Medical Ethics

Evening Ethics Discussion Group

2004

  • January: "People in Glass Houses..." Ethical Problems for Bioethicists
  • February: Arbitration: Rights, Rates and Medical Relationships
  • March: The Placebo: Harmful or Harmless?
  • April: Privacy: An Impossible Goal
  • May: Dangerous and Highly Communicable Infectious Diseases: Have We Answered the Ethical Questions Yet?
  • May #2: Doctors, Patients, State Laws and State Funds: Defining and Determining Ethical Medical Practice
  • June: Science, Politics, and Federal Advisory Committees
  • August: Organs for Sale: Is This A Solution to the Mismatch Between End Stage Organ Disease Patients and Available Organs?
  • September: Ethical Issues in Health Care Reform: State and Federal
  • October: Medical Care for Undocumented Aliens
  • November: God at the Bedside
  • December: New Ways to Help Patients Deal with Medical Decisions

"People in Glass Houses..." Ethical Problems for Bioethicists

We are particularly fortunate to have with us for this discussion Carl Elliott, M.D., Ph.D., who is an Associate Professor of Philosophy and Pediatrics at the Center of Bioethics at the University of Minnesota, and our 2004 Cowan Memorial Lecturer.  He is currently on sabbatical at the Institute for Advanced Study at Princeton.  Dr. Elliott is bright, unconventional and provocative.  We will discuss 2 of his articles, in The London Review of Books, is intriguing and stimulating.  The second, in The Hastings Center Report is informative and important for all of us to be aware of. 

Write up of the January  Program

Arbitration: Rights, Rates and Medical Relationships

The topic for our discussion is Arbitration: Rights, Rates and Medical Relationships. If you've been following this topic in the local newspapers, you'll be aware that discussion on the topic has been stimulated by an IHC decision to make receipt of care from their providers and institutions conditional on patients signing an agreement to arbitrate, not litigate, possible malpractice claims. Relevant factors for the discussion include the "malpractice crisis," a proposal by the Utah Medical Association and a statute passed by the Utah State Legislature, implementation of a corporate-wide program, and some printed and public protests by attorneys, labor unions and some patient and public advocacy group. We have listed some materials that should help you become familiar with the process of arbitration for alleged medical malpractice and give you an idea of the arguments for and against arbitration and for required arbitration, in particular.

References:

The Placebo: Harmful or Harmless

The venerable and mysterious placebo has come in for increasing and controversial commentary since the World Health Organization revised its code for scientific research in 2000.  Statisticians, clinical investigators, the FDA and the pharmaceutical industry still recommend, use and justify placebos in clinical trials where effective therapy exists.  Some philosophers, other investigators and the World Health Organization argue that placebos should not be used in these circumstances.  Needless to say, and as the enclosed articles illustrate, the clinical and even the geographic context is relevant.  We've invited people who do research, people who participate in research, and those who regulate research to join us for this discussion.

Write up of March Program

Privacy: An Impossible Goal      

We are fortunate that we have two distinguished visitors who will join us for the discussion, both of whom are interested in and expert on the topic.  Pamela Sankar, Ph.D., an anthropologist from the University of Pennsylvania will be participating in a conference about privacy sponsored by the Philosophy Department and addressing the senior medical students in our ethics course.  Bruce Jennings, M.A., Senior Research Scholar at The Hastings Center, will also be here for the privacy conference.  We will discuss " Patient Persepctives on Medical Confidentiality" (Sankar P, Moran S, Merz JF, Jones NL. J Gen Intern Med. 2003;18:659-669. ) by Professor Sankar, but I expect the discussion will likely address other issues beyond the scope of Dr. Sankar's article.

Write up of the April Program.

Dangerous and Highly Communicable Infectious Diseases: Have We Answered the Ethical Questions Yet?

The discussion will be the night before our Fourteenth Annual Intermountain Medical Ethics Conference, Ethics and Infectious Disease: Balancing Liberty, Responsibility and Danger.  At the Evening Discussion our State Epidemiologist, Robert Rolfs, M.D., M.P.H., will join us.  In light of extensive experience with tuberculosis, drug-resistant tuberculosis, influenza, AIDS and HIV infection, SARS and a concern about a theoretical use of smallpox virus as a weapon of bioterrorism, one would imagine that policies for health care professional behavior and response would be well worked out.  The enclosed article from the New York Times Magazine and the physician statements from the American College of Physicians and American Medical Association point out that while there may be general guidelines in place, a response to a specific outbreak is often uncertain and unpredictable.  Our discussion will explore why this remains so and whether it's possible to develop guidelines, incentives and perhaps even consequences that could more predictably guide professional behavior in situations that raise conflict between danger and duty.

Doctors, Patients, State Laws and State Funds: Defining and Determining Ethical Medical Practice

The medical profession has generally accepted the view that physicians are obliged to share information with patients about the range of available, effective treatments for their treatment, as well as the risks and benefits of treatment and non-treatment.  Most patients expect this and expect to be able to choose or reject treatment.  The absence of insurance and the exclusions by particular third-party payers presently constrain patient's choices, most notably for expensive treatments, such as organ transplantation.  Recently, a Utah statute and a policy decision by our University Medical Center have constrained the medical options and the physicians who provide them at that institution and potentially in our State. We hope to explore the ramifications of the recent law and policy for medical ethics, medical practice, medical decision-making and medical care in Utah.  As we usually do, we will invite people with expertise and/or strong opinions about this issue to attend the discussion.  These include state legislators, University Hospital leaders, counsel for health care institutions and the State Health Department and Obstetricians/Gynecologists

Science, Politics, and Federal Advisory Committees    

Our topic was stimulated by an article of the same name by Robert Steinbrook, M.D., which recently appeared in the New England Journal of Medicine. The article begins by stating that there is a “continuing dispute about whether the administration of President George W. Bush has compromised the system of advisory committees by manipulating it for political and ideological reasons and seeking scientific advice that matches the administration's own views.” It seems that all presidential committee’s are subject to at least the potential for this kind of agenda driven appointment process. It may be fruitful to consider how within a two-party system such committees are best composed. It’s also worth while to think about how much weight to give their recommendations when they are finally elaborated

Organs for Sale: Is This A Solution to the Mismatch Between End Stage Organ Disease Patients and Available Organs?

