for example physicians and lawyers do not override the other committee members’ opinions. DeVille & Hassler (2001) note that when lawyer members of HECs speak, other members may not feel any further discussion is needed. HECs might consider the technique of the military where some military tribunals vote in reverse order of seniority.
4. Consider the pooled opinion technique described by Surowiecki (2004) in the Wisdom of Crowds. Within the HEC meetings opinions might first be gathered on a paper ballot allowing each voice to be heard as an individual before pooling. As Surowieki (2004) notes no one expert is consistently right and pooled opinions are on average better than the individual.
5. Require ethics training for all members (Wilson, 2002). Exposure to the techniques of ethical analysis gives a common frame of reference for all committee members.
6. All information provided to HECs should be adequate in volume and organized in such a manner as to be interpretable by the committee. Clinical evidence should follow standard guidelines and reflect the best evidence available. Decisions should occur only after all relevant information is considered. However, committees should be aware that more information may not be better; it may only increase error (Kosko, 1993).

Note: The references are listed in the full article.
If any of my visitors here are associated with hospital ethics committees, posting their comments here on this article is most encouraged. Of course, others are encouraged to write too! ..Maurice.

Sunday, December 19, 2004

Physicians Making Decisions for Unconscious Patients Without Family, Friends or Surrogates (4): Options

So what are the options available when the physician is faced with such a dilemma? An obvious one might be that the physician holds him/herself as the surrogate decision-maker. After all, in a number of these patients such as those elderly with no family who have been attended by the same physician in a nursing home for many years, the physician has had a chance to observe and talk with the patient and may have the best understanding of anyone with regard to the patient’s values and wishes. The physician also more clearly understands the science and rationale for therapy than someone else and finally the physician has a professional duty for providing only beneficence or “good” to his/her patient. On the other hand, it has been argued that the treating physician as surrogate may have no oversight by others regarding the decisions he/she is making in the patient’s name. This could be important if there is any conflict of interest, often financial. For example, the value to the physician or others to continue to treat or overtreat the patient in a fee-for-service environment or to undertreat under managed care. Finally, the physician could be reflecting his/her own values and not play the usual role of providing to the patient or family an objective evaluation of their decisions. In California, as I assume elsewhere, a treating physician cannot be named as a legal surrogate by the patient in an advance directive.

Another option would be court directed. In all states in the U.S., the court can be petitioned to appoint a conservator to make healthcare decisions for patients who are incompetent. Usually, the court appoints a public guardian when patient related individuals are absent. The problem with a public guardian is that the system is usually under-funded and they often have a huge load of clients about whom they know little and certainly cannot follow their clinical courses on a frequent basis. Because of inadequate training in medical decision-making and end-of-life care, many guardians when faced with a significant decision in starting or withholding treatment will resist and delay while consulting with a judge who has never seen the patient.

Finally, options that have been considered but still have not received uniform consensus in the bioethics or legal community of the United States involves the hospital ethics committees. One suggestion would be to assign the hospital ethics committee as surrogate decision maker for these unconscious patients without family or friends. An argument in favor would be that there are a multitude of voices on the committee with a potential variety of views including, hopefully, views from the community and that the patient’s “best interest” decision would be most reliable based on a consensus of this group. However, this role for an ethics committee would be very unusual since the committee’s function is for ethical and legal education, mitigation of conflicts and dispute resolution and not for making clinical decisions for patients. Many if not most of the committees would not accept a role of clinical decision-making.

So what is left? : A vague combination of the treating physician consulting with the hospital ethics committee before starting or withdrawing treatment. The ethics committee’s responsibility would be to assure that there are no family, friends or other potential surrogates which are present but unknown to the physician. The committee would then hear the clinical story and treatment issue from the physicians and other healthcare staff. Then the committee would, along with the physician, try to come to some consensus regarding the law, ethics, conflicts of interest and “patient’s best interest”. If all were in agreement then the committee would simply approve the decision and action by the physician. In issues involving standards of medical practice, appropriate senior medical staff or consultants may be called in. If there is no agreement between committee and physician, there is always, unfortunately, the court system. By this approach, though it is the treating physician who is making the final medical decision, the ethics committee is providing the oversight to ensure that the decision is legal and ethical. Any comments? ..Maurice.

