Screening for medical and psycho-social problems should be a primary function in physician history-taking beyond asking about the symptoms for which the patient has come for consultation and treatment. Screening is a pro-active way of discovering conditions in the patient’s life which may lead to disorder and symptoms in the future. Screening often involves asking patients about whether they smoke, drink alcohol or take illicit drugs. Hopefully, with the feedback from the physician, the patients will understand the reason for screening and will be forthcoming in their answers. However, screening may involve issues which are felt by some patients to be “too personal” to disclose to anyone. Screening about sexual history and practices, as an example, is being discussed on another thread.
An important screening topic which physicians should inquire is history of domestic violence. This also is complicated by the patient’s concern about the privacy issues and consequences of providing the physician with such information if their abusive spouse finds that the patient “talked.”
An interesting article about this subject is present in Postgraduate Medicine Online
titled “Screening for domestic violence
Identifying, assisting, and empowering adult victims of abuse” by
Katherine J. Little, MD in the August 2000 issue.
Barriers to disclosure are noted both on the part of the patient and that of the physician. Excerpts from the article:
Patients also face barriers to disclosing violent relationships. The perpetrator may have threatened to beat the victim more severely if she discloses information, or he might have implied that their children would be taken away. If the victim reported abuse in the past, she may have been blamed for the situation or the abuse may have escalated. Perpetrators may not allow victims who disclose information to participate in appropriate medical follow-up care. In some cases, a victim's cultural background may have taught her that she must accept her situation and that she should not question or discuss the subservient role into which she has been forced by the perpetrator.
...
Physicians face many barriers when trying to provide the kind of patient care that they themselves would expect to receive. Lack of time--to establish rapport with a patient, to hear in detail about all of her problems, and to ask a multitude of questions for further diagnostic elucidation--is a commonly cited reason for not routinely screening for domestic violence in primary care practice. Physicians do not want to open a Pandora's box of complicated social and psychological issues that could not possibly be evaluated in an allotted 30 minutes or less. Also, for some physicians, such a discussion may trigger memories of their own violent relationships; in such cases, the well-recognized survival technique of distancing oneself from a patient's pain may be ineffective.
I wonder if my visitors might discuss here how they would consider their being screened for domestic violence by their physician, perhaps as part of a routine history and physical. Would it be easier to disclose information about abuse if the questions were asked not face-to-face but in the form of a written or computer driven questionnaire? Is there a kind of modesty involved in this screening, modesty not to reveal ones private marital life? ..Maurice.
Monday, September 3, 2007
Saturday, September 1, 2007
Hypocrisy: Do You See It in the Practice of Medicine?
Hypocrisy is a word in the news these days. Currently it is being used in the context of the alleged behavior of U.S. Senator Craig as contrasted with his prior pronouncements and governmental activities. The word is defined in various ways but essentially can be understood as insincerity by virtue of pretending to have qualities or beliefs that one does not really have. My interest in using this word on this blog is to discover if hypocrisy is absent or is present, perhaps flagrantly present within medical practice and the various components that make up medical care from the pharmaceutical companies, insurance companies and HMOs,to the various medical societies including the American Medical Association, to the hospitals and down to the individual physicians, nurses and technicians involved in the care of patients. Do my visitors feel that at any level of health care, there are qualities or beliefs that are expressed to patients but by actions are really not present and not considered when dealing with society, patient groups and individual patients? If present, in what ways do you see it expressed? What do you think? ..Maurice.
Saturday, August 25, 2007
Doctor Doesn't Ask, Patient Doesn't Tell: Sexual Activity in the Elderly
Although the value and need for taking a sexual history from a patient, even for a routine complete history and physical is emphasized to the first year medical student, it is clear from the article "A Study of Sexuality and Health among Older Adults in the United States" by Lindau and others in the current August 23 2007 issue of the New England Journal of Medicine and the editorial "Sex and Aging" in the same issue (no free reprints available) that doctors are not asking and elderly patients are not telling their doctors about sexual activity and issues they may have. In the survey study of 1550 women and 1455 men ages 57-85, only 38% of the men and 22% of the women reported having discussed sex with a physician since the age of 50 years. The study showed that the prevalence of sexual activity declined with age (73% ages 57-64, 53% 65-74, 26% 75-85) with women aignificantly less likely than men at all ages in this study to report sexual activity. It is clear, if you are able to read the study, that sexual activity is not gone just by being old. All the forms of sexual activity are carried out by the elderly. The person's health has an influence on whether sexual interest and activity can continue. The article by Lindau concludes: "Many elderly adults are sexually active. Sexual problems are frequent among older adults, but these problems are infrequently discussed with physicians. Physician knowledge about sexuality at older ages should improve patient education and counseling, as well as the ability to clinically identify a highly prevalent spectrum of health-related and potentially treatable sexual problems."
I think that physician knowledge of sex in the elderly is generally poor. I think that physicians may be reticent to talk to the elderly about sex for some of the same reasons our first year medical students give: "The elderly patients are like my grandma and grandpa and I wouldn't dare talk about their sex with them." Further, physicians, though aware of the effects of illness and medications on sex, are probably unaware of the extent of sexual activity present in the elderly. That is why, just as the elderly talking to their doctor about their symptoms and treatments is important so is it important for the elderly to communicate their their own personal concerns regarding sex and sexual activity and the quality of that activity associated with how they feel and their illnesses.
Studies such as the one noted above should be publicized to both physicians and patients for the knowledge and benefit of both groups. Actually, that is why I thought this was an important thread to begin now. ..Maurice.
ADDENDUM 8-25-2007: I found the initial commentary by MJ KC stimulated a response by me which after writing it seemed appropriate to include on this Home page. ..Maurice.
At Saturday, August 25, 2007 7:32:00 PM, MJ_KC said...
I have never been asked anything related to this issue, ever, by any doctor. Seems that most doctors don't want to discuss this.
At Saturday, August 25, 2007 10:00:00 PM, Maurice Bernstein, M.D. said...
MJ KC, isn't that interesting? It seems that you are not the only one. Obviously, there is a resistance for sex to be brought up by the patient unless there is some symptoms of specific concern.But what is the resistance for a physician not to try routinely to obtain a sexual history as part of the patient's general history? I mentioned in my posting something about age difference and transference. Other factors could be gender and cultural differences.All of these factors may represent social taboos which need to be overcome. Beyond general social taboos, there is something which might be interprete by the physician as a "professional taboo." This would be concern by the physician that asking about and delving into the sexual life of a patient may be considered by the patient or others as voyeuristic, intrusive or seductive, all of which are professional "no-nos." They are really not that if the approach of the physician is consistent with good basic interviewing principles in an appropriate setting, approached in a professional manner and a professional vocabulary ( but with appropriate use of the patient's own terms or expressions to facilitate communication.) All of this is carried out after establishing general rapport and trust with the patient.Obviously, the initiation of the discussion of sex should be in the context of the patient's concerns or symptoms and appropriate to the clinical situation. Asking about sex when the patient comes to the office for a simple cold is inappropriate. Asking about sex as part of a initial complete history or annual exam or related to specific symptoms or side effects of medications is appropriate.One of the most important conditions which physicians need to bear in mind regarding asking about sex as with other personal questions deals with the need to emphasize confidentiality of what is discussed.Finally, other barriers which may present to the physician regarding talking to the patient about sex and sexual activity is what the physician might consider "acceptable" vs "deviant" behavior. These attitudes might affect whether and how the doctor communicates with the patient regarding sex. Perhaps related to this or not, a barrier may have to do with the personal sexual difficulties of the physician. After all, physicians are human beings with their own sexual history and it may be difficult to ask questions and interpret the answers of the patient objectively.This commentary was all about my thoughts of why despite learning about the taking of a sexual history in medical school some physicians just don't do it in practice. The other issue is, if the doctor doesn't ask, why is it that the patient doesn't tell?What factors would my visitors see as affecting why the patient doesn't tell and what could the physician do to mitigate that resistance?.. Maurice.
I think that physician knowledge of sex in the elderly is generally poor. I think that physicians may be reticent to talk to the elderly about sex for some of the same reasons our first year medical students give: "The elderly patients are like my grandma and grandpa and I wouldn't dare talk about their sex with them." Further, physicians, though aware of the effects of illness and medications on sex, are probably unaware of the extent of sexual activity present in the elderly. That is why, just as the elderly talking to their doctor about their symptoms and treatments is important so is it important for the elderly to communicate their their own personal concerns regarding sex and sexual activity and the quality of that activity associated with how they feel and their illnesses.
Studies such as the one noted above should be publicized to both physicians and patients for the knowledge and benefit of both groups. Actually, that is why I thought this was an important thread to begin now. ..Maurice.
ADDENDUM 8-25-2007: I found the initial commentary by MJ KC stimulated a response by me which after writing it seemed appropriate to include on this Home page. ..Maurice.
At Saturday, August 25, 2007 7:32:00 PM, MJ_KC said...
I have never been asked anything related to this issue, ever, by any doctor. Seems that most doctors don't want to discuss this.
At Saturday, August 25, 2007 10:00:00 PM, Maurice Bernstein, M.D. said...
MJ KC, isn't that interesting? It seems that you are not the only one. Obviously, there is a resistance for sex to be brought up by the patient unless there is some symptoms of specific concern.But what is the resistance for a physician not to try routinely to obtain a sexual history as part of the patient's general history? I mentioned in my posting something about age difference and transference. Other factors could be gender and cultural differences.All of these factors may represent social taboos which need to be overcome. Beyond general social taboos, there is something which might be interprete by the physician as a "professional taboo." This would be concern by the physician that asking about and delving into the sexual life of a patient may be considered by the patient or others as voyeuristic, intrusive or seductive, all of which are professional "no-nos." They are really not that if the approach of the physician is consistent with good basic interviewing principles in an appropriate setting, approached in a professional manner and a professional vocabulary ( but with appropriate use of the patient's own terms or expressions to facilitate communication.) All of this is carried out after establishing general rapport and trust with the patient.Obviously, the initiation of the discussion of sex should be in the context of the patient's concerns or symptoms and appropriate to the clinical situation. Asking about sex when the patient comes to the office for a simple cold is inappropriate. Asking about sex as part of a initial complete history or annual exam or related to specific symptoms or side effects of medications is appropriate.One of the most important conditions which physicians need to bear in mind regarding asking about sex as with other personal questions deals with the need to emphasize confidentiality of what is discussed.Finally, other barriers which may present to the physician regarding talking to the patient about sex and sexual activity is what the physician might consider "acceptable" vs "deviant" behavior. These attitudes might affect whether and how the doctor communicates with the patient regarding sex. Perhaps related to this or not, a barrier may have to do with the personal sexual difficulties of the physician. After all, physicians are human beings with their own sexual history and it may be difficult to ask questions and interpret the answers of the patient objectively.This commentary was all about my thoughts of why despite learning about the taking of a sexual history in medical school some physicians just don't do it in practice. The other issue is, if the doctor doesn't ask, why is it that the patient doesn't tell?What factors would my visitors see as affecting why the patient doesn't tell and what could the physician do to mitigate that resistance?.. Maurice.
Friday, August 24, 2007
Physician's Right to Choose and Duty Not to Neglect
The responsibilities of a physician include not to abandon his or her patient. A patient can abandon their physician as desired but the physician cannot abandon the patient. Abandoning a patient means halting the attention and care of a patient without referral and establishment to another source of care. Physicians do have the right not to accept a patient who comes to a physician when no life or death emergency exists. Physicians also have the right to terminate a doctor-patient relationship for a number of ethical reasons including problems with personality issues, inability to follow patient requests either based on moral reasons or standards of medical practice and perhaps some others including a beginning non-professional interest between the two parties. Reasons to terminate the relationship that are not ethical might include inability of the patient to fully pay for the services rendered. Another would be to terminate care simply because the patient failed to respond to treatment and that the physician might not want an unsuccessful result to be part of his or her medical record which might discourage further aquisition of patients.
There is a whole history regarding the right of physicians to choose patients and the duty not to neglect as written in the American Medical Association's Code of Medical Ethics. The story of the Code and its revisions is presented by Faith Lagay in the September 2001 issue of Virtual Mentor. Read the article.
It would be interesting to read my visitors experiences regarding termination of relationships with their physicians or about physicians who refused to start a relationship with a visitor. Remember, no names please! ..Maurice.
There is a whole history regarding the right of physicians to choose patients and the duty not to neglect as written in the American Medical Association's Code of Medical Ethics. The story of the Code and its revisions is presented by Faith Lagay in the September 2001 issue of Virtual Mentor. Read the article.
It would be interesting to read my visitors experiences regarding termination of relationships with their physicians or about physicians who refused to start a relationship with a visitor. Remember, no names please! ..Maurice.
Sunday, August 19, 2007
Donation By Cardiac Death: When Is the Patient Dead?
