Medical Ethics – Denialism

Rating your doctor online – is this a good idea?

I have just finished taking my last major exam of medical school – Step 2 of the boards (including Step 2 Clinical Skills, or CS, which costs 1200 bucks, requires you to travel to one of a few cities in the country hosting it, and is sealed by a EULA that forbids me from talking about what the test was like), and am winding down my medschool career in the next few weeks. It’s about 2 weeks from Match Day (the 19th), when I’ll find out for sure where I will spend the next 5 or so years of my life. I’ll be sure to have a post up a little after noon that day when I find out what the answer is. And then, around May 17th, graduation day, I’ll be a medical doctor, ready to start internship (also known as the hardest year of your life).

One of the things I’ve found universal to all medical students is that we really want to be good doctors when we are finished with our training. I don’t think I’ve ever met a medical student who was in this career for the money (you’d be crazy), or for other selfish reasons. They tend to be hard working, dedicated, humble people who, if anything, are sickeningly sincere about wanting to help other people. Maybe that’s just my school, but my experience is, these folks want to do good in the world.

But another universal is that not all doctors will be able to avoid making mistakes. Doctors are human, they all will eventually make errors, and the goal of any profession dedicated to improving the human condition should be constant self-reflection and efforts at self-improvement. This is not a simple thing to do however. Medicine is complex, and quality of medical treatment is very difficult to assess. We’ve discussed before, using metrics in medicine is challenging, and often rather than studying medical quality you end up merely assessing the social demographics of the physicians’ patients.

So it is with interest that I see reading boingboing that lots of people are upset because some doctors are forcing their patients not to rate them on sites like RateMD.com by having them sign a contract forbidding them from doing so.

The arguments for and against this practice are fascinating. We tread into the mucky waters of free speech, free enterprise, the practice of medicine, and the practical problem of assessing physician quality…

More below the fold…
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Look, Ma, I’m on TV!

Ok, really, it’s bloggingheads.tv. Dr. Free Ride from Adventures in Ethics and Science invited me for a chat about ethics, which you can view, well, right now. Next time, I’ll remember to keep the camera a bit further away.

Does alternative medicine have alternative ethics?

We’ve talked quite a bit about ethics in this space, especially medical ethics and “blog ethics”. Today, though, we will specifically examine the nature of medical ethics as they apply to so-called alternative medicine.

First, and perhaps most important, I am not an ethicist. I do not have the depth of reading, the knowledge of terminology, or the specific education to lead a formal discussion on ethics. What I am is a practicing internist, who must make ethical decisions on a daily basis. Most of these decisions are of necessity made “from the heart”, but it is not infrequent that I must evaluate a situation more formally and fall back on some of the ethical principles of my profession.

Ethics are not static. They are not a divine gift bestowed on each of us as we don our white coats. They are a living part of our specific cultures, and of the profession we serve. Some of the modern principles of medical ethics are newer than others. Beneficence, non-maleficence, and confidentiality are ancient principles of medical ethics, which continue to be relevant today. Patient autonomy is a more recent value, reflecting a shift in how society views the relationship between patient and physician. These ethics must be mutable, as the profession itself is ever-changing. Despite this fluidity, there is an identifiable line of “doctor-hood” that has existed for at least the last century, and the members of this guild have always tried to adhere to some type of code of behavior.

Alternative medicine poses real challenges to the principle of medical ethics. First, we’ll discuss who, in fact, is bound by these principles, then the way in which alternative medicine is or is not compatible with medical ethics.

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How drunk is too drunk—another foray into medical ethics

The best ethical questions are real ones. Sure, it’s fun to play the lifeboat game, but when you’re dealing with flesh and blood human beings on a daily basis, games aren’t all that helpful. So here’s a non-life-and-death question: if a patient comes to see you and smells of alcohol, can you add an alcohol level to their blood work without specifically informing them?

Ethical discussions are best held as, well, discussions, so I’ll lay out some ethical principles and let you discuss before I weigh in further.

First, any patient who comes to see a doctor signs a “general consent for treatment” which usually contains a phrase such as:

I request and authorize Health Care Services by my physician, and his/her designees as may deem advisable. This may include routine diagnostic, radiology and laboratory procedures and medication administration.

Second, for your reference, here is the summary of the AMA’s code of medical ethics.

And finally, a brief list of the most agreed-upon basic principles of medical ethics:

Beneficence – acting in the best interest of the patient.

Non-maleficence – avoid harm to the patient

Autonomy – the patient has the right to refuse or choose their treatment

Justice—fair distribution or resources

Dignity

Truthfulness/informed consent

Remember that ethics aren’t a checklist. Real life situations are just that—real, with real people.

OK, the thread is now open.

Do physicians really believe in placebos?

This article is cross-posted at Science-Based Medicine. Check it out. –PalMD

In a previous post, I argued that placebo is an artifact of certain clinical interactions, rather than a treatment that we can exploit. Apparently, there are a whole lot of doctors out there who don’t agree with me. Or are there?

A recent study published in the British Medical Journal is getting
a lot of enk (e-ink) in the blogosphere. As a practicing internist, I have some pretty strong opinions (based in fact, of course) about both this study and placebos in general.

The Study

The current BMJ study defines placebo as “positive clinical outcomes caused by a treatment that is not attributable to its known physical properties or mechanism of action.” I’ve got a lot of problems with this definition, but we’ll get to that later. It also allowed physiologically active medications to “count” as placebos. Oops.