Saturday, December 18, 2004

Physicians Making Decisions for Unconscious Patients Without Family, Friends or Surrogates (3): Disorders of Consciousness

In order to better understand the decision-making issue, I have, in the previous posting, described the hospital ethics committee form and function since the committee could be involved in the process. Another element of the issue to understand is a current description and definition of the various disorders of consciousness that determine the conclusion that the patient is incompetent to participate in his or her decision-making. Also the prognosis of the specific disorder may well affect the decision made by others.

The following Glossary of Disorders of Consciousness is taken from the “State Initiatives in End of Life Care” Oct. 2004, Issue 22 published by Center for Practical Bioethics

Brain Death: The permanent absence of all brain functions, including those of the brain stem (which controls basic function like reflexes and breathing).
Coma: Patients in coma lack both wakefulness and awareness. Comas are typically transient: patients recover, die or evolve in some other state of impaired consciousness.
Vegetative States: The Multi-Society Task Force on Persistent Vegetative State (PVS), which included representatives from many of America’s most prestigious neurology associations, has defined the vegetative state as a condition of complete unawareness of self and environment, accompanied by sleep-wake cycles and either total or partial preservation of areas of the brain controlling automatic functions like heart activity and reflexes. PVS patients may cry or smile but these actions are reflexive and do not reflect true awareness.
“Persistent” versus “Permanent” Vegetative States: A vegetative state is considered “persistent” after one month. Vegetative states are considered “permanent” after one year if caused by traumatic injuries such as a blow to the head; non-traumatic vegetative states caused, for example, by oxygen deprivation to the brain are considered permanent after three months. Guidelines for children differ.
Minimally Conscious States: Patients in minimally conscious states posses sleep-wake cycles and limited, inconsistent but definite awareness of self and environment (e.g., avoiding unpleasant stimuli, uttering intelligible sounds or reaching for objects in a way that adjusts for their size and location).
Dementia: A degenerative neurological disorder characterized by progressive loss of all cognitive functions with some arousal mechanisms remaining normal. Patients with advanced dementia who lose self-awareness and learned behavior often evolve into minimally conscious states and,at times,into vegetative states.

It should be emphasized that in the case of brain death, the patient is by law considered dead and there are no treatment decisions to be made.
Coma, if produced by administration of CNS depressants as well as various metabolic causes, can be fully reversible.
The “minimally conscious state” is a more recent diagnostic entity and there is still professional controversy about this diagnosis.
Now we will go on to consider possible approaches to the ethical issue of Physicians Making Decisions for Unconscious Patients Without Family, Friends or Surrogates. ..Maurice.

Friday, December 17, 2004

Physicians Making Decisions for Unconscious Patients Without Family, Friends or Surrogates (2): Hospital Ethics Committees

Before going into the alternative approaches which has been suggested regarding dealing with the issue of treatment decisions of the unconscious patient who has no family, friends or surrogates and which would involve the hospital ethics committee, I would like to describe the history, composition and functions of those committees.

Hospital ethics committees began to be formed over 20 years ago as a need to consolidate the committees which had been created earlier to select patients for hospital renal dialysis, for abortion review and federally required review of the care given to critically ill infants. Actually, in the 1960s, US Catholic hospitals first created committees for the Discussion of Morals in Medicine.
The concerns about end-of-life issues triggered by the legal decision in the Quinlan case gave further motivation to create ethics committees.
Today, hospital ethics committees or some equivalent are required by JCAHO, a hospital certifying organization, as part of the goal to assure that the ethical concerns of patients are considered.

Although the committee will vary in size and composition depending on each hospital’s policy, there are usually about 20 or so members. The disciplines represented on the committee usually consist of physicians, nurses, spiritual care, social service, representative of staff departments such a respiratory care, members of the administration and, strongly encouraged is the presence of representatives of the community, not affiliated with hospital affairs. There also may be a professional ethicist present as well as a hospital lawyer. It may be true that many ethics committees do not really have multi-racial or multi-cultural members or members who are themselves or represent the disabled..

The function of the ethics committee is to educate its own members, the medical and nursing staff and the community about the ethics and law of various issues that arise in patient care. The committee also is involved in the offering and writing of policies and procedures dealing with activities involving clinical ethics. A very important role of the ethics committee is to provide for patients, families, physicians, nurses and any other hospital staff a resource for help in resolution of conflicts involving ethical issues. The ethics committee serves as an educator and mediator to help facilitate the resolutions of those conflicts. The hospital ethics committee cannot and will not make clinical decisions, which bear on standards of medical care. The committee is interested and considers aspects of care in which established standards of ethics are related. But hospital ethics committees do not act as “ethics police”. Most ethics committees only attend to cases in which some stakeholder has invited the committee.

