Bioethics Discussion Blog: April 2013

REMINDER: I AM POSTING A NEW TOPIC ABOUT ONCE A WEEK OR PERHAPS TWICE A WEEK. HOWEVER, IF YOU DON'T FIND A NEW TOPIC POSTED, THERE ARE AS OF MARCH 2013 OVER 900 TOPIC THREADS TO WHICH YOU CAN READ AND WRITE COMMENTS. I WILL BE AWARE OF EACH COMMENTARY AND MAY COME BACK WITH A REPLY.

TO FIND A TOPIC OF INTEREST TO YOU ON THIS BLOG, SIMPLY TYPE IN THE NAME OR WORDS RELATED TO THE TOPIC IN THE FIELD IN THE LEFT HAND SIDE AT TOP OF THE PAGE AND THEN CLICK ON “SEARCH BLOG”. WITH WELL OVER 900 TOPICS, MOST ABOUT GENERAL OR SPECIFIC ETHICAL ISSUES BUT NOT NECESSARILY RELATED TO ANY SPECIFIC DATE OR EVENT, YOU SHOULD BE ABLE TO FIND WHAT YOU WANT. IF YOU DON’T PLEASE WRITE TO ME ON THE FEEDBACK THREAD OR BY E-MAIL DoktorMo@aol.com

IMPORTANT REQUEST TO ALL WHO COMMENT ON THIS BLOG: ALL COMMENTERS WHO WISH TO SIGN ON AS ANONYMOUS NEVERTHELESS PLEASE SIGN OFF AT THE END OF YOUR COMMENTS WITH A CONSISTENT PSEUDONYM NAME OR SOME INITIALS TO HELP MAINTAIN CONTINUITY AND NOT REQUIRE RESPONDERS TO LOOK UP THE DATE AND TIME OF THE POSTING TO DEFINE WHICH ANONYMOUS SAID WHAT. Thanks. ..Maurice

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Monday, April 29, 2013

Patient Modesty: Volume 54








It seems that back and forth comments on this thread continues the disagreement regarding which gender is subjected to or is suffering more from acts within the medical community which intrudes upon the patient's physical modesty, perhaps even causing psychological harm.  My view is this discussion shouldn't be relegated to a gender issue but directed to establishing changes in medical practice to be followed by all of its caregivers for patients of all genders.

For those who are first time visitors to this thread may benefit to follow the discussion by reading  the previous Volume "Patient Modesty: Volume 53".   ..Maurice.

Graphic: A repeat of the graphic I set for "Patient Modesty: Volume 4" June 26, 2008.

NOTICE: AS OF TODAY MAY 26,2013  "PATIENT MODESTY: VOLUME 54" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 55.

Monday, April 15, 2013

Are There Ethical and Legal Limits to Emotional Comfort?







"Creature comforts" have been usually defined as "things that contribute to bodily comfort and ease of mind as food, warmth or sleeping facilities" (The Free Dictionary). However, the "creature" in that definition is us. What if it is animal creatures that have been selected to provide the human with psychological comfort? And now we are talking about "emotional support animals" (ESA), which are a variety of animals which provide emotional comfort for their emotionally ill owner but unlike dogs for the deaf or blind or psychotic patients which are trained for specific duties, these emotional support animals are untrained but after being prescribed by a physician or psychologist or other therapist, the animal's owner has been provided with certain legal rights under federal and state laws to keep the animal with them in housing and travel.

Here is an excerpt from "Comfort Creatures" in the April 22 2013 issue of
Time Magazine: "Petey the pig contains multitudes. He is a beloved member of the Forgione household in suburban Whitestone, Queens. He is a bona fide form of prescription medicine. He is an enemy of the New York City department of
health. And on a spring afternoon walk with his owner, Danielle Forgione, 1-year-old Petey is just a pig pursuing wholesome piggish endeavors: snorting, grazing, rooting through the dirt, searching out bugs." Read the article.

A variety of animals have been used for emotional comfort from dogs, cats, pigs, horses, birds and even lizards. Though ESA have been shown to be of value to those in emotional distress, they all have not been fully accepted by others in all
environments. Indeed as of March 15 2011 in a revision of the Americans with Disabilities Act, those creatures which are not trained to perform specific services to a patient are no longer considered "service animals" and are no longer permitted in environments where they pose problems with regard to safety, sanitation or disturbance. A question can be asked as towhy in our society it is necessary to turn to lower animals to provide emotional comfort? Is there no adequate benefit available from inter-personal relationships. Or is a common denominator of the discomforted patient
the lack of personal ability to develop a helpful relationship with another person who could provide needed emotional support?

