Medical Ethics

Evening Ethics Discussion Group

2008

How Do We Manage and Share the Cost of Healthcare?

Cassel and Brennan write, “The Physician’s Charter on medical professionalism maintains that among other responsibilities, physicians must be committed to managing medical resources.  This responsibility is controversial largely because it can be seen as in conflict with the more traditional altruistic commitment of the physician to the patient.  Moreover, control of cost is inextricably linked to the business interests of insurers.  Physicians ask, is this really our responsibility?”  The authors say yes: “Physicians cannot afford to ignore the profound logic of the link between care for individual patients and the costs of care.  The more care costs, the more likely many individuals will be without good insurance, and research clearly shows their health will suffer.  It is impossible to avoid the fact that physicians live and work in a medical commons and bear responsibility for it.”

The NY Times article thoroughly identifies areas where costs are unnecessarily high and outlines ways to reduce them.

Most experts agree that cost, access, and quality are tightly linked and, in some ways, in tension with each other.  All three must be considered to evaluate changes in the healthcare system.

Articles:

1.Cassel, CK & Brennan, TE. "Managing Medical Resources." JAMA. June 13, 2007. Vol. 297, No.22.
2."The High Cost of Health Care."  The New York Times. November 25, 2007 Sunday.
3."Straw Man Proposal for Health System Reform." 9/24/07 working draft.

Questions we’ll address at our discussion include:

  1. Which cost-reducing strategies in the NY Times article do you think would have a positive or, at least, no negative effect on quality and access?
  2. The Salt Lake Chamber of Commerce framework for healthcare reform offers some increased access with personal responsibility and consumer choice reminiscent of the Massachusetts Plan.  What effects would you anticipate on cost and quality?
  3. Is there a right percentage of our GDP that should be spent on healthcare?

We will invite individuals to our discussion who have a special interest in our topic.   We look forward to seeing you and hearing your thoughts.

In the Service of the Sick: To Whom Are We Obligated?

Our topic of discussion will be “In The Service of the Sick: To Whom Are We Obligated?”  The philosopher Hans Jonas in 1969 had one answer: The physician is obligated to the patient and no one else….we may speak of a sacred trust; strictly by its terms, the doctor is, as it were, alone with his patient and God.”  The patients’ relatives feel that they too have a strong claim on the doctor’s time and attention.  Doctors may agree that patients may be in some circumstances their allies in treatment, and in others, valuable informants who assist in diagnoses.  Reimbursement schemes ignore time that doctors specifically devote to patients’ relatives.

As you read an article from the English Family Practice Journal that explores what doctors think of their relationships with patients’ relatives and come to appreciate the doctor’s views on several relevant issues, you can formulate your own perspective on several questions we’ll consider at our discussion:

  1. If you accompany a patient to a visit, would you prefer to be present during the interview, and post-examination discussion, and why?
  2. What experiences have you had in terms of being invited to remain, or to leave, during a medical history and examination?
  3. How did you and the patient respond to that experience?
  4. Who should decide how much time and attention a doctor devotes to a patient’s relatives, and should that process, if it occurs, be compensated?

We will invite individuals to our discussion who have a special interest in our topic.   We look forward to seeing you and hearing your thoughts.

Medical Tourism

Hundreds of thousands of American patients each year travel to various locations around the globe to receive their medical, surgical, and dental care. This trend is called "medical tourism"--sometimes "medical outsourcing"—and is quite different from the traditional form of international medical care where patients from less developed countries come to receive advanced medical care in highly developed countries. Medical tourism typically occurs for one of two reasons: the treatments may be unavailable or illegal in the U.S. or the treatments may be elective or medically indicated and available in the U.S. but deliverable sooner and for less cost, perhaps due to inadequate insurance, in other countries. Medical tourism issues range from cardiac surgeries, organ transplantation, and hip replacements, to cosmetic, weight loss and dental surgeries. Reproductive issues, from infertility to giving birth, are popular. The attached articles and book chapter explore several aspects of medical tourism.

Dr. Paul Gahlinger, physician, anthropologist, and adjunct professor at the University of Utah, who has traveled to India, Thailand, Singapore, and the Philippines to study medical tourism, will be joining our discussion. His recent book, Medical Tourism: Your Complete Guide to Top-quality, Low-Cost Dental, Cosmetic, Medical Care and Surgery Overseas, will soon be available in paperback. Among the questions we will focus on at our discussion are:

  1. Is medical tourism undercutting our medical industry?
  2. How does medical tourism impact the healthcare of local populations?
  3. What responsibilities do U.S. physicians have to care for patients who have suffered complications from treatments performed abroad?
  4. What are the national and international implications for policy and public health?

We will invite individuals to our discussion who have a special interest in our topic. We look forward to seeing you and hearing your thoughts.