An organ procurement practice, in order to obtain more organs for the needy patients, has involved obtaining organs by permission from patients who are alive but have decided to end life-supportive treatment but also want to donate their organs after death. The procurement of organs, in keeping with the ethical "dead donor rule" cannot begin until the patient is pronounced dead. The process is called DCD (donation by cardiac death) and the procedure is to terminate life support (ventilators, blood pressure support, etc.) and wait until the patient's heart stops but if the heart does not spontaneously stop within an hour or so, the patient is no longer a candidate for donation (because of deterioration of organs beyond an hour) and is given comfort care until the patient dies. If the heart has stopped within the hour, then the patient's physician must wait for usually 5 minutes before pronouncing the patient dead.
Here is the issue with DCD: Is the patient really dead after 5 minutes with no heart beating (and associated no breathing)? It has been fairly well established that the heart will not resume beating on its own and without physician resusitation after about 5 minutes. So therefore if no mechanical/electrical resusitation is attempted by the physician, could the physician honestly and with confidence pronounce the patient dead? When the patient is pronounced dead by the attending physician, the procurement surgeons are then given permission to begin removing organs. But at that point is that patient really dead? At 5 minutes, the brain is working to some degree even if the patient is unconscious. And if the physician at 5 minutes actually attempted to restart the heart and it started beating, how would that be consistent with a dead patient?
Moreover, suppose the heart had stopped beating in the donor patient and was removed and eventually transplanted into the recipient patient and then began to beat and function in the recipient's chest, would that mean that, in essence, when the still heart was removed from the donor patient, that patient was actually alive and not dead?
These are all questions which continue providing consternation to doctors, lawyers and ethicists.
What is death, when does it really happen and when can an essential organ, like the heart, be removed from a patient for transplant without the fear that that very act of removal is in essence killing the patient? These are not just philosophical and medical or legal questions that can only be answered by ethicists, physicians or lawyers. There has to be a societal consensus of everyone like my visitors for "donation by cardiac death" to be an acceptable way of fairly, ethically and legally obtaining those very much needed organs for the sick. This process for obtaining organs must be publicly in the open and not in any way made secret.
Please write me your answers to these questions. I will describe without identification your responses to a bioethics listserv so that physicians and ethicists and lawyers there learn what the public thinks. ..Maurice.
Here is the issue with DCD: Is the patient really dead after 5 minutes with no heart beating (and associated no breathing)? It has been fairly well established that the heart will not resume beating on its own and without physician resusitation after about 5 minutes. So therefore if no mechanical/electrical resusitation is attempted by the physician, could the physician honestly and with confidence pronounce the patient dead? When the patient is pronounced dead by the attending physician, the procurement surgeons are then given permission to begin removing organs. But at that point is that patient really dead? At 5 minutes, the brain is working to some degree even if the patient is unconscious. And if the physician at 5 minutes actually attempted to restart the heart and it started beating, how would that be consistent with a dead patient?
Moreover, suppose the heart had stopped beating in the donor patient and was removed and eventually transplanted into the recipient patient and then began to beat and function in the recipient's chest, would that mean that, in essence, when the still heart was removed from the donor patient, that patient was actually alive and not dead?
These are all questions which continue providing consternation to doctors, lawyers and ethicists.
What is death, when does it really happen and when can an essential organ, like the heart, be removed from a patient for transplant without the fear that that very act of removal is in essence killing the patient? These are not just philosophical and medical or legal questions that can only be answered by ethicists, physicians or lawyers. There has to be a societal consensus of everyone like my visitors for "donation by cardiac death" to be an acceptable way of fairly, ethically and legally obtaining those very much needed organs for the sick. This process for obtaining organs must be publicly in the open and not in any way made secret.
Please write me your answers to these questions. I will describe without identification your responses to a bioethics listserv so that physicians and ethicists and lawyers there learn what the public thinks. ..Maurice.
Thursday, August 16, 2007
Illegal Immigrant to a U.S. Citizen Physician: What Can We Learn by this Story?
From the August 9 2007 Perspective column of the New England Journal of Medicine:
"You will spend the rest of your life working in the fields," my cousin told me when I arrived in the United States in the mid-1980s. This fate indeed appeared likely: a 19-year-old illegal migrant farm worker, I had no English language skills and no dependable means of support.
Click on the above link and read the whole story (free full text) of Alfredo Quiñones-Hinojosa, M.D. and how he made the journey from migrant farm worker to neurosurgeon and professor at Johns Hopkins School of Medicine.
What does this migration of an illegal immigrant to a U.S. citizen physician and scientist tell us about issues of illegal immigration but also the potential of living and developing in the United States? Do you find anything unethical or of concern or caution in this uplifting story? ..Maurice.
"You will spend the rest of your life working in the fields," my cousin told me when I arrived in the United States in the mid-1980s. This fate indeed appeared likely: a 19-year-old illegal migrant farm worker, I had no English language skills and no dependable means of support.
Click on the above link and read the whole story (free full text) of Alfredo Quiñones-Hinojosa, M.D. and how he made the journey from migrant farm worker to neurosurgeon and professor at Johns Hopkins School of Medicine.
What does this migration of an illegal immigrant to a U.S. citizen physician and scientist tell us about issues of illegal immigration but also the potential of living and developing in the United States? Do you find anything unethical or of concern or caution in this uplifting story? ..Maurice.
Monday, August 13, 2007
Power of a Fetus vs the Autonomy of the Mother and the Carder Court Reversal Decision
You are a woman and you are pregnant. You are at term, in labor, and you have been fully informed by your doctor who insists that you deliver by C-section otherwise the baby might not survive. You have previously told your doctor that you never want a C-section operation and you are sure that you can deliver vaginally as you did with your other child. Your doctor is upset with your refusal for surgery.. the doctor is angry that you will not listen to medical advice. Guess what? The doctor and the hospital are contacting the court for an emergency order by a judge to perform a C-section against your wishes. The fetus is, at this moment, more important than your autonomous decision.
You are a pregnant woman with cancer and needs chemotherapy. Your fetus is viable but the doctors don't want to treat you for your cancer until they protect the fetus by removing it from the womb otherwise the chemotherapy will poison it. You are fully informed about the benefits of chemotherapy and the potential risks to the fetus and yourself. They get a court order to perform a C-section against your decision to treat your cancer now and not be concerned at present with the fetus.
You are a pregnant woman and have been voluntarily snorting cocaine. You have heard that there is some controversy that cocaine may be harmful for the fetus but, nevertheless, you consciously decided that you wanted to continue the drug. You are arrested, convicted of harming your fetus by the cocaine and you are now in prison.
If you think these stories are all made up, you are wrong. This is what has been happening in the United States. It appears that legislatures and the federal government put more power in the unborn denying the born pregnant woman the autonomy regarding the control of her body, such autonomy being granted to every adult woman or man. The unborn, through court order, can lead to personally unwanted and perhaps unneeded operations or other procedures carried out on the woman's body. Even a born infant or other born child of the mother would not be granted such power. So why the unborn fetus?
Read the Angela Carder story of a young lady whose drive for her own survival from cancer caused her and her fetus to become the fatal victims of a court decision. Read about the entire subject of "The Rights of Unborn Children and the Value of Pregnant Women" in the Hastings Center Report. And finally, read the advice of the American College of Obstetrics and Gynecology regarding autonomy of pregnant women in view of the D.C. Court of Appeals reversal of the initial court decision regarding Carder but after both the mother and fetus had died.
Although the word has not fully gotten around to all the doctors, lawyers and legislatures and federal government, the courts are not the ones to be ordering surgery and other procedures on women who are pregnant against the woman's autonomous decision in order to attempt to preserve the life of a fetus. In fact, no one, even doctors may do so either. ..Maurice.
You are a pregnant woman with cancer and needs chemotherapy. Your fetus is viable but the doctors don't want to treat you for your cancer until they protect the fetus by removing it from the womb otherwise the chemotherapy will poison it. You are fully informed about the benefits of chemotherapy and the potential risks to the fetus and yourself. They get a court order to perform a C-section against your decision to treat your cancer now and not be concerned at present with the fetus.
You are a pregnant woman and have been voluntarily snorting cocaine. You have heard that there is some controversy that cocaine may be harmful for the fetus but, nevertheless, you consciously decided that you wanted to continue the drug. You are arrested, convicted of harming your fetus by the cocaine and you are now in prison.
If you think these stories are all made up, you are wrong. This is what has been happening in the United States. It appears that legislatures and the federal government put more power in the unborn denying the born pregnant woman the autonomy regarding the control of her body, such autonomy being granted to every adult woman or man. The unborn, through court order, can lead to personally unwanted and perhaps unneeded operations or other procedures carried out on the woman's body. Even a born infant or other born child of the mother would not be granted such power. So why the unborn fetus?
Read the Angela Carder story of a young lady whose drive for her own survival from cancer caused her and her fetus to become the fatal victims of a court decision. Read about the entire subject of "The Rights of Unborn Children and the Value of Pregnant Women" in the Hastings Center Report. And finally, read the advice of the American College of Obstetrics and Gynecology regarding autonomy of pregnant women in view of the D.C. Court of Appeals reversal of the initial court decision regarding Carder but after both the mother and fetus had died.
Although the word has not fully gotten around to all the doctors, lawyers and legislatures and federal government, the courts are not the ones to be ordering surgery and other procedures on women who are pregnant against the woman's autonomous decision in order to attempt to preserve the life of a fetus. In fact, no one, even doctors may do so either. ..Maurice.
Saturday, August 11, 2007
Specieism: Treatment of My Kitten vs My Child
Should we treat our kitten different than our young child? How much protection do we owe the animals we own? And if they need to be protected against pain or death, why do we need to do that? Is it for our own comfort and peace of mind? Do our animals know the consequences of what we are deciding for them? Should non-human species of animals who are believed to be able to think be treated the same or differently than humans? If cattle can think, why do we kill them for food? If dogs think, why, in some cultures, they are killed for food? Is it fair for humans to behave in a different manner depending on what species of animals are being considered and acted upon? This is all bioethics and currently on a bioethics listserv these questions are being considered. One of the ethicists on the listserv wrote the following questions today which I am reproducing here. Maybe some visitor can provide an answer to one or more of my questions or those of the ethicist. ..Maurice.
Is it true that specieism is on a par morally with racism?
Singer thinks that there’s nothing wrong with human animals having sexual relations with non-human animals, e.g., the great apes. Is that true?
Is it true that we are as much responsible for evils we could have prevented as those we cause?
Non-human animals display specie preference (and sex preference). If specieism and sexism are inherently objectionable, shouldn’t we breed that out of them, if possible? If not, why not?
A non-human prey animal’s loss when killed by a non-human animal predator is the same as his loss when imposed by a human animal hunter. Why is predation by non-human animals Ok, but predation by human animal predators not-Ok?
If one objects to wearing the skins of animal martyrs on principle, mustn’t one object to accepting medical treatments developed at the cost of animal martyrs for the same reason?
And mustn’t one similarly object to accepting insurance coverage specifically targeted to offset the costs of products and services developed at the expense of animal martyrs?
Isn’t it perverse to favor further expansion of insurance coverage that fuels an industry based on the idea that non-human animals shall bear the initial costs of product development?
Is it true that specieism is on a par morally with racism?
Singer thinks that there’s nothing wrong with human animals having sexual relations with non-human animals, e.g., the great apes. Is that true?
Is it true that we are as much responsible for evils we could have prevented as those we cause?
Non-human animals display specie preference (and sex preference). If specieism and sexism are inherently objectionable, shouldn’t we breed that out of them, if possible? If not, why not?
A non-human prey animal’s loss when killed by a non-human animal predator is the same as his loss when imposed by a human animal hunter. Why is predation by non-human animals Ok, but predation by human animal predators not-Ok?
If one objects to wearing the skins of animal martyrs on principle, mustn’t one object to accepting medical treatments developed at the cost of animal martyrs for the same reason?
And mustn’t one similarly object to accepting insurance coverage specifically targeted to offset the costs of products and services developed at the expense of animal martyrs?
Isn’t it perverse to favor further expansion of insurance coverage that fuels an industry based on the idea that non-human animals shall bear the initial costs of product development?
Commercialization of Healthcare
Js md brought up an issue that has been noted on previous threads here but I haven't presented it as a specific thread--the commercialization of healthcare in the United States. I would like to present this subject now. Obviously, this is a major issue in the upcoming presidential debates because how healthcare is to be provided for everyone in the U.S. should be a concern for all of us. I look forward to read responses from my visitors to js md's comment. ..Maurice.
The commercialization of health care is harmful to everyone, especially patients. I'm not a big fan of Michael Moore either. He gives a one sided biased view to make a point, but his anecdotes are all valid.We have an insurance based system which is not rational to begin with. You shouldn't insure expenses which absolutely everyone will face sometime in their lives; it cries out for a different mechanism. The insurance companies provide no health care; they just shuffle paper and soak up profits. The CEO of I believe United Healthcare retired with the better part of a billion dollar bonus! What a colossal misuse of health care dollars. We are I believe the only Western country in the world which doesn't have a national health care system and doesn't regulate the price of pharmaceuticals. We only regulate doctor's fees.I could go on, but I'll quit now.
