A Medical Student and YOU: The "Hidden Curriculum"

Another in a series of threads regarding the ethical/professional issues that could involve a medical student and you or a family member as a patient. This thread is based on the book Professionalism in Medicine : A Case-Based Guide for Medical Students. Cambridge:Cambridge University Press; 2010 and  from the website "Professionalism in Medicine" prepared by Jefferson Medical College in Philadelphia Pennsylvania. This thread begins with a video dramatization of a vignette which is followed by a faculty member perspective commentary.First go to the following link, read, view and then return and present the visitors to this thread your own view of the particular professional issue from the perspective of the patient:Commitment to Professional Competence

A STARTING COMMENT FROM ME:


Being competent as a physician requires proper education and experience. Much of the basic education in diagnosis and the treatment of the patient's disease actually occurs during the first two years of medical school. It is there where the theory and also the scientific basis for accomplishing these responsibiities are presented. What happens as part of the student, intern or resident's professional development after these two years is a learning activity which can be distorted by various suspected or realistic practicalities and clinical habits of those performing the instruction. This later teaching regarding the profession of medicine has been called the "hidden curriculum". Often this "hidden curriculum" while perhaps assumed to facilitate certain clinical actions and certain doctor-patient relationships may, in fact, pose unnecessary patient cost and unnecessary patient harm and may even go against medical professional code of ethics. Though it is doubtful that the "hidden curriculum" in medical education and behavior will ever be eliminated, however knowing about this phenomenon should provide patients with a reason to retain a touch of attention and indeed a bit of skepticism with regard to the behavior and decisions of their physicians. ..Maurice.

A Medical Student and YOU: Like to Know Who is Closing the Incision?

I am putting up a series of excellent discussions about ethical/professional issues that could involve a medical student and you or a family member as a patient. Each discussion as a separate thread is based on the book Professionalism in Medicine : A Case-Based Guide for Medical Students. Cambridge:Cambridge University Press; 2010 and  from the website "Professionalism in Medicine" prepared by Jefferson Medical College in Philadelphia Pennsylvania.  Each issue at the website is begun with a brief vignette, and then a brief video dramatization of the vignette and then followed by perspective commentaries by a medical student and followed by that of a faculty member. First go to the following link, read, view and then return and present the visitors to this thread your own view of the particular professional issue from the perspective of the patient: Principle of Patient Autonomy.  

A STARTING COMMENT FROM ME:

In the case of surgery, informed consent for a procedure means that the patient understands the need for the surgery, the risks and in general how and specifically who is performing the surgery. By becoming informed and then agreeing, the patient's autonomy is maintained. To intentionally fail to inform the patient beforehand as to who is part of the surgical team, except in the case of an emergent switch of surgeons, defeats the validity of informed consent. Patients expect the best of surgical skills and to have a novice involved without informing the patient and receiving patient consent for that novice is unethical and fails professional standards regardless of the necessity for novice (student) education. ..Maurice.

A Medical Student and YOU:Patient Confidentiality

I am putting up a series of excellent discussions about ethical/professional issues that could involve a medical student and you or a family member as a patient. Each discussion as a separate thread is based on the book Professionalism in Medicine : A Case-Based Guide for Medical Students. Cambridge:Cambridge University Press; 2010 and  from the website "Professionalism in Medicine" prepared by Jefferson Medical College in Philadelphia Pennsylvania.  Each issue at the website is begun with a brief vignette, and then a brief video dramatization of the vignette and then followed by perspective commentaries by a medical student and followed by that of a faculty member. First go to the following link, read, view and then return and present the visitors to this thread your own view of the particular professional issue from the perspective of the patient: Commitment to Patient Confidentiality.

A STARTING COMMENT FROM ME:

It's all about the "need to know". Comments about an individual patient's medical or psycho-social condition have to be guarded and away from those individuals who have "NO need to know" where the need is to provide diagnosis, therapy, financial or other specific benefit to the patient unless otherwise specifically requested by the patient. That is why,in the United States, we have the HIPAA regulations which penalizes those who violate the "need to know" dictum.

One could argue that, if the information is unidentifiable regarding any specific patient such release of information is safe. Unfortunately, in these days of mass communication and the internet with search engines, specific patient identification is easier and unidentifiable can be a "wishful thinking" concept. ..Maurice.

 

  ..Maurice.

A Medical Student and YOU: The Matter of Honesty

I am putting up a series of excellent discussions about ethical/professional issues that could involve a medical student and you or a family member as a patient. Each discussion as a separate thread is based on the book Professionalism in Medicine : A Case-Based Guide for Medical Students. Cambridge:Cambridge University Press; 2010 and  from the website "Professionalism in Medicine" prepared by Jefferson Medical College in Philadelphia Pennsylvania.  Each issue at the website is begun with a brief vignette, and then a brief video dramatization of the vignette and then followed by perspective commentaries by a medical student and followed by that of a faculty member. First go to the following link, read, view and then return and present the visitors to this thread your own view of the particular professional issue from the perspective of the patient: Commitment to Honesty with Patients.

A STARTING COMMENT FROM ME:
Honesty with the patient or family requires that those who are called "doctors" are indeed "doctors" and not medical students who haven't graduated. As I have written on a much earlier thread, I totally disagree with the identification of the student as even a "student doctor" as I also disagree with the term "student nurse". I think all those who interact with a patient should be identified as to their role. This is part of being honest with the patient. So let's call the students what they are: "nursing student" and "medical student"--- NOT a nurse and NOT a doctor. ..Maurice.

