Bioethics Discussion Blog: March 2013





Thursday, March 28, 2013

Same-Sex Marriage: Is It Ethical?

While currently, in the United States, the issue of same-sex marriage is holding attention of the public and the United States Supreme Court, it is a settled matter in a number of other countries (Argentina, Belgium, Canada, Denmark, Iceland, Netherlands, Norway, Portugal, Spain, South Africa an Sweden)
An excellent description of same-sex marriage and its views around the world with links to further detailing of the subject can be found in Wikipedia.

In a writing by Peter Sprigg sponsored by the Family Research Council  titled "The Top Ten Harms of
Same-Sex 'Marriage'" the following alleged "harms" are outlined.
1.Taxpayers, consumers, and
businesses would be forced to subsidize homosexual relationships.
2,Schools would teach that homosexual relationships are identical to heterosexual ones.
 3.Freedom of conscience and religious liberty would be threatened.
4.Fewer people would marry.
5. Fewer people would remain monogamous and sexually faithful.
6. Fewer people would remain married for a lifetime.
7.Fewer children would be raised by a married mother and father.
8. More children would grow up fatherless.
9. Birth rates would fall.
10.Demands for legalization of polygamy would grow.

The question for my blog is whether my visitors consider that same-sex marriage is an ethical act. Does it do good and is it fair and just?  To help in making the decision, read the brief summary of how to make an ethical decision by the Markulla Center of Santa Clara University.  Remember ethical decisions sometimes may have one principle trump others having lesser ethical significance for that particular issue. Take a few minutes and read at the above links and return here and express your analysis or if you already have considered your response write it now.  ..Maurice.

Graphic: From Google Images and Christian Medical Comment, modified by me with Picasa3.

Friday, March 22, 2013

Who Should Be Held Responsible for Your Unhealthy Lifestyle?

Unfortunately, unhealthy lifestyles are all around us and maybe even some of them belong to us. I
am writing about eating practices leading to obesity and associated diabetes or heart disease,
smoking leading to chronic lung disease and cancer, alcohol abuse leading to liver disease and
mental illness along with drug habituation leading to numerous consequences. There are other
unhealthy lifestyles that one can suggest.

There appears a basic question when considering the ethics and responsibilities related to unhealthy
lifestyles.  Who is primarily responsible for the individual's pathology and its consequences? And
beyond the patient bearing the physical or psychological costs of the illness itself,should others
be considered as responsible toward continuation of that style or the monetary costs and other
impacts regarding medical care which result from that patient's lifestyle? Should parents,
politicians, physicians, manufacturers, media or society in general be responsible for either
promoting the starting of the bad health habits or failure to educate or prevent such habits and
therefore bear the costs.

On the other-hand if,in fact, lifestyle selection and its continuation is really being set by the
individual's genetics and that development of an unhealthy lifestyle is simply an immutable matter
initiated and continued by the individual's genes does that mean that neither the individual or
anyone else can be pointed at as being responsible?

In selecting to post this thread, I wasn't really thinking of going deeply into the philosophical
or political aspects of unhealthy lifestyles (for that you might want to read an article
"Lifestyle, Responsibility and Justice" by E.Firing in the Journal of Medical Ethics 2008 and which
can be obtained by this link), what I wanted is for my visitors who, for examples, continue to
smoke or who are obese and avoid dieting, tell us who they feel could be considered responsible for
the consequences of their life style and why.  ..Maurice.

p.s.- By the way, on another issue, is it right for doctors to use the word "obese" when telling a
patient who meets the medical definition of obesity? Maybe this topic will be for another thread
like "What words doctors should not speak to their patients?"

Graphic: From via Google Images

Monday, March 18, 2013

Patient-Doctor Texting Each Other: Should They Do It?

Are you texting your doctor and is your doctor texting you back? I have been
surprised reading about the extent to which the social activity of smart phone
texting has become some part of medical practice. Read about it in the
New York Times. Look at statistics in the Atlantic. And see a communication company's
statement about the financial value for texting in medical practice.

