Bioethics Discussion Blog: May 2005





Monday, May 30, 2005

Viagra/Sex Offenders:"Leave prescriptions to the doctor"

Laura Berman, Ph.D., is a sex therapist, director of Chicago's Berman Center writing her column in the Chicago Sun- Times supports my view about physicians prescribing Viagra to former sex-offenders. Dr. Berman writes: "In my clinical experience, healthy sexual encounters are actually a key part of a sex offender's successful recovery. They teach the sex offender to refocus his desire on an appropriate subject. Some convicted sex offenders have been in treatment for decades, with no recidivism. To deny them access to a normal sex life -- as refusing them treatment for erectile dysfunction would do -- would be counterproductive. Rather than aiding and abetting a sex offender, it's more likely that Viagra is being prescribed to those in a healthy, consensual relationship who are experiencing erectile dysfunction." She encourages that physicians, aware of the patient's prior sexual behavior, do the prescribing to the individual patient and not the politicians. ..Maurice.

Friday, May 27, 2005

Viagra/Sexual Offenders:Is the Government Going Off "Half-Cocked"?

Is it possible that our government, in response to the current
brouhaha about Viagra prescriptions to former sexual offenders, is initially behaving
like our government did in the Terri Schiavo case.. first acting out of their
"heart" and not from using their "brains"? Because what is really needed is
a little biology instead of gross politics.

It is very important, in order to
understand whether the ethical principles of beneficience and justice are
being denied some or all of these former offenders, to know what is understood as
to the pathogenesis of their illegal behavior and whether the behavior was
related to either organic or psychologic erectile dysfunction. Specifically,
whether these men have had problems with the ability to attain or maintain an
erection which then led to impaired socially acceptable sexual activity. I have
read that most of the molestation of children is manifiested by fondling
rather than penetration. Could this be an important fact? In cases of rape of
adults, do we know that normal penetration has occurred in most cases? What
symptoms did the former sex offenders present to their physicians and what were the
physical findings that led to a prescription being written for Viagra? Maybe correcting the erectile problem will mitigate the illegal behavioral problem? I really don't know. But someone may or will know.

Therefore, it may be wrong (and for the affected patients non-beneficent and unjust) to just assume that because Viagra is used in sexual activities, it will stimulate the wrong sexual behavior and therefore some patients should not be able to receive it--at government expense or even otherwise. My suggestion is that these and other questions should be answered by those who know and our government shouldn't be going
off "half-cocked" to speak. ..Maurice.

Addendum 5-28-2005: Just in case you didn’t think about it, as a consequence of the findings that sex-offenders in many states were receiving Viagra through Medicaid, Congress is now preparing to terminate Medicaid payments for erectile dysfunction medication. This would deny effective medication for the poor to engage in a healthy family behavior thus go against the declared administration goal to encourage family values. And curiously, in addition, this act would likely prevent potential pregnancies and therefore go against the declared administration goal to promote life. Oh well, there is no consistency to politics. ..Maurice.

Wednesday, May 25, 2005

President Bush: How Do You Explain Two Issues?

Mr. President Bush, I’ve got two issues to pick with you and I would appreciate hearing the answers. I have been thinking about them for the past several days and lo and behold, the questions popped up today on a bioethics listserv to which I subscribe. Perhaps you will be able to explain them to me and us in non-political terms. OK? [Note: Each issue was written by a separate ethicist and I have excerpted their words, in quotes, in a way to fit the context of my posting but the meaning and significance of their questions are unchanged.]

If you are “so concerned with embryos why is no one trying to make it illegal for IVF clinics to destroy embryos in the first place? Shouldn't they be up in arms about that if they are opposed to using them for research? … if this concern for embryos were well thought out, the same people would want to require that all ‘leftover’ embryos be adopted and implanted or at least not destroyed.”

And the other issue..

President Bush, you seem to be against the concept, as the listserv writer put it, “the noble aspiration [finding cures through use of embryonic stem cells] to justify the
ignoble action [killing of 'our embryonic cousins']. … No matter how promising the
ends, we must not use immoral means to achieve them.”
Now, Mr. Bush, might you not apply your, as the listserv writer continued, “strict moral principle as well to real-live
human beings - say, with regard to the killing in a ‘preemptive’ war,
as in Iraq.”? “Substitute the word ‘Iraq’ for ‘embryonic stem cells:’
‘The noble aspiration [finding weapons of mass destruction, deposing
a dictator, saving future lives - whatever one that's au courant] to
justify the ignoble action [killing and destroying the lives of
innocent Iraqi citizens, American troops, and others].’ Even if the
full status of personhood were conferred on embryos, why should
conscious human beings living real lives be given less consideration?
How can they be used as means to an end, however worthy?”