Medical Slang Leading to Logical Fallacy: A Practice to be Avoided

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

05/03/2013

MEDICAL SLANG LEADING TO LOGICAL FALLACY: A PRACTICE TO BE AVOIDED

Maurice Bernstein, M.D.

Medical slang is a form of slang used by doctors, nurses, paramedics and other hospital or medical staff. It is expressed either in informal vocabulary as words, abbreviated terms or also as acronyms (words made up of initial letters of the words the acronym represents) related to medical terms or conditions, persons or events. Presumably the basis for the use of medical slang is to communicate one’s concept or clinical finding or evaluation or diagnosis to other caregivers in a rapid and concise way. Unfortunately, the use of medical slang may lapse into derogatory expression or become ambiguous. Derogatory means that findings or persons are expressed in a disrespectful or degrading manner. Ambiguity can be related to the fact that an acronym or abbreviated word may not be sufficiently distinctive and can be used or interpreted for more than one medical term.

Examples of medical slang can be as benign as but also potentially ambiguous as the following medical transcription terms: “lytes”=electrolytes, “nitro”=nitroglycerine,”sats”=saturations, “crit”=hematocrit, “mets”=metastases, “osteo”=osteoporosis. On the other hand, medical slang can be derogatory even though amusing when applied to medical specialties. For example: “baby catcher” for obstetrician or “butchers” or “knife happy” for surgeons. Examples of medical slang as applied to patients include “dirt ball” for a patient who enters the emergency room filthy and smelling badly or “druggie” for patients known or suspected for illicit drug use or “goldbrick” for a patient who demands more attention than their (minor) condition warrants or the acronyms LOBNH for “lights on but nobody home” for a patient with suspected dementia and, of course, GOMER for “get out of my emergency room!”.

My argument is that medical slang generally can not only be or become disrespectful or ambiguous but also in the case relating to patients themselves, the derogatory descriptions may actually represent an action by the professional to create a logical fallacy. What is a logical fallacy? It is an error in reasoning that renders an argument invalid. Why attribute a medical slang expression as promoting a logical fallacy? First, a basic premise within the profession of medicine is the responsibility to obtain history and facts, if possible directly from the patient, and then to attempt to draw and present a conclusion from the facts. Drawing that conclusion is a logical exercise. Because, unlike the application of medical slang to “conditions” when this slang is applied to a person (an ad hominem), it may allow a fallacious conclusion by the healthcare provider originating the slang which rejects any argument or facts given by the patient since these arguments or facts are trumped by the provider’s own conclusion about the character or reliability of the patient. This is a logical fallacy since such a conclusion may be unwarranted. The explanation and facts provided by the patient must be logically evaluated separately for their validity and value and not invalidated by simply the provider’s personal decision regarding the patient as a person. The doctor can’t fairly make a judgment that the patient’s descriptions of pain should not be considered and reconsidered because the patient is known or suspected and described as a “druggie.” Some person on the street may say “that guy over there looks like a druggie” but that person is not required professionally to go beyond that assumption and so the statement may only be considered “unfair” or “uncouth.” My argument is that in a doctor-patient relationship such a slang expression by the doctor would represent a professional ad hominemimproperly affecting the doctor’s judgment regarding the history and facts presented by the patient.

For a number of reasons, including medico-legal, there is said to be a diminution in the general use of medical slang. Hopefully this is true and will continue to diminish. Certainly, expressions by physicians, nurses and other healthcare providers which are non-humanistic, are demeaning to the patient and indirectly to the profession itself and finally, as a consequence, allows a logical fallacy to be exercised, which distracting from and preventing proper clinical evaluation of the patient, cannot be considered of value to be continued to be used in medical communication.

Addendum: Beyond the issue of how derogatory medical slang may affect a physician's fair decision making  responsibilities, what do you think about medical slang in general, particularly if it was applied to you as a patient? ..Maurice.

"Incidental Finding": No Symptoms and Rarely Dangerous: Now What??

"Incidental Finding". The finding was one which was not sought for when a patient is being worked up to explain their symptoms and treat a disease, if present. The finding was not producing any symptoms. The dilemma for both the doctor and the patient is what to do if the examination or testing discloses an abnormality in the body not sought for.  And what, as is not uncommon, the abnormality is not normal as the word states but the abnormality has developed absolutely no symptoms for the patient and most of the time the abnormality does no harm to the patient if left alone and untreated.  Rarely, it may cause some symptom and rarely it would be considered dangerous, threatening the activities or life of the patient.  If the test had not been performed neither the patient nor the doctor would know about the abnormality. But yet, it was found and now what?  Just knowing may be very disturbing to the patient but also even for the doctor.  If the incidental finding was a growth, should the growth be removed despite routine procedure risks and financial costs to the patient?

The issue of the "incidental finding" in medicine was recently discussed at the Presidential Commission for the Study of Bioethical Issues and was written up in the Commission's blog, blog.bioethics.gov and a section of the discussion is reproduced below. My question to my blog visitors is how would you react and what would you want if you were told that you had such a "incidental finding".  Would you accept the risks and cost of doing something about the finding or would you go on the statistics and feel comfortable with the "incidental"
description and statistics? ..Maurice.