It sounds like a wonderful and practical addition to the providing of medical
care and particularly care for patients in the ages known to avidly text as part
of their daily activities. But is texting while treating or being treated really
and fully a "medical good" or contains issues and hazards, bad outcomes, which
have been documented with texting while walking or driving or other activities?
Instead of distraction, a recognized hazard, texting by and to patients in
medicine can lead to other concerns. One obvious concern, that of medical
privacy, as directed in the United States HIPAA regulations, would be knowing
exactly who is texting who. Also, is there any assurance of medical privacy of
all communication when texting with our current technology? Finally, there is the
issue of what should and what shouldn't be texted between patient and doctor. A
request for an appointment with the doctor and a reply might be one use and could
be acceptable. But how much more than that? And beyond texting is doctor-patient
participation in other social media interactions such as Facebook an ethical way
of communication? (But that is for another thread.. here, lets stick to texting.)

Communication within a doctor-patient relationship can be a complex process with
subtle nuances, particularly in dealing with symptoms, disease and treatment.  There
are many important subtleties in direct communication which are not just verbal but also involve
facial expressions and other body language and touch Communication of clinical issues
by normal phone talk are devoid of such essentials and certainly with texting and only
a few text characters there is no possibility for more detail of a patient's attitude and feelings and expressions of concern, understanding or uncertainty or cooperation except with "LOL" type characterizations.

Read the links above and then come back and write about your thoughts about the
benefits or harms to texting either by the patient or the doctor. And by the way,
on this blog, unlike most smart phone texting, your comments can contain up to
4096 characters! ..Maurice.

Graphic: From Google Images

Friday, March 15, 2013

CPR on a Loved One: Should/Would You Watch?

There has been much debate over the recent decades since cardio-pulmonary resusciation (CPR) has
become the established medical response to when a heart stops pumping about whether it
was appropriate for both a family member or the medical staff to have a family member present
and observe that procedure. The debate has mostly been amongst the medical professionals themselves
who are involved in the CPR procedure. However, whatever studies have been performed to try to clarify an
answer to the question overall tend to favor and not discourage family attendance. A current statistical study of the emotional outcomes of family members in France who either witnessed or did not witness CPR being performed on their loved one was published March 14 2013 (volume 368, number 11, page 1008) in the New England Journal of Medicine. The study was looking for the evidence of and magnitude of post traumatic stress disorder (PTSD) in those family who witnessed CPR and those who did not, along with medical staff issues was consistent with what has been  considered previously that "family presence during CPR was associated with positive results on psychological variables and did not interfere with medical efforts, increase stress in the healthcare team, or result in medicolegal conflicts." In fact, those who watched CPR even in the resulting death of their loved one were psychologically better off than those who were in the vicinity but did not watch.

But, on developing this thread, my intention was not necessarily to have my visitors review the statistical evidence presented in this or previous studies but really to discuss the personal thoughts or feelings about participating as an observer when a family member is undergoing CPR. Perhaps, some visitors may have actually experienced such an activity.

CPR is, as a medical response to cardiac arrest, a rather hurried and intensely active process, with clinical confirmation  f the arrest and maintaining monitoring for a heartbeat, attention to get the patient into the proper position for effective chest compression, beginning vigorous chest compression after establishing that an initial open airway is available until an endotracheal tube is inserted for mechanical ventilation. Then may come an electric shock applied to the chest to start a heart rhythm or improve a rhythm which causes the patient's body to violently jerk. Meanwhile, there must be the need for coordination of the activities by the staff involved and then final decision making of when to end an unsuccessful attempt at resuscitation. So where is the family visitor in all of this? Where should the  family visitor stand and should  there be a staff member dedicated to attend directly to the needs or questions of the visitor? Should the family visitor take any role at all in any decision making with regard to stopping or continuing the resuscitation attempt? Are these witnessed last moments of the loved one's life something to be thought of and sought as of value to the family? If so, of what value? Should you or would you watch? These are just some of the questions I would like to ask my blog visitors. Maybe you have some additional issues to discuss. If you have witnessed CPR at home by paramedics or in a hospital environment, can you tell us about your experience? ..Maurice.

Graphic: From Google Images

Wednesday, March 13, 2013

Is What is Ethical Lies "In the Eyes of the Beholder"?

The following original article which I wrote and was published today at the website is reproduced here with permission.   ..Maurice.

March 13, 2013 11:33 am
Maurice Bernstein, M.D.