Mr. Bush, many others and I would be more understanding of your stand if you could answer these questions and explain the logic. Thanks. ..Maurice.

p.s. I thank my two anonymous ethicists for their fine words which I used for this posting.

Termination of Life-Support Without Patient Request

To clarify my views on life-support described in the last posting, I want to note the situation that I didn’t really include. I wrote that it is my view (and it is the consensus in law and ethics) that a patient with capacity for medical decision-making can request and must be granted termination of life-support. To continue the support against the patient’s wishes could be considered legal battery. What I didn’t write was whether, without the permission of the patient or surrogate, life-support could be removed based on the argument of medical futility. The answer should be no if the life-support is physiologically effective and the patient finds that the current or future quality of life satisfactory since there would exist no futility issue. In an unresolved conflict between physician and patient, the courts must decide. The problem arises when the patient has no capacity to make medical decisions and there is no advance directive, no previous expression of goals and no surrogates. Life-support could be removed from such a patient on the basis that the treatment would not be expected to produce recovery to a state that a “reasonable person” might expect and a hospital ethics committee that included community members confirmed the decision of the physician to terminate treatment. The ethics of this issue is all that simple!?? Any questions? ..Maurice.

Tuesday, May 24, 2005

More On "No Right to Artificial Nutrition and Hydration"

"The most important bioethics litigation in the world today involves a 45-year-old Englishman, Leslie Burke... He isn't asking for very much. Burke has a progressive neurological disease that may one day deprive him of the ability to swallow. If that happens, Burke wants to receive food and water through a tube. Knowing that Britain's National Health Service (NHS) rations care, Burke sued to ensure that he will not be forced to endure death by dehydration against his wishes...

Why do Britain's medical establishment and government insist that Burke be denied a right to decide whether he receives tube-supplied food and water? It all boils down to two concepts that are increasingly intertwined in modern bioethics theory and practice. First is the so-called quality-of-life ethic that presumes to judge the worth of patients' lives according to their mental and physical capacities. Under this view, doctors or bioethicists may judge a life to be of such low quality that it is not worth extending, irrespective of the patient's wishes. The second issue is money -- an especially potent factor for England's increasingly strained socialized medical system."

Writing for the U.K. Weekly Standard and published online by CBS News on May 24, 2005,Wesley J. Smith, a lawyer and well-known spokesperson for the disabled presents his views of the two concepts he notes in the above excerpt. In his column, he expresses the conclusion that this case is even more important than the Terri Schiavo case in that he is concerned that our judicial system which is beginning to look to foreign decisions to guide to U.S. law, may use this British case as a source. ..Maurice.

p.s.- My view is that unless the artificial nutrition and hydration is physiologically futile, which it rarely is, whether this specific treatment is started or removed should be the patient's own decision after comparing the risks vs the quality of life to be gained. I think food and fluid decisions should be that of the patient and in all cases requests should be followed by the healthcare providers. There may be medical resistance to starting other life-supporting treatments if the physician finds the medical benefit to be nil, such as beginning dialysis in a terminal cancer patient. There may be special circumstances, such as temporary prolongation of life, which would make starting them appropriate. All life-supportive treatments should also be stopped at the patient's request. Beyond life-supportive treatments, other treatments requested by the patient should be subject to medical standards of practice.

Friday, May 20, 2005

$aving a $carce Re$ource: No Right to Artificial Nutrition and Hydration

In the Schiavo affair, there were no questions raised about providing artificial nutrition and hydration (ANH) if the patient herself wanted it to continue. The debate was whether to terminate ANH as her surrogate voiced her wishes. But when a national health service is paying the bill, there is a certain concern raised about providing ANH which was represented as the beginning of a slippery slope encouraging patients to request other “not appropriate” treatment. Leslie Burke, 45 was the patient involved. He has a degenerative brain condition and last July, in a British court, won the right to stop doctors withdrawing artificial nutrition or hydration treatment until he dies naturally. The original ruling was hailed as a breakthrough for the rights of terminally ill patients.