With this brief description, we will shortly return to discussing the unconscious patient. ..Maurice.

Thursday, December 16, 2004

Physicians Making Decisions for Unconscious Patients Without Family, Friends or Surrogates (1): The Issue

What is in the patient’s best interest is a major and frequently encountered issue in medical ethics. A conscious patient can very likely be able to tell the physician what are their values, goals and wishes with respect to their lives. An unconscious patient obviously can’t. However, if there are family and friends or legal surrogate of an unconscious patient available to communicate with the physician, they may be able to relate what they knew about the patient in this regard. But what if there are no family or friends or legal surrogate and there is no record by the patient that tells about his/her desires, how does the doctor really know what treatment or termination of what treatment would be accepted by the patient if he/she was conscious? Examples of such patients could include “street people” or often nursing home patients whom haven’t been visited by a relative in many years and/or whose location is unknown.. Without the ability to obtain informed consent, the physician has a problem that even or particularly in these days of “high-powered” medicine where so much more is known about disease and treatment, there is very little help. As I have been mentioning in the previous postings, “patient’s best interest” has a number of connotations. One definition that is used in cases of an unconscious patient without a surrogate or an advance directive, either of which can shed some light on patient desires, is “what an average or ordinary person might decide is in his/her best interest.” And how do we know what an average or ordinary person might decide? Well, it ends up being the opinion of those making the decision for the patient!

And here is the ethical dilemma that faces virtually all hospitals and their medical staffs, what is the fairest and most ethical and legal way for a physician to start treatment or terminate treatment in such an unconscious patient? It should be noted that in an emergency where a person’s life might be at stake and the patient is not able to communicate, physicians have the right and duty to do what is necessary to preserve life even without informed consent. But what if the situation is not emergent? What if the situation is a patient in whom the physicians on the case find that further treatment will not accomplish the medical benefit or that it wouldn’t provide the quality of life that an average person might expect? What should the physician do? This is the area of ethics in medicine in which most hospitals are still contemplating and trying to figure out guidelines to help their physicians. What are your views on how to solve this problem? ..Maurice.

Physician Wearing Two Hats and Patient's Best Interest (2)

Another important example of the kind of potential conflict of interest which can occur is written by Steven H. Berger, M.D. in the Psychiatric Times June 1998 Vol. XV Issue 6. It deals with the issue of ethics in forensic psychiatry. This excerpt describes the situations in which the conflict can occur.

"Dual agency also occurs when: 1) A company psychiatrist owes a treatment duty to his patient-an employee of the same company-and a simultaneous obligation to the company to return the patient to work immediately; 2) a military psychiatrist owes a treatment duty to his enlisted patient and a simultaneous duty to the military to maintain security; 3) a jail psychiatrist owes a treatment duty to his inmate patient (who is awaiting his trial) and a simultaneous duty to the state to get a confession from the inmate; 4) a state-employed psychiatrist owes a duty to the best interest of his death row patient and a simultaneous job assignment to get the execution done. Clearly, the two roles of the psychiatrist in these examples conflict with each other."

To read more about this example of a physician wearing "two hats" go to this link to read the entire article

Monday, December 13, 2004

Physician Wearing Two Hats and Patient’s Best Interest

The doctor’s duty, by law, to report to authorities evidence which may be related to criminality in the patient history such as gunshot or stab wounds or other trauma or alcohol or drug blood levels is an example of a physician’s potential conflict of interest. This conflict can deny their professional goal of providing care that is in their patient’s best interest. The physician is faced with a decision of protecting his/her own self-interest by abiding by the law or following the professional ethical standards of patient confidentiality and attempting to ensure the patient’s best interest. But would the physician’s ignoring the longer-term psychosocial implications of the gunshot wound or drug level by treating the immediate problem be really in the patient’s best interest? (This again sets the question of the definition of “patient’s best interest”. Is it the goals, values and decisions of the patient or the perhaps paternalistic definition by the physician?)

One view of the work of physicians is that as part of the privileges that society has given to them is to be responsible not only to the patient but also to protect the health and safety of the greater community. The requirement of physicians to report to health officials communicable diseases is an example. Most physicians would probably not disagree with that duty. Reporting suspected child or elder abuse may pose difficulties at times since the physician may be unsure whether true abuse has really occurred and may worry about the consequences to innocents of his/her reporting.