Incidental Findings in the Clinic: Extra Information and Extra Worry

Written by Bethany Brookshire on April 30, 2013 

During today’s meeting of The Presidential Commission for the Study of Bioethical Issues, it soon became clear that dealing with an incidental finding can involve more than just reporting to the patient impacted. As Haavi Morreim, J.D, Ph.D. Professor of Internal Medicine at The University of Tennessee Health Science Center, stated, there may be a difference between “standards by which care should be provided… and standards by which care should be assessed.”

Danielle Ofri, M.D., Ph.D., Associate Professor at the New York University School of Medicine, spoke of a patient with gastrointestinal pain. While Ofri, as her primary care physician, Ofri knew that the gastrointestinal pain was a common occurrence and probably nonthreatening. However, when her patient checked into the Emergency Room, the doctors, who did not know the patient’s history, performed a CT scan. The CT scan showed no cause of gastrointestinal pain. But it did turn up something else: “a 2 cm nodule in the right adrenal gland” or as Ofri wryly called it “The dreaded incidentaloma.”

Nodules in the adrenal glands are common, and while Ofri notes that 98% are entirely benign, in rare cases they can lead to problems such as the overproduction of hormones, or to cancer. “Nevertheless,” Ofri said, “once the incidental finding had been given life, so to speak, it was no longer incidental.”

Ofri had to refer to the standard-of-care for an adrenal incidentaloma, which involved a list of complicated tests. “As clinicians,” said Ofri, “we have a bias toward doing something, as opposed to doing nothing…Our patients, almost uniformly, want us to do something. Both doctor and patient are enthralled within this overwhelming medical imperative to act.” The tests would cost thousands of dollars, and also threatened to expend Dr. Ofri’s medical capital with her patient.

There was only so much time she had to spend with the patient, and with all of the information required to discuss the incidental finding, Ofri was obliged to skip over many other issues that the patient needed to have discussed, such as high blood pressure, cholesterol, and diabetes. These issues “…ended up with the short end of the clinical stick that day—an outcome” Ofri noted, “that is surely not incidental.”

Next, Carol Krucoff spoke of her experience as a patient who received an incidental diagnosis of a small acoustic neuroma. Even though her so-far benign neuroma has caused her significant anxiety, Krucoff stated that she would rather know about the presence of the neuroma than not. She recommended policies to help patients deal with incidental findings, including keeping patients informed in simple, direct language, training providers with communication skills to ensure both compassionate and clear communication, and to add a support person to the healthcare team, to help patients and their families process difficulty information.  And, she says “Unless it’s a necessity, don’t rush to treatment.”

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.

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

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

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.

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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. 

Same-Sex Marriage: Is It Ethical?

While currently, in the United States, the issue of same-sex marriage is holding attention of the public and the United States Supreme Court, it is a settled matter in a number of other countries (Argentina, Belgium, Canada, Denmark, Iceland, Netherlands, Norway, Portugal, Spain, South Africa an Sweden)
An excellent description of same-sex marriage and its views around the world with links to further detailing of the subject can be found in Wikipedia.

In a writing by Peter Sprigg sponsored by the Family Research Council  titled "The Top Ten Harms of
Same-Sex 'Marriage'" the following alleged "harms" are outlined.
1.Taxpayers, consumers, and
businesses would be forced to subsidize homosexual relationships.
2,Schools would teach that homosexual relationships are identical to heterosexual ones.
 3.Freedom of conscience and religious liberty would be threatened.
4.Fewer people would marry.
5. Fewer people would remain monogamous and sexually faithful.
6. Fewer people would remain married for a lifetime.
7.Fewer children would be raised by a married mother and father.
8. More children would grow up fatherless.
9. Birth rates would fall.
10.Demands for legalization of polygamy would grow.

The question for my blog is whether my visitors consider that same-sex marriage is an ethical act. Does it do good and is it fair and just?  To help in making the decision, read the brief summary of how to make an ethical decision by the Markulla Center of Santa Clara University.  Remember ethical decisions sometimes may have one principle trump others having lesser ethical significance for that particular issue. Take a few minutes and read at the above links and return here and express your analysis or if you already have considered your response write it now.  ..Maurice.

Graphic: From Google Images and Christian Medical Comment, modified by me with Picasa3.

Who Should Be Held Responsible for Your Unhealthy Lifestyle?

Unfortunately, unhealthy lifestyles are all around us and maybe even some of them belong to us. I
am writing about eating practices leading to obesity and associated diabetes or heart disease,
smoking leading to chronic lung disease and cancer, alcohol abuse leading to liver disease and
mental illness along with drug habituation leading to numerous consequences. There are other
unhealthy lifestyles that one can suggest.

There appears a basic question when considering the ethics and responsibilities related to unhealthy
lifestyles.  Who is primarily responsible for the individual's pathology and its consequences? And
beyond the patient bearing the physical or psychological costs of the illness itself,should others
be considered as responsible toward continuation of that style or the monetary costs and other
impacts regarding medical care which result from that patient's lifestyle? Should parents,
politicians, physicians, manufacturers, media or society in general be responsible for either
promoting the starting of the bad health habits or failure to educate or prevent such habits and
therefore bear the costs.