However the General Medical Council(GMC)which regulates medical practice in the U.K. and the Secretary of State for Health has appealed. The full article in the on May 18, 2005 tells the whole story but here are excerpts.

"A right by patients to demand life-prolonging treatment has ‘very serious implications’for National Health Service (NHS) resources, appeal judges were told today. …
Backing a GMC bid to reverse the ruling, the health department claimed that if a right to ANH was established, patients would be able to demand other life-prolonging treatments.

Philip Sales, representing the Health Secretary, told a panel of three appeal judges… ‘A general right, as identified by the judge in the High Court), for an individual patient to require life-prolonging medical treatment has very serious implications for the functioning of the NHS. It may be interpreted as giving patients the right to demand certain treatments, contrary to the considered judgment of their medical team, that would lead to patients obtaining access to treatment that is not appropriate for them, and to inefficient (and unfairly skewed) use of resources within the NHS.’”

Do you think what is unsaid here may be the concern that the ANH would be keeping patients alive too long? The case is still pending in appeal. I will try to get a followup. ..Maurice.

Thursday, May 19, 2005

More On Weeding Out Medical Ethical Misfits

"Finding oneself in the hands of an unethical physician can be a terrifying experience. How can we know whether the physician to whom we entrust our bodies and our confidences seriously lacks medical ethics? Are government and medical community safeguards effective in weeding out unsafe doctors?" So writes Philip R. Alper,Robert Wesson Fellow in Scientific Philosophy and Public Policy at the Hoover Institution in the Hoover Digest titled "Why Medical Ethics Matter". It is worth reading as we continue the discussion of the topic of weeding out medical misfits. Alper contrasts the various approaches through the centuries to establish professional behavior from the threatening Code of Hammurabi to the motivating Oath of Hippocrates and to the perhaps legally scripted American Medical Association's Code of Medical Ethics and finally to the complex recently developed Charter of Medical Professionalism. The latter, according to Alper "created by three preeminent internal medicine organizations in the United States and Europe, ... speaks in near-religious terms of 'three fundamental principles and ten commitments' (the latter actually total 36 by my count when compound sentences are teased apart) that would challenge a genius to comprehend and a saint to perform." Do you think these literal guideposts to ethical behavior accomplish what they were intended? Can you suggest other approaches to this issue? ..Maurice.

Monday, May 16, 2005

Weeding Out Medical Student Ethical Misfits: Who is Responsible to Do That?

I was stimulated by the’s link to the UK Guardian’s article about testing medical students for how well they have learned ethics and if they failed the test they should be dropped from medical school and not given the M.D. degree. I put the issue up to the ethicists on a bioethics listserv and interestingly two points of view were presented in response.

One view was the argument that the degree of medicine was nothing more than representing a technical achievement and medical schools should not be responsible for weeding out “ethical misfits or even miscreants”:

“ I propose that this task should be left to
licensing boards (just as lawyers have to pass character tests in
addition to the bar). If someone of dubious ethical constitution wants
to go out and *learn* about medicine, I don't see any reason why anyone
should object. Now, if he wants to *practice* medicine, then there is a
problem. More generally, I view a medical degree as a ‘certification of
technical merit’ (to use a phrase the DoD has been using) and object to
their being any moral prerequisites for the degree (note that the
requirement for courses in medical and legal ethics are requirements for
study, not for character).”

The other view:

“I believe that professional schools such as medical and nursing schools
have a strong, pro-active duty to "weed out ethical miscreants". There
are several reasons for this:

1) It is unreasonable to expect that this could be done at licensing. As
teachers we are in the best position (perhaps the ONLY position) to
observe behaviors that are inappropriate. There is absolutely *no*
mechanism by which a sociopath could be identified at the point of
licensing but many points during their education process.

2) The public funds a significant portion of professional education and
clearly expects that we will produce not just competent clinicians but
also decent ones. There is a very clear public expectation that a student
who exhibits truly egregious behavior will be 'culled' from the ranks.
Examples of behavior that ought to result in dismissal include patterns of
behavior (not necessarily single instances) of lying, covering up errors,
harsh treatment of patients, inappropriate interactions with colleagues
(such as yelling, demeaning comments), etc.

