Wondering about "Ethical Analysis"

Rosemary Flanigan

February 27, 2010

We’re beginning preparation for one of our twice-yearly ethics committee workshops, and we always ask ourselves, “What do our members NEED?” Even if we advertise them for new members or experienced members, we usually get a mixture.

My colleague Terry Rosell called our attention to the fact that in many ethics committees only a small group does actual case consults. Whether or not this is a good practice, I still think it advisable to model ethical analysis using a mock case with all levels of ethics committees.

WHY?

Because we can get in bad habits and “ethical” analysis becomes “what the doctors say to do.”

If we are not self-reflective in the analysis, then we need to model forced self-reflection by asking what presuppositions or assumptions are at play in the last remark, and what are the implications of the suggestion just made for ”solving the problem.”

We ought to be aware whether we are thinking consequentially or deontologically—and to tell one another that we know where we are coming from and where we are going in our arguments. (It takes pressure off the listener.) There are weaknesses built in to each ethical theory and our arguments ought to reflect our awareness of that fact.

If we’re not doing that in our meetings, it doesn’t surprise me that people wonder what an “ethical analysis” really is.

Anybody agree???? Disagree????

Is it ethical to live forever?

Glenn McGee, PhD

Francis Chair in Bioethics

February 19, 2010

10 minutes 12 seconds

Is it ethical for individuals, or for society generally, to take advantage of technologies that will change our entire notion of what it means to age? Is it okay to want to live forever?

Those are the questions to be addressed by Doctor Glenn McGee, the Francis Chair at the Center for Practical Bioethics, during a lecture February 24 in Kansas City. Dr. McGee talks about the concept during Health Talk on KMBZ Radio in Kansas City.

Link: Podcast, Is it ethical to want to live forever?

A Dispute over Dartmouth Data

John Carney

February 19, 2010

An analysis written in the New England Journal of Medicine suggests that much of the Dartmouth Atlas research is flawed and that it should not be used to compare the relative efficiency of hospitals.

This is an academic argument. What the Dartmouth Atlas (DA) data show are that higher payments do not result in better outcomes or necessarily better care. DA doesn’t say that higher costs for some patients is bad.

There is no quarrel with the suggestion Dr. Bach makes that we should be cautious in drafting payment policy based on what Dartmouth Atlas shows us; oversimplifying the problem by paying all providers in high cost regions less, won’t solve the problem. But the argument that Dartmouth uses faulty methodology in drawing its conclusions is simply not true.

In a nutshell here is what the Dartmouth data show - Unwarranted variation occurs and it has at least three causes - underuse, overuse and misuse.

* Underuse is caused by patients not getting good evidenced based care (i.e., the standard of care is not met).

* Overuse is associated with supply sensitive care, which means we “fill the bed” or perform the service because the incentives to treat in a fee for service payment environment align with “more is better”

* Misuse is associated with preference sensitive care, which means that when there are
significant tradeoffs among available options, choices should be based on the patient’s own values; but often they are not. Misuse results from the failure to accurately communicate the risks and benefits of alternative treatments, and the failure to base the choice of treatment on the patient’s values and preferences.

Despite Dr. Bach’s contention that the DA findings lead policy makers to propose bad payment fixes (i.e., reform proposals to lower payments to high cost hospitals), that doesn’t invalidate the methodology used by DA. Data show that healthcare systems use what we build and the incentives in the systems are used to maximize reimbursements to providers.

The payment policy conundrum is that currently there is little available to Medicare as a payer to adjust its incentives other than “squeezing” payments when inexplicable claims clustering occurs. Payers are looking for easy mechanisms, and historical evidence shows that claims clustering is a solid fraud and abuse investigative tool.

Dartmouth has never claimed that examining costs alone is the only way to look at cost effective care, but when outcomes are not part of value equation in determining payment, why should analysis look any further? Just because DA doesn’t take into account every cost factor that might affect outcomes doesn’t mean those they do somehow render their findings meaningless.