On the other-hand if,in fact, lifestyle selection and its continuation is really being set by the
individual's genetics and that development of an unhealthy lifestyle is simply an immutable matter
initiated and continued by the individual's genes does that mean that neither the individual or
anyone else can be pointed at as being responsible?

In selecting to post this thread, I wasn't really thinking of going deeply into the philosophical
or political aspects of unhealthy lifestyles (for that you might want to read an article
"Lifestyle, Responsibility and Justice" by E.Firing in the Journal of Medical Ethics 2008 and which
can be obtained by this link), what I wanted is for my visitors who, for examples, continue to
smoke or who are obese and avoid dieting, tell us who they feel could be considered responsible for
the consequences of their life style and why.  ..Maurice.

p.s.- By the way, on another issue, is it right for doctors to use the word "obese" when telling a
patient who meets the medical definition of obesity? Maybe this topic will be for another thread
like "What words doctors should not speak to their patients?"

Graphic: From Freepic.com via Google Images

Patient-Doctor Texting Each Other: Should They Do It?

Are you texting your doctor and is your doctor texting you back? I have been
surprised reading about the extent to which the social activity of smart phone
texting has become some part of medical practice. Read about it in the
New York Times. Look at statistics in the Atlantic. And see a communication company's
statement about the financial value for texting in medical practice.


It sounds like a wonderful and practical addition to the providing of medical
care and particularly care for patients in the ages known to avidly text as part
of their daily activities. But is texting while treating or being treated really
and fully a "medical good" or contains issues and hazards, bad outcomes, which
have been documented with texting while walking or driving or other activities?
Instead of distraction, a recognized hazard, texting by and to patients in
medicine can lead to other concerns. One obvious concern, that of medical
privacy, as directed in the United States HIPAA regulations, would be knowing
exactly who is texting who. Also, is there any assurance of medical privacy of
all communication when texting with our current technology? Finally, there is the
issue of what should and what shouldn't be texted between patient and doctor. A
request for an appointment with the doctor and a reply might be one use and could
be acceptable. But how much more than that? And beyond texting is doctor-patient
participation in other social media interactions such as Facebook an ethical way
of communication? (But that is for another thread.. here, lets stick to texting.)

Communication within a doctor-patient relationship can be a complex process with
subtle nuances, particularly in dealing with symptoms, disease and treatment.  There
are many important subtleties in direct communication which are not just verbal but also involve
facial expressions and other body language and touch Communication of clinical issues
by normal phone talk are devoid of such essentials and certainly with texting and only
a few text characters there is no possibility for more detail of a patient's attitude and feelings and expressions of concern, understanding or uncertainty or cooperation except with "LOL" type characterizations.

Read the links above and then come back and write about your thoughts about the
benefits or harms to texting either by the patient or the doctor. And by the way,
on this blog, unlike most smart phone texting, your comments can contain up to
4096 characters! ..Maurice.





Graphic: From Google Images

CPR on a Loved One: Should/Would You Watch?

There has been much debate over the recent decades since cardio-pulmonary resusciation (CPR) has
become the established medical response to when a heart stops pumping about whether it
was appropriate for both a family member or the medical staff to have a family member present
and observe that procedure. The debate has mostly been amongst the medical professionals themselves
who are involved in the CPR procedure. However, whatever studies have been performed to try to clarify an
answer to the question overall tend to favor and not discourage family attendance. A current statistical study of the emotional outcomes of family members in France who either witnessed or did not witness CPR being performed on their loved one was published March 14 2013 (volume 368, number 11, page 1008) in the New England Journal of Medicine. The study was looking for the evidence of and magnitude of post traumatic stress disorder (PTSD) in those family who witnessed CPR and those who did not, along with medical staff issues was consistent with what has been  considered previously that "family presence during CPR was associated with positive results on psychological variables and did not interfere with medical efforts, increase stress in the healthcare team, or result in medicolegal conflicts." In fact, those who watched CPR even in the resulting death of their loved one were psychologically better off than those who were in the vicinity but did not watch.

But, on developing this thread, my intention was not necessarily to have my visitors review the statistical evidence presented in this or previous studies but really to discuss the personal thoughts or feelings about participating as an observer when a family member is undergoing CPR. Perhaps, some visitors may have actually experienced such an activity.

CPR is, as a medical response to cardiac arrest, a rather hurried and intensely active process, with clinical confirmation  f the arrest and maintaining monitoring for a heartbeat, attention to get the patient into the proper position for effective chest compression, beginning vigorous chest compression after establishing that an initial open airway is available until an endotracheal tube is inserted for mechanical ventilation. Then may come an electric shock applied to the chest to start a heart rhythm or improve a rhythm which causes the patient's body to violently jerk. Meanwhile, there must be the need for coordination of the activities by the staff involved and then final decision making of when to end an unsuccessful attempt at resuscitation. So where is the family visitor in all of this? Where should the  family visitor stand and should  there be a staff member dedicated to attend directly to the needs or questions of the visitor? Should the family visitor take any role at all in any decision making with regard to stopping or continuing the resuscitation attempt? Are these witnessed last moments of the loved one's life something to be thought of and sought as of value to the family? If so, of what value? Should you or would you watch? These are just some of the questions I would like to ask my blog visitors. Maybe you have some additional issues to discuss. If you have witnessed CPR at home by paramedics or in a hospital environment, can you tell us about your experience? ..Maurice.

