Medical Ethics

Evening Ethics Discussion Group

2003

  • January: Doctors Learning on Newly Dead or Nearly Dead Patients
  • February: Ethical Issues in Smallpox Vaccination
  • March: Refusal of Life Support After Receiving a Lung Transplant
  • April: Informed Consent for Pediatric Research: Is it Really Possible?
  • May: The Socio-Political Role of Physicians
  • June: Severe Acute Respiratory Syndrome (SARS)
  • July: Unequal Treatment: Confirming Racial and Ethnic Disparities in Health Care
  • August: Changes in Healthcare Policy: Perspectives from the Community and from the Capitol
  • September: Informed Consent or Demonstrated Understanding
  • October: The Jensen Case: Who Decides What's Best for Children - Parents or the State?
  • November: What if There Is Something Going On in There?
  • December: Complications: A Surgeon's Notes on an Imperfect Science, by Atul Gawande

Doctors Learning on Newly Dead or Nearly Dead Patients  


The short but extremely provocative and even shocking article from the Wall Street Journal, “Doctors Question Use of Dead or Dying Patients for Training,” seems a fit subject for us to discuss. Unlike stem cell research, cloning or health care reform, it’s something we can probably have an effect on here in our own community, at our medical school and at our hospitals.  I’ll try to ensure that we have proponents of the practice and people with strong opinions about stopping it our changing it.

Glader, P. Doctors Question use of Dead or Dying Patients for Training. The Wall Street Journal, Nov. 12, 2002. p.B1.

Write up of the January  Program

Ethical Issues in Smallpox Vaccination  

Health care providers, health policy analysts and governmental agencies are struggling with the mandate from the White House and the Department of Health and Human Services requiring the development of smallpox response plans by state and local health departments.  Some of the issues and concerns being considered include:  how risk and benefit get defined (to some the vaccination is seen as a risk, to others a benefit); the challenges of good decision making in the face of many uncertainties of what the risks and benefits are; opportunity costs of such a wide-ranging effort; questions of liability when local agencies are implementing a policy mandated by a higher level; logistical questions of implementation, especially how to minimize risks (fears) about amplification if health care workers are immunized.  

Refusal of Life Support After Receiving a Lung Transplant

This month we are very fortunate to have as a special guest, John Armstrong, MD. Dr. Armstrong, until recently, was Professor of Pulmonary Sciences and Critical Care, and the Associate Director of the Center for Bioethics and Humanities, Department of Preventive Medicine and Biometrics, at the University of Colorado Health Sciences Center in Denver. He will be sharing with us his experience with a recent case in which a patient received a lung transplant and subsequently refused life support.

Informed Consent for Pediatric Research: Is it Really Possible?   

The subject for this evening’s discussion will be “Informed Consent for Pediatric Research: Is it Really Possible?” That is also the title an article by Eric Kodish, M.D, our distinguished guest facilitator and this year’s David Green Memorial Lecturer. Dr. Kodish will present Pediatric Grand Rounds at 8:00 a.m. on Thursday, April 10th, at PCMC Auditorium. His topic will be “Informed Consent in Childhood Leukemia.” He will also be teaching in our Senior Medical Student Ethics Course that morning, and joining us at our Literature and Medicine Discussion of “Waiting” by Ha Jin, that evening. For more information about any of these activities, please call our office. Dr. Kodish is Director of the Rainbow Center for Pediatric Ethics and Associate Professor of Pediatrics, Oncology, and Biomedical Ethics School of Medicine, Case Western Reserve University.

The following quote from his article should help frame our discussion. “Although clinical medical care is designed and intended solely for the benefit of the patient, research is defined as an effort to contribute to the development of generalized knowledge. The implicit expectation for research is that the knowledge generated will be applied to benefit other members of society. Deontological moral theories, such as those put forth by Immanuel Kant, would reject pediatric research that uses children as a means to the end of helping other members of society. By contrast, teleological theorists like John Stuart Mill would apply a utilitarian calculus to determine whether the benefits to society outweighed the potential harm to the child-subject. In general, the former would have a more restrictive, and the latter would employ a more permissive, approach to the conduct of pediatric research. The fact that most pediatric research is likely to benefit other children may also carry moral relevance. The fact that truly informed consent may not exist for pediatric research does not relieve us of the obligation to strive for improvement. As written in the ancient rabbinical text Ethics of the Fathers, ‘The task is not yours to complete, but you are not free to desist from it.’”

Informed Consent for Pediatric research: Is It Really Possible?
Kodish E. J of Ped. February 2003;142;89-90.

The Socio-Political Role of Physicians

This month's host, Dr. Lou Borgenicht, writes:

The impetus for this session was an article in The New York Times Magazine about Bill Frist, Senate Majority Leader entitled "The Best Medicine." Ann Pachett posited that "maybe doctors can cure what ails our political system."