The problem is real. DA’s methodology is not at fault, nor is it responsible for the payer’s inability to formulate sound policy. It is just one more reason why we need Congress to get out of the business of deciding what Medicare should and shouldn’t pay for.

Hospitals that provide effective care and treatment should be rewarded and we should reform indiscriminate payment systems that incentivize the wrong things.

Link: Report Cited by Obama on Hospitals Is Criticized, New York Times, February 17

Justifying Futile CPR

Rosemary Flanigan

February 18, 2010

In the Feb. 11th New England Journal of Medicine Robert Truog, MD (who seems to write as often as Atul Gawande) justifies performing futile CPR for the benefit of family members.

Not often, of course, and never when it would cause substantial suffering or the withdrawal of resources from others would be a credible threat—but sometimes—and in instances where no “practice guidelines” might ever catch—as an act of sincere caring and compassion.

I think most professionals of all sorts can look back on their lives and “justify” futile actions that they would repeat, given the same circumstances. It makes finger pointing and eyes-to-heaven looks rather silly.

But then to Dr. Truog I’d say: “But not too often, I hope.”

Good reflection. Life just isn’t so simple!

Catholics and Infertility Treatments

A St. Louis Post Dispatch article on February 16 outlines guidance on using reproductive technology approved by US bishops.

The Center's Francis Chair, Glenn McGee, is quoted extensively in this story.

"American Catholics are no more going to listen to this than they listen to the church about birth control," said Glenn McGee, a scholar at the Center for Practical Bioethics in Kansas City.

McGee said Pope Benedict XVI had begun "to play hardball" with American Catholics who flout church teaching on assisted reproductive technologies by issuing a 2008 document called Dignitas Personae, or the Dignity of the Person.

The document reaffirmed church teaching that human dignity should begin at the moment of conception, and that the only morally acceptable method of procreation is "an act which expresses the reciprocal love" between a wife and husband.

What do you think?

Rosemary lambasted? Not quite.

Rosemary Flanigan, PhD

February 16, 2010

I am grateful to you all for NOT lambasting me over my analysis of the right thing to do in the Hastings Center Report case.

Even the ER doc on our Carondelet Health ethics committee urged me to bring the young woman into the discussion and not act simply because she said, “No” to re-doing the pregnancy test. And I like having a nurse around—good point.

On reflection, I thought it ironic that I, who have moaned over the loss of the sharp edge to informed consent requests would so easily slide right over it because the 14 year old refused—and I would get the information ANYWAY.

But what if I had acted so AND the test came out positive? How could I re-establish trust with my patient?

I shall tell you a presupposition that led to my heavy-handedness: I’ve taught 14 year olds. They are VERY young. But guidance need not be accompanied by a heavy tread.

THANKS.

Gay Men and Donating Blood

Art Caplan, PhD

Director/Center for Bioethics

University of Pennsylvania

February 12, 2010

8 minutes 48 seconds

The current FDA policy excluding gay men from giving blood is absurd and flies in the face of both need and science. That’s according to Dr. Art Caplan in the February 2010 issue of the American Journal of Bioethics.

Dr. Caplan argues this policy on gays excludes millions from giving blood during growing blood shortages. He explains in this edition of The Bioethics Channel with Lorell LaBoube.

Link: Podcast, Gay Men & Donating Blood

Testing for Pregnancy without Consent

Rosemary Flanigan
February 12, 2010

The recent issue of the Hastings Center Report has a case study, the content of which surprised me. And then I knew that, if I offered it to you,, I would learn a lot. So here it is:

Samantha is a pale and withdrawn fourteen-year-old brought to the ER by her mother. She is fatigued, nauseated, and has been vomiting. Her mother tells the physician on call that she’s very worried; Samantha lately refuses to eat, has lost weight, has stopped going to soccer practice, and has missed several days of school.