Waiving Informed Consent in Newborn Screening Research: Balancing Social Value and Respect

Several decades of medical ethics discussion in the United States have increased attention on informed consent and full disclosure in both the research and clinical contexts.  It will be interesting and provocative to consider a proposal to go in the opposite direction by waiving informed consent in newborn screening  (NBS) research.  One of the authors of the enclosed article--our 2008 David Green Memorial Lecturer Dr. Benjamin Wilfond--will be with us to answer questions and help us think about how his proposal would fit in with NBS initiatives in Utah. You may also wish to attend his Pediatric Grand Rounds presentation at 7:45AM on Thursday, April 10, “Show Me the Money: Financial Considerations And Ethical Implications In Responding To Parental Requests For Medical Interventions In Children With Profound Disabilities,”  at  Primary Children’s Medical Center. Dr. Wilfond directs the Trueuman Katz Center for Pediatric Bioethics at Children’s Hospital and Regional Medical Center and is Professor and Chief of the Division of Bioethics, Department of Pediatrics, at the University of Washington.  Some of the questions that we’ll consider at our discussion include:

  1. What is your view on implementing NBS tests through legislation without population-based evidence, thus avoiding IRB review?
  2. When many NBS tests are evidence-based and routinely used, should a new test be considered as posing only risks of daily activity and not an additional risk?

We will invite individuals to our discussion who have a special interest in our topic. We look forward to seeing you and hearing your thoughts.

Is it Ethical to Conduct Clinical Trials with Patients in a Hospice Environment?

In recent years, excellent end-of-life care has been an increasing concern for the public and for policy-makers and a priority for health care providers.  Developing the evidence for what constitutes best care in this highly vulnerable population of patients who are often unable to provide informed consent is quite a challenge.  In the articles we will be discussing, LeBlanc and Abernethy note  the ethical problems associated with research done with hospice patients and conclude that “the many objections to hospice-based trials are not insurmountable.”  Dr. Fine focuses on the domains of knowledge that are important for review committees and investigators to master.  He provides examples of research methodologies which, when used appropriately,  would be particularly suited for this kind of research.  Both papers focus particular attention on the use of placebos. That invites us to think about the placebo effect, not only on patients but on family members that are so closely involved in end-of-life care.  Questions that we will consider at our discussion include:

  1. When terminally ill patients lack mental or physical ability to consent to research, are surrogate decision-makers appropriate, and on what basis should they grant consent?
  2. Is this an area of research that should be addressed by an advance directive that permits presently competent patients to consent to certain types of research in the event they lose mental capacity?
  3. If consent can be obtained from patients presently or previously competent or their surrogates, are there any practical or ethical considerations that would limit the kind of research conducted?

We will invite individuals to our discussion who have a special interest in our topic.   We look forward to seeing you and hearing your thoughts.  This program is approved for 1-½ hours of CME credit.

Remodeling the Health Care System: Aspiring Architects and Their Plans

We've seen more political and public attention to health care this year than at any time since 1993.  All of the aspirants to the Presidency have plans, but perhaps more surprising and perhaps more likely to succeed are the plan co-sponsored by Senators Bennett and Wyden and one proposed by another bi-partisan coalition of Senate leaders. All of the plans address cost and access and, to a lesser extent, quality.  They differ, of course, in the details, especially with respect to where the responsibility for payment falls, whether the programs are encouraged or mandated and the role of the federal government in the design, construction and operation of the various plans.  We’ve attached brief descriptions of the presidential contenders’ plans and a description of the Wyden/Bennett Plan, and the one proposed by Senators Dole, Baker, Daschle and Mitchell.  We’ve invited Chamber of Commerce and business leaders, members of the Utah Task Force on Health System Reform, and the State Director and Constituent Liaison staff of Senator Bennett’s Utah office to join us at the Discussion.

We look forward to seeing you and hearing your thoughts.

Some treatments are simply too expensive:" Responding to Emerging Concerns of Doctors and Health Plans

Avastin, an anti-cancer drug with limited efficacy at a price of $100,000/year is one of the latest examples of an emerging class of drugs dubbed hyper expensive.  In the accompanying articles you will see the financial implications of these expensive agents for physicians and health insurance providers.  For historically fatal diseases without alternative curative or effective treatment it is easy to understand the desire of patients and their families for an intervention that offers even the hope, if not expectation, of survival.  What is difficult and not yet well established is to withhold prescription or payment for a licensed drug solely because of its cost.  Previous denials of coverage have been based on lack of proven efficacy for a specific indication or for exceeding an overall cap on medical expenses often set at $1 million.  As incredibly expensive but effective drugs emerge it is likely that we will hear arguments about the degree of efficacy, cost effectiveness, disproportionate claims on limited resources, and threats to financial stability of practices and health plans.  At our discussion we will consider:

  1. Is any price high enough to be the sole reason for denial of coverage?
  2. Is there a cost-per-life saved or quality life years gained that is too high or too low to merit coverage?
  3. How should plans respond, if at all, to their members who secure uncovered treatments using their own resources?

We will invite individuals to our discussion who have a special interest in our topic.   We look forward to seeing you and hearing your thoughts.

This program is approved for 1-½ hours of CME credit.