On my bioethics blog I wrote a post titled “Good People Do Bad Things for Good Reasons”. I suggested in that post that “what is ethical or not is often in the eye of the beholder”. An anonymous visitor wrote back the following:

“I would like to think that ethics is NOT in the eye of the beholder. That logic leaves too much room for justifications of any actions. Ethics is not religious doctrine. Ethics is not law. Ethics is not social standards. Ethics is not what feels right. These are all subjected to variables that can change the outcome of the ethical or unethical action. Ethics is simply what we OUGHT to do. Ethics is a code of values that is reasonable and well-founded. Beauty is for the eye of the beholder. Ethics is for everyone, everywhere. It is NOT subjective.”

Shouldn’t I disagree with that visitor’s comment?  If decisions and actions in ethics were immutable and fixed, documented in clear and non-ambiguous language, why would there be a need for “ethical consensus”? This need already supports my argument.

Think about the four ethical principles: autonomy, beneficence, non-maleficence and justice which are considered, for example, within clinical ethics but also in other ethical decision-making. Have decisions and actions carried out or proposed said to be in keeping with a principle actually met the philosophic or dictionary definition of each? Can there ever be decisions that are said to be and, indeed, are, actually fully faithful to autonomy (an individual’s strength of self-governing and independence), beneficence (contributing to an individual’s good), non-maleficence (doing no harm) or justice (fairness to all individuals)? Most decisions require the consideration of each of these principles in terms of the final result of the action. While the definitions of the ethical principles are “reasonable and well-founded”, their application in terms of a decision towards an action may lead, in all reality, to an ethical dilemma where it would be impossible for each to be equally applied. The solution to the dilemma would require the principles to be prioritized. But what makes an ethical dilemma most complicated is that each case may be different in that there may be a different set of facts. In addition, there may be more than one stakeholder in the results who will be affected by the decision and each stakeholder may have their own individual prioritization of the principles in order to produce a result consistent with their individual goals. So, what is necessary to proceed to a solution to the dilemma is the development of a consensus amongst the stakeholders.

Consensus means that those individuals involved have come to an agreement with regard to how the ethical principles should be prioritized. And consensus may not be a static conclusion but may vary over time depending in how people look at issues in their current environment. For example, was justice served at the onset of the second World War when American citizens of Japanese ancestry were interned for years in camps? Surely, it was the concern for the safety (beneficence) of the other American citizens that trumped the ethics of non-maleficence or justice toward those of Japanese ancestry. And yet, later, in a different time, this ethical decision was found to be unethical. In the past, medical research performed on human subjects that was carried out without fully informed consent by the subject and even with intended harm was accepted but in recent times have been rejected as unethical.

In summary, yes, ethics should be “what we OUGHT to do” but, in reality, applying all ethical principles we “ought” to do is not universally possible if we intend to come to a decision. And beyond that in practice with different cases, different stakeholders have different views of the issue and their individual visions set the ethics for the solution. Those are the eyes of the beholders.

Monday, March 11, 2013

Is Death a Medical Failure?

At our medical school, second year students have an opportunity, if they wish, to visit our local Coroner's office to learn about the duties of the coroner but also watch autopsies in progress. I have been given the opportunity of taking groups of student there. Each group is usually taught by their physician-instructor but in the case of the coroner's office experience, those groups which I take over, have instructors who have indicated that they didn't want to participate in the experience. I have not talked in detail with these physicians regarding their rejection to participate but I suspect a reason. It is most likely too emotionally  traumatic to be present and to stand and watch the autopsies. But why? I think I know the answer. For many physicians, perhaps most, death represents a failure. If the particular death was not the result of the failure of that specific physician, it could represent the failure of another physician.

The idea that the death of a patient could represent a failure on the part not only of a physician but even the medical system might be suggested by the facts. Supporting this idea is that it seems it is the goal of the medical system to provide and perform everything and almost anything to keep a sick patient alive. This intense direction to maintaining life at literally "all costs" and not to "give up" was always an old goal but has become more common in recent decades when the knowledge and technology has developed so that attempts at maintaining life of the terminally ill has become more realistic and, indeed, possible.

The goal and detailing the techniques of preserving life usually starts in medical school and progresses as the student goes on to internship and residency when the individual's responsibility for direct patient care is now present. Yes, teaching sessions about "telling the patient bad news" is part of the early medical student education but what I think is missing is the emphasis to the students about the need at some time and some point in the clinical course of the patient "to give up" both on the part of the physician but also the patient and family and then how to relate this "giving up" to the patient and family. Also, missing may be how to deal with the patient or family who refuses to "give up".