The commercialization of health care is harmful to everyone, especially patients. I'm not a big fan of Michael Moore either. He gives a one sided biased view to make a point, but his anecdotes are all valid.We have an insurance based system which is not rational to begin with. You shouldn't insure expenses which absolutely everyone will face sometime in their lives; it cries out for a different mechanism. The insurance companies provide no health care; they just shuffle paper and soak up profits. The CEO of I believe United Healthcare retired with the better part of a billion dollar bonus! What a colossal misuse of health care dollars. We are I believe the only Western country in the world which doesn't have a national health care system and doesn't regulate the price of pharmaceuticals. We only regulate doctor's fees.I could go on, but I'll quit now.
Thursday, August 9, 2007
The Sexually Seductive Patient: How Should Doctors React?
On my other threads on patient modesty and why doctors are hated, there is much concern and worry about sexually seductive doctors. Such concerns are warrented even though I am sure most doctors will treat patients professionally and keep to the professional and legal boundaries of behavior. However, physicians have their own concerns. One of their concerns is the behavior that the patient will bring into the office. There are the angry, disruptive and frankly belligerant patients. Medical students are taught to expect such patients and to react by trying to understand what is motivating these patients to these behaviors since such understanding may provide a therapeutic approach rather than the physician simply reflecting anger back to the patient. One of the more subtle and difficult patient behaviors for physicians to deal with is the sexually seductive patient. Such a patient, often a female relating to a male physician enters with the expression of obvious greater attention and interest with respect to the physician's personality and appearance than true concern about her own symptoms. Her actions may be sexually provocative. The patient may expose her body to the physician during the interview or exam to an extent which is clinically unnecessary. Female physicians are not free of seductive male patients.
Psychologists explain these patients' behavior as expressions of transference--where psychologic unmet needs are attempted to be met by engaging physicians who seem to resemble and reflect critical persons in the patients' emotional life. Of concern is the issue of counter-transference--where the physician may respond to this situation in a manner to support the physician's unmet needs based on the physician's emotional life. This can lead to physicians responding to the seductive patient in a manner beyond the professional boundaries of sexual attention.
How should physicians react to the seductive patient? Should they consider the patient has a psychologic or psychiatric problem in addition to their other disease and seek out evaluation, patient education and treatment for this disorder? Or should the doctor go ballistic and spell out the established rules of further behavior? Medical schools find that the need to educate students regarding how to deal with the seductive patient an important topic. I would like to read the views of my visitors on the subject of the seductive patient and what they think would be the very best approach to deal with the issue if it arises. One point I don't want to read from my visitors is that there is no such person as a sexually seductive patient or that the way patients behave is simply a reflection of the doctor's unprofessional behavior at the onset of the relationship. You have to be in medical practice yourself to see that this conclusion applied to all is not true! ..Maurice.
Psychologists explain these patients' behavior as expressions of transference--where psychologic unmet needs are attempted to be met by engaging physicians who seem to resemble and reflect critical persons in the patients' emotional life. Of concern is the issue of counter-transference--where the physician may respond to this situation in a manner to support the physician's unmet needs based on the physician's emotional life. This can lead to physicians responding to the seductive patient in a manner beyond the professional boundaries of sexual attention.
How should physicians react to the seductive patient? Should they consider the patient has a psychologic or psychiatric problem in addition to their other disease and seek out evaluation, patient education and treatment for this disorder? Or should the doctor go ballistic and spell out the established rules of further behavior? Medical schools find that the need to educate students regarding how to deal with the seductive patient an important topic. I would like to read the views of my visitors on the subject of the seductive patient and what they think would be the very best approach to deal with the issue if it arises. One point I don't want to read from my visitors is that there is no such person as a sexually seductive patient or that the way patients behave is simply a reflection of the doctor's unprofessional behavior at the onset of the relationship. You have to be in medical practice yourself to see that this conclusion applied to all is not true! ..Maurice.
Monday, August 6, 2007
Pro-Life and Favoring the Death Penalty: An Ethical Conflict?
Here is an apparent ethical conflicting view that I have heard. How can a person be "pro-life" and still be in favor of the death penalty? Is the answer simply that "pro-life" means in favor of the life an innocent embryo or fetus and not necessarily for the maintaining of all life, including criminals who are to be executed nor the killing of enemy soldiers or innocent civilians during times of war? If being "pro-life" means something more than protecting the fetus, is that being clearly expressed to society? Or if not, should those who claim to be "pro-life" define their objectives. Or have they and I have missed it. Physicians are involved in this distinction as they are personally and professionally challenged by various people including patients and authorities with issues such abortion, contraception, invitro fertilization, termination of life-supportive measures, participating in death penalty activities and in war and torture. Those of my visitors who consider themselves "pro-life" can you define the extent to which you support the preservation of life. Should the preservation of life only be extended to the embryo and fetus, to the ill or patients in the persistent vegetative state? Is the death penalty, war and torture another matter? ..Maurice.
Sunday, August 5, 2007
What is a "Good" Patient?
Anonymous has written in a previous thread regarding patients ideas regarding teaching ethics to medical students an interesting comment about what patients are looking for in their medical care and how they should or should not respond. Anonymous wrote:
"I read somewhere that patients try to prevent three things inherent in the healthcare system: depersonalization, loss of control and lack of knowledge. I would consider it normal and healthy for a patient to try to prevent these things from happening to them. But the behaviours they use to prevent this go against how a "good" patient is supposed to behave."
I thought it might be worthwhile to set up a new thread on a subject I haven't tackled before. On this blog, I have covered about what make up an ideal doctor but I have never covered the issue of what is a "good" patient, either from the view of patients or from the view of the healthcare provider. So here is the chance to make your opinions known. How do you think a "good" patient should behave? ..Maurice.
"I read somewhere that patients try to prevent three things inherent in the healthcare system: depersonalization, loss of control and lack of knowledge. I would consider it normal and healthy for a patient to try to prevent these things from happening to them. But the behaviours they use to prevent this go against how a "good" patient is supposed to behave."
I thought it might be worthwhile to set up a new thread on a subject I haven't tackled before. On this blog, I have covered about what make up an ideal doctor but I have never covered the issue of what is a "good" patient, either from the view of patients or from the view of the healthcare provider. So here is the chance to make your opinions known. How do you think a "good" patient should behave? ..Maurice.
Friday, July 27, 2007
3 Questions in One Day: #3: Teachers and DNAR
I am posting 3 medical ethical questions today, all without any preliminary discussion by me but a reference for each so that my visitors, if they desire, can review the issue more completely before responding. However, if you have a strong feeling about the issue, you may go ahead and comment directly. ..Maurice.
Question #3: In the event of a cardio-pulmonary arrest should school teachers be required to follow "Do Not Attempt Resusitation" orders written by the parents of incurable, life-limiting, potentially terminally ill children who are still able to attend school? (Reference: American Journal of Bioethics, Jan-Feb 2005)
Question #3: In the event of a cardio-pulmonary arrest should school teachers be required to follow "Do Not Attempt Resusitation" orders written by the parents of incurable, life-limiting, potentially terminally ill children who are still able to attend school? (Reference: American Journal of Bioethics, Jan-Feb 2005)
3 Ethical Questions in One Day: #2: Selling Info about Doctors
I am posting 3 medical ethical questions today, all without any preliminary discussion by me but a reference for each so that my visitors, if they desire, can review the issue more completely before responding. However, if you have a strong feeling about the issue, you may go ahead and comment directly. ..Maurice.
Question #2: Should information identifying physicans be sold by the American Medical Association to pharmaceutical companies so that the physician's prescribing habits can be collected and used for marketing purposes by the pharmaceutical company representatives visiting doctors in their offices? (Reference: San Francisco Chronicle, July 25, 2007 via SFGATE.com)
Question #2: Should information identifying physicans be sold by the American Medical Association to pharmaceutical companies so that the physician's prescribing habits can be collected and used for marketing purposes by the pharmaceutical company representatives visiting doctors in their offices? (Reference: San Francisco Chronicle, July 25, 2007 via SFGATE.com)
3 Ethical Questions:in One Day: #1 Right to Meds
I am posting 3 medical ethical questions today, all without any preliminary discussion by me but a reference for each so that my visitors, if they desire, can review the issue more completely before responding. However, if you have a strong feeling about the issue, you may go ahead and comment directly. ..Maurice.
Question #1: Should terminally ill cancer victims who have failed to respond to all standard treatments for their condition have the right to be prescribed and administered drugs which are still undergoing pharmaceutical investigation and are not approved by the FDA for use? (Reference: New England Journal of Medicine, July 26, 2007, p. 408.)
Question #1: Should terminally ill cancer victims who have failed to respond to all standard treatments for their condition have the right to be prescribed and administered drugs which are still undergoing pharmaceutical investigation and are not approved by the FDA for use? (Reference: New England Journal of Medicine, July 26, 2007, p. 408.)
Wednesday, July 25, 2007
"I Hate Hospitals"
I am sure that most of us hate to be hospitalized. Sometimes, we are compelled by our medical situation to stay in a hospital. Though we may be aware of the benefit of observation and treatment there, nevertheless behaviors of hospitals and their staffs often leave much to be desired. I am sure many of my visitors will have stories to tell (no names please). Though some complaints will be due to misunderstandings (and even misunderstandings represents a problem of communication), many will be clearly issues that are absent from hospital policy, are ignored and remedial action not enforced or are frankly not beneficent to the patient or their family. Thanks to the hospital-oriented publication Blue H News, I got the reference for the following sampling of former hospital patients regarding their consideration of violations of patient rights. I could not find any description of the sampling methodology to present here, but in any event I think it is worth looking over the issues that hospital patients find upsetting for them. Can any of my visitors add to the list? ..Maurice.
In an recent survey of former patients, the National Institute for Patient Rights (NIPR)identified the following as the top ten violations of patient rights:
1. The right to informed consent in accepting or refusing treatment.
2. A respect for personal, spiritual, cultural, and religious values and beliefs.
3. The right to an advance directive, such as a living will or durable power of attorney for health care.
4. The right to privacy and confidentiality.
5. The right to be told of realistic care alternatives when hospital care is no longer appropriate.
6. The right to review the hospital bill, have the information explained, and get a copy of the bill.
7. The right to know about hospital rules on charges and payment methods.
8. The right to know about hospital resources, such as patient complaints and grievance processes, patient representatives or ethics committees.
9. The right to know the identity and professional status of those who care for the patient.
10. The right to review your medical records and to receive an accounting of disclosures regarding health information.
(based on a random sampling of over 1000 former patients)
Discussion of the results of the sampling by the NIPR CEO, Mark Meaney, can be found at Associated Content.
In an recent survey of former patients, the National Institute for Patient Rights (NIPR)identified the following as the top ten violations of patient rights:
1. The right to informed consent in accepting or refusing treatment.
2. A respect for personal, spiritual, cultural, and religious values and beliefs.
3. The right to an advance directive, such as a living will or durable power of attorney for health care.
4. The right to privacy and confidentiality.
5. The right to be told of realistic care alternatives when hospital care is no longer appropriate.
6. The right to review the hospital bill, have the information explained, and get a copy of the bill.
7. The right to know about hospital rules on charges and payment methods.
8. The right to know about hospital resources, such as patient complaints and grievance processes, patient representatives or ethics committees.
9. The right to know the identity and professional status of those who care for the patient.
10. The right to review your medical records and to receive an accounting of disclosures regarding health information.
(based on a random sampling of over 1000 former patients)
Discussion of the results of the sampling by the NIPR CEO, Mark Meaney, can be found at Associated Content.
Friday, July 20, 2007
Your Job as Experienced Patient is to Teach Medical Students Ethics and Ethical Behavior
Pretend that you have been given the responsibility to prepare and teach an ethics course for medical students. Your duty would be to provide the students who are learning how to become doctors with the key ethical issues that they may face as they go out into practice. You must also provide them with the knowledge and tools which they need to make fair ethical decisions and be, themselves, ethical. The goal is for all the medical students under your wing to end up as moral, ethical physicians who are free from misbehavior and who are looked upon with trust by their patients and by their medical colleagues. We are all calling for doctors who are good, do good and are honest and trustworthy to care for us and our families. Now, here is your chance, based on your own experiences, to set down in writing what you are going to instruct them and how they will be able to develop the behavior benchmarks that you are setting for them.
You might say to me, "It's hopeless. Students are either ethical or they are not when they come to medical school. Education is not going to help the one's who are not." Really?
You might say to me, “I am not a physician, philosopher or a teacher..I am only a patient!” Don’t give up on this challenge. The approaches suggested by experienced patients to teaching medical students ethics and ethical behavior may be more constructive and realistic then what is coming from our current medical school teachers. Give it a try. Medical school classes for the first and second year students begin in just a month and we have to get an ethics program started now. Even if you respond after classes begin, we can always change course. Remember, setting the students on the right path is more constructive than later just complaining about them as physicians and mumbling “I hate doctors”. ..Maurice.
You might say to me, "It's hopeless. Students are either ethical or they are not when they come to medical school. Education is not going to help the one's who are not." Really?