The doctor examines Samantha and then asks if she may speak to her alone. Samantha and her mother agree; her mother leaves the room.

In response to the doctor’s questions, Samantha says that she first menstruated at age eleven, that her periods have been regular, and that she last had one four weeks ago. When the doctor asks whether she is sexually active, she admits that she had her first sexual contact right before her last period. She says it was consensual and that her partner used a condom.

She says she knows she’s not pregnant—she took a home pregnancy test the day before, and the results were negative.

The doctor asks if she can test Samantha again, and Samantha starts to cry. “I already told you, the test said I’m not,” she says. "I’m not pregnant!”

The question for us, of course, is whether or not the physician, who strongly suspects pregnancy, can test again as part of her workup.

And I shall argue (remember, it’s been a long time since I was 14) that if the physician fears the young woman will walk out of the ER without any tests, then the physician should talk fast about the need for blood tests to check for diabetes and a urine test to check for an infection.

Of course, the tests will also make clear whether or not she is pregnant (won’t they?) But I would risk not getting explicit informed consent if I could get consent for the other tests. It’s not ideal, but I can justify it.

Am I going to be lambasted??????? HELP!!!

Annual Dinner Set for April 13

The Center for Practical Bioethics has scheduled its Annual Dinner for April 13 at the Marriott Muehlebach Hotel in downtown Kansas City, MO. The event is the Center’s primary fundraising event of the year.

This year’s Annual Dinner keynote speaker is Eleanor Clift of Newsweek magazine and The McLaughlin Group on PBS.

Anne and Robert St. Peter, MD are honorary co-chairs of the event. The evening begins with a reception at 5:30 pm, followed by dinner and program at 7 pm.

The 4th Annual Ethics Symposium is scheduled for the next day, April 14, at the Kansas City Public Library. The symposium will run from 7:30 am to noon.

For sponsorship and reservation information, please contact Donna Blackwood at 816-979-1352, or email dblackwood@PracticalBioethics.org.

Links:

Event overview

2010 Leadership Sponsors

Can’t attend? Click here and support the Center’s mission with your online contribution; direct your donation to “Celebratory.”

Good Facts = Good Ethics. Right?

Rosemary Flanigan

February 10, 2010

When all our ethical analysis models stress, “Be sure of the facts,” we all know how twisted the meaning of “fact” can get.

Think of the distortions made by presuppositions, beliefs, years of bias. What if a beloved daughter brings home a grubby, tattooed, slouchy fellow and announces they’re engaged? Who IS this new son-in-law-to-be?

At the end of a patient’s life, the very meaning of “life” can be different for patient and family than it is for clinicians—one sees living; the other may see dying. And it helps to try to suspend all interpretations of the two words in order to try to agree on what “living” and what “dying” really mean in themselves.

An Update on Pain Policy

Myra Christopher

President/CEO

Center for Practical Bioethics

February 5, 2010

14 minutes 47 seconds

As we age in America, more of us than ever before will suffer from chronic pain.
Whether we receive appropriate for that pain may be an open question, as many patients today continue to suffer from chronic pain even as therapies are available for treatment.

Lorell LaBoube talks about the status on achieving a balanced pain policy with Myra Christopher, president and CEO of the Center for Practical Bioethics, in this edition of The Bioethics Channel.

Link: Podcast, An Update on Pain Policy, Myra Christopher, The Bioethics Channel, February 5, 2010

Rethinking Vegetative States

Glenn McGee, PhD

John B. Francis Chair in Bioethics

Center for Practical Bioethics

February 4, 2010
12 minutes 44 seconds

Do we need to rethink what a vegetative state means? That question is prompted by an article in the New England Journal of Medicine regarding brain activity in patients in a persistent vegetative state.

Glenn McGee and Lorell LaBoube talk about it in this edition of The Bioethics Channel.