That this teaching to students and young doctors appears to be inadequate is shown by the facts regarding the high medical expenditure for  tests and treatments in the last months of the patient's life, the lack of time doctors spend with patients teaching and encouraging the creation of Advance Directives to set the limits of the patient's desired life supporting treatment. Further, is the observation of seemingly prognostic inconsistency by consultants who provide "mixed messages" to the sick patient and family with some encouraging procedures and life-support despite rejection of this advice by other physicians.  Finally, is the fact that often futile cardio-pulmonary resuscitation  is always performed by default unless a "do not resuscitate" order had been written. All these facts support a conclusion that physicians and the
medical system find that death of a patient represents a professional failure. But is death by definition a medical failure or is it really part of but the ending of what is called life something that all who are alive must accept. It usually is the latter and this concept should also be emphasized in the teachings of the medical students, the doctors, patients and families.

It is encouraging that in recent years, in addition to medical technical advancements, the concept of palliative care and hospice management has develop emphasizing that attention and care for the patient can continue despite progression of the illness and actually not fail up to the end of the patient's life.

So for those doctors who feel that the death of a patient is a failure on their part, it seems to be that it is only life itself that has failed to continue.  What is your opinion? ..Maurice.

ADDENDUM:  You may be interested to read more on this subject.  The following is an abstract and here is the link to a PhD Dissertation written by Deborah Jo Corker and titled "PHYSICIAN‟S EXPERIENCES WITH DEATH AND DYING: A PHENOMENOLOGICAL STUDY"

End-of-Life, the topic of the decade of 1990-2000, brought the focus on how we
die in America. Death encompasses cultural, ethnic, spiritual, social and physical
elements, which are often played out under the guidance of a medical provider or in
medical setting. As society redefines how we wish to handle our dying process and endof-
life care, medical society must also redefine how it trains its physicians and prepares
them to handle our death and dying. Medical school curriculum has added some end-of life
training, but there are limitations in time and scope of training available.
This qualitative phenomenological study attempts to gain the physician‟s
essences, meanings and understanding surrounding death and dying. Starting with
themes revealed in literature, in-depth interviews were used to ask selected physicians
providing care: How does death affect them? Are physicians receiving adequate training
in end-of-life care? Does the medical culture still see death as failure? How do they find
meaning in end-of-life care? Using three different groups of physicians: early in career,
mid-career, and retired, this research attempted to examine the phenomena of death
and dying over apparent time and developmental experiences of physicians.
Results: Physicians have not been adequately trained to handle end-of-life care.
Communications skills, specific end-of-life care training and support for physicians
dealing with death and dying are needed.

Graphic: From Google  Image

Saturday, March 09, 2013

Job Description of a "Clinical Ethicist"

The first question would be is a "job description" really necessary when involved with decisions regarding patient care?  Shouldn't aspects of the job be already presumed?  If one is a physician or a nurse, the job description is virtually presumed.  The thread here is not about the role of the physician or nurse but that of those who call themselves "clinical ethicists".

Interestingly, to be called a "clinical ethicist" there is no professional body to provide the accreditation of teaching programs for learning that occupation, there is no professional body who is responsible to certify that the individual who calls him/herself a "clinical ethicist" has really met the educational and other professional standards (no agreed upon standards yet!) for that title and there is no "Code of Ethics" to set ethical standards of behavior.  Beyond all that.. there is no established job description for the "clinical ethicist".  Why do we need some sort of job description? Well, basically there is some controversy as to whether the "clinical ethicist" should be the advocate for the patient who is the focus of the ethical consultation and directly contribute to the final decision. Some say "yes" but some say the ethicist should not be considered a stakeholder in the deliberation. So, yes, a job description is certainly a first step in the development of criteria for a formal profession.

As former chairman of two different hospital ethics committees and currently a member of one, based on my experience and view of the issues that ethicists and ethics committees experience, I would like to state my idea of what a clinical ethicist should do and be doing as part of his or her occupation.