Historically, physicians have been called on to engage in social and political action. Nineteenth-century pathologist, Rudolph Virchow, wrote:

Should medicine ever fulfill its great ends it must enter into the larger political and social life of our times. It must indicate the barriers which obstruct the normal completion of the life cycle and remove them. Should this ever come to pass, medicine whatever it may then be will become the good of all.

Since then, physicians have been notably involved in social and political issues: the civil rights movement, war time resistance, environmental lobbying, humanistic efforts in third world, human rights issues and the anti-nuclear movement, to name a few. Significant issues have been raised by these activities.

What expertise do physicians have to address these issues? Does the fact that one is a physician carry more influence when s/he speaks out on these issues? Is there a question about medicalization of socio-political issues to make them addressable in a medical context? Should physicians try to influence their patients about issue they care about? Is the clinical context ever neutral? What about physicians refusing smallpox immunization?

For further "food for thought," check out the following websites: http://www.psr.org/
http://www.doctorswithoutborders.org/
http://phrusa.org/

Severe Acute Respiratory Syndrome (SARS)

Given the extraordinary amount of press and media coverage, I hardly need to reiterate what is now widely known about the biology, epidemiology and mortality of Severe Acute Respiratory Syndrome (SARS). In our discussion we will focus on the ethical issues associated with this new, but not unprecedented, communicable viral respiratory disease. On the public health level we've had an opportunity to observe a variety of public policy initiatives ranging from no population-based control measures to extraordinary measures coupled with extreme penalties for noncompliance. On a more individual level, there are hosts of questions, ranging from whether an exposed or infected individual has a duty to prevent or minimize transmission to whether health professionals have a duty to take some level of personal risk in order to care for seriously-ill and infected patients. We last visited the second question in the context of the emerging AIDS epidemic. It's notable that even early evidence during that outbreak suggested that that disease was not highly communicable to healthcare providers. The SARS epidemic begins with evidence that points in the exact opposite direction.

At our discussion we'll talk about the two theme outlined above, and if time permits, make some comparisons between the effort and expense our government has mobilized against the theoretical threat of small pox and compare that with what's being done about SARS.


Unequal Treatment: Confirming Racial and Ethnic Disparities in Health Care

About a year ago we held an Evening Ethics Discussion at the Centro de la Familia.  The Institute of Medicine report, “Unequal Treatment,” stimulated us to discuss racial and ethnic disparities in health care (please see the enclosed summary of the report geared to health care providers).  Those who attended that discussion urged us to revisit the issue in a year to see what we had learned and what progress had been made.  Some surprising things have been learned and there is at least the will to change in some components of local and national health care.  An article from JAMA, based on a national sample of about 30,000 patients, concluded that “black Medicare patients hospitalized with heart failure received comparable quality of care, slightly higher readmission rates, but lower mortality…” than white patients.  That paper doesn’t negate the findings of previous related studies, but it does invite us to examine this issue at regional, health care system, or even an individual hospital level.  One institution locally, The University of Utah School of Medicine has launched an ambitious program called “Mutual Respect in Health Care,” which could address racial disparities.  We’ll invite the leaders of that program to our discussion.  The American College of Physicians has outlined quite a comprehensive program in response to the IOM report.  The executive summary and the first seven pages of their twenty-four-page position paper, http://www.acponline.org/hpp/healthcare_disp.pdf

While our principal focus will be racial disparities in health care, Leslie Francis will help us connect the discussion to disparities in education by commenting on the soon-to-be released U. S. Supreme Court decision on Affirmative Action at the University of Michigan Law School. 

  1. Institute of Medicine. Unequal Treatment: What Healthcare Providers Need to Know About Racial and Ethnic Disparities in Healthcare. March 2002. Full text is available at www.nap.edu/catalog/10260.html.
  2. Rathore SS, Foody JM, Wang Y, Smith GL, Herrin J, Masoudi FA, Wolfe P, Havranek EP, Ordin DL, and Krumholz HM. Race, Quality of Care, and Outcomes of Elderly Patients Hospitalized With Heart Failure. JAMA. 2003;289(19):2517-2524.
  3. Kaiser Family Foundation and American College of Cardiology Foundation. Racial/Ethnic Differences in Cardiac Care: The Weight of the Evidence. October 2002. Full text is available at http://utahinternalmedicine.com/www.kff.org.