The issue of providing emotional comfort can be looked at beyond the use of ESA but also with regard to drug and alcohol abuse and other behaviors which society might look upon unfavorably. Beyond the treatments utilized for comfort, there is the overriding question of whether attempting to maintain emotional comfort is always an ethical "good" and should always be encouraged including with legal support if necessary. Does such comfort always provide a path to the betterment of the
individual or society? Shouldn't emotional discomfort be considered a natural and acceptable challenge to stimulate the individual to make constructive changes with improvements in his or her life and perhaps even in addition better the life of
others? What is your opinion regarding use of ESA but also that of the primacy of maintaining emotional comfort under all circumstances?  ..Maurice.

Graphic: From Wikimedia commons


Friday, April 12, 2013

Ethics: Not Hiring/Firing Those Who Smoke












There is a thread on this blog titled "Ethics of Smoking".  It was started in April 2009  In that posting, a visitor wrote that her insurance company was " threatening their employees who will not quit smoking with a dock in pay of $25.00 per pay period, until they decide to quit. The employees must have quit for 12 weeks before they can be reimbursed the so-called surcharge."

The issue of companies non-hiring prospective employees or penalizing or firing employees who do not stop smoking continues on as an occupational, public health and ethical issue and dilemma. There are two opposing commentaries in the Perspective section of the April 11, 2013 issue of the New England Journal of Medicine with each looking at the two sides of the issue. The first commentary "Ethics of Not Hiring Smokers" presents the following conclusion: "By cherry-picking “low-risk” employees and denying employment to smokers, employers neglect this obligation, risk hurting vulnerable groups, and behave unethically. The same goes for imposing high penalties on smokers under the guise of providing wellness incentives.
We believe that employers should consider more constructive approaches than punishing smokers. In hiring decisions, they should focus on whether candidates meet the job requirements; then they should provide genuine support to employees who wish to quit smoking. And health care organizations in particular should show compassion for their workers. This approach may even be a win–win economic solution, since employees who feel supported will probably be more productive than will those who live in fear of penalties."

Whereas the next commentary "Conflicts and Compromises in Not Hiring Smokers", the authors conclude "We recognize that these hiring practices are controversial, reflecting a mix of intentions and offering a set of outcomes that may blend the bad with the good. We know that many companies will want merely to continue their current level of anti-tobacco efforts, but given the threats that tobacco presents to our communities and institutions, we believe it's time to climb another rung on the ladder,,," [toward the final rung "Eliminate Choice: Make Smoking Illegal"].

Read both free articles (click on the above links) and then return and present your opinion here. ..Maurice.

Graphic: From Google Images and modified by me with Picasa3

Sunday, April 07, 2013

Texting and Driving: Is That You and Is That Ethical?






The content of this thread is about the ethics of texting when driving and my visitor's views on this currently common activity. When one reads the statistics available regarding the  extent of the texting while driving activity and the known statistics of the outcomes of distracted driving,  unless my visitors represent a special statistical outlier population, it could be reasonable to consider that half of my visitors are out there texting and driving. Am I correct?

OK..what are the statistics? According to the article in the March 28 2013 issue of USA Today as extracted: Forget teenagers. Adults are the biggest texting-while-driving problem in the USA. What's worse — they know it's wrong.Almost half [49%] of all adults admit to texting while driving in a survey by AT&T provided to USA TODAY, compared with 43% of teenagers. More than 98% of adults — almost all of them — admit they know it's wrong. Six in 10 say they weren't doing it three years ago."I was a little bit surprised," Charlene Lake, AT&T's senior vice president-public affairs, says of the survey of 1,011 adult drivers. "It was sobering to realize that texting while driving by adults is not only high, it's really gone up in the last three years."  


Though statistics of death and injuries are not yet available regarding the activity of texting itself which is considered as distracting driving, according to US Government statistics "in 2011, 3,331 people were killed in crashes involving a distracted driver, compared to 3,267 in 2010. An additional, 387,000 people were injured in motor vehicle crashes involving a distracted driver, compared to 416,000 injured in 2010. 18% of injury crashes in 2010 were reported as distraction-affected crashes."  It appears that repeated texting while driving can be a habit of major health significance such as smoking, excess alcohol or illicit drug use. 

With regard to the ethics, an  activity or decision is ethical if the consequences can be shown to be an ethical "good" not a "bad" to an individual and if pertinent to others and society.  An example of an ethical "good" would be an activity which is of value to the individual or others without causing harm or that the value is of such a magnitude that it would easily trump the degree of harm which might occur. It is hard to argue that texting while driving is an ethical "good". but what do you think? And if you text while driving tell us how you personally look at this activity. Is this a habit of yours and if you think it is a bad habit do you feel motivated to break it?
You are writing anonymously, so speak up!  ..Maurice.

Graphic: Photograph taken by me today and edited with Picasa3.


Tuesday, April 02, 2013

The Ethics of "Hand-Offs" in Medicine





The following original article which I wrote and was published today at the bioethics.net website is reproduced here with permission.  I will put some additional comments as an Addendum at the end of the copy. ..Maurice.