You might say to me, “I am not a physician, philosopher or a teacher..I am only a patient!” Don’t give up on this challenge. The approaches suggested by experienced patients to teaching medical students ethics and ethical behavior may be more constructive and realistic then what is coming from our current medical school teachers. Give it a try. Medical school classes for the first and second year students begin in just a month and we have to get an ethics program started now. Even if you respond after classes begin, we can always change course. Remember, setting the students on the right path is more constructive than later just complaining about them as physicians and mumbling “I hate doctors”. ..Maurice.
Saturday, July 14, 2007
Pay for Performance: Doctors, Hospitals and Pills
So you want a change in the way medicine is practiced? You are not satisfied with the way doctors and hospitals perform their duties? Do you want to find a way to get treatment from “better” doctors; doctors who are able to do a better job to cure you but with less risk of complications? Would you like to see all doctors and hospitals required to follow protocols and achieve benchmarks for the results of treatments based on evidence based medicine studies or statistically achievable norms? Should their report cards be made public regarding how well they are following the rules ad how well they are doing?
Would you like to select from a list of doctors and hospitals who are better than others and know which doctors and hospitals one should avoid? Should doctors and hospitals be paid by patients, insurance companies and the government based on where on the list of acceptable performance they are located?
How about pills and other medicines? Would you like for pharmaceutical companies to be held responsible through selective payment based on results? Would you like to have the ability to pay for them only if they prove to be effective in improving your very own condition and not pay for them or get full refund of your money if you they show no results for you personally?
You may not be aware that all this is not some futuristic dream but is already by little spurts going into practice. It has a name: Pay for Performance. The question is when all medical care is practiced this way will there be a net benefit for the patient and society in general. Are there any problems, flaws or something unethical that you can see in this concept of improving medical care? Let’s hear from you. After all, Pay for Performance is all being done for you. ..Maurice.
Read more about this:
Report cards and benchmarks for doctors and hospitals:”Is Zero the Ideal Death Rate?” by Thomas H Lee, M.D.,David F. Torchiana, M.D., and James E. Lock, M.D., New England Journal of Medicine, July 12, 2007 issue page 111.
AMA: Delegates Want Principles First with Pay for Performance (MedPage Today)
Pricing Pills by the Resuts (New York Times)
Would you like to select from a list of doctors and hospitals who are better than others and know which doctors and hospitals one should avoid? Should doctors and hospitals be paid by patients, insurance companies and the government based on where on the list of acceptable performance they are located?
How about pills and other medicines? Would you like for pharmaceutical companies to be held responsible through selective payment based on results? Would you like to have the ability to pay for them only if they prove to be effective in improving your very own condition and not pay for them or get full refund of your money if you they show no results for you personally?
You may not be aware that all this is not some futuristic dream but is already by little spurts going into practice. It has a name: Pay for Performance. The question is when all medical care is practiced this way will there be a net benefit for the patient and society in general. Are there any problems, flaws or something unethical that you can see in this concept of improving medical care? Let’s hear from you. After all, Pay for Performance is all being done for you. ..Maurice.
Read more about this:
Report cards and benchmarks for doctors and hospitals:”Is Zero the Ideal Death Rate?” by Thomas H Lee, M.D.,David F. Torchiana, M.D., and James E. Lock, M.D., New England Journal of Medicine, July 12, 2007 issue page 111.
AMA: Delegates Want Principles First with Pay for Performance (MedPage Today)
Pricing Pills by the Resuts (New York Times)
Tuesday, July 10, 2007
Doctor of a Nation or Doctor of a Political Party: Duty of the U.S. Surgeon General
From today's Los Angeles Times:
So, who is the Surgeon General and what is his or her duties? Here is some background information from Wikipedia:
Though in today's Congressional hearings where Dr. Carmona and two previous Surgeon General's told their story of political pressures being applied to the Surgeon General during the current and previous administrations, it was brought out that Carmona in the current administration was under the most pressure. It is interesting to find that President Bush who has made much of the fact that he was depending and listening to the views of the "generals on the ground" would seem to avoid listening to his Surgeon General about the science regarding stem cell research and teen pregnancy and stick to his political ideology. ..Maurice.
President Bush's first surgeon general charged today that administration officials prevented him from providing the public with accurate scientific and medical information on such issues as stem cell research and teen pregnancy.
"The reality is that the 'nation's doctor' has been marginalized and relegated to a position with no independent budget and with supervisors who are political appointees with partisan agendas," Dr. Richard H. Carmona told the House Committee on Oversight and Government Reform. "Anything that doesn't fit into the political appointees' ideological, theological or political agenda is ignored, marginalized or simply buried.
"The problem with this approach is that in public health, as in a democracy, there is nothing worse than ignoring science or marginalizing the voice of science for reasons driven by changing political winds," said Carmona, who served from 2002 to 2006. "The job of surgeon general is to be the doctor of the nation — not the doctor of a political party."
So, who is the Surgeon General and what is his or her duties? Here is some background information from Wikipedia:
The Surgeon General of the United States is the head of the United States Public Health Service Commissioned Corps and, ex officio, is the leading spokesperson on matters of public health in the U.S. government. The Surgeon General is nominated by the U.S. President and confirmed via majority vote by the Senate. The Surgeon General serves a four year term of office and is commissioned as a Vice Admiral in the PHSCC. [1] In carrying out all responsibilities, the Surgeon General reports to the Assistant Secretary for Health, who is the principal advisor to the Secretary of Health and Human Services on public health and scientific issues, and who serves as the overall head of the United States Public Health Service. The former Surgeon General, Vice Admiral Richard Carmona, appointed by President George W. Bush in 2002, left office when his term expired on July 31, 2006. [2]. Rear Admiral Kenneth P. Moritsugu is functioning as the Acting Surgeon General. [3].
On May 24, 2007, President Bush nominated Dr. James W. Holsinger, Jr., a University of Kentucky medical professor to be the 18th surgeon general of the United States. [4]
The Surgeon General functions under the direction of the Assistant Secretary for Health and operationally heads the 6,000-member Commissioned Corps of the United States Public Health Service, a cadre of health professionals who are on call 24 hours a day, and can be dispatched by the Secretary of HHS or the Assistant Secretary for Health in the event of a public health emergency. The Surgeon General is also the ultimate award authority for several public health awards and decorations, the highest of which that can be directly awarded is the Surgeon General's Medal (the highest award bestowed by board action is the Distinguished Service Medal).
The Surgeon General also has many informal duties, such as educating the American public about health issues and advocating healthy lifestyle choices.
The office also periodically issues health warnings. Perhaps the best known example of this is the Surgeon General's Warning labels that can be found on all packages of American cigarettes. A health warning also appears on alcoholic beverages.
Past American Surgeons General have often been characterized by their outspoken personalities and often controversial proposals on how to reform the U.S. health system. Because the office is not a particularly powerful one, and has little direct impact on policy-making, Surgeons General are often vocal advocates of unconventional, unusual, or even unpopular health policies. Vice Admiral C. Everett Koop and Vice Admiral Joycelyn Elders were two former Surgeons General who were well known for their controversial ideas, especially on sex education.
The U.S. Public Health Service was under the direction of the Office of the Surgeon General and was an independent government agency until 1953 at which point it was integrated into the United States Department of Health, Education and Welfare, and later into the United States Department of Health and Human Services. Although the U.S. Public Health Service and the Surgeon General were at various times under the umbrella of the Department of the Treasury or the Federal Security Agency, the agency operated with a substantial amount of independence.
The U.S. Army, Navy, and Air Force also have officers overseeing medical matters in their respective services who hold the title Surgeon General.
In Republic of Ireland and United Kingdom, the term chief medical officer is used as equivalent.
Service rank
The Surgeon General holds the rank of Vice Admiral [5] in the Public Health Service Commissioned Corps, one of the seven Uniformed services of the United States. Officers of the PHSCC and the National Oceanic and Atmospheric Administration Commissioned Corps are classified as non-combatants, but can fall under the uniform code of military justice (UCMJ) and the Geneva Convention when designated by the Commander in Chief as a military force. Officers Members of these services wear uniforms that are similar to those worn by the U.S. Navy, except that the commissioning devices, buttons, and insignia are unique. Officers in PHS and NOAA wear unique devices which are similar to U.S. Navy Staffing Corps Officers (e.g., Medical Services Corps, Supply Corps, etc.)
Though in today's Congressional hearings where Dr. Carmona and two previous Surgeon General's told their story of political pressures being applied to the Surgeon General during the current and previous administrations, it was brought out that Carmona in the current administration was under the most pressure. It is interesting to find that President Bush who has made much of the fact that he was depending and listening to the views of the "generals on the ground" would seem to avoid listening to his Surgeon General about the science regarding stem cell research and teen pregnancy and stick to his political ideology. ..Maurice.
Thursday, July 5, 2007
More on the Mentally Ill:King Lear and the Madness
fear I am not in my perfect mind.
Methinks I should know you and know this man;
Yet, I am doubtful; for I am mainly ignorant
What place this is; and all the skill I have
Remembers not these garments; nor I know not
Where I did lodge last night. Do not laugh at me.
(William Shakespeare (1605) King Lear, Act IV, Scene 7)
As an extension to my recent threads on how informed consent should be obtained in pharmaceutical experiments on the mentally ill and whether the mentally ill should be given assisted suicide, I wanted to include a posting about a classic example of mental illness in literature, Shakespeare's King Lear, and how mental illness was explained long ago and how it was treated. Did King Lear have Alzheimer's Disease or some other psychiatric illness? Whichever, it was a therapeutic challenge then and today in many ways it is still a challenge.
The following is an essay on King Lear, his madness and how mental illness was evaluated in the Renaissance period. I obtained it from John Mark Ministries
(Note: I took the above photograph of the painting of King Lear and Cordelia by Benjamin West today at the Huntington Library and Botanic Gardens, San Marino, CA). ..Maurice.
Renaissance Views of Madness: King Lear
By Adrian Ingham, December 1996
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The essay that follows was researched and written by Adrian Ingham as part of the course on Shakespeare by Individual Studies, 1996; it is reprinted here with his permission. While copyright is retained by Adrian Ingham, this material may freely be used for educational and non-profit purposes, so long as the author and source are cited.
Samuel Johnson describes the age of Shakespeare as a time when "speculation had not yet attempted to analyze the mind" (118), but there was a range of theories and opinions regarding madness. And although it has been demonstrated that Shakespeare's portrayal of madness parallels Bright's A Treatise of Melancholie (Wilson 309-20), that medical model alone is insufficient to describe the madness of King Lear. Shakespeare was not limited to a single book in his understanding of madness; he had at his disposal the sum total of his society's understanding of the issue. Since Lear's madness is derived from a mixture of sources, it can only be effectively described in this larger context.
Because much of Renaissance medical theory was based on premises from the Middle Ages, a starting point for our understanding of Lear's madness can be found in the 1535 translation of De Propriatibus Rerum by the thirteenth century monk Batholomaeus Anglicus. This work is based entirely on the traditional model of illness as an imbalance of the four humours: melancholy (or black bile), choler (or yellow bile), blood, and phlegm. Batholomaeus classifies melancholy and madness separately, attributing them to different humours and different areas of the brain (1-4). The condition of melancholy is caused by an excess of the melancholy humour. It makes a person "ferefull without cause, & oft sorry. And that is through the melancholi humor that constreineth & closeth the herte" (2). In extreme cases melancholy causes symptoms quite like madness, "somme fall into evyll suspections without recover: & therfore they hate - blame, and confounde theyr frendes, and sometyme they smyte and slee them" (2). But although Lear could be described as falling into "evyll suspections" he probably does not have melancholy. He is choleric by nature and it is likely that his madness is caused by an excess of that humour. Goneril describes his choler and foreshadows his madness in an early attempt to discredit him:
The best and soundest of his time hath been but rash; then must we look from his age to recieve, not alone the imperfections of long-engraffed condition, but therewithal the unruly waywardness that infirm and choleric years bring with them. (1.2.294-298)
In Bartholomeus' model madness caused by an excess of choler is called "the frenesie". Its signs are "woodnes and contynual wakynge, mevynge and castynge aboute the eyen, ragynge..." (3). It is caused by the red choler "made lyght with heate of it self... ravysshyd upwarde by veynes, synewes, wosen and pypes" (2). The cure involves bleeding the patient, shaving his head and applying vinegar and ointment to the head. However it also recommends creating a calm environment for the patient, feeding him a sparse simple diet, and "above all things... men shall labour to bringe hym a slepe" (3-4). Kent seems to be aware of this most important part of the cure, and through him we realize that Lear's madness may have been shortlived had he been able to rest before fleeing to Dover:
Oppressed nature sleeps.