As the article "The Sale of a Kidney On a Path of Poverty and Hope" (Rohter L. Tracking. New York Times. May 23, 2004) indicates, there are at least two countries that explicitly permit, or do not seriously interfere with the sale of human organs.  The article illustrates the international scope of this unlikely form of commerce and some of its hazards, problems and benefits. This is one of several timely issues that bear directly on the supply and demand problem in organ failure. The second is the category of “non-heart beating donors”, which could increase the available supply. A third phenomenon, which we have already encountered in Utah, is the voluntary unrestricted donation of organs, which could also affect the supply. Each of these potential solutions to the supply problem may make one of the other solutions less likely or less effective. That should make for a lively and provocative discussion. As usual, with our evening program we will invite people who are knowledgeable about the transplant process and the promotion of organ donation to join us.

If you would like to read more about this topic before our discussion, here are two JAMA citations:

 

  1. Goyal M, Mehta Rl, Schneiderman LJ, Sehgal AR.   Economic and Health Consequences of Selling a Kidney in India. JAMA. 2002:288:1589-1593.
  2. Rothman DJ.  Ethical and Social Consequences of Selling a Kidney. JAMA. 2002:28:1640-1641.

Write up of the August Program

Ethical Issues in Health Care Reform: State and Federal

This month we will be discussing Health Care Reform and in particular three proposals which should help make our discussion informed and timely. The first two are the statements on health care and particularly change in Federal Health Care Policy that I've extracted from the Democratic Party Platform and President Bush's agenda for health care. The third is a proposal for health care reform at the state level prepared by Dr. Joseph Jarvis, former director of Nevada State Health Department and the Utah Health Alliance. The material is rich with topics for discussion. It might be useful to begin with asking yourself which ethical problem with our health care system seems most important to you and see whether any or all of these proposals address that issue. If they do address it, then is it a solution to the problem that conforms to your own theory of just and/or equitable health care. This promises to be a particularly interesting and informative discussion for all of us.

Medical Care for Undocumented Aliens

The topic for this month’s discussion is medical care for a special category of uninsured patient - undocumented aliens. This group may be both uninsured and uninsurable, or at least ineligible for certain federal and state benefits. Facilities and their staff that treat patients who are emergently ill are obliged under EMTALA to provide treatment of such patients regardless of their citizenship or documentation. A new program provides selective reimbursement for this otherwise unfunded mandate if hospitals can show that the recipients of emergency care were undocumented aliens. Paradoxically, perhaps, if they care for non-emergently ill undocumented aliens doctors and hospitals in Texas may be subject to financial and criminal penalties.

The Federal Welfare Reform Act of 1997 changed and reduced benefits for non-citizens and state rules and laws continue to evolve.

This complex situation invites us to think in some new ways about what might constitute or preclude a right to health care and whether health care providers may have duties to sick patients that are independent of patient rights but somehow shaped by patients’ citizenship and/or documentation.

Two short journal articles by Coyle (Coyle, S (ACP Ethics and Human Rights Committee Providing Care to Undocumented Immigrants. HOSPITALIST, Page 24. July/Aug 2003.)and Slifkin (Slifkin, RF and Charytan, C. Ethical Issues Related to the Provision or Denial of Renal Services to Non-Citizens. Seminars in Dialysis, 10:173, 1997)about this problem in general and specifically with respect to ESRD patients and a newspaper article about the new emergent care reimbursement plan. These short pieces provide plenty of material for discussion.  

Write up of the October Program

God at the Bedside


The topic for our discussion is “God at the Bedside”. The basis for this discussion is the article in the New England Journal of Medicine by Jerome Groopman, M.D. (New England Journal of Medicine. Mar 18, 2004:350:12:1176-78.) with the same title. While we could talk, as the article does, specifically about a patient’s request to pray with them or for them, the discussion is likely to be broader than that. As Groopman says, “Religion, perhaps more than any other single force, can sculpt the experience of illness.

Write up of the November Program

New Ways to Help Patients Deal with Medical Decisions

The subject for this month’s discussion will be “New Ways to Help Patients Deal with Difficult Medical Decisions”. Our guest for this discussion will be Jodi Halpern, M.D., Ph.D. who will be visiting Salt Lake to give the Cowan Memorial Lectures. Dr. Halpern is the author of From Detached Concern to Empathy: Humanizing Medical Practice. She is Assistant Professor of Bioethics in Medical Humanities at the University of California at Berkeley.  She simultaneously pursued her M.D. degree and Ph.D. in Philosophy at Yale and before she left, collected several prizes for her medical school and Ph.D. theses.

Jodi Halpern's article, “What is Clinical Empathy?” (JGIM. 2003; 18:670-674), provides both relevant background and concrete examples that will help focus our discussion on patients who are reluctant to make decisions or patients who make decisions that seem inexplicable to us.     

Write up of the December Program