I look at the "job" of someone who calls themselves a "clinical ethicist" as a sub-specialty of being an ethicist (similar to being a cardiac surgeon while also responsible for the duties of being a physician).  To me "clinical" sets the interest to the issues related to the care and treatment of a specific patient and is not describing any administrative nor organizational aspects of being an ethicist.  It is that sub-specialty that I want to see a job description clarified.
To me, the difference between "patient advocate" and "teacher and mediator for all the stakeholders" is non-comparable.  To me, the end result is either: the clinical ethicist or the ethics consultation committee selects and makes the final decision    vs    a  final decision made by agreement of the stakeholders is also distinctively different.  I would feel satisfied if the job description of a "clinical ethicist" participating (and I am not saying "leading") in a case of a patient is one that states "teaching current ethical consensus and law to the stakeholders, teaching methods of looking at conflicting values, mediating discussion by the stakeholders toward their goal of the stakeholders selecting a final decision."  The "clinical ethicist" must then accept whatever decision is reached by the stakeholders as long as it does not grossly violate current ethics and current law. If it does, the violation, as judged by the ethicist, must be explained and the discussion by the stakeholders continued as they desire.  To me, while the hospital and administration itself may be one of the stakeholders, the clinical ethicst or ethical consultation committee is not.  
More on the job description:
In the case of making a life-death decision (such as turning off life-support) for an clearly established un-befriended patient who has no capacity to make medical decisions and for which the attending physician has solitary responsibility for the decision, the "clinical ethicist" performs the same role as with patients who have or have no capacity but who have family, friends or documents to provide surrogate decision-making or "best interest" decisions. The role is that of educating the physician regarding the ethics and law involved and to state and document the ethicist's conclusion as to whether the physician's decision was in keeping or violating the ethics and law. 

If you were attending an ethics committee consultation meeting as a family member of a sick hospital patient and a serious medical decision had to be made, what role would you want the ethicist or ethics committee members to play in the meeting or in the final decision?  ..Maurice.

Graphic: From Google Image and Chief Happiness Officer

Sunday, March 03, 2013

Do Medical "Conscience Clauses" Mean Being Unconscious to Patient Care?

"Conscience Clauses" either proposed or actually written into governmental legislation of medical practice have stirred controversy on both sides of the issue. A "conscience clause" would permit physicians freedom from any legal retribution, discipline or discrimination to reject performing or otherwise carrying out an action or service which would go against the physician's "conscience", conscience being the physician's belief of right vs wrong, good vs bad based on the physician's own ethical or religious  principles as applied to the patient care. In rejecting, the physician may be required to attempt to refer the patient to another physician who would agree to perform the service. On the other hand, this responsibility may not be required since some might find such a referral to be facilitating an act which was already deemed suspect. It should be noted that the "conscience clause" is supported by the First Amendment to the U.S. Constitution: "Congress shall make no law respecting an establishment of  religion, or prohibiting the free exercise thereof.." Apparently the Amendment applies to physicians and other medical care providers as well as their patients.

An example of a "conscience clause" written into a United States state law, which is one about which I am familiar, is that of the California Probate Code.Within the California state Probate Code is the following:

"4734.  (a) A health care provider may decline to comply with an
individual health care instruction or health care decision for
reasons of conscience.
   (b) A health care institution may decline to comply with an
individual health care instruction or health care decision if the
instruction or decision is contrary to a policy of the institution
that is expressly based on reasons of conscience and if the policy
was timely communicated to the patient or to a person then authorized
to make health care decisions for the patient."

If the provider or institution declines, then:

"4736.  A health care provider or health care institution that
declines to comply with an individual health care instruction or
health care decision shall do all of the following:
   (a) Promptly so inform the patient, if possible, and any person
then authorized to make health care decisions for the patient.
   (b) Unless the patient or person then authorized to make health
care decisions for the patient refuses assistance, immediately make
all reasonable efforts to assist in the transfer of the patient to
another health care provider or institution that is willing to comply
with the instruction or decision.
   (c) Provide continuing care to the patient until a transfer can be
accomplished or until it appears that a transfer cannot be

The "conscience clause" may be applied to legislation that could deal with various aspects of medical care but is more often related to issues of reproduction such as sterilization,abortion,contraception and stem cell procurement and use.