There is, on the other hand, another view that the role of the physician as desired by society is one of healing the patient and not the simultaneous role of a policeman—“wearing of two hats”. Physicians are instructed by professional societies to avoid entering into situations where they may compromise their responsibility to the patient by the other role such as participating in the medical evaluation of prisoners scheduled for execution or in the execution process itself.

This posting provides an example of another conflict of interest that plagues physicians. I have noted others in previous postings and will likely describe others later. ..Maurice.

Saturday, December 11, 2004

More on Patient's Best Interest or Is It the Physician's Interest?

As I implied in the previous posting, the physician does experience a conflict of interest when deciding what to do with his/her patient's request. Issues regarding denial of the request deal with concern about an "angry" or difficult or non-complient patient to manage in the future, loss of a patient to another physician, and finally malpractice suit by the patient or family for failure to diagnose or treat. Thus some physicians may feel it is really in their own best interest to agree to the patient or family's request. This has led, for example, in terminally ill patients,within intensive care units, apparent physician denial of the fact that the patient is dying and that any of the multitude of treatments and life-support being provided is futile with regard to any recovery. Full cardio-pulmonary resusitation in case of a cardiac arrest is continued despite the fact that this traumatic procedure usually does nothing than break ribs or may occasionally prolong the dying process. Often the physician may speak to his/her colleagues about a "no hope" prognosis but refuse to write this opinion in the chart or write orders appropriate for that prognosis. Interestingly, it is often the nursing staff who recognize the irrational decision-making by the physicians and bring the matter to hospital ethics committees for resolution. Extreme examples of the influence of family's requests to physicians and hospitals include those requests which have led to patients who are dead taken home by the family with ventilation machines working. In all these examples, whose interest is being served: family, physician, hospital?-- certainly not that of the patient. ..Maurice.

Friday, December 10, 2004

In the Patient’s Best Interest: But Within What Limits?

It is said that the physician has a fiduciary responsibility to the patient. This means that the doctor must keep the trust of the patient. In that regard, the patient retains a trust that the doctor will always be making decisions and caring for the patient in the “patient’s best interest”. This would meet the ethical requirement that the physician’s acts be consistent with beneficence to the patient. But what does “patient’s best interest” really include and should, indeed, there be limits to the extent of those professional actions?

One question might be: under what conditions, if any, should a physician consider a responsibility to the patient’s family, to other parties including society in general? Should the physician’s concern at the bedside be only for that ill person lying in the bed? How does the “patient’s best interest” actions conflict with professional standards of medical treatment, established laws, responsibilities of shepherding common resources especially if they are scarce in order to enable the ethical principle of justice in the distribution of those resources?

Is “patient’s best interest” to placate the patient to prevent unpleasant or even unhealthy emotional turmoil? Or is it an expression to emphasize the exclusion of actions of self-interest by the physician for his or her actions? Many questions—but, in practice, these issues abound. Take these common examples and decide for yourself how the physician should respond or act. The patient wants an antibiotic for a viral respiratory illness that has been shown not to be improved by antibiotic treatment. The patient wants a medical excuse from jury duty or wants the physician to authorize a disabled parking permit when none is medically indicated. The patient, surrogate or family request a test, treatment or life-support, perhaps to produce a miracle response, when any of these requests would be a medically futile action for the patient’s condition based on known scientific knowledge and standards of practice Would it be right to deny all these requests? Would “best interest” be satisfied by educating the patient about scientific facts, the law, about ethical behavior, about social demands and requirements?

How do physicians know what is in the patient’s “best interest” if they never did or were unable to ask the patient what were the patient’s own view about needs and goals? Or is “best interest” only something the physicians know? And if the physician knows and acts, should there be limits to that action? ..Maurice.

Thursday, December 09, 2004

What Should Medical Students be Called--Revisited

This posting is a revisiting as an ethical issue of a situation in medical education which was first considered here on August 7, 2004 (scroll down this page if you want to read it.) The view today is written by a medical student herself for a class discussing ethical issues. Jennifer Piel is a second year medical student at the University of Southern California Keck School of Medicine. Jennifer will have any comments on her essay by visitors to this blog accessible to her. Thanks Jennifer for allowing me to post your words here. ..Maurice.

