Medical Ethics

Evening Ethics Discussion Group

2006

Bioethics in the National Security State

We will be discussing an unusually carefully documented and provocative article, "Bioethics in the National Security State", by Jonathan Moreno (Journal of Law, Medicine and Ethics, 2004;32:198-208.) who is a Professor of Biomedical Ethics and Director of the Center for Biomedical Ethics at the University of Virginia. He will present this year's Cowan Memorial Lecture, "The New Medicine:      Ethical and Policy Issues in Human Embryonic Stem Cell Research" at Internal Medicine Grand Rounds in the Eccles Genetics Auditorium on Thursday morning, January 19th at 8:00 a.m. and a special lecture, "Mind Wars: Ethics, National Security and the Brain" at 4:00-5:00 p.m. in the Eccles Genetics Auditorium. Dr. Moreno will join us for what I'm sure will be a spirited discussion of his paper. Two quotations used from his paper will give you a preview of the scope and importance of his presentations and our discussion.

"Innovation within the armed forces will rest on experimentation with new approaches to warfare, strengthening joint operations, exploiting U.S. intelligence advantages, and taking full advantage of science and technology." (George W. Bush. The National Security of the United States of America, September 17th, 2002)

"Neuroscience research presents a variety of opportunities for still more futuristic military applications. Neural receptors responsible for brain development have already been enhanced in mice, with evidence that learning is significantly improved. In the heat of battle complex instructions must be recalled under highly stressful conditions, such as target orders for fighter pilots. Substances that achieve memory enhancement prior to a mission would be very attractive under these conditions. For homeland defense, the clumsy and nonselective screening procedures now used   in airports and other sensitive public places could be complemented or replaced by remote functional, magnetic resonance imaging that identified individuals with high levels of neural activity in systems associated with violence or other forms of excitability. Although such applications may seem like science fiction, we have seen that the national security state leaves no stone unturned if some tactical advantage might be lurking beneath it." (Jonathan Moreno. Journal of Law, Medicine and Ethics, 2004;32:198-208.)          

Write up of the January Program

Diabetes Epidemic: How we live, how we die, who cares, and who pays

The New York Times published "Bad Blood: The Stealth Epidemic",a series of four articles that ocument the serious epidemic of type II diabetes which is affecting our nation and some of its population disproportionately. We will focus on the first "Diabetes and Its Awful Toll Quietly Emerge as a Crisis" (Kleinfield NR. New York Times. January 9, 2006). At our discussion we will concentrate on the following questions:

  1. If type II Diabetes is primarily the result of "personal choices" about diet and exercise, what does that tell us about personal, parental, medical, employer, insurer and government     responsibility for prevention and treatment?
  2. What does the epidemic of type II diabetes reveal about the incentives and function of our healthcare system?
  3. Will this crisis in diabetes drive us toward prevention oriented, universally available healthcare system or toward a new class of unemployable, underinsured stigmatized individuals?
  4. Are there ethically defensible strategies other than public education that can or should be implemented to reverse this non-infectious disease epidemic?  

Write up of the February Program

Propranalol as a Prophylaxis for Post Traumatic Stress Disorder: Is it Morally Acceptable to Remove the "Sting" of Bad Memories?

“Some scientists are defending and developing a new science that can be called therapeutic forgetting. True posttraumatic stress can be intractable and does not tend to respond to most therapies. So these scientists are bucking the current trend in memory research, which is to find a drug or a gene that will help people remember. They are, instead, trying to help people forget.” 

In "The Quest to Forget", Robin Marantz Henig (New York TImes, April 4, 2004) describes such research and explores its ethical implications. Jane Austin's thoughts about memory provide a fitting introduction to our discussion. "If any one faculty of our nature may be called more wonderful than the rest, I do think it is memory. There seems something more speakingly incomprehensible in the powers, the failures, the inequalities of memory, than in any other of our intelligences. The memory is sometimes so retentive, so serviceable, so obedient- at others, so bewildered, so weak- and at others again, so tyrannical, so beyond control! We are to be sure a miracle every way- but our powers of recollecting and of forgetting, do seem peculiarly past finding out."   

The President's Council on Bioethics, in it's working paper of March 2003, put it well."Perhaps it is fitting, as we begin to evaluate the human significance of intervening and the workings of human memory, that we have more questions than answers, more dilemmas than solutions". What could be better for our Evening Ethics Discussion.    

Write up of the March Program

Doctor if this were your child, what would you do?