Graphic: From Google Images

Is What is Ethical Lies "In the Eyes of the Beholder"?

The following original article which I wrote and was published today at the bioethics.net website is reproduced here with permission.   ..Maurice.

March 13, 2013 11:33 am

IS WHAT IS ETHICAL LIES “IN THE EYE OF THE BEHOLDER”?

Maurice Bernstein, M.D.

On my bioethics blog I wrote a post titled “Good People Do Bad Things for Good Reasons”. I suggested in that post that “what is ethical or not is often in the eye of the beholder”. An anonymous visitor wrote back the following:

“I would like to think that ethics is NOT in the eye of the beholder. That logic leaves too much room for justifications of any actions. Ethics is not religious doctrine. Ethics is not law. Ethics is not social standards. Ethics is not what feels right. These are all subjected to variables that can change the outcome of the ethical or unethical action. Ethics is simply what we OUGHT to do. Ethics is a code of values that is reasonable and well-founded. Beauty is for the eye of the beholder. Ethics is for everyone, everywhere. It is NOT subjective.”

Shouldn’t I disagree with that visitor’s comment?  If decisions and actions in ethics were immutable and fixed, documented in clear and non-ambiguous language, why would there be a need for “ethical consensus”? This need already supports my argument.

Think about the four ethical principles: autonomy, beneficence, non-maleficence and justice which are considered, for example, within clinical ethics but also in other ethical decision-making. Have decisions and actions carried out or proposed said to be in keeping with a principle actually met the philosophic or dictionary definition of each? Can there ever be decisions that are said to be and, indeed, are, actually fully faithful to autonomy (an individual’s strength of self-governing and independence), beneficence (contributing to an individual’s good), non-maleficence (doing no harm) or justice (fairness to all individuals)? Most decisions require the consideration of each of these principles in terms of the final result of the action. While the definitions of the ethical principles are “reasonable and well-founded”, their application in terms of a decision towards an action may lead, in all reality, to an ethical dilemma where it would be impossible for each to be equally applied. The solution to the dilemma would require the principles to be prioritized. But what makes an ethical dilemma most complicated is that each case may be different in that there may be a different set of facts. In addition, there may be more than one stakeholder in the results who will be affected by the decision and each stakeholder may have their own individual prioritization of the principles in order to produce a result consistent with their individual goals. So, what is necessary to proceed to a solution to the dilemma is the development of a consensus amongst the stakeholders.

Consensus means that those individuals involved have come to an agreement with regard to how the ethical principles should be prioritized. And consensus may not be a static conclusion but may vary over time depending in how people look at issues in their current environment. For example, was justice served at the onset of the second World War when American citizens of Japanese ancestry were interned for years in camps? Surely, it was the concern for the safety (beneficence) of the other American citizens that trumped the ethics of non-maleficence or justice toward those of Japanese ancestry. And yet, later, in a different time, this ethical decision was found to be unethical. In the past, medical research performed on human subjects that was carried out without fully informed consent by the subject and even with intended harm was accepted but in recent times have been rejected as unethical.

In summary, yes, ethics should be “what we OUGHT to do” but, in reality, applying all ethical principles we “ought” to do is not universally possible if we intend to come to a decision. And beyond that in practice with different cases, different stakeholders have different views of the issue and their individual visions set the ethics for the solution. Those are the eyes of the beholders.

Is Death a Medical Failure?

At our medical school, second year students have an opportunity, if they wish, to visit our local Coroner's office to learn about the duties of the coroner but also watch autopsies in progress. I have been given the opportunity of taking groups of student there. Each group is usually taught by their physician-instructor but in the case of the coroner's office experience, those groups which I take over, have instructors who have indicated that they didn't want to participate in the experience. I have not talked in detail with these physicians regarding their rejection to participate but I suspect a reason. It is most likely too emotionally  traumatic to be present and to stand and watch the autopsies. But why? I think I know the answer. For many physicians, perhaps most, death represents a failure. If the particular death was not the result of the failure of that specific physician, it could represent the failure of another physician.

The idea that the death of a patient could represent a failure on the part not only of a physician but even the medical system might be suggested by the facts. Supporting this idea is that it seems it is the goal of the medical system to provide and perform everything and almost anything to keep a sick patient alive. This intense direction to maintaining life at literally "all costs" and not to "give up" was always an old goal but has become more common in recent decades when the knowledge and technology has developed so that attempts at maintaining life of the terminally ill has become more realistic and, indeed, possible.

The goal and detailing the techniques of preserving life usually starts in medical school and progresses as the student goes on to internship and residency when the individual's responsibility for direct patient care is now present. Yes, teaching sessions about "telling the patient bad news" is part of the early medical student education but what I think is missing is the emphasis to the students about the need at some time and some point in the clinical course of the patient "to give up" both on the part of the physician but also the patient and family and then how to relate this "giving up" to the patient and family. Also, missing may be how to deal with the patient or family who refuses to "give up".