3) We have a duty to begin mentoring students in the fiduciary nature of
the health care relationship, and to live by our own teachings.
Professions are self-regulating. We are granted the right to practice our
professions with the agreement that *we* will insure that our clinicians
are competent. To ignore egregious behavior in students is to ignore our
professional duty to police ourselves.”

I would very much like to read comments from my visitors (including medical students) to this blog as to what they consider are the responsibilities of medical schools to society with regard to the ethical behavior and ethical knowledge of the student who may be receiving the degree of Doctor of Medicine. ..Maurice.

Friday, May 13, 2005

Taxing Cosmetic Procedures by Physicians: Is That Ethically Just?

From the Washington Times and United Press International:"California State Board of Equalization is considering a proposal to levy a tax on Botox, the prescription medication used by many men and women to temporarily eliminate their character lines. ... The Texas Legislature is considering a bill that includes a 7.5-percent tax on elective cosmetic surgery, while Washington state legislators are thinking about a 6.5-percent tax on cosmetic procedures that would be used to pay for children's healthcare."

It is interesting that state legislatures are considering to tax the professional acts or skills of physicians who do cosmetic procedures. What are the legislatures saying about these procedures? Is it that cosmetic procedures are all luxuries and deserve to be taxed. Are these considerations ethically just? And what is next? What is it that physicians do which will be taxed next in the frantic races of states to balance their budgets? By the way, I doubt those in state government will tax what lawyers do professionally since lawyers probably make up a good proportion of the legislators themselves. ..Maurice.

Thursday, May 12, 2005

In Defense of Medicine: Why Doctors Do as They Do

I would like to elaborate a bit more about the reason for satire of physicians and medicine. I hope this isn’t too rambling as I try to express my thoughts.

The satire of doctors and the profession of medicine has gone on for ages and surely it will continue to go on. Everyone will have their laughs and maybe as suggested will feel a bit more cheerful about the unknown. And I think there have been good reasons for society taking the harder look at medicine, scratching their heads and then finding humor in what they feel is the unexpected and the unwelcome part of the profession. Why is it that the public doesn’t understand doctors and their behavior?

I think there are explanations for the way doctors do their job and how they behave and the public may really not be fully aware about them. The behavior starts with consideration of the job. Becoming a doctor nowadays requires our own hard look at what we are getting into. Whether one goes to a private or a state run medical school, it is expensive. The expense has a large monetary dollar sign but also one will be spending a significant part of one’s early life just studying to be a doctor. And that studying can be at the expense of a starting family life or years of missing an income amongst other losses. The hard look also looks ahead to the career, often without stable, readily calculated working hours. Yes, many hours will be rewarding and ego-boosting as a true professional. But there will be the hours of frustration and uncertainty that are handmaidens to the doctor and his or her work. Sometimes, when busy doing doctoring, a doctor will go from a encouraging high to a discouraging low all in the same day or part of a day or even from patient to patient. And there is a lot of self-reflection. What did I do right? What did I do wrong? What will happen with the next patient? Sometimes physicians have to develop behavior techniques to mitigate those feelings that can lead to discomfort. Doctors are under observation by their patients, their colleagues and others and always at risk of getting sued for malpractice. This leads to a defensive practice behavior that may be misunderstood by the patient. These investments of money, time and emotions all affect how the doctor behaves attending to a patient.

I think that the public can’t understand what doctors are all about because they don’t know about the “split personality” that is part of being a doctor. From the very beginning of medical school out to the professional practice of medicine, we are morphed from one into two personalities. There is the white coat part of the physician who has been indoctrinated from the beginning into a guild of doctors with their own special speech, special thinking and behavior and special requirements of practice and ethics. This is indoctrination and not being simply taught to “act” as a doctor. But there is also the original personality and character of that body and mind which is still present and who simply wears the white coat at work. This “split personality” provides the basis for conflicts involving communication and behavior. Being the guardian of medical resources, those in the white coat find that a paternalistic approach to communication with patients most natural and what many doctors feel is expected. Also, with the need to care for more patients in a limited time, paternalistic communication is the more efficient. Being also a husband, wife, mother or father with family responsibilities leads at times to attempts to avoid doctoring responsibility in favor of the family. This can produce inconveniences or worse for the patients. Patients now come to expect less paternalism and more dedication of time and interest by physicians to their own complaints. When this doesn’t happen, patients may become disillusioned with the doctor.