This rest might yet have balmed thy broken sinews,
Which, if convenience will not allow,
Stand in hard cure. (3.6.94-98)
However, not all contemporary models of madness relied solely on humours. Timothy Bright's model simplifies Bartholomeus' categorization of madness by calling all madness melancholy, but diversifies it by distinguishing two separate types of melancholy. In Brights words: "the difference is betwixt natural melancholie, and that heavy hande of God upon the afflicted conscience, tormented with remorse of sinne, & fear of his judgement" (37). Natural melancholy resembles Bartholomeus' model in that it has humoreal origins and in its extreme manifestation the melancholy humour can cause "stormes of outrageous love, hatred, hope or feare, wherewith bodies so passionate are here and there, tossed with disquiet..." (Bright 38). But unnatural melancholy has no parallel in the medieval model. Natural melancholy can be recognized from the general symptoms of madness occurring in a stable person in a stress free environment. In this case the madness can only be attributed to physical imbalances (38), while unnatural melancholy, ironically, can be recognized by its occurrence in situations when it seems more natural to go mad: situations in which the mind is tormented by worry and stress (37). The natural/unnatural distinction should not be taken to imply rarity or probability but rather physical or non-physical causes. In Bright's model, like Bartholomeus', Lear would probably not be diagnosed with natural melancholy. We have seen that he is naturally choleric rather than melancholic, and he certainly has recognizable cause to go mad from mental stress and guilt, as Kent, once again, recognizes:
A sovereign shame so elbows him: his own unkindness That stripped her from his benediction, turned her To foreign casualties, gave her dear rights To his dog-hearted daughters -- these things sting His mind so venomously.... (4.3.44-49)
And because Lear is suffering from unnatural melancholy, his prognosis is not good in Bright's model: "Here no medicine, no purgation, no cordiall, no tryacle or balme are able to assure the afflicted soule and trembling heart, now panting under the terrors of God" (39-40). So we see that mere rest may not have been enough to cure Lear's condition. Upon his reconciliation with Cordelia it is rest which calms his anger, but it is her forgiveness which brings him out of his depression. Had Lear not been parted from her again through her death he may well have survived his madness.
Had Lear survived, however, it would not have been to recover his former self. Lear's madness is a journey as much as it is an illness. Even in his brief interlude of lucidity before Cordelia's death he is a different man:
When thou dost ask me blessing, I'll kneel down And ask of thee forgiveness. So we'll live, And pray, and sing, and tell old tales, and laugh At gilded butterflies, and hear poor rogues Talk of court news... (5.3.10-14)
This humble speech to Cordelia is in reaction to the affront of losing a war and being led to prison; compare it to Lear's reaction to friendly advice from the Earl of Kent at the beginning of the play:
Hear me, recreant, On thine allegiance, hear me! That thou hast sought to make us break our vow -- Which we durst never yet -- and with strained pride To come betwixt our sentence and our power -- Which nor our nature nor our place can bear... (1.1.166-71)
Through his madness Lear breaks down the false illusions of his courtly world. Where the earlier speech is concerned with power and title, the later speech is concerned with humanity and friendship. Lear's madness can be seen both as a result of his arrogance and as a remedy for it: "Lear's experience is purgatorial; madness is both punishment and insight" (Byrd 7). The Fool's statement that "truth's a dog must to kennel; he must be whipped out" (1.4.111-12) foreshadows the pain that Lear will have to pass through before attaining enlightenment. This vision of madness is characteristic of Shakespeare's era. The Renaissance held the Aristotelian view that there is a fine line between madness and divine inspiration (Skultans 20), but by the eighteenth century madness was viewed as no more than degradation and shame. In testimony to this, the eighteenth century's favorite version of King Lear was a version rewritten by Nahum Tate to include a happy ending (Byrd 7-8). In this version Lear recovers from his illness, wins the battle and reigns again: by suffering madness Lear pays for his sins and is returned to health and prosperity. In contrast to this, Lear's transformation in the original play leaves him so guileless that it is unlikely that he would survive long with the intrigues of running a kingdom even if he had won the war. When Lear dies it is because he has finally learned to love; and when the one he loves dies, the intensity of his sorrow kills him. "His death is a release from suffering, but also a testimony to what he has become" (Byrd 8).
Thus Lear's madness transcends a purely medical model. Lear is a fusion of not only Bright and his predecessors, but also of Renaissance feelings towards madness. The medical model had not changed significantly by the eighteenth century, but common opinions about madness had. The fact that Tate's maudlin happy ending was ever preferred to Shakespeare's original is testimony to the difference that such attitudes can make. While the similarities between Shakespeare's mad men and Timothy Bright's A Treatise of Melancholie are evident, it would be a mistake to infer from these parallels that the characters are based solely on that model. They are, instead, derived from both medical and non-medical sources, and they can be most effectively analyzed using a simular variety of sources.
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Works cited
Bartholomaeus Anglicus. De Proprietatibus Rerum. Qtd. in Hunter 1-4.
Bright, Timothy. A Treatise of Melancholie. Hunter 36-37.
Byrd, Max. Visits to Bedlam: Madness and Literature in the Eighteenth Century. Columbia: U of South Carolina P, 1974.
Hunter, Richard, and Ida MacAlpine, eds. Three Hundred Years of Psychiatry 1535-1860: a History Presented in Selected English Texts. London: Oxford UP, 1963.
Johnson, Samuel. "Preface." Johnson on Shakespeare. Ed. R. W. Desai. New Delhi: Orient, 1985.
Shakespeare, William. "King Lear." William Shakespeare: the Tragedies, the Poems. Ed. John D. Wilson. Cambridge: Cambridge UP, 1986.
Skultans, Vieda. English Madness: Ideas on Insanity, 1580-1890. London: Routledge, 1979.
Wilson, J. Dover. What Happens in Hamlet. Cambridge: Cambridge UP, 1967.
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Sunday, July 1, 2007
Child Abuse and Neglect: Where There's Smoke is There Always Fire?
What exactly is child abuse? On what basis can a provider be charged with that potentially criminal behavior? This issue was brought to my attention today by an e-mail from a concerned parent which I will post here but anonymously. I then would like to present my response to him. Finally, though much has been already written on child abuse from the legal, child protective viewpoint, I thought it might be interesting but also fair to read the views of another side, a representative from the provider vulnerability side.
Finally, as my visitor, what are your views on the subject of provider vulnerability when child abuse or neglect is the issue? Should anyone worry about the providers of the child in question? ..Maurice.
1st off.. me and my girlfriend have a baby (5 months old now)
i had a beer with my dinner one night and my girlfriend decided to drink heavily. later on, my girlfriend got angry at me and we fussed alot... fearing the situation was spiraling out of control, i called the police. when they arrived, they arrested her for child neglect, however, i was sober and they arrested me saying i was drunk too!! I even requested a breathalizer test but was denied (stating its only used in driving casses) DSS came and took our baby!
we have a VERY happy and PERFECTLY healthy baby girl. Not a scratch has/or EVER will be placed on her.
although i had a beer earlier in the evening, and WAS sober and alert,
Is what has happened to me child neglect?
Reply:
I think I can imagine how concerned and upset you are now. I am not a lawyer and I don't know the applicable laws in the area where you live so I can't specifically answer your question. My best advice to you, as you probably are already aware, is to contact a lawyer. As I suggested, the criteria to define "child abuse" is variable both ethically and legally. At one extreme, personally and intentionally physically damaging their child is considered abuse. A mother or father driving a vehicle with their small child in the car but without proper restraints has been called abuse. Going to another extreme, the term has also been used for parents who allow their child to become obese. You can therefore see what I mean when I say "variable".
Even though I haven't answered your question, I do extend my best wishes to you, the mother and your child. ..Maurice.
The following is by Marian Ruth Turner and the Family Child Care Page
Some Myths of Maltreatment Allegations and Caregiver Risk
by Marian Ruth Turner, Coalition on Provider Vulnerability
Marian Turner was a postal letter carrier before opening her family child care business in 1971. She enjoys baking, bookkeeping, research, mythic storytelling, and physical care. After 32 years of ten- hour days, her back aches, and she can't sit at meetings anymore, but she still can't think of a better job than family day care. Marian likes learning, and hates teaching.
(Copywright 1999. This essay may be reproduced, but you must give credit to Marian Ruth Turner and the Family Child Care Page.)
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Have you heard about that provider? the one who broke the baby's arm? the one who let the school-ager get into the matches? the one who's teenage son was fondling the 5-year-old?
The myth: where there's smoke, there's fire; an allegation must have some truth to it. This is a very pervasive and destructive myth about allegations of child maltreatment. The hard truth is that where there is smoke...there is smoke. Period.
The reality: all people in crisis deserve support, unconditionally. An allegation is a story, a rumor. Hearing it, you don't know what to believe. Exactly.
Some people accused of child maltreatment are innocent. Some are guilty. Some are in the middle. You can't tell which is which. Innocent people and guilty people say the same things, and show the same distress.
If a neighbor's house is gutted by fire, and you know for certain they smoke in bed, would you refuse to let them use your telephone?
Whether innocent or guilty, caregivers who go through a maltreatment allegation undergo profound grief, just as if someone had died. The stages of grief sweep through, affecting sleep, appetite and self-esteem. Afterwards, healing is slow, hampered by post-traumatic stress syndrome. This is heavy stuff.
***
My interest in providers' rights began, in part, because society changed very fast during the 70s and 80s, our ideas on child-rearing changed. I heard stories of caregivers who were fired on-the-spot or had a license revoked because of behaviors that would have been fine in 1970, but not in 1985. The flush labor market supported a throw-away attitude toward workers. There was little training and no support available to guide providers in adjusting to the new rules.
The myth: you can protect yourself from allegations of child maltreatment. Excellence will protect you. Honesty will protect you. Good intentions. Reputation. Innocence. Awards.
The reality: the honest answer is no, but you can be sensible, and take precautions. It is like 'burn-out' in this regard. It happens, and you deal with it. You can communicate with your clients. You can document, as a habit. You can learn to keep a closed mouth if you tend toward nervous chatter.
Maltreatment allegations are a risk for all caregivers, in nursing homes, foster homes, day care centers, and family child care homes, regardless of their commitment, training, or skill.
Some risk of maltreatment allegation is in the very nature of the work, being immersed with a vulnerable population. Our culture is ambivalent about adult-child relationships.
***
My interest in providers' rights began, in part, because of the male provider who is my business partner. At the annual 'Men In Child Care' retreat he learned new finger plays. He also heard discussions year after year on how to guard yourself from exaggerated fears of sexual misconduct with children. Minnesota is a leader in encouraging men to enter the field, but most of them don't stay long.
The myth: it is better to err on the side of the children. To protect children we must believe them, which means not believing adults.
The reality: to err is to err. Treating a confused child as abused is not in fact helping her to shed confusion, or 'protecting' him from anything; it is like a medical mis-diagnosis.
It is possible, and important, to improve the current system of maltreatment investigation. Children and adults both need to know they will not be sacrificed by mistake.
In the ideal, providers would say that no matter how unpleasant it was to go through that investigation, they were impressed with the process, and the staff's professional behavior.
We cannot in the long run protect one group by sacrificing another group.
***
My interest in providers' rights crystalized when I observed an especially incompetent investigation. With my general knowledge of family child care I could see and interpret things that were obvious to me, but were grievously invisible to the investigator. This provider lost thousands in legal fees, and suffered irreparable damage to her reputation.
The myth: let the professionals do their job. While an investigation is in progress, either licensing or child protection, the provider's role is to wait.
The reality: you are the lead professional in every situation every day. You cannot control the situation, but there is one thing you can control.
Your demeanor can be civilized. Your courtesy (or lack) will be the one thing everyone notices and remembers. Superficial? No. You have duties.
Be persistent, business-like, knowledgeable. You have rights.
Document your own investigation. Log, tape record, keep notes. This can take months or years.
Remember, people who are accused of child maltreatment should never be labeled as child abusers by co-workers, neighbors, or rivals. It is unattractive, unkind, and unprofessional, and it might be untrue.
***
When the Coalition on Provider Vulnerability began meeting, 50 people came, mostly by word of mouth. They were from centers, family child care homes, foster care, and group homes. Subsequent meetings included volunteer attorneys, a retired judge, social workers, an anonymous licensing worker, all troubled by an imperfect regulatory system that harms people. This is not a fringe issue.
The myth: stiffer licensing standards will increase quality in child care.
The reality: rules alone do not create overall quality, but debate can.
Rules can encourage and support quality by standardizing the behaviors in the field. This eliminates both the very worst and the most brilliantly best, leaving a great average middle. While not totally exterminating the colorful eccentricity that used to exist, licensing does make child care programs more predictable.
Quality always comes from within. Quality is intentionality. Standardization is not quality, but it does allow the public and the regulators to see and count and judge certain program qualities.
***
I heard the whining, furious, shamed voices of people caught in an unexpected legal and financial nightmare. Some of them are literally told they have no rights, told they are not allowed to speak to anyone, threatened with having their own children taken for 'neglect' if they fight the allegations.
The myth: children don't lie about abuse. This well-meant generalization is confusing.
The reality: they do sometimes, and they also tell untrue things without lying.
Adults and children have memory confusion. Saying that children invent memories is not an insult to children. Adult witnesses of crime scenes are notorious for contradictory accounts. Research on memory is incredibly interesting.