That this teaching to students and young doctors appears to be inadequate is shown by the facts regarding the high medical expenditure for  tests and treatments in the last months of the patient's life, the lack of time doctors spend with patients teaching and encouraging the creation of Advance Directives to set the limits of the patient's desired life supporting treatment. Further, is the observation of seemingly prognostic inconsistency by consultants who provide "mixed messages" to the sick patient and family with some encouraging procedures and life-support despite rejection of this advice by other physicians.  Finally, is the fact that often futile cardio-pulmonary resuscitation  is always performed by default unless a "do not resuscitate" order had been written. All these facts support a conclusion that physicians and the
medical system find that death of a patient represents a professional failure. But is death by definition a medical failure or is it really part of but the ending of what is called life something that all who are alive must accept. It usually is the latter and this concept should also be emphasized in the teachings of the medical students, the doctors, patients and families.

It is encouraging that in recent years, in addition to medical technical advancements, the concept of palliative care and hospice management has develop emphasizing that attention and care for the patient can continue despite progression of the illness and actually not fail up to the end of the patient's life.


So for those doctors who feel that the death of a patient is a failure on their part, it seems to be that it is only life itself that has failed to continue.  What is your opinion? ..Maurice.


ADDENDUM:  You may be interested to read more on this subject.  The following is an abstract and here is the link to a PhD Dissertation written by Deborah Jo Corker and titled "PHYSICIAN‟S EXPERIENCES WITH DEATH AND DYING: A PHENOMENOLOGICAL STUDY"

End-of-Life, the topic of the decade of 1990-2000, brought the focus on how we
die in America. Death encompasses cultural, ethnic, spiritual, social and physical
elements, which are often played out under the guidance of a medical provider or in
medical setting. As society redefines how we wish to handle our dying process and endof-
life care, medical society must also redefine how it trains its physicians and prepares
them to handle our death and dying. Medical school curriculum has added some end-of life
training, but there are limitations in time and scope of training available.
This qualitative phenomenological study attempts to gain the physician‟s
essences, meanings and understanding surrounding death and dying. Starting with
themes revealed in literature, in-depth interviews were used to ask selected physicians
providing care: How does death affect them? Are physicians receiving adequate training
in end-of-life care? Does the medical culture still see death as failure? How do they find
meaning in end-of-life care? Using three different groups of physicians: early in career,
mid-career, and retired, this research attempted to examine the phenomena of death
and dying over apparent time and developmental experiences of physicians.
Results: Physicians have not been adequately trained to handle end-of-life care.
Communications skills, specific end-of-life care training and support for physicians
dealing with death and dying are needed.

Graphic: From Google  Image

Job Description of a "Clinical Ethicist"

The first question would be is a "job description" really necessary when involved with decisions regarding patient care?  Shouldn't aspects of the job be already presumed?  If one is a physician or a nurse, the job description is virtually presumed.  The thread here is not about the role of the physician or nurse but that of those who call themselves "clinical ethicists".

Interestingly, to be called a "clinical ethicist" there is no professional body to provide the accreditation of teaching programs for learning that occupation, there is no professional body who is responsible to certify that the individual who calls him/herself a "clinical ethicist" has really met the educational and other professional standards (no agreed upon standards yet!) for that title and there is no "Code of Ethics" to set ethical standards of behavior.  Beyond all that.. there is no established job description for the "clinical ethicist".  Why do we need some sort of job description? Well, basically there is some controversy as to whether the "clinical ethicist" should be the advocate for the patient who is the focus of the ethical consultation and directly contribute to the final decision. Some say "yes" but some say the ethicist should not be considered a stakeholder in the deliberation. So, yes, a job description is certainly a first step in the development of criteria for a formal profession.

As former chairman of two different hospital ethics committees and currently a member of one, based on my experience and view of the issues that ethicists and ethics committees experience, I would like to state my idea of what a clinical ethicist should do and be doing as part of his or her occupation.

I look at the "job" of someone who calls themselves a "clinical ethicist" as a sub-specialty of being an ethicist (similar to being a cardiac surgeon while also responsible for the duties of being a physician).  To me "clinical" sets the interest to the issues related to the care and treatment of a specific patient and is not describing any administrative nor organizational aspects of being an ethicist.  It is that sub-specialty that I want to see a job description clarified.
To me, the difference between "patient advocate" and "teacher and mediator for all the stakeholders" is non-comparable.  To me, the end result is either: the clinical ethicist or the ethics consultation committee selects and makes the final decision    vs    a  final decision made by agreement of the stakeholders is also distinctively different.  I would feel satisfied if the job description of a "clinical ethicist" participating (and I am not saying "leading") in a case of a patient is one that states "teaching current ethical consensus and law to the stakeholders, teaching methods of looking at conflicting values, mediating discussion by the stakeholders toward their goal of the stakeholders selecting a final decision."  The "clinical ethicist" must then accept whatever decision is reached by the stakeholders as long as it does not grossly violate current ethics and current law. If it does, the violation, as judged by the ethicist, must be explained and the discussion by the stakeholders continued as they desire.  To me, while the hospital and administration itself may be one of the stakeholders, the clinical ethicst or ethical consultation committee is not.  

More on the job description:
In the case of making a life-death decision (such as turning off life-support) for an clearly established un-befriended patient who has no capacity to make medical decisions and for which the attending physician has solitary responsibility for the decision, the "clinical ethicist" performs the same role as with patients who have or have no capacity but who have family, friends or documents to provide surrogate decision-making or "best interest" decisions. The role is that of educating the physician regarding the ethics and law involved and to state and document the ethicist's conclusion as to whether the physician's decision was in keeping or violating the ethics and law. 