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Hmm…ethics…

Ok, I pulled my post while considering ethical issues, viz this conversation:

Dianne, PAL:

I’m out of my depth here, so could you address what the ethical boundaries are for describing a case (even without personal identification) on an open board?

I’ve always dealt with that one by Just Don’t — and I know it’s overly conservative. And I promise to not take you as too authoritative, but it’s an interesting subject …

Posted by: D. C. Sessions | October 15, 2008 9:09 PM

Well, it’s an interesting issue. Generally, cases are fine to present as long as enough details are changed. Given that I’ve lived/practiced in a number of different cities/states, and that the only real identifying info is that the patient is a male in his 60s (which may or may not be true), and i’ve presented a picture that may or may not be the actual patient, the ethics seem to be in my favor.

NEJM, for example, is a publicly available journal, and regularly presents cpc’s without identifying info.

Curse/bless you for bringing this up.

Case presentations are not in and of themselves unethical. The ethical issues involve what is in the patient’s best interest. If a patient is not identifiable, there should be no ethical issue.

Except when there is.

Some would argue that a patient can be ethically harmed even if they are not identified, as the information about them belongs to them, and is theirs to hold or release. This, I think, is where the issue of mixing up case details comes in. If the details are not traceable to a particular patient, then there is no harm.

However, since I am talking about a path report, one could argue that there is an ethical problem.

There is also a question as to what benefit a patient may or may not derive…

Hmm…

Posted by: PalMD [TypeKey Profile Page] | October 15, 2008 9:16 PM

Discuss amongst yourselves while I consult my betters….

Why be in such a hurry (to kill someone)?

Once again, I find myself straying into a political issue (although I’d argue that it’s more a human rights issue). I understand that I’m probably in the minority in this country in my opposition to the death penalty. My fellow Americans generally vote to allow it, and my vote only counts once. One area where my opinion my carry a bit more weight (or maybe not) is in the area of medical ethics. Given that the death penalty is legal in the U.S., what role should doctors play?

Troy Anthony Davis is a guy that Georgia wants dead so badly that they can’t be bothered to wait for the U.S. Supreme Court to weigh in (SCOTUS is scheduled to discuss the case on the 29th, six days after the state kills Davis).

But here’s the part that really gets me as a physician (from the Atlanta Journal Constitution):
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I’ve been (not) workin’ on the railroad

This story is disturbing for a host of reasons, but there’s a medical ethics issue hiding in here.

Apparently, if you work for the Long Island Railroad, you can retire at 50, then claim disability for a job you no longer have, and collect both a disability check and a pension. I shit you not. But it gets better. According to the Times, “Virtually every career employee — as many as 97 percent in one recent year — applies for and gets disability payments soon after retirement….”

I strongly encourage you to read the whole article, but let’s focus on a particular point.

Dr. Melhorn, who has studied disabilities, said the numbers alone were a cause for concern, “in particular if there seems to be a limited number of physicians who are providing this disability impairment.”
[…]
L.I.R.R. employees favor certain doctors, and their disability applications are sometimes so similar as to be almost interchangeable, said one Long Island resident who has seen dozens of those applications. That person said that M.R.I.’s merely document physiological changes that commonly affect people over the age of 50.
(empasis mine)

In my practice, I often have to fill out temporary disability forms. It’s pretty standard—when a patient has a knee replacement or a heart attack their work requires them to file certain papers.

There is a separate subset of patients who believe themselves to be completely disabled, and want me to fill out forms from the state to help them get disability payments. Very few of my patients are so disabled as to be unable to work at all, ever. But many of them think they are. Who wouldn’t want to collect a check for doing nothing? I usually tell them that if I answer the questions on the form truthfully, they are unlikely to ever get disability. I let them decide at that point whether they really want me filling them out (which may, of course, be passing the buck, and ducking a responsibility, but since the state can assign doctors for disability exams, I don’t feel I’m shirking).
Continue reading “I’ve been (not) workin’ on the railroad”

A very confused pharmacist

I’ve written often about the ethics of doctors and pharmacists imposing their own morals on their patients and customers. Our Sb pharmacologist has as well. And even though all of our legitimate professional organizations recognize this line, Bush’s Department of Health and Human Services has jumped into the ring to join a fight that should never have started. And just to demonstrate how single-mindedly idiotic an evangelical (small “e”) mindset can be when applied to medicine, PZ Myers, uber-atheist, received an interesting solicitation (please, don’t quote-mine that).

To remind you of the issue at hand, there are a number of doctors and pharmacists out there who think that their own religious beliefs should trump the standards of good medical care and the needs of their patients. This is why I write of “evangelism”: professionals who are trying to teach the Good Word (any Good Word) to their patients have stepped very far over an ethical line.
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Doctors aren’t preachers (or at least they shouldn’t be)

I’ve written a number of times about how a physician must be careful not impose his or her personal beliefs on patients.

Another interesting case has hit the news. The decision of the California Supreme Court hinged on interpretation of state non-discrimination law. I’m not a lawyer, but I do know a bit about medicine and medical ethics. Regardless of law, this doctor’s behavior was wrong. The details are a little sketchy, but an unmarried lesbian woman was denied fertility treatments by a California doctor because the treatment conflicted with the doctor’s faith.

Conflicted with the doctor’s faith. There’s the rub.
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