Children say untrue things at a high rate, and they also stun us with accurate, insightful truths.
Of course, children's confidences should be listened to. Their stories should not be dismissed as outrageous fabrications, even if sometimes they are. A good comparison is the citizen who jokes at the airport about smuggling a bomb in his suitcase. Suddenly he is the center of attention. He can say it is just a joke, but he and the suitcase will be scrutinized, just in case.
Interviewing children is a specialty, eliciting information without contaminating possible evidence. Recording the interview is critical.
***
My passion for the issue of providers' rights pushed me to overcome my shy reluctance for public speaking. The aura of a basic civil rights struggle is not just illusion, and it gave me courage. When people patronizingly explained that providers had to sacrifice their rights in order to ensure the well-being of children, I just knew it was Wrong. If I couldn't make the field safer, it would be time to get out. In other organizations I took minutes or chaired the bylaws committee. In the Coalition on Provider Vulnerability, I became Convenor of the meetings.
The myth: bad things happen more often in day care homes (or in centers). Nonsense.
The reality: insurance statistics show off Minnesota's excellent licensed homes.
Comparing child care homes with centers is like comparing soccer and basketball. They both have a team, they both have a ball, but... one group is always using hands on the ball, the other group is using their feet.
Informal community standards tell the story. For example: mixed-age groups are better than separated ages. Play is better than instruction. Pot luck suppers are better than meetings.
Don't agree? Fine; many providers don't.
***
Themes emerged among the sad stories, and the Coalition focused on practical action. We took several years to brainstorm on all the perceived weaknesses in the regulatory and protection systems, taking in many viewpoints on what to 'fix'.
Agencies always have some great staff and some rotten staff. We wanted to strengthen the built-in structures so the rotten staff would be held accountable, just like we are, and the great staff would not be punished by adding a great burden of unworkable rules.
The myth: there are a few 'bad' providers who should be driven out of child care.
The reality: our single greatest strength is diversity among providers, not just color and religion, but the deep differences in character that define values such as risk and privacy and tidiness. Parental preference is diverse, too.
What looks different isn't bad.
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For further reading:
Robin, M. (Ed), multiple authors (1991). Assessing Child Maltreatment Reports: The Problem of False Allegations. Child & Youth Services, 15 (2), entire issue. Haworth Press.
Phipps-Yonas, S., Yonas, A., Turner, M., & Kauper, M. (1993). 'Sexuality in Early Childhood: The Observations and Opinions of Family Daycare Providers'. CURA Reporter, 23 (2), 1-5. University of Minnesota.
Kulp, J. (1993). Families at Risk: a guide to understanding and protecting children and child care providers involved in out-of-home or adoptive care, Minneapolis, MN: Better Endings New Beginnings.
Jordan, N.(1993). Sexual Abuse Prevention Programs in Early Childhood Education: A Caveat. Young Children, 48 (6) 76-79.
Hammerslough, J. (1998). Could You Be Accused of Child Neglect? Parenting, June/July 1998, 122-129.
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| Essays on Child Care | My Life as a Child Care Provider | Coalition on Provider Vulnerability |
| Child Care Horror Stories | Index Family Child Care Page |
| Send E-Mail to Marian |
Rev. March 3, 2004
ADDENDUM 7-5-2007: Photograph taken by me today in the sculptural garden of the Huntington Library and Botanic Gardens, San Marino, CA.
Saturday, June 30, 2007
The Placebo:Lying to the Patient-A Skillful Use of Reassurance and Encouragement?
The American Medical Association (AMA) has a policy regarding the use of placebos in clinical practice and here it is:
Thoughtful and empathetic communication from the physician to the ill patient is a therapeutic tool. In fact from the above AMA policy: "Physicians can avoid using a placebo, yet produce a placebo-like effect through the skillful use of reassurance and encouragement. In this way, the physician builds respect and trust, promotes the patient-physician relationship, and improves health outcomes."
My question: What if the reassurance and encouragement is to the physician clinically unrealistic? However this is unknown to the patient. Nevertheless, to the physician, at this point, such reassurance would be considered as theraputic and beneficent. Would that misrepresenation to the patient of the patient's clinical condition be considered "a placebo of a 'placebo-like' effect"? A placebo of a placebo? Does lying to the patient represent "skillful use" of reassurance and encouragement? And is that consistent with AMA's ethics policies? ..Maurice.
H-140.869 Placebo Use in Clinical Practice
A placebo is a substance provided to a patient that the physician believes has no specific pharmacological effect upon the condition being treated. In the clinical setting, the use of a placebo without the patient’s knowledge may undermine trust, compromise the patient-physician relationship, and result in medical harm to the patient.
Physicians may use placebos for diagnosis or treatment only if the patient is informed of and agrees to its use. A placebo may still be effective if the patient knows it will be used but cannot identify it and does not know the precise timing of its use. A physician should enlist the patient’s cooperation by explaining that a better understanding of the medical condition could be achieved by evaluating the effects of different medications, including the placebo. The physician need neither identify the placebo nor seek specific consent before its administration. In this way, the physician respects the patient’s autonomy and fosters a trusting relationship, while the patient still may benefit from the placebo effect.
A placebo must not be given merely to mollify a difficult patient, because doing so serves the convenience of the physician more than it promotes the patient’s welfare. Physicians can avoid using a placebo, yet produce a placebo-like effect through the skillful use of reassurance and encouragement. In this way, the physician builds respect and trust, promotes the patient-physician relationship, and improves health outcomes. (CEJA Rep. 2, I-06)
Thoughtful and empathetic communication from the physician to the ill patient is a therapeutic tool. In fact from the above AMA policy: "Physicians can avoid using a placebo, yet produce a placebo-like effect through the skillful use of reassurance and encouragement. In this way, the physician builds respect and trust, promotes the patient-physician relationship, and improves health outcomes."
My question: What if the reassurance and encouragement is to the physician clinically unrealistic? However this is unknown to the patient. Nevertheless, to the physician, at this point, such reassurance would be considered as theraputic and beneficent. Would that misrepresenation to the patient of the patient's clinical condition be considered "a placebo of a 'placebo-like' effect"? A placebo of a placebo? Does lying to the patient represent "skillful use" of reassurance and encouragement? And is that consistent with AMA's ethics policies? ..Maurice.
Medical Challenges: Jumping to Conclusions and Medical Uncertainty
"A DOG'S STORY
The man dressed all in white quickly raised the dogs over the flames. Fortunately they were neither burned nor damaged. Covered with the yellow emoliment, he bedded them to rest for now but not for long. Every dog lover must know that
Nathan's on the Coney Island boardwalk is famous for their dogs."
When you read A Dog's Story, you are presented the perfect example of what all physicians face when confronted with a patient's medical story without sufficient time because of scheduling or where an action must be taken quickly and that is--jumping to conclusions and, in fact, the wrong conclusion.
And if the challenge of "conclusion jumping" is not enough for the physician there is also the "fog of medicine", the certainty that there is uncertainty in medicine.
Patients may unrealistically expect their doctors to uniformly overcome these challenges. But it really is difficult. Robert Lowes writes about this issue in the October 24 2003 Medical Economics: "In fact, The doctor-on-a-pedestal model of medicine also makes it hard for doctors to voice their doubts. Patients naturally prefer comfort and reassurance to any talk about percentages. Many physicians assume that anything less than supreme certitude on their part will discourage them and set back their progress. In the end, doctors have no choice but to live with unease."
How do you expect your doctor to respond to these challenges? How would you feel if your physician expresses personal doubt about his or her diagnosis or prediction of the outcome of any treatment? Would you be willing to face the uncertainty together or would you expect to be transferred to another physician who would be able to provide you with all the answers to the questions you are asking? But is there such an "other physician"? ..Maurice.
The man dressed all in white quickly raised the dogs over the flames. Fortunately they were neither burned nor damaged. Covered with the yellow emoliment, he bedded them to rest for now but not for long. Every dog lover must know that
Nathan's on the Coney Island boardwalk is famous for their dogs."
When you read A Dog's Story, you are presented the perfect example of what all physicians face when confronted with a patient's medical story without sufficient time because of scheduling or where an action must be taken quickly and that is--jumping to conclusions and, in fact, the wrong conclusion.
And if the challenge of "conclusion jumping" is not enough for the physician there is also the "fog of medicine", the certainty that there is uncertainty in medicine.
Patients may unrealistically expect their doctors to uniformly overcome these challenges. But it really is difficult. Robert Lowes writes about this issue in the October 24 2003 Medical Economics: "In fact, The doctor-on-a-pedestal model of medicine also makes it hard for doctors to voice their doubts. Patients naturally prefer comfort and reassurance to any talk about percentages. Many physicians assume that anything less than supreme certitude on their part will discourage them and set back their progress. In the end, doctors have no choice but to live with unease."
How do you expect your doctor to respond to these challenges? How would you feel if your physician expresses personal doubt about his or her diagnosis or prediction of the outcome of any treatment? Would you be willing to face the uncertainty together or would you expect to be transferred to another physician who would be able to provide you with all the answers to the questions you are asking? But is there such an "other physician"? ..Maurice.
Sunday, June 24, 2007
Should The Mentally Ill Deserve Assisted Suicide?
Although physician assisted suicide is legal, with restrictions, in but one U.S. state, Oregon, it is practiced in other countries. One such country is Switzerland, which allowed assisted suicide since 1918 and not requiring physician involvement and not requiring the patient to be a resident. A recent decision by the Swiss Federal Supreme Court now permits assisted suicide, under guidelines, to be available to psychiatric patients and others with mental illnesses. The issue of whether the mentally ill should have suicide rights is discussed as an Essay in the May-June 2007 issue of the "Hastings Center Report" titled "A Suicide Right for the Mentally Ill?" by Jacob M. Appel. (The link will lead you to the full text article after a free sign-in.) Read the article and then return and write about the issue. ..Maurice.
Pharmaceutical Testing in the Incompetent Patient
The issue of the ethics involved in the pharmaceutical testing of the mentally incompetent patient (one who does not have the capacity to make medical decisions for himself or herself) was presented on my now inactive "Bioethics Discussion Pages". As with other topics on the "Pages", I would like to migrate them here to the blog and read what my current visitors might comment on them.
I recently got an e-mail from L.R. Booth (boteone@yahoo.com) who does not believe any surrogate has the right to make a decision for a mentally ill patient to participate in a drug experiment and believes that there are patients who could eventually make their own decision. He writes:
" I do not feel you can use the terms incompetent and mentally ill interchangeably. Someone who is incompetent cannot give consent, therefore, it is unethical.
I do not believe anyone has the right to make that decision for the Pt. It's a shame that too many DPOA's and legal guardians do not have the Pt.'s best interests at heart. If the Pt. has outlined this tx in the form of a Advanced Directive then it would be ethical. If someone is suffering from a mental illness that does not mean they are incompetent. Mental illness includes a wide variety of disease processes; depression, bi-polar etc. If treated properly these Pt.'s can make a informed decision on experimental drug txs"
I should explain my understanding of mental illness and capacity to make medical decision. Not every mentally ill patient has lost capacity to make their own medical decision. The loss of capacity must be determined by careful testing by the physician. It can be done successfully. A patient can have the capacity to make a medical decision in one context and not in another, so the testing should include the context in which the patient may be involved. Does the patient understand what drugs are and what they do, for what they are used, by whom and how drugs are developed and how they are tested, for what are they tested and upon whom they are tested? Does the patient understand that the patient might not get to take the drug that is being tested and might get another drug or a sugar pill? Does the patient understand that the drug being investigated might not be any more useful than a sugar pill or another drug? Does the patient understand that the patient might suffer complications from the testing either by bad effects of the drug or by the fact that their usual medication may have to be discontinued? If the patient passes all these questions by demonstrating understanding, then I would think the patient would have the mental capacity to make their own self-decision whether or not to participate in the study regardless of their established psychiatric diagnosis. For those who have no capacity to understand and give consent, the main question of this post is whether someone else should. But unlike surrogates giving consent for treatments that are not experimental and are known to be effective, balanced against the risks, in the case of experimental drugs tha effectiveness is unknown and the risks may only be partially known. Is the altruistic properties of being a subject in a test that might help oneself and many others sufficient to override the inability of the patient to understand and agree with the surrogate's decision?
In the comments below, the oldest replies are at the bottom of the posting. ..Maurice.
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Pharmaceutical companies must test new drugs for the treatment of mental illness on patients with the illnesses for which the drugs were developed to treat. This seems a very clear statement. The ethical concern is how can these patients who may have lost the capacity to understand the purpose, nature, risks, benefits and alternatives (including nonparticipation) of the research, to make a decision about participation? Should a family member or other surrogate make the decision for such a patient? Ordinarily, surrogate medical decisions deal with therapeutic issues. In the case of drug testing, the testing itself may not prove to be therapeutic, may be painful or even harmful for the patient. Should surrogates be given the power to allow the patient to be subjected to medications which have not been proven therapeutic but may be harmful? If there is no surrogate, who should make the decision or should the patient be eliminated as a candidate for the study?