If you were attending an ethics committee consultation meeting as a family member of a sick hospital patient and a serious medical decision had to be made, what role would you want the ethicist or ethics committee members to play in the meeting or in the final decision?  ..Maurice.

Graphic: From Google Image and Chief Happiness Officer

Do Medical "Conscience Clauses" Mean Being Unconscious to Patient Care?

"Conscience Clauses" either proposed or actually written into governmental legislation of medical practice have stirred controversy on both sides of the issue. A "conscience clause" would permit physicians freedom from any legal retribution, discipline or discrimination to reject performing or otherwise carrying out an action or service which would go against the physician's "conscience", conscience being the physician's belief of right vs wrong, good vs bad based on the physician's own ethical or religious  principles as applied to the patient care. In rejecting, the physician may be required to attempt to refer the patient to another physician who would agree to perform the service. On the other hand, this responsibility may not be required since some might find such a referral to be facilitating an act which was already deemed suspect. It should be noted that the "conscience clause" is supported by the First Amendment to the U.S. Constitution: "Congress shall make no law respecting an establishment of  religion, or prohibiting the free exercise thereof.." Apparently the Amendment applies to physicians and other medical care providers as well as their patients.

An example of a "conscience clause" written into a United States state law, which is one about which I am familiar, is that of the California Probate Code.Within the California state Probate Code is the following:

"4734.  (a) A health care provider may decline to comply with an
individual health care instruction or health care decision for
reasons of conscience.
   (b) A health care institution may decline to comply with an
individual health care instruction or health care decision if the
instruction or decision is contrary to a policy of the institution
that is expressly based on reasons of conscience and if the policy
was timely communicated to the patient or to a person then authorized
to make health care decisions for the patient."

If the provider or institution declines, then:

"4736.  A health care provider or health care institution that
declines to comply with an individual health care instruction or
health care decision shall do all of the following:
   (a) Promptly so inform the patient, if possible, and any person
then authorized to make health care decisions for the patient.
   (b) Unless the patient or person then authorized to make health
care decisions for the patient refuses assistance, immediately make
all reasonable efforts to assist in the transfer of the patient to
another health care provider or institution that is willing to comply
with the instruction or decision.
   (c) Provide continuing care to the patient until a transfer can be
accomplished or until it appears that a transfer cannot be
accomplished." 

The "conscience clause" may be applied to legislation that could deal with various aspects of medical care but is more often related to issues of reproduction such as sterilization,abortion,contraception and stem cell procurement and use.

But the issue I want to discuss here is with regard to what is the impact of the "conscience clause" on the professional duties of physicians and other providers in the medical system. Should we look at it as an impediment, within the law, to proper patient care? Irrespective of the permission of the "clause", should physicians, nevertheless, divest themselves of their personal moral decisions when they take on
professional responsibilities? Should  responsibilities be only directed toward attending to the request and the best care of the needy patient and not, in some circumstances, directed toward the caregiver themselves? And what do you think about physicians or other healthcare providers who find situations where, to maintain
self-directed responsibilities and conscience intact, the duty even to transfer the patient to another provider who would follow the patient's request is unacceptable?

If you are a doctor how would you look at the permission offered by the "conscience clauses"? If you disagreed with the patient's request because of your moral or religious values, would you reject the request? ..Maurice.

Graphic: From Google Images modified by me with ArtRage and Picasa3







  

"DEATH PANELS": Do You Believe They Exist?

Hey! Do you remember,starting in 2009,the political fury, concern and cries about "Death Panels" in the United States as the Affordable Care Act ("Obamacare") was being debated? If you don't..where were you? Wikipedia has an excellent article on this topic to refresh your memory.

My understanding of what the public considers as a "death panel" would be a group of individuals not related to any specific patient but who becomes responsible to make a decisions as to what life-supportive treatment or other treatment would be allowed to be started or terminated for a patient. "Death" is used in the name since it is felt that death could well be the outcome of their decision. One way or another, it was this group "pulling the plug" on the patient's life-support.

An example of such a concern prior to the Affordable Care Act was the matter of the Texas statute Section 166.046 passed in 1999. The statute stated "If an attending physician refuses to honor a patient's advance directive or a health care or treatment decision made by or on behalf of a patient, the physician's refusal shall be reviewed by an ethics or medical committee. The attending physician may not be a member of that committee. The patient shall be given life-sustaining treatment during the review." The patient or patient's surrogate may attend the meeting and receive a written explanation of the decision reached.  If the physician, patient or surrogate don't agree with the decision, then the physician must attempt to transfer the patient to another physician or institution who will agree with the decision or follow the request of the patient or surrogate. Life-supportive treatment must be continued for 10 days after the decision or prolonged by court action. Following the letter of the law, provides legal immunity to the physician and hospital's ethics committee if the patient dies. There has been many patient cases decided in this manner under this Texas law along with considerable controversy.


I can't speak for Texas law and behaviors, but we, in California, have a similar law in the Probate Code regarding following patients' instructions or decisions:

 "Section 4735. A health care provider or health care institution may decline to comply with an individual health care instruction or health care decision that requires medically ineffective health care or health care contrary to generally accepted health care standards applicable to the health care provider or institution
Section 4736. A health care provider or health care institution that declines to comply with an individual health care instruction or health care decision shall do all of the following:
(a) Promptly so inform the patient, if possible, and any person then authorized to make health care decisions for the patient.
(b) Unless the patient or person then authorized to make health care decisions for the patient refuses assistance, immediately make all reasonable efforts to assist in the transfer of the patient to another health care provider or institution that is willing to comply with the instruction or
decision. (c) Provide continuing care to the patient until a transfer can be accomplished or until it appears that a transfer cannot be accomplished. In all cases, appropriate pain relief and other palliative care shall be continued."