But the issue I want to discuss here is with regard to what is the impact of the "conscience clause" on the professional duties of physicians and other providers in the medical system. Should we look at it as an impediment, within the law, to proper patient care? Irrespective of the permission of the "clause", should physicians, nevertheless, divest themselves of their personal moral decisions when they take on
professional responsibilities? Should  responsibilities be only directed toward attending to the request and the best care of the needy patient and not, in some circumstances, directed toward the caregiver themselves? And what do you think about physicians or other healthcare providers who find situations where, to maintain
self-directed responsibilities and conscience intact, the duty even to transfer the patient to another provider who would follow the patient's request is unacceptable?

If you are a doctor how would you look at the permission offered by the "conscience clauses"? If you disagreed with the patient's request because of your moral or religious values, would you reject the request? ..Maurice.

Graphic: From Google Images modified by me with ArtRage and Picasa3


Friday, March 01, 2013

"DEATH PANELS": Do You Believe They Exist?

Hey! Do you remember,starting in 2009,the political fury, concern and cries about "Death Panels" in the United States as the Affordable Care Act ("Obamacare") was being debated? If you don't..where were you? Wikipedia has an excellent article on this topic to refresh your memory.

My understanding of what the public considers as a "death panel" would be a group of individuals not related to any specific patient but who becomes responsible to make a decisions as to what life-supportive treatment or other treatment would be allowed to be started or terminated for a patient. "Death" is used in the name since it is felt that death could well be the outcome of their decision. One way or another, it was this group "pulling the plug" on the patient's life-support.

An example of such a concern prior to the Affordable Care Act was the matter of the Texas statute Section 166.046 passed in 1999. The statute stated "If an attending physician refuses to honor a patient's advance directive or a health care or treatment decision made by or on behalf of a patient, the physician's refusal shall be reviewed by an ethics or medical committee. The attending physician may not be a member of that committee. The patient shall be given life-sustaining treatment during the review." The patient or patient's surrogate may attend the meeting and receive a written explanation of the decision reached.  If the physician, patient or surrogate don't agree with the decision, then the physician must attempt to transfer the patient to another physician or institution who will agree with the decision or follow the request of the patient or surrogate. Life-supportive treatment must be continued for 10 days after the decision or prolonged by court action. Following the letter of the law, provides legal immunity to the physician and hospital's ethics committee if the patient dies. There has been many patient cases decided in this manner under this Texas law along with considerable controversy.

I can't speak for Texas law and behaviors, but we, in California, have a similar law in the Probate Code regarding following patients' instructions or decisions:

 "Section 4735. A health care provider or health care institution may decline to comply with an individual health care instruction or health care decision that requires medically ineffective health care or health care contrary to generally accepted health care standards applicable to the health care provider or institution
Section 4736. A health care provider or health care institution that declines to comply with an individual health care instruction or health care decision shall do all of the following:
(a) Promptly so inform the patient, if possible, and any person then authorized to make health care decisions for the patient.
(b) Unless the patient or person then authorized to make health care decisions for the patient refuses assistance, immediately make all reasonable efforts to assist in the transfer of the patient to another health care provider or institution that is willing to comply with the instruction or
decision. (c) Provide continuing care to the patient until a transfer can be accomplished or until it appears that a transfer cannot be accomplished. In all cases, appropriate pain relief and other palliative care shall be continued."

Notice in the Code there is no mention of a final decision to be made by an ethics committee. An ethics committee would meet, however, to allow the patient or surrogate an opportunity to understand and counter the physician's view and for the committee, beyond moderating the meeting, to establish whether the physician's decision is appropriate with regard to current law and ethical consensus.  The medical decision to reject the patient's request is solely that of the physician.

I might add, that in California, hospital ethics committees may participate in a similar way with regard to expressing current law and ethical consensus in cases where the physician intends to terminate life-supportive treatment in a patient who has had no Advance Directive, no present capacity to make medical decisions and not expected to recover that capacity and, after searching with due diligence unable to find any relatives or friends who could contribute to the understanding of the patient's desires.

Defending only hospital ethics committees, as a current member and former chairperson, based on what I explained above, I would reject the view that our committee is a "death panel". We, as a committee, have no capacity to make medical decisions about appropriate therapy for a specific patient. We can listen to all sides and explain what is ethical and legal.  If the physician's view is ethical and legal, then, as a hospital ethics committee, we can support his or her decision.

 But, finally, how about you? Do you think that "Death Panels" exist in our United States medical system? ..Maurice.

Graphic: From Google Images.