Here are the questions:
How can the patient's rights be protected and still provide for necessary testing of drugs in the mentally ill? Who, if anyone, should make the decision for an incompetent patient regarding participation in a drug testing experiment?
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Date: Tue, Mar 9, 2004 7:06 PM From: khmaio@earthlink.net To: DoktorMo@aol.com
Please do not employ the term, "the" mentally ill. No group is generic.How to obtain informed consent when a person is not capable of giving it? Stop.If I know someone is not competent, proceeding is unethical. Only greed motivates past knowing the person cannot consent. The greed for an answer or for a recognition.More the latter than the former. Harold A. Maio
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Date: Wed, Jan 21, 2004 11:20 AM From: khmaio@earthlink.net To: DoktorMo@aol.com
How can the patient's rights be protected and still provide for necessary testing of drugs in the mentally ill? Who, if anyone, should make the decision for an incompetent patient regarding participation in a drug testing experiment?
There is no generic "the" mentally ill. There is however a commodity, "the" mentally ill, which is widely exploited. There have been many such "commodities" in history. Once one has retreated to an abstract "the", societies seem to offer that group to be expolited. Generally the exploited group has no political power, ergo the Tuskegee "study". Even the Salk vaccine was tested on people unable to consent.
If one is a "patient" are there not already ethics in place, or is the term just a convenient empty metaphor?
Should a person unable to consent be forced to participate? No. Whatever term someone wishes to employ, it amounts to force since consent cannot be obtained. Florida law accepts that infomed consent has been obtained when "sufficient" explanation has been given. "Sufficient" is a metaphor of force, since it will be defined by the person intent on forcing, not by the person forced.
Harold A. Maio,Consulting Editor Psychiatric Rehabilitation Journal Boston University
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Date: Tue, Apr 8, 2003 3:52 PM From: bpspiper@msn.com To: DoktorMo@aol.com
I believe that it is wrong to conduct experimental testing for unapproved drugs on the mentally ill without express consent from a legal guardian, power of attorney, or judgment of the state. As a nursing student we have been taught that our highest priority is to protect the rights of our patients. Through education we can help the families and guardians come to a better understanding of how pharmaceutical companies work to improve and or create new drugs that could better serve the people. With this education now comes the power of the families and guardians to decide what is in the best interest of the patient. We cannot arbitrarily stand by while others decide our fate. We have to stand up for the rights of those who cannot stand up for themselves. If we don't who will stand up for us if the time comes?
Becki Price
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Date: Mon, Oct 22, 2001 8:52 AM From: CBlades@JPMC.ORG To: DoktorMo@aol.com
Not all mentally ill people are incompetent. I think that has to be determined before you can make a blanket statement as to who can make the decision for their participation in a drug trial. Many mentally ill patients would welcome the chance even during stable periods, if it meant decreasing the effects that their illness has on their lives. Look at the Clozaril trials for instance...while there are great risks associated with this medication the benefits for the majority of the patients outweighed the risk. I believe we allow the patient to make the choice unless the court has declared them incompetent and if that is the case, give the information to the legal guardian and assist them in make the appropriate decision as needed.
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Date: Thu, Jan 11, 2001 5:46 PM From: mlammers3@home.com To: DoktorMo@aol.com
Using experimental drugs on persons who are mentally incompetent because of illness is not a clear cut issue. However, if the drugs are being designed to specifically treat their disease or disorder, and this disease or disorder often or always leads to mental incompetence, the treating physicians are really left with no choice but to test the drugs on these people. Certainly the drugs cannot be used on healthy people. I think the decision of whether or not these patients should be used in experimental drug testing should be left up to their relatives, who will hopefully act in the best interest of the patient.
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Date: Tue, May 19, 1998 3:44 PM From: sheilac@kalama.doe.Hawaii.Edu To: DoktorMo@aol.com
Pharmaceutical testing in the incompetent patients? This is a really tough issue. It's like a gamble, you test the drug on a person like a guinea pig, if it lives and does its purpose it works, but if the patient gets worse or dies it's a failure and you loose. I say let a family member make the decision for him or her. Discuss the drugs purpose and whats expected to happen, Also explain it's risk and possible side effects. Also explain what the patient may feel physically and mentally.
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Date: Sat, Jul 26, 1997 1:35 PM From: DocReading@sprintmail.com To: DoktorMo@aol.com
Mentally ill patients are not by definition incompetent to consent to drug testing. Many mentally ill patients do not lack the capacity to understand the purpose, nature, risks, benefits, and alternatives of the research. As a matter of fact, I have many patients (I am a Psychiatrist) who are more altruistic than their non-mentally ill designated counterparts. If a drug can be tested on willing and factually competent individuals, it should. Only if it can be proved that an illness renders all people who contract it incompetent to consent then legislation could be enacted to appoint a committee to decide based on the individual's premorbid preferences if possible whether or not to allow the person into the study. The principle of autonomy should rule whenever possible.
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Date: Wed, Apr 16, 1997 2:41 AM From: gottlieb@hp380.ist.unige.it (Prof. Alberto Gottlieb) To: DoktorMo@aol.com
The problem of consent to diagnostic and therapeutic procedures of incompetent individuals has not yet been solved adequately and you already ask about the consent relative to experimental therapy ?! It seems evident that caring for, let's say, a demented Alzheimer patient is quite easy when benefits prevail over risks by far :e.g.in case of arterial hypertension or acute appendicitis. If, on the contrary, performing diagnostic and therapeutic procedure entails a certain morbidity (annoying side effects) or mortality e.g. coronary disease, then every person deciding for the incompetent patient will be criticized , and perhaps also legally sued by relatives with conflicting interests , if things don't go straight. Deciding about new diagnostic or therapeutical procedures (namely drugs) to be applied in incompetent patients should start from the same point: the benefits either real or awaited (on serious scientific grounds)should prevail by far over risks. It must brought in mind however that only at the beginning of the dementing process, such as Alzheimer or Multiinfarctual dementia, a real benefit may be awaited from a therapy and it will be, when it will be, a stop to mental deterioration. It seems actually unbelievable to restore mental abilities that have been lost because the corresponding neuronal centers are atrophic and millions of neural cells and their fibers are absent. This stimulates drug researchers to focalize their efforts on the beginning of the dementia when the best resuls are perhaps attainable and, if attained, best measurable. But it is just the moment when patients usually are still competent and may be asked their consent about new drug treatments. I think morevover that in this period of initial restriction of mental capacity which does not intefere yet with the ability of caring about theirselves patients may be asked advanced directives about the future behaviors of the caregivers (deciding substitute) and the medical staff.
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Date: Thu, Dec 19, 1996 2:43 AM EDT From: BBrodie960@aol.com To: DoktorMo@aol.com
Society provides a surrogate decision maker for its immature and mentally incompetent members. To an extent, the rights of this unfortunate class are transferred to those close enough to them to act in a manner as similar as possible to the incompetent person. Usually, this is a family member, but it might be a friend, or even the state when that's the best society can come up with. It's not a perfect system, but more often than not, the designated decision maker acts in the incompetent individual's best interest and in a way that is reasonably similar to the way that individual would act if he or she were competent.
I think the testing of psychotropic drugs is so important that the risk of unnecessarily violating a person's right to make an informed decision is significantly outweighed by the benefit of making appropriately tested and effective drugs available to those who need them. (Not only does the mentally ill patient benefit from the drug, but society benefits from him or her taking the drug.)
I say, let the party designated to make any important healthcare decision on behalf ot the incompetent individual make the decision regarding participation in a drug study. The only exception I would make to this rule would be when the incompetent individual's guardian is the state because the state is least likely to know how the incompetent individual would act if he or she were competent.
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I recently got an e-mail from L.R. Booth (boteone@yahoo.com) who does not believe any surrogate has the right to make a decision for a mentally ill patient to participate in a drug experiment and believes that there are patients who could eventually make their own decision. He writes:
" I do not feel you can use the terms incompetent and mentally ill interchangeably. Someone who is incompetent cannot give consent, therefore, it is unethical.
I do not believe anyone has the right to make that decision for the Pt. It's a shame that too many DPOA's and legal guardians do not have the Pt.'s best interests at heart. If the Pt. has outlined this tx in the form of a Advanced Directive then it would be ethical. If someone is suffering from a mental illness that does not mean they are incompetent. Mental illness includes a wide variety of disease processes; depression, bi-polar etc. If treated properly these Pt.'s can make a informed decision on experimental drug txs"
I should explain my understanding of mental illness and capacity to make medical decision. Not every mentally ill patient has lost capacity to make their own medical decision. The loss of capacity must be determined by careful testing by the physician. It can be done successfully. A patient can have the capacity to make a medical decision in one context and not in another, so the testing should include the context in which the patient may be involved. Does the patient understand what drugs are and what they do, for what they are used, by whom and how drugs are developed and how they are tested, for what are they tested and upon whom they are tested? Does the patient understand that the patient might not get to take the drug that is being tested and might get another drug or a sugar pill? Does the patient understand that the drug being investigated might not be any more useful than a sugar pill or another drug? Does the patient understand that the patient might suffer complications from the testing either by bad effects of the drug or by the fact that their usual medication may have to be discontinued? If the patient passes all these questions by demonstrating understanding, then I would think the patient would have the mental capacity to make their own self-decision whether or not to participate in the study regardless of their established psychiatric diagnosis. For those who have no capacity to understand and give consent, the main question of this post is whether someone else should. But unlike surrogates giving consent for treatments that are not experimental and are known to be effective, balanced against the risks, in the case of experimental drugs tha effectiveness is unknown and the risks may only be partially known. Is the altruistic properties of being a subject in a test that might help oneself and many others sufficient to override the inability of the patient to understand and agree with the surrogate's decision?
In the comments below, the oldest replies are at the bottom of the posting. ..Maurice.
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Pharmaceutical companies must test new drugs for the treatment of mental illness on patients with the illnesses for which the drugs were developed to treat. This seems a very clear statement. The ethical concern is how can these patients who may have lost the capacity to understand the purpose, nature, risks, benefits and alternatives (including nonparticipation) of the research, to make a decision about participation? Should a family member or other surrogate make the decision for such a patient? Ordinarily, surrogate medical decisions deal with therapeutic issues. In the case of drug testing, the testing itself may not prove to be therapeutic, may be painful or even harmful for the patient. Should surrogates be given the power to allow the patient to be subjected to medications which have not been proven therapeutic but may be harmful? If there is no surrogate, who should make the decision or should the patient be eliminated as a candidate for the study?
Here are the questions:
How can the patient's rights be protected and still provide for necessary testing of drugs in the mentally ill? Who, if anyone, should make the decision for an incompetent patient regarding participation in a drug testing experiment?
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Date: Tue, Mar 9, 2004 7:06 PM From: khmaio@earthlink.net To: DoktorMo@aol.com
Please do not employ the term, "the" mentally ill. No group is generic.How to obtain informed consent when a person is not capable of giving it? Stop.If I know someone is not competent, proceeding is unethical. Only greed motivates past knowing the person cannot consent. The greed for an answer or for a recognition.More the latter than the former. Harold A. Maio
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Date: Wed, Jan 21, 2004 11:20 AM From: khmaio@earthlink.net To: DoktorMo@aol.com
How can the patient's rights be protected and still provide for necessary testing of drugs in the mentally ill? Who, if anyone, should make the decision for an incompetent patient regarding participation in a drug testing experiment?
There is no generic "the" mentally ill. There is however a commodity, "the" mentally ill, which is widely exploited. There have been many such "commodities" in history. Once one has retreated to an abstract "the", societies seem to offer that group to be expolited. Generally the exploited group has no political power, ergo the Tuskegee "study". Even the Salk vaccine was tested on people unable to consent.
If one is a "patient" are there not already ethics in place, or is the term just a convenient empty metaphor?
Should a person unable to consent be forced to participate? No. Whatever term someone wishes to employ, it amounts to force since consent cannot be obtained. Florida law accepts that infomed consent has been obtained when "sufficient" explanation has been given. "Sufficient" is a metaphor of force, since it will be defined by the person intent on forcing, not by the person forced.
Harold A. Maio,Consulting Editor Psychiatric Rehabilitation Journal Boston University
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Date: Tue, Apr 8, 2003 3:52 PM From: bpspiper@msn.com To: DoktorMo@aol.com
I believe that it is wrong to conduct experimental testing for unapproved drugs on the mentally ill without express consent from a legal guardian, power of attorney, or judgment of the state. As a nursing student we have been taught that our highest priority is to protect the rights of our patients. Through education we can help the families and guardians come to a better understanding of how pharmaceutical companies work to improve and or create new drugs that could better serve the people. With this education now comes the power of the families and guardians to decide what is in the best interest of the patient. We cannot arbitrarily stand by while others decide our fate. We have to stand up for the rights of those who cannot stand up for themselves. If we don't who will stand up for us if the time comes?