A problem that I have seen repeatedly at the hospital and in situations in community practice is the scenario in which a practicing physician introduces a medical student as a “doctor.” Addressed here are some of the ethical issues presented by the scenario.

Students Placed in Awkward Position

When a supervising physician introduces a medical student as a “doctor,” it places the student in an awkward position. Most likely, a physician makes these introductions to encourage trust between the student and patient. Nevertheless, it places the student in an uncomfortable position to correct the physician and inform the patient of the mistake.

Although the student should take responsibility to correct the statement of mistaken identity, it may be difficult for the student to confront his/her supervisor, particularly when the physician would feel that the student is undermining his/her authority or intentionally being confrontational. The student may be correct in recognizing an ethical conflict, but feel prevented from addressing the issue out of fear of reprisals from the physician.

Similarly, the student is placed in the difficult position of addressing the issue with the patient. Some students may fear that correcting the issue of mistaken identity will result with the patient refusing care by the student. However, even if some subset does refuse student care, many patients will likely be quite willing to allow appropriate student involvement in their care, In my opinion, the fact that some patients decline student care is no justification for deliberately misleading them.

Moreover, clarifying the mistake with the patient will likely preserve trust between patient and student, if the patient realizes that the student is trying to be honest and straight-forward.

Effect on Patient Decisions

When a medical student is introduced as a doctor, particularly when the student is going to be involved in the patient’s care, it prevents the patient from making informed health care decisions. Not only does this scenario present ethical concerns, but legal concerns as well.

The first issue here involves the student holding himself/herself out as a physician. To respect patient decision-making autonomy, there should be a free exchange of material information between the patient and student. Autonomy is a key ethical consideration, focusing on the right of self-determination. It is grounded in the idea that patients should have control over their personal decisions. Accordingly, it is appropriate to disclose to the patient that the physician-in-training is, in fact, a student.

It may be argued that the principle of beneficence should be the key ethical consideration in situations involving medical care. The principle of beneficence commands that benefits to individuals and society be maximized and that harms be minimized. Under this principle, one could argue that it is in the patient’s best interest to identify the student as a physician because, then, the patient is not burdened with potentially troubling information. Some patients are likely to consent to student care, but subsequently feel uncomfortable with the student’s level of knowledge or skill. This argument begs the conclusion that, because the patient would have consented to the student care, the patient is subject to less harm when the student’s true identity is withheld.

A number of flaws exist with this latter line of reasoning. To begin with, it is naïve to suggest that we could benefit a patient by withholding relevant information. Patients would likely prefer that their health care professionals are honest with them. As mentioned above, the patient may justifiably feel disrespected. This could cause the patient to mistrust other members of the hospital’s staff. Additionally, to even minimally respect a patient’s autonomy, health care providers should give the patient the option to refuse care. Even patients that would consent to student care should be asked.

In situations where a student is held out as a doctor, a second issue concerning the patient’s decision-making is brought into question. In this situation, the patient will not know to ask, nor be informed, whether the procedure or care in question is ordinarily provided by a student. Like the failure to disclose the student’s true identity, failure to adequately provide the patient with this information inhibits the patient from making a fully-reasoned decision. It could be that the patient would have agreed to the student performing the procedure, subject to certain conditions, such as an experienced physician being present or that the procedure be conducted in a particular manner. Alternatively, the patient might have agreed to student participation, but, upon hearing that a particular procedure is not a routine responsibility of medical students, decide that he rather have a physician perform the procedure after all. This illustrates the situation where the patient is unaware that the student’s competency is even a question to consider.

In terms of the law surrounding informed consent, physicians have a duty to disclose and ensure that patients understand all information material to the patient’s decision to undergo or deny particular medical attention. A physician who fails to fulfill these requirements may face liability under a simple negligence theory. Further, medical personnel who perform medical procedures without gaining proper consent may be liable for civil battery. Although courts disagree as to whether informed consent cases should be evaluated from a patient-oriented or physician-oriented approach, it is risky in either case to mislead a patient about the identity and skill-level of an individual treating the patient. This information is likely material.

Facilitating the Unauthorized Practice of Medicine

As a society, we have established regulations to prohibit non-physicians from practicing as doctors. We do this to protect the public from incompetent or unethical performance of medical services. It further serves to protect the integrity of the medical profession. Because patients often cannot distinguish between their doctors, medical students, and other health care personnel, it seems imperative that providers make specific efforts to minimize any confusion.