Notice in the Code there is no mention of a final decision to be made by an ethics committee. An ethics committee would meet, however, to allow the patient or surrogate an opportunity to understand and counter the physician's view and for the committee, beyond moderating the meeting, to establish whether the physician's decision is appropriate with regard to current law and ethical consensus.  The medical decision to reject the patient's request is solely that of the physician.

I might add, that in California, hospital ethics committees may participate in a similar way with regard to expressing current law and ethical consensus in cases where the physician intends to terminate life-supportive treatment in a patient who has had no Advance Directive, no present capacity to make medical decisions and not expected to recover that capacity and, after searching with due diligence unable to find any relatives or friends who could contribute to the understanding of the patient's desires.

Defending only hospital ethics committees, as a current member and former chairperson, based on what I explained above, I would reject the view that our committee is a "death panel". We, as a committee, have no capacity to make medical decisions about appropriate therapy for a specific patient. We can listen to all sides and explain what is ethical and legal.  If the physician's view is ethical and legal, then, as a hospital ethics committee, we can support his or her decision.

 But, finally, how about you? Do you think that "Death Panels" exist in our United States medical system? ..Maurice.

Graphic: From Google Images.

Patient Modesty: Volume 53

                                                                                                                                       

The matter of how patients can get their physical modesty issues known, acknowledged and satisfied by the medical system seems to be a repetitive consideration on this blog thread and continues with no final conclusion. With regard to this issue, I thought to add to the conversation or perhaps even throwing in a "monkey wrench", so to speak, by putting up the graphic for this Volume which displays a known expression  thought to be a solution but then, on second thought, it might not be considered acceptable by some of my visitors. Instead they may say "we must change what we can get!" Ah! That will make the solution more complex. So what is the answer? Continue the discussion and maybe an answer will find consensus. ..Maurice.

p.s.- For those visitors who would like to access the recent conversation of my thread on this issue,
click on this link to Volume 52.

Graphic: Created by me with ArtRage and Picasa 3.

NOTICE: AS OF TODAY APRIL 29 2013 "PATIENT MODESTY: VOLUME 53" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 54.

Challenging Your Autonomy: Others Telling You What Not to Eat

It is all about what has been called the "precautionary principle" which as defined in Wikipedia (where you can read all about it): "The precautionary principle or precautionary approach states if an action or policy has a suspected risk of causing harm to the public or to the environment, in the absence of scientific consensus that the action or policy is harmful, the burden of proof that it is not harmful falls on those taking an act. This principle allows policy makers to make discretionary decisions in situations where there is the possibility of harm from taking a particular course or making a certain decision when extensive scientific knowledge on the matter is lacking. The principle implies that there is a social responsibility to protect the public from exposure to harm, when scientific investigation has found a plausible risk. These protections can be relaxed only if further scientific findings emerge that provide sound evidence that no harm will result.In some legal systems, as in the law of the European Union, the application of the precautionary principle has been made a statutory requirement."

Do you want your government to order you or, if not, pressure you, what to eat and what not to eat and all based on the application of the "precautionary principle"?

I found an excellent discussion of this issue in The New York Review of Books review by Cass R. Sunstein who reviews the book"Against Autonomy: Judging Coercive Paternalism" written by Sarah Conly. The review starts out with the introduction "In the United States, as in many other countries, obesity is a serious problem. New York Mayor Michael Bloomberg wants to do something about it. Influenced by many experts, he believes that soda is a contributing factor to increasing obesity rates and that large portion sizes are making the problem worse. In 2012, he proposed to ban the sale of sweetened drinks in containers larger than sixteen ounces at restaurants, delis, theaters, stadiums, and food courts. The New York City Board of Health approved the ban."

Sunnstein then compares the views of John Steward Mill's well-known essay "On Liberty" ("Mill insisted that as a general rule, government cannot legitimately coerce people if its only goal is to protect people from themselves. Mill contended that the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or mental, is not a sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so, because it will make him happier, because, in the opinion of others, to do so would be wise, or even right.") with that of Conly.

Her view, as introduced by Sunstein is "Sarah Conly’s illuminating book Against Autonomy provides such a discussion. Her starting point is that in light of the recent findings, we should be able to agree that Mill was quite wrong about the competence of human beings as choosers. 'We are too fat, we are too much in debt, and we save too little for the future.' With that claim in mind, Conly insists that coercion should not be ruled out of bounds. She wants to go far beyond nudges. In her view, the appropriate government response to human errors depends not on high-level abstractions about the value of choice, but on pragmatic judgments about the costs and benefits of paternalistic interventions. Even when there is only harm to self, she thinks that government may and indeed must act paternalistically so long as the benefits justify the costs."

Please go to the New York Review of Books and read the entire review and then return to post here your views of whether John Steward Mill is right or the view held by the author Sarah Conly or some alternate view that you hold. ..Maurice.

GIF Graphic: From Tumblr, John Locke