In conclusion, I believe that the public has an image of a physician which is based on some historical character, some wise, caring, idealistic and altruistic character, which is the representation of all doctors, particularly expected in their own doctor. The patient expects the doctor to be this unified imagined character, especially when they are sick. If they see doctors as pompous, paternalistic, uncaring and greedy, intent on their own self-interest, the doctor and the medical profession becomes the subject for satire. What is missing in the understanding by the public is the fact that all doctors are as human as they are with many of the same foibles they bear. Most doctors try to create a persona that attempts to deal with and do right for the patient despite their own burdens including the burden of trying to live and practice medicine with their “split personalities”. ..Maurice.

Tuesday, May 10, 2005

More Satire of Doctors and Medicine:"So What's Wrong with a Little Fun?"

A 2004 talk at Notre Dame by William J. Cashore, M.D., Professor of Pediatrics, Brown
University about satire of the professions including medicine is available as a pdf file entitled "So What's Wrong with a Little
Fun?" at the Ethics Center of Notre Dame University. Dr.Cashore had visited my blog when I first started the satire thread on Friday May 6, 2005 and made some worth noting comments to that posting about other satirical writings directed at medicine. Here is an excerpt he selected from his Notre Dame talk to post here. ..Maurice.

Mel Brooks said recently that, "Laughter is a scream of protest against
death. When the truth is too grim to face, we turn to comedy." (NPR
interview, August, 2004)

What's it all for? As we read satire and comedy for pleasure, we also
use humor to display cleverness, expose folly, challenge authority,
sublimate envy, and express truth too painful to face. Humor can
function as non-violent subversion when our direct criticism of someone
more powerful threatens both parties. Successful satire on the
professions also depends on shared ideals between writer and reader as
to what these professions ought to represent and how their practitioners
should act.

In today's medicine, materialism, others' perceptions of success, and
various unacknowledged conflicts of interest can subtly undermine the
altruism and high professional ideals which we try to uphold. Humor can
be a very good way to highlight inconsistencies between what we think of
ourselves and what we actually do.

Monday, May 09, 2005

More Satire of Doctors and Medicine: Imaginary Invalid

The Imaginary Invalid


by Jean Baptiste Poquelin de Moliere
The adaptation is by:
Timothy Mooney

(Permission has been granted by Timothy Mooney to publish this excerpt on this blog site. To enjoy the full adaptation of this play and other Moliere plays adapted to English, go to the link above. ..Maurice.)

(ARGAN is the imaginary invalid. BERALDE is his brother. MONSIEUR PURGON is Argan’s doctor)

Let me pursue this just a little more,
You don’t believe in doctors, or their cure?

No sir, and I don’t think my soul’s salvation
Needs me to swear to doctor’s inspiration.

What! You resist the knowldege of our sages,
A truth that’s been respected through the ages?

I think, not only is it vanity
It’s mankind’s worst kind of insanity!
It is a pointless bit of flummery;
Elaborate dramatic mummery!
For greater farce, I can’t imagine other
Than one pretending he can cure another.

And why won’t you admit this can be done?

We know not just how these machines are run,
And nature will not let us know the tale,
As ‘cross the body, she has drawn a veil.

The doctors are but fools, by your account.

Oh, most of them know quite a great amount:
At letters and in Latin; they excel
Or Greek ... diseases names they know quite well.
They can define them and then classify,
But as for curing, they don’t satisfy.

But still, you must agree that in this matter,
The doctor’s discourse is not idle chatter.

They know that which I said, which won’t cure much
What they know best is just how they might clutch
The guise of truth, through dull equivocation
Purporting reasons with mere speculation,
And lending promise but not one result.

But why then, brother, do all men consult
With doctors when they’re laid up with the flu?
Most surely some are just as wise as you?

That tells the more of our frivolity,
Than it might of the treatment’s quality.

A doctor must think its good for his health,
Or else he wouldn’t use it on himself.