Becki Price
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Date: Mon, Oct 22, 2001 8:52 AM From: CBlades@JPMC.ORG To: DoktorMo@aol.com
Not all mentally ill people are incompetent. I think that has to be determined before you can make a blanket statement as to who can make the decision for their participation in a drug trial. Many mentally ill patients would welcome the chance even during stable periods, if it meant decreasing the effects that their illness has on their lives. Look at the Clozaril trials for instance...while there are great risks associated with this medication the benefits for the majority of the patients outweighed the risk. I believe we allow the patient to make the choice unless the court has declared them incompetent and if that is the case, give the information to the legal guardian and assist them in make the appropriate decision as needed.
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Date: Thu, Jan 11, 2001 5:46 PM From: mlammers3@home.com To: DoktorMo@aol.com
Using experimental drugs on persons who are mentally incompetent because of illness is not a clear cut issue. However, if the drugs are being designed to specifically treat their disease or disorder, and this disease or disorder often or always leads to mental incompetence, the treating physicians are really left with no choice but to test the drugs on these people. Certainly the drugs cannot be used on healthy people. I think the decision of whether or not these patients should be used in experimental drug testing should be left up to their relatives, who will hopefully act in the best interest of the patient.
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Date: Tue, May 19, 1998 3:44 PM From: sheilac@kalama.doe.Hawaii.Edu To: DoktorMo@aol.com
Pharmaceutical testing in the incompetent patients? This is a really tough issue. It's like a gamble, you test the drug on a person like a guinea pig, if it lives and does its purpose it works, but if the patient gets worse or dies it's a failure and you loose. I say let a family member make the decision for him or her. Discuss the drugs purpose and whats expected to happen, Also explain it's risk and possible side effects. Also explain what the patient may feel physically and mentally.
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Date: Sat, Jul 26, 1997 1:35 PM From: DocReading@sprintmail.com To: DoktorMo@aol.com
Mentally ill patients are not by definition incompetent to consent to drug testing. Many mentally ill patients do not lack the capacity to understand the purpose, nature, risks, benefits, and alternatives of the research. As a matter of fact, I have many patients (I am a Psychiatrist) who are more altruistic than their non-mentally ill designated counterparts. If a drug can be tested on willing and factually competent individuals, it should. Only if it can be proved that an illness renders all people who contract it incompetent to consent then legislation could be enacted to appoint a committee to decide based on the individual's premorbid preferences if possible whether or not to allow the person into the study. The principle of autonomy should rule whenever possible.
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Date: Wed, Apr 16, 1997 2:41 AM From: gottlieb@hp380.ist.unige.it (Prof. Alberto Gottlieb) To: DoktorMo@aol.com
The problem of consent to diagnostic and therapeutic procedures of incompetent individuals has not yet been solved adequately and you already ask about the consent relative to experimental therapy ?! It seems evident that caring for, let's say, a demented Alzheimer patient is quite easy when benefits prevail over risks by far :e.g.in case of arterial hypertension or acute appendicitis. If, on the contrary, performing diagnostic and therapeutic procedure entails a certain morbidity (annoying side effects) or mortality e.g. coronary disease, then every person deciding for the incompetent patient will be criticized , and perhaps also legally sued by relatives with conflicting interests , if things don't go straight. Deciding about new diagnostic or therapeutical procedures (namely drugs) to be applied in incompetent patients should start from the same point: the benefits either real or awaited (on serious scientific grounds)should prevail by far over risks. It must brought in mind however that only at the beginning of the dementing process, such as Alzheimer or Multiinfarctual dementia, a real benefit may be awaited from a therapy and it will be, when it will be, a stop to mental deterioration. It seems actually unbelievable to restore mental abilities that have been lost because the corresponding neuronal centers are atrophic and millions of neural cells and their fibers are absent. This stimulates drug researchers to focalize their efforts on the beginning of the dementia when the best resuls are perhaps attainable and, if attained, best measurable. But it is just the moment when patients usually are still competent and may be asked their consent about new drug treatments. I think morevover that in this period of initial restriction of mental capacity which does not intefere yet with the ability of caring about theirselves patients may be asked advanced directives about the future behaviors of the caregivers (deciding substitute) and the medical staff.
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Date: Thu, Dec 19, 1996 2:43 AM EDT From: BBrodie960@aol.com To: DoktorMo@aol.com
Society provides a surrogate decision maker for its immature and mentally incompetent members. To an extent, the rights of this unfortunate class are transferred to those close enough to them to act in a manner as similar as possible to the incompetent person. Usually, this is a family member, but it might be a friend, or even the state when that's the best society can come up with. It's not a perfect system, but more often than not, the designated decision maker acts in the incompetent individual's best interest and in a way that is reasonably similar to the way that individual would act if he or she were competent.
I think the testing of psychotropic drugs is so important that the risk of unnecessarily violating a person's right to make an informed decision is significantly outweighed by the benefit of making appropriately tested and effective drugs available to those who need them. (Not only does the mentally ill patient benefit from the drug, but society benefits from him or her taking the drug.)
I say, let the party designated to make any important healthcare decision on behalf ot the incompetent individual make the decision regarding participation in a drug study. The only exception I would make to this rule would be when the incompetent individual's guardian is the state because the state is least likely to know how the incompetent individual would act if he or she were competent.
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Thursday, June 21, 2007
Sick, Unconscious and Without Family, Friends or Surrogates--What's Next?
OK..here's the deal: You are in a hospital sick..you are unconscious..you need to have a surgical procedure done to attempt to make you better to some degree but you are unable to weigh the risks and benefits or to give the surgeon permission to operate..you are unconscious. In addition..you have been homeless..you have lived on the street..different streets..you have no friends..you have no relatives..you have no one to come to the hospital to visit you or talk to your surgeon. The surgeon wants to make you better..he or she needs to operate..but there is no one..not you or anyone else to give the surgeon permission. There is no law where the hospital is located which would instruct anyone what to do under these circumstances..Should the surgeon act as a family member or legal surrogate and make the decision for you? If you really were that patient..what do you think would be legal and ethical.. what would be the fairest act for that doctor to do for your benefit? Should the surgeon make the decision for you? And what if the decision to be made was not simply to operate to attempt to make you better but involved a decision to stop all life-supportive treatment because your condition was hopeless and you would never recover. Who should make that decision? You can't..you are unconscious and you have no one to speak for you. Got the picture?
By the way, this scenario is not at all rare. It can happen every day in some hospital. Most states in the U.S. have no laws which tell doctors what to do under these circumstance. Sure, the doctor and hospital can take the problem to the courts and have a judge decide or to have a legal guardian appointed. But this takes time and there may be no time. The guardian will not be available to respond for every single medical procedure nor will the guardian be free of conflict of interest or free of pressure from the judge when it comes to terminating life-support. So the doctors and hospitals have to make up their own guidelines. But my question is ..what would you want them to do if a patient comes in with no capacity to make decisions and no friends, family or surrogates to help with a medical decision? ..Maurice.
By the way, this scenario is not at all rare. It can happen every day in some hospital. Most states in the U.S. have no laws which tell doctors what to do under these circumstance. Sure, the doctor and hospital can take the problem to the courts and have a judge decide or to have a legal guardian appointed. But this takes time and there may be no time. The guardian will not be available to respond for every single medical procedure nor will the guardian be free of conflict of interest or free of pressure from the judge when it comes to terminating life-support. So the doctors and hospitals have to make up their own guidelines. But my question is ..what would you want them to do if a patient comes in with no capacity to make decisions and no friends, family or surrogates to help with a medical decision? ..Maurice.
Tuesday, June 19, 2007
More on the Issue of Killing vs Letting Die
Back on October 14 2006, I had a posting about a case of a quadriplegic who required the ventilator for survival but finally wanted it turned off. The issue was if the physicians or others turned off the ventilator would this represent a killing or letting the patient die of his underlying paralysis. Patients have a legal and ethical right to terminate unwanted treatment.
I wanted today to present another killing vs letting die situation for consideration. Cardiac pacemakers are inserted into patients whose heart cannot beat without electrical assistance or on its own beats so slowly that the patient is very symptomatic and if not improved the patient may die from stroke or heart failure.
There are two case scenarios discussed at the American Medical Association’s Virtual Mentor (link 1, link 2) which deal with the issue of the ethics involved in turning off cardiac pacemakers. Read them, return and indicate whether you feel that removing a device attached to preserve the life of a patient who would otherwise die is an intentional killing act such as euthanasia or murder. ..Maurice.
I wanted today to present another killing vs letting die situation for consideration. Cardiac pacemakers are inserted into patients whose heart cannot beat without electrical assistance or on its own beats so slowly that the patient is very symptomatic and if not improved the patient may die from stroke or heart failure.
There are two case scenarios discussed at the American Medical Association’s Virtual Mentor (link 1, link 2) which deal with the issue of the ethics involved in turning off cardiac pacemakers. Read them, return and indicate whether you feel that removing a device attached to preserve the life of a patient who would otherwise die is an intentional killing act such as euthanasia or murder. ..Maurice.
Wednesday, June 13, 2007
XDR TBC and the Fallacy of a Moat
Steven Miles, physician and ethicist from the University of Minnesota has given me permission to post here his retelling of a classical story and his challenging commentary to his colleagues which he sent to a bioethics listserv.
I suggested to Steve that it was my impression that our current U.S. administration was, perhaps until recently, presenting the issue of greenhouse gasses leading to global warming with the same "moat-like" defense. He replied "On global warming, the US has acted the same way, ie Kyoto protocol, although the problem is much more complex and less amenable to rectification. TB treatment is especially infuriating because TB treatment was available, affordable. TB eradication was recognized as needed; it was proposed and it was possible. XDR-TB was the predictable alternative outcome."
By the way, for those of my visitors who don't know to what Steve referred to as "TRIPS", the acronym stands for "Agreement on Trade=Related Aspects of Intellectual Property Rights". This was the international agreement that some felt had prevented AIDS victims in developing countries to get the best AIDS therapy.
..Maurice.
With admiration from Edgar Allen Poe:
THE "Red Death" had long devastated the country. No pestilence had ever been so fatal, or so hideous. Blood was its Avatar and its seal -- the redness and the horror of blood. There were sharp pains, and sudden dizziness, and then profuse bleeding at the pores, with dissolution. The scarlet stains upon the body and especially upon the face of the victim, were the pest ban which shut him out from the aid and from the sympathy of his fellow-men. And the whole seizure, progress and termination of the disease, were the incidents of half an hour.
But the Prince Prospero was happy and dauntless and sagacious. When his dominions were half depopulated, he summoned to his presence a thousand hale and light-hearted friends from among the knights and dames of his court, and with these retired to the deep seclusion of one of his castellated abbeys. This was an extensive and magnificent structure, the creation of the prince's own eccentric yet august taste. A strong and lofty wall girdled it in. This wall had gates of iron. The courtiers, having entered, brought furnaces and massy hammers and welded the bolts. They resolved to leave means neither of ingress or egress to the sudden impulses of despair or of frenzy from within. The abbey was amply provisioned. With such precautions the courtiers might bid defiance to contagion. The external world could take care of itself. In the meantime it was folly to grieve, or to think. The prince had provided all the appliances of pleasure. There were buffoons, there were improvisatori, there were ballet-dancers, there were musicians, there was Beauty, there was wine. All these and security were within. Without was the "Red Death."
It was toward the close of the fifth or sixth month of his seclusion, and while the pestilence raged most furiously abroad, that the Prince Prospero entertained his thousand friends at a masked ball of the most unusual magnificence. ... And now was acknowledged the presence of the Red Death. He had come like a thief in the night. And one by one dropped the revelers in the blood-bedewed halls of their revel, and died each in the despairing posture of his fall. ...
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XDR TB is not a new act of bacterial creationism, it is a killing automaton which we have made as a living testament to our failure to detect and treat TB. It is not hard to treat TB, $25/cure suffices in developing countries. We locked ourselves in game rooms to fret about face transplants, reality television, and fantasy sports. Globally TB treatment is in shambles, few cases are found, fewer than 30% of those found complete therapy. International agreements, like the bioethics ignored TRIPS, have put the cost of routine treatment out of reach of those most likely to be infected.
XDR TB is in 37 countries at least. Now a telegenic and selfish yuppie couple, one of Prince Prospero's favored guests, show the fallacy and porousness of our "castellated abbey."
An idiotic press and pithed congressmen demand to know why we did not build a better moat so that our slumber party could proceed without being so rudely disturbed.
Will the bioethicists say "Here! Here!" ?
I suggested to Steve that it was my impression that our current U.S. administration was, perhaps until recently, presenting the issue of greenhouse gasses leading to global warming with the same "moat-like" defense. He replied "On global warming, the US has acted the same way, ie Kyoto protocol, although the problem is much more complex and less amenable to rectification. TB treatment is especially infuriating because TB treatment was available, affordable. TB eradication was recognized as needed; it was proposed and it was possible. XDR-TB was the predictable alternative outcome."
By the way, for those of my visitors who don't know to what Steve referred to as "TRIPS", the acronym stands for "Agreement on Trade=Related Aspects of Intellectual Property Rights". This was the international agreement that some felt had prevented AIDS victims in developing countries to get the best AIDS therapy.
..Maurice.
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