Write up of the  July Program

Changes in Healthcare Policy: Perspectives from the Community and From the Capitol

The subject for our discussion is “Changes in Healthcare Policy: Perspectives from the Community and from the Capitol.”  Utah’s United States Second District Representative, Jim Matheson, will join us for this discussion. The topic is always important but seems especially timely.  The US Congress has just passed a complicated prescription drug benefit bill for senior citizens and rejected a limit on damages for pain and suffering in medical malpractice cases.  Most contenders for the Democratic presidential nomination have advanced ideas for healthcare reform, including a constitutional amendment.  New, effective, expensive treatments for a variety of diseases continue to appear.  Drug prices, once again, have risen substantially while inflation has almost disappeared.  The size of our uninsured population remains in the 40 million range, and the number of underinsured is also substantial.  This discussion will provide an opportunity for Congressman Matheson to hear which healthcare problems cause the most concern in Utah and which might be most amenable to a solution at the Federal level.  Similarly, it provides us with a chance to hear his perspective on what kinds of issues are most likely to receive congressional attention and what the outcome of that attention is likely to be.  

Write up of the  August Program

Informed Consent or Demonstrated Understanding

In June, Leslie Francis and Jay Jacobson led a discussion on this topic at an Annual Bioethics Summer Retreat in Michigan. We shared with the participants four facts and a proposal for their consideration. The facts were:

  1. Potential research participants have difficulty comprehending informed consent documents, even when they're presented at a significantly reduced reading level.
  2. Many research participants do not comprehend the risks of the research.
  3. Comprehension of a research study is influenced by age, intellectual ability, education, mood and the absolute risk of the study. 
  4. Many participants believe that being in the study will produce a benefit for them - something called the "therapeutic misconception."

Given these facts, we wondered whether it would be desirable to examine the comprehension of potential participants with a quiz and require that participants to demonstrate a certain level of comprehension before they enter a research project. Our Division Program Associate, Howard Mann, has also been thinking about this issue and he will join us for the Discussion. We've invited Institutional Review Board members, directors, clinical investigators and study coordinators to join us for this discussion. We have some readings that expand a bit on our presentation.

The Jensen Case: Who Decides What's Best for Children - Parents of the State?

As recent newspaper articles attest, the Jensen case has stirred intense controversy that rapidly stripped the case of its complexity and reduced it to a confrontation between concerned parents and a state agency that escalated toward criminal charges.  In our discussion we’ll use this case as a platform to explore in what circumstances it seems ethically appropriate to override parents’ choices for the health care of their children.  We’ll consider, but probably won’t limit our discussion to: certainty of diagnosis, prognosis of the disease untreated, prognosis with different treatments, the burden of treatments, age of the child, developmental competence of the child, decision-making capacity of the parents, the depth of parental understanding and the reasons for parental objection to medical recommendations.  We’ll invite professionals who have responsibility and involvement in this case or in cases like it.  This is a timely discussion.  It may prove especially valuable if there are bills proposed in the next Utah Legislature that address this issue.

Articles available in the Deseret News:

Write up of October's Program

What if There Is Something Going On in There?

As the two references below from articles from the New York Times indicate, there is still considerable interest regarding brain function in unconscious or minimally conscious patients and the prognosis for recovery. As we have known for some time, the prognosis in stroke requires the passage of time but there is no doubt that the prognosis has been improved by prompt intervention with thrombolytic agents. On the other hand, we have had a fairly stable understanding of persistent or chronic vegetative state. The article by Carl Zimmer may cause us to think quite differently about this state or especially the state of minimal consciousness. His article with the observations of brain activity in some of these patients and an altered prospect of improvement may cause the public and the medical community to rethink some of the ways we approach decision-making at the end of life. We have invited individuals with expertise in neurology, neurosciences, and brain imaging to join us at this program.

References:
1. What if There Is Something Going On in There?. Zimmer C. The New York Times Magazine. September 29, 2003.
2. My Father Wasn't There. Clendinen D. The New York Times Magazine. October 26, 2003.

Complications: A Surgeon's Notes on an Imperfect Science 

Atul Gawande is a physician/writer who has received considerable positive attention for his essays in The New Yorker and his recent book, Complications: A Surgeon's Note on an Imperfect Science. This book was the basis of a provocative discussion at our Physician's Literature and Medicine Group this past August. The first chapter (which we'll discuss) describes the experience of a trainee "learning and doing" (but not necessarily in that order) medical procedures that pose significant risk to patients. Among several ethical issues raised in this chapter is a process of learning skills that are essential for subsequent patient care but that potentially or actually put present patients at risk. This raises the question of whether the process of informed consent should include information about the skill and experience of the individual performing the procedure. You may recall that we have discussed informed consent for procedures done on the newly or nearly dead. This discussion will focus on the much more prevalent practice of learning and practicing procedures on patients who are awake and competent, who are fully capable of understanding the risks and benefits of having the procedure done by a trainee, and who can themselves grant or refuse permission.