Well, many of them share in this delusion,
Through which, their pocketbooks receive infusion.
Your Monsieur Purgon’s one who makes great bones
About how science helps to cure your groans.
From head to toe, he’s doctor most complete,
And well believes his aptitude to treat.
He trusts in his injections’ cleansing bath,
More than he’d trust a bit of simple math!
To him, there’s nothing doubtful or obscure,
He’s confident, imperious and sure.
But do not bear him ill for what I mention,
He kills you off with finest of intention!
And doing so, he’d only lose your life,
Just as he’d kill his children, or his wife.
He’d send himself off with the same dispatch!

Sunday, May 08, 2005

The Story of an M.D. Mother on Mother's Day

"'Call on line three,' announces a voice over the intercom. I pick up the phone in the exam room, listen to the voice on the other end, and smile at the woman across from me as I answer. 'Honey, I'm sure I washed it. Did you look in your drawer on the right side under the blue top?'"

From the website of the American Academy of Family Physicians read the story by Carla Jardim, M.D. of life as a family medicine physician but also as a mother. It's worth reading on this special day for mothers.

Happy Mother's Day to all the mothers and particularly those who are also physicians in practice. ..Maurice.

Saturday, May 07, 2005

Popularity by Physicians as a Basis for Patient Drug Prescribing: Is That Good Medical Practice?

I have already complained about the misleading and incomplete information presented to the public by pharmaceutical companies in their direct-to-consumer advertising. Now I want to present an example of misleading information being presented to physicians in medical journal advertising.

In the current May 5, 2005 issue of the New England Journal of Medicine, there is an advertisement for physicians by Pfizer regarding their cholesterol lowering drug Lipitor.
The lead title says: “According to a recent physician survey Lipitor is the #1 choice of physicians (especially when they need treatment).” The graphic of the ad shows a friendly appearing middle aged black physician (whom I presume is one of those who is need of Lipitor treatment.) The text of the ad follows: “Lipitor is the world’s #1 prescribed treatment for patients with dyslipidemia. And now—according to a recent survey of physicians who take a prescription medication for their own dyslipidemia—Lipitor is far and away their #1 choice, too. So when you choose Lipitor for your patients (or maybe even yourself), you should know that you’re in extremely good company.”
This text is then followed by a trademarked tag line “Health takes Lipitor”.

My concern about this ad for physicians is that it is not providing the scientific basis for prescribing the drug for their patients as the main point of the ad, but instead is using the pitch that because other doctors take the drug for their own use, this information should be included in the decision to prescribe Lipitor for patients. This is totally misleading. The number of persons taking a drug has nothing to do with its efficacy or safety.. Should I remind our visitors of the Vioxx and Celebrex safety concerns despite the millions of users who were taking the drugs? Further, whether physicians themselves are Lipitor users is immaterial with regard to prescribing it to others. We don’t know what motivated each physician in the survey to take the product. Was the drug available gratis from the pharmaceutical company for physicians? Was it based on comments from pharmaceutical company reps during their office visits? Was it because a colleague was using the drug?

It is my opinion, that while we do practice medicine by the numbers: cholesterol, LDL, HDL, triglyceride fasting blood levels, blood sugar levels, patient’s age, number of family members with cardio-vascular disease or diabetes as examples, we don’t or shouldn’t practice medicine based on popularity numbers either related to the public or ourselves.

I welcome and hope for a comment by a representative of a pharmaceutical company or Pfizer to present a defence to my comments that I can publish on this blog. ..Maurice.

Friday, May 06, 2005

Satire of Doctors and Medicine: An Appropriate Therapeutic Potion?

I think that the medical profession is deserving of satire. Doctors are looked to for help with personal illness. Any personal illness is loaded with uncertainty even if it is more or less trivial. "Can I get over this cough to go the the concert tomorrow?" "Does this runny nose mean I am going to have a permanent allergy?" "What does this cough and runny nose mean? Do I have pneumonia?" And with these concerns and even more deadly questions including those regarding death itself, we go to the doctor for that help we need. But the doctor is still a mysterious entity even and perhaps even moreso in this age of consumerism. Consumers no long take the physician for granted as they did over 50 years ago. Do we all know who can become a doctor? What does it take to become a doctor? Do doctors follow any rules? Do they have ethics? What are the ethics? Are they trained for "bedside manner"? How do they make their money? Do they order things or schedule repeat visits to make more money? What is the doctor thinking about when the doctor asks those personal questions or examines me? Are they interested in me or some other interest? ..and so on.