Lainie Ross, our distinguished guest at the discussion, thinks their views are wrong and has a very different view about the significance and the resolution of this question and answer problem. When patients ask their physicians, "If you faced the same choice that I do what would you do?" or when parents ask, "Doctor if this were your child, what would you do?", the question, the answer, and even the decision about whether to answer are more complex than they might first appear. Highly regarded medical ethicists have expressed reservations about physicians even answering these questions, or parents asking them or acting upon the answers. Dr Ross has written:         

"To evade the question…is a sign of disrespect. The question may be an attempt to establish intimacy, and its rejection is an affront to those who are asking for help. Even if the question is asked out of mistrust, a contextualized response may help bridge the cultural divide that may exist between parents and physicians and help establish a trusting relationship. The issue, then, is not whether to answer the question, but how."   

Dr. Ross is Associate Professor in the University of Chicago's Department of Pediatrics where she is the Assistant Director of their Center for Clinical Medical Ethics. She is also this year's David Green Memorial Lecturer and she will be presenting Pediatric Grand Rounds on the topic: Children in Medical Research: Has the Pendulum Swung too Far? On Thursday, April 20th at 8:00 a.m. at the Primary Children's Medical Center Auditorium.    

The articles that we sent you, which are related to Dr. Ross's lead article in the Journal of Clinical Ethics, are intended to be simply an appetizer for what I am sure will be a rich rewarding and helpful discussion for clinicians and for the patients who depend on us. Questions of this type, which invite a deeply felt personal response, may catch an unprepared physician quite off guard. The answer in those circumstances may be less than helpful and maybe even fail to identify the information or emotional guidance that the asker is seeking.

Write up of the April Program   

Conscientious Objection

The news media have recently called attention to the practice of pharmacists and some pharmacies of refusing to fill lawfully written prescriptions for medical indications with which they disagree. State legislatures have also weighed in on this issue, in some cases supporting this "Conscientious Objection." Physicians, although not the focus of the media stories or the statutes, also face situations in which they feel that they are morally opposed and should conscientiously object to a preventive or therapeutic intervention. We will discuss the article by Julian Savulescu, Concientious Objection (BMJ 2006:332:294-297), which stakes out a very strong position against moral judgment as a basis for a qualified professional's refusal to treat or assist in the provision of treatment. The article begins on a very provocative and seemingly counterintuitive note.

Shakespeare wrote that "Conscience is but a word cowards use, devised at first to keep the strong in awe" (Richard III V.i.v1 7) conscience, indeed can be an excuse for vice or invoked to avoid doing one's duty. When the duty is a true duty, conscientious objection is wrong and immoral. …A Doctor's conscience has little place in the delivery of modern medical care.   

We will be sure to invite pharmacists and physicians who hold strong and opposing views on this question to our discussion. 

The Massachusetts Universal Health Coverage Law: Could this be the start of the healthcare  revolution?

On April 12, 2006, Massachusetts Governor Mitt Romney signed bi-partisan legislation that would provide nearly universal healthcare coverage to state residents. It mandates everyone in the state to purchase health insurance by July 1, 2007. It requires that employers with more than ten employees provide health insurance coverage for a "fair share" contribution for each employee. The state will subsidize the cost of insurance for individuals with incomes up to 300% of the federal poverty level. This will be based on a sliding scale. The Kaiser Family Foundation in the enclosed article says, "The innovative plan to achieve near universal coverage should encourage debate about how to address the nation's problem of the uninsured. Elements of the plan may be useful to other states interested in expanding coverage, as will the strategy for reaching political agreement. Understanding the factors that contributed to the plan's passage and monitoring its implementation will be important for encouraging discussions in other states and at the national level over ways to reduce the number of uninsured." 

Betsy Mccaughey, former Lieutenant Governor of New York writes in the Romneycare's Fine Print (Wall Street Jounal, May 5, 2006) more about how this plan will impact individuals and employers. She is critical of the desirable but medically unnecessary services that are required in the HMO policies, which are the only options for individuals purchasing their own insurance.    

Because Utah shares some circumstances with Massachusetts such as the approximately 10% of the population that is uninsured and a strong emphasis on individual responsibility we want to ask whether a plan of this kind would be feasible in Utah. We will discuss what the  likely response of the small business community would be to required coverage and "Fair share" contributions. We will also consider what the legislature's response might be to a requirement for individual purchase of insurance, which might be out of reach for many of our un-insured without a government subsidy.