04/02/2013

THE ETHICS OF “HAND-OFFS” IN MEDICINE

Maurice Bernstein, M.D.
Here is a realistic scenario as written in the U.S. government’s Agency for Healthcare Research and Quality “Web M&M” website which could occur in any teaching or even in non-teaching hospital with hospitalists on duty.
An 83-year-old man with a history of chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), and paroxysmal atrial fibrillation with sick sinus syndrome was admitted to the cardiology service of a teaching hospital for initiation of dofetilide (an antiarrhythmic medication) and placement of a permanent pacemaker.
The patient underwent the pacemaker placement via the left subclavian vein at 2:30 PM. A routine postoperative single view radiograph was taken and showed no pneumothorax. The patient was sent to the recovery unit for overnight monitoring. At 5:00 PM, the patient stated he was short of breath and requested his COPD inhaler. He also complained of new left-sided back pain. The nurse found that his pulse oxygenation had dropped from 95% percent to 88%. Supplemental oxygen was started and the nurse asked the covering physician to see the patient. The patient was on the nurse practitioner (NP) non-housestaff service; however, the on-call intern provides coverage for patients after the NPs leave for the day. The intern, who had never met the patient before, examined him and found him already feeling better and with improved oxygenation with the supplemental oxygen. The nurse suggested a stat x-ray be done in light of the recent surgery. The intern concurred, and the portable x-ray was done within 30 minutes. About an hour later, the nurse wondered about the x-ray and asked the covering intern if he had seen it. The covering intern stated that he was signing out the x-ray to the night float resident, who was coming on duty at 8:00 PM.
Meanwhile, the patient continued to feel well except for mild back pain. The nurse gave the patient acetaminophen as prescribed and continued to monitor his heart rate and respirations. At 10:00 PM, the nurse still hadn’t heard anything about the x-ray so he met with the night float resident. The night float had been busy with an emergency but promised to look at the x-ray and advise the nurse if there was any problem. Finally at midnight, the nurse signed out to night shift, mentioning the patient’s symptoms and noting that the night float had not called with any bad news. The next morning, the radiologist read the x-ray performed at 4:00 PM and notified the NP that it showed a large left pneumothorax. Cardiothoracic surgery service was consulted and a chest tube was placed at 2:30 PM, nearly 23 hours after the x-ray was performed.   Luckily, the patient suffered no long-lasting harm from the delay.
The team subsequently learned that the night float resident had mistakenly examined the radiograph done immediately postoperatively rather than the chest x-ray done at 4:00 PM, and therefore did not see the film with the large pneumothorax.
The ethical issue is to preserve patient beneficence and to avoid patient harm. Although the Joint Commission—the organization in the United States charged, through scrutiny of practices to maintain patient safety in hospitals receiving federal payment—has mandated structured signout systems, it is still the personal professional duty of each healthcare provider to make those systems work. The systems themselves involve both written and verbal forms of communication and with regard to the verbal communication, the opportunity for both parties to ask and answer questions is considered important.
There is the problem with systems described on paper: how to convert words into effective actions. This hoped for reaction is limited, I think, by a virtual natural conflict of interests within each professional participant in the care of a patient. One interest is physical and mental comfort. Interns and resident physicians working long hours without adequate rest naturally experience fatigue and opportunity to leave work becomes a specific goal. Then there is the natural conflict between the physician’s work and personal life. Beyond these conflicts is a hidden but perhaps unfounded feeling or assurance regarding the capacity or intentions of the upcoming physician toward the attentive, understanding and thus constructive continuity of the patient’s care. That is why, I think, direct communication between doctors is essential and, of course together with the nursing staff. And then, there is the patient. I would think that another participant in the “hand-off” should be, if possible, the patients themselves. They should be introduced to the “new team” and not simply be the “stable post-pacemaker placement patient in Room 231″, an object to be discussed but otherwise not participating.
It is now understood that the action of “hand-off” from one patient care team to another is a critical part of the care of patients in terms of potentially creating medical errors and thus adding to the other errors that can occur in medicine and surgery. Patients may assume that these changes carry no risk. I think patients and their families should be made aware of the need, and patients—within their capacity—be a participant in this transition just as they are asked to monitor their medication or tests performed on them. Hopefully with all actively participating, both beneficence and non-maleficence will be the ethical result of this common hospital action, the “hand-off”.
____________________________________________
ADDENDUM:  I am curious regarding the understandings of my visitors.  When you were in the hospital as a patient  (if you ever were!) were you informed or were aware about "hand-offs" between nurses, nursing staff and physicians or between the physicians themselves? If you were informed, how was that done? Did the physician actually come into your room and identify him/herself?  Did you suspect the possibility of medical errors associated with "hand-offs" or actually had one happen? I'm just wondering.. ..Maurice.