Satire (the use of ridicule, sarcasm, irony, etc. to expose, attack, or deride vices, follies, etc.) is a way to nervously express the uncertainties one faces when confronted with a personal illness and their personal physician. I have found a great article on medical satire in the British Medical Journal 1994;309:1714-1718 (24 December)titled "Dr Doubledose: a taste of one's own medicine" by Roy Porter. (Note: the link to the full article may be available only to those who subscribe or who have institutional library permission.)

As an example, from the article, of the concerns of those in the 18th century when "doctors were taunted with caring only for their fees" is the satiric verse of 1714 by Bernard Mandeville, himself a practitioner within "The Fable of the Bees".

"Physicians valued Fame and Wealth
Above the drooping Patient's Health,
Or their own Skill: The greatest Part
Study'd, instead of Rules of Art,
Gave pensive Looks, and dull Behaviour;
To gain th' Apothecary's Favour,
The Praise of Mid-wives, Priests and all,
That served at Birth, or Funeral."

Another example of satire of doctors is in the "The New Yorker Book of Doctor *(*and psychiatrist) Cartoons" published by Alfred A. Knopf 2003. Actually, a number of the cartoons are literally a satire of patients since I guess as patients we also deserve a bit of mockery. What has all of this got to do with medical ethics? I think satire also reflects the ethical misbehavior of physicians or the misinformation about the ethics of the profession as received by patients. In either case, there is a need for improvement. In conclusion, it may be that writing and reading satire of doctors and medicine provides us all with a therapeutic potion for what concerns ails us when we get sick. What do you think? ..Maurice.

Wednesday, May 04, 2005

Whose Right to What Life?

The National Right to Life organization has currently proposed a model legislation to be used by individual states in the U.S. which would deny any "guardian, surrogate, public or private agency, court, or any other person … the authority to make a decision on behalf of a person legally incapable of making health care decisions to withhold or withdraw hydration or nutrition from such a person…” This would be based on the presumption “ … that every person legally incapable of making health care decisions has directed his or her health care providers to provide him or her with nutrition and hydration to a degree that is sufficient to sustain life.” The exceptions, beyond the physiologic, would be “if the person executed a directive in accordance with [the state advance directive statute] specifically authorizing the withholding or withdrawal of nutrition and/or hydration, to the extent the authorization applied.” or “ if there is clear and convincing evidence that the person, when legally capable of making health care decisions, gave express and informed consent to withdrawing or withholding hydration or nutrition in the applicable circumstances.” As I read the proposal, substituted judgment, now legal and ethical in many states, would no longer apply to termination of food or fluid but would require “clear and convincing” evidence to do so. Is this legislation really in the best interest of the incapacitated patient or for promoting the further interest of organizations such as the National Right to Life? The entire model is reproduced below. ..Maurice.