As usual we will invite interested and expert individuals from relevant disciplines and professions to join our discussion. That will include Health Department Officials, Legislators, and people from the employers and insurers that are most likely to be affected by plans like the one in Massachusetts. We look forward to a lively and enlightening discussion.

Write up of the June Program   

Playing Doctor: Medical Dramas on Television

At our discussion, we will view a short segment from the prize-winning and popular television show, "House." It's one of many television dramas that portray contemporary medicine and the  doctor/patient relationship. These shows influence the decision to become a physician and even which specialty to pursue. They also influence what patients expect of their doctors and what they expect will happen to them in a medical encounter. In our discussion, we will explore several questions. Is the show we view a representative portrayal of the contemporary physician and medical
culture? How does that affect what physicians and patients understand about and expect from each other? What are the values exemplified by the medical characters in the show? How do these relate to the values that seem to influence medical practice?  

A New York Times article, Magical Medicine on TV (S Jaujar, July 19, 2005) invites us to consider whether medicine on screen or in the hospital is an assembly line job or an intellectual enterprise.    

The Ethics of Exhibiting Human Remains

In the recent article by Dr. Michael Barilan writes: "In the past few years the exposition of Bodyworlds by German anatomist Gunter von Hagens has been traveling around the world engendering much attention and controversy. Millions have flocked to see Bodyworlds, which is by the now the most attended exhibition in German history.    

Opponents, mainly conservative Christians, try to ban the exhibition on the grounds of moral improprietary, usually with little success. When I wrote these words, Bodyworlds was open to the public in the Olympic park in Munich. Only one item, a dissected horseman mounting a dissected horse, was censored. . .[because] the object had no educational value and that it also offended human dignity by degrading man to the level of the beast." 

At our discussion, we will explore these three questions:

  1. Do we have a different view of bodies that are available for examination by physicians in training or by the curious public?    
  2. Are there religious, ethical and legal reasons to bar the exhibition of bodies from willing, informed donors?
  3. What is the basis for the special concern expressed about exhibiting remains from persons who were not willing, informed donors?

Medical Errors: Do Apologies Help?

A recent JAMA article (Apology in Medical Practice: An Emerging Clinical Skill. Lazare, A. JAMA. 296:1401-1404) begins "The idea that physicians should make full disclosure of medical error to their patients has grown in importance since the late 1980's and early 1990's. This movement gained momentum following the 1999 Institute of Medicine report To Err is Human, an indepth study of the extent of medical errors, and the 2001 Safety Standards of the Joint Commission on accreditation of Health Care Organizations on disclosure of patient harm.'' The article reviews the arguments and policies related to disclosure and apology. A second article from August's month's New York Times ("Medical Errors? Patients May Be the Last to Know". Bakalar,N. The New York Times. August 29, 2006) reports a survey of what almost 3,000 North American doctors report that they would tell patients about serious medical errors in four hypothetical cases. It's probably no surprise that practice and policy are still far apart. At our discussion we will talk about why that is, what teachers and trainers of physicians can do about it, how patients should respond to this information and what policies might address and perhaps improve this situation.

Write up of the October Program

Dialysis Redux: Insufficient Ventilators for Epidemic Influenza

"No one knows whether an avian flu virus that is racing around the world might mutate into a strain that could cause a human pandemic, or whether such a pandemic would cause widespread illness iin the United States. But if it did, public health experts and officials agree on one thing: the nation's hospitals would not have enough ventilators, the machines that pump oxygen into sick patients' lungs…. To some experts, the ventilator shortage is the most glaring example of the country's lack of readiness for a pandemic."    

Like the article from the New York  Times (McNeil DG. "Experts Say Medical Ventilators Are in Short Supply in Event of Bird Flu Pandemic". March 12, 2006), which included the above quotations, our discussion will focus not so much on global readiness, but rather the specific problems that are raised by a sudden, enormous and vital need for ventilators and too few ventilators to meet that need. Questions for discussion will include: Should we plan and provide for such a possible but unpredictable need? If we cannot meet the need, how should we allocate the available ventilators? How should the decision to allocate be made and who should participate in that process? Do we prefer a hospital, city, state, or federal response to this problem?  

An article in Academic Emergency Medicine (Hicks JL, O'Laughlin DT. "Concepts of Operations for Triage of Mechanical Ventilation in an Epidemic". February 2006;13:223-229) offers guidelines for determining which patients should be removed from ventilators and allowed to die in a crisis. It doesn't address how to select the next patient who would be put on a ventilator. The author leaves that for us to ponder.