Body Worlds: Invitation to the Interior

The next Evening Ethics Discussion group will meet at 7:00PM on Thursday, September 25th at the University of Utah Health Sciences Education Building, Alumni Hall, Salt Lake City. Kurt Albertine, Professor of Anatomy and Editor of The Anatomical Record, will be our host. The theme for the discussion is, “Body Worlds: Invitation to the Interior.” We hope that participants will have attended the Body Worlds exhibit at the Leonardo and completed the response form we’ll have available there. What you and others write and think will be what we discuss. Light refreshments will be provided.

Body Worlds functions like Roentgen’s X-rays at the turn of the previous century: viewers are invited to peer into the human body, seeing the interior from entirely new perspectives. Physicians are intimately familiar with these views from anatomy courses, dissections, and autopsies. Yet the plastinate corpses—preserved and posed like sculptures under dramatic lighting—are also works of art, inviting viewers to contemplate the body’s interior on multiple levels. Writing, whether on the level of craft or artistic expression, offers us a way into the interior, where we can explore questions addressed in medical humanities: from the beauty and significance--literally and metaphorically--of organs to existential questions about human vulnerability and mortality. (Participants don’t have to have any prior experience as writers.)

The Body Worlds exhibit opens at The Leonardo Wednesday, September 19th, and will remain open through December. Click here for the “Evening Ethics Discussion Group Response Form” to take to the exhibit, fill out, and bring to the Evening Ethics Discussion.

We will invite individuals to our discussion who have a special interest in our topic. We look forward to seeing you and hearing your thoughts. This program is approved for 1-½ hours of CME credit.

Will Insured Citizens Give Up Benefit Coverage to Include the Uninsured?

In keeping with our recent focus on health reform and the challenges it faces, we’ll discuss the article, “Will Insured Citizens Give Up Benefit Coverage to Include the Uninsured?,” by Susan Dorr-Goold from the University of Michigan. She is our distinguished visiting speaker at the 18th Annual Intermountain Medical Ethics Conference on Friday, October 3rd. Susan will join our evening discussion and participate in it. It promises to be an exciting preview of a great conference. We will invite individuals to our discussion who have a special interest in our topic. We look forward to seeing you and hearing your thoughts. This program is approved for 1-½ hours of CME credit.

Voluntariness of Informed Consent to Research

The article “Voluntariness of Consent to Research” is scheduled to appear soon in the Hastings Center Report. Its author, Paul Appelbaum, will be this year’s Cowan Memorial Lecturer in Humanistic Medicine. He will participate actively in our discussion of his paper.

In response to the horrific and unconsented research on concentration camp prisoners during the holocaust, the Doctor’s Trial at Nuremburg concluded that consent was a pre-requisite to research participation. It emphasized that “voluntary consent of the human subject is absolutely essential.” However, as Dr. Appelbaum writes, literature on informed consent has focused extensively on the information disclosed and how well it is communicated, and the theoretical and practical aspects of the assessment of decisional competence. The nature of the requirement of voluntariness has been more resistant to exploration. All voluntary decisions reflect a variety of influences. Decisions are involuntary only if those influences are external, intentional, illegitimate and causally linked to the ultimate choice. In research settings, constraints on voluntariness may derive from offers, pressures, threats, or non-consensual interventions. The Nuremburg decision explicated the requirement of voluntariness by insisting that the subjects should be so situated as to be able to exercise the free power of choice, without the intervention of any element of force, fraud, deceit, duress, overreaching, or other ulterior form of constraint or coercion. An alternative view of volunteerism has been defined by Roberts as “ideally encompassing the individual’s ability to act in accordance of one’s authentic sense of what is good, right and best in light of one’s situation, values and prior history.”

Questions that we’ll address during our discussion include:

  1. Which definition of “voluntary” seems best suited to human subjects research?
  2. What questions would you ask to decide if consent to research is voluntary?
  3. What conditions, independent of the patient’s self-assessed voluntariness, would you regard as unacceptably coercive?

Unreal Conversations: How Art Speaks to Us When the Patient Can't

When William Utermohlen, a 62-year-old figurative painter, was diagnosed with Alzheimer’s disease, he began a series of self-portraits, which he continued for six years until he no longer could paint. The result is a powerful exhibit that documents the progression of the disease and the artist's emotional journey from sadness to defiance, confusion, and anguish as he experiences the disintegration of his self-identity. This “visual narrative” of Alzheimer’s is especially relevant to health-care professionals. How we communicate with patients with dementia influences not only how their self-image, but also, according to researchers, how resistant they are to our care. We will begin the evening with a tour of the Utermohlen exhibit during which you'll be given an opportunity to respond to his self-portraits through written prompts. From these, we'll script conversations, leading us into a discussion of communication with patients with Alzheimer's and dementia, and the ethical issues that arise.

We will invite individuals to our discussion who have a special interest in our topic. We look forward to seeing you and hearing your thoughts. This program is approved for 1-½ hours of CME credit.