Section 1. Short Title
This act shall be known and may be cited as the [STATE NAME] “Starvation and Dehydration of Persons with Disabilities Prevention Act”.
Section 2. Definitions
A. “Attending physician” means the physician who has primary responsibility for the overall medical treatment and care of a person.
B. “Health care provider” means a person who is licensed, certified, or otherwise authorized by the law of this state to administer health care in the ordinary course of business or practice of a profession.
C. “Express and informed consent” means consent voluntarily given with sufficient knowledge of the subject matter involved, including a general understanding of the procedure, the medically acceptable alternative procedures or treatments, and the substantial risks and hazards inherent in the proposed treatment or procedures, to enable the person giving consent to make an understanding and enlightened decision without any element of force, fraud, deceit, duress, or other form of constraint or coercion.
D. “Nutrition” means sustenance administered by way of the gastrointestinal tract.
E. “Person legally incapable of making health care decisions” means any person who:
1. Has been declared legally incompetent to make decisions affecting medical treatment or care, or
2. In the reasonable judgment of the attending physician, is unable to make decisions affecting medical treatment or other health care services, or
3. Is a minor.
F. “Physician” means a physician licensed by [relevant state statute].
G. “Reasonable medical judgment” means a medical judgment that would be made by a reasonably prudent physician, knowledgeable about the case and the treatment possibilities with respect to the medical conditions involved.
Section 3. Presumption of Nutrition and Hydration Sufficient to Sustain Life
A. It shall be presumed that every person legally incapable of making health care decisions has directed his or her health care providers to provide him or her with nutrition and hydration to a degree that is sufficient to sustain life.
B. No guardian, surrogate, public or private agency, court, or any other person shall have the authority to make a decision on behalf of a person legally incapable of making health care decisions to withhold or withdraw hydration or nutrition from such a person except in the circumstances and under the conditions specifically provided for in Section 4 of this act.
Section 4. Presumption of Nutrition and Hydration, When Inapplicable
The presumption pursuant to Section 3 of this act shall not apply:
A. To the extent that, in reasonable medical judgment:
a) provision of nutrition and hydration is not medically possible,
b) provision of nutrition and hydration would hasten death, or,
c) because of the medical condition of the person legally incapable of making health care decisions, that person would be incapable of digesting or absorbing the nutrition and hydration so that its provision would not contribute to sustaining the person’s life.
B. If the person executed a directive in accordance with [state advance directive statute] specifically authorizing the withholding or withdrawal of nutrition and/or hydration, to the extent the authorization applies.
C. If there is clear and convincing evidence that the person, when legally capable of making health care decisions, gave express and informed consent to withdrawing or withholding hydration or nutrition in the applicable circumstances.
Section 5. Civil Remedies
A. A cause of action for injunctive relief may be maintained against any person who is reasonably believed to be about to violate or who is in the course of violating this act, or to secure a court determination, notwithstanding the position of a guardian or surrogate, whether there is clear and convincing evidence that the person legally incapable of making health care decisions, when legally capable of making such decisions, gave express and informed consent to withdrawing or withholding hydration or nutrition in the applicable circumstances.
B. The action may be brought by any person who is:
(a) The spouse, parent, child, or sibling of the person;
(b) A current or former health care provider of the person;
(c) A legally appointed guardian of the person;
(d) The state protection and advocacy agency, or
(e) A public official with appropriate jurisdiction to prosecute or enforce the laws of this state.
C. Pending the final determination of the court, it shall direct that nutrition and hydration be provided unless it determines that Section 4A is applicable.

Tuesday, May 03, 2005

The Meddling Has Ended

I guess the 13 year old pregnant Florida girl under the guardianship of the Department of Children and Families is going to have her abortion as she requested. Yesterday, the Juvenile Court judge decided that the girl was competent to make her decision for abortion and that the abortion would not cause her mental or physical harm. And today Governor Jeb Bush indicated there would be no further legal appeal from the Florida government. So the girl can get out of the spotlight and the Department can get on with their job of providing a permanent safe placement for her. I think that Governor Bush has learned something from the Schiavo case in which he was heavily involved. There are times when a politician must give up being a judge and let the legal system work its way until the politicians decide after diligent review to change the law. And that is what may be happening in Florida. The Florida state Legislature is moving a bill through committees to require notification of parents or guardians when girls seek abortion. In 2003, the Florida Supreme Court struck down a 1999 law requiring parents to be notified if their minor daughters seek an abortion. ..Maurice.

Sunday, May 01, 2005

"The Troubled Living Don't Matter as Much as the Yet-to-be-Born"

Continuing on with the lack of ethical behavior of the Florida Department of Children and Families (DCF) as a reflection of a confusion of what are the priorities regarding the humanitarian issues in life, the born vs the unborn.

Howard Goodman writes in his column in the South Florida Sun-Sentinal a commentary which I wish I had the skill to write. Read it. Here is an excerpt:

"L.G. is the young teen under DCF care who, 14 weeks pregnant, has been halted from getting an abortion.

DCF is claiming to be motivated by a concern for the young lady's health and psyche.

Which is very touching, seeing as the girl has run away from state-supervised homes at least five times. She went missing for a month when she got pregnant.

DCF was so deeply concerned that no one notified Palm Beach County Juvenile Court that she was gone, something that's understandably angered Circuit Judge Ronald Alvarez. DCF does say it told the local Sheriff's Office.

But as is so often the case with anti-abortion forces, the troubled living don't matter as much as the yet-to-be-born.

So DCF -- reflecting the 'culture of life' leanings of Florida's governor and legislative leaders so recently showcased in the Terri Schiavo case -- roused itself from its torpor regarding L.G. with an urgent, proprietary interest in the welfare of her womb."

The entire column speaks for itself. Now we must wait and see what the 4th District Court of Appeals has to say on the issue. ..Maurice.