Although students practicing under the supervision of a licensed physician are generally protected from claims of unauthorized practice of medicine, this may not hold true where a student holds himself/herself out as a physician and/or the student is not adequately supervised. A physician may not delegate ultimate responsibility for providing medical care to an assistant. Such delegation is appropriate only when it is consistent with the assistant’s training and education.

The legal case of Oliver v. Sadler (Jury Verdicts Weekly, Oct. 7, 1994) involves a similar situation to the illustration presented here. In that case, a patient was seen by a physician assistant. When the treatment proved harmful, the patient sued Dr. Sadler, in part, because he misrepresented his physician assistant as a physician. It was argued that the patient assumed the physician assistant was a doctor because he wore a white coat and had a stethoscope. This presents the very picture of medical student and underscores the need to accurately identify for the patient the individuals who are involved in the patient’s care. Isn’t it unethical to foster patient confusion?

This essay highlights some of the ethical issues faced when a student is introduced to a patient as a “doctor.” It is unrealistic to expect that this situation will never again occur. Accordingly, it is advised that students and their supervising physicians speak openly about the student’s status, role, and responsibilities before being introduced to a patient.

Tuesday, December 07, 2004

"Medical Miracle" and the Other Side of the Coin

To present a different view regarding the question "what is a medical miracle?", I have extracted a small portion of a paper written by Boguslaw Lipinski, Ph.D., D.Sc. and to be found at the Faith and Culture website. Go there to read the entire paper titled "Christian Roots of Western Medicine" Also it would be most interesting to read what my visitors to this blog have to say about medical miracles. So.. comment! ..Maurice.

What is a medical miracle? There is a religious meaning, a lay meaning,
and what we shall call a scientific meaning. We define a scientific miracle an
event that has an extremely low probability of occurring. Such miracles are well
known in medicine, but generally physicians call them spontaneous remissions.
Scientific, or medical, miracles do not need any explanation: their occurrence is
explained by statistical probabilities. In other words, miracles - in our scientific
sense of the word - are definitely part of scientific thinking. (Berry RJ: “What to
believe about miracles.” Nature, 1986;322:321-322.)
In 1984 fourteen signatories, all of them professors of science in British
universities, submitted a letter to the Times about miracles (The Times, 13 July
1984). They asserted that:" It is not logically valid to use science as an argument
against miracles. To believe that miracles cannot happen is as much an act of
faith as to believe that they can happen. We gladly accept the virgin birth, the
Gospel miracles, and the resurrection of Christ as historical events. Whatever
the current fashions in philosophy or the revelations of opinion polls may
suggest, it is important to affirm that science can have nothing to say on the
subject. Its 'laws' are only generalizations of our experience." The authors have
exposed the fallacy of Hume's attack on miracles based on an assumption that
events have only a single cause and can be explained if the cause is known. "
This is logically wrong. For example, an oil painting can be 'explained' in terms
either of the distribution of pigments or the intention and design of the artist. In
the same way, a miracle may be the work of (say) a divine up -holder of the
physical world rather than a false observation or unknown cause. The authors
quote Medawar (Medawar P. The Limits of Science. [Harper&Row, New York,
1984]) who said: " There is then a prima facie case for the existence of a limit to
scientific understanding." Most of our anxieties, problems and unhappiness
today stem from a lack of purpose which were rare a century ago and which can
fairly be blamed on the consequences of scientific inquiry.

Sunday, December 05, 2004

A Miracle Drug for an Advertising Generated Condition?

Could this be an example of a drug company advertising a miracle drug to be used for a condition which the advertising itself generates by its advertising to normal adults? Maybe. If you didn't watch CBS 60 Minutes tonight, here is the link to the full text and an introductory excerpt is copied below. ..Maurice.

(CBS) The use of drugs to treat children who are disruptive or inattentive in school -- children with attention deficit disorder (ADD) -- has been highly controversial for decades.

The assumption was that with treatment, kids with ADD outgrew the condition. But as Correspondent Morley Safer reports, the disorder isn't just for kids any more.

Adult ADD has created a whole new market for the drug industry, which claims that 8 million American adults now have this mental illness.

And at least one drug maker claims that a simple six-question quiz can give a strong indication whether an adult has ADD or not. Are you impulsive, restless, indecisive? Adult ADD is quickly becoming the disease du jour.