Links:

Podcast: Rethinking Vegetative States, Glenn McGee, PhD, The Bioethics Channel, February 5, 2010

Practical Bioethics blog:

Interesting. But what does it mean for ethics? Terry Rosell, February 4, 2010
In response to Terry Rosell, February 4, 2010

Bioethics.net

The Plural of Anecdote is not Ambien, October 6, 2006
Can Ambien Wake Up PVS Patients?, May 2006

In response to Terry Rosell

John Carney
Vice President/Aging and End of Life
Center for Practical Bioethics
February 4, 2010

I appreciate to my colleague Terry Rosell’s introspective narrative on the ethical impact of Monti’s (et.al) study on brain activity in disorders of consciousness. My take, however, is far more tentative and less personal.

The implication for ethics, I agree reinforces the critical importance of appointing an agent and making your wishes known to that person. On the other hand, the implications for state policy could only heighten anxiety and advocacy from life protection and disability rights groups - emphasizing the state’s interest in protecting patients who cannot speak for themselves.

That’s not a bad thing. We don’t know nearly as much about how the brain functions as we do other organs of the body. As we move away from the “heart” embodying the notion of personhood to that of the “brain”, it only makes this issue all the more confounding.

What I like about Terry’s argument is that he sets his judgment about the nature of his physical condition and ability to “be human” within the context of time and place, recognizing that the state of the science of medicine and its ability to explain and treat his condition are part of the meaning he gives his life. Our ability to understand and treat conditions is a function of our place in history.

His physical well being and his appreciation of what it means to be fully human is subject to that experience as well.

If medicine cannot help improve his condition but only prolongs his temporal, indefinite and mechanical path to death then what purpose does medicine serve? Does ongoing treatment offer benefit if its imposition only subjects him to further health risks? Is that help or harm?

If the latter, we all know that above all else we should do no harm.

On the other hand it is possible that someone could believe she could reconcile being “locked in” to an indefinite transcendent experience or as a redemptive act of longsuffering.

We certainly would not then judge her life as unworthy. I wouldn’t, especially if she spent her time praying for me.

Interesting. But what does it mean for ethics?

Terry Rosell, DMin, PhD
February 4, 2010

Monti, et al. have published in the New England Journal of Medicine an interesting study that should have very little effect on what constitutes ethical response to brain injured patients in a minimally conscious or vegetative state. We need to be clear both about what the research indicates and what it means.

This study is premised on the fact that diagnoses of disorders of consciousness are accurate only about 60% of the time, and that MRI technology might improve accuracy by imaging even faint brain activity in patients for which none might be expected otherwise. Of the 54 patients in this study, all diagnosed as either minimally conscious or vegetative, 5 gave evidence under MRI of some awareness. One patient could even respond “yes” or “no.”

This is interesting. But what does it mean for ethics?

To me, it means that I am wise to be explicit in oral and written healthcare directives regarding my strong disvaluing of potentially being maintained for months or years in anything like a minimally conscious or vegetative state, with or without awareness. Especially if that state of being were to involve awareness like that of a “locked in” state, I can imagine no worse hell. Could one cope? Yes. Do I want the opportunity to try? Not on your life.

Hence my worry is not that someone will pull the plug on me while I still retain awareness, but that some well meaning vitalist with a mandate from God might overrule my directives and subject me to a torturous existence for years on end.

In the process, my moral community would have spent enormous medical and monetary resources on my “care,” ironically violating yet another value I hold in regard to personal frugality and distributive justice. Life is indeed sacred, or nearly so; but my life is no more sacrosanct than the precious lives of, say, Haitian children who die for lack of access to basic healthcare resources on account of disparate distribution.

Let it be known to any who care that extending my own life under conditions like those of the patients in the NEJM study is not worth it to me. Don’t do it.

There could be someone whose valuations on this matter are quite the opposite of mine, and who wishes personal physiological extension of life no matter how cruel and costly an existence. If so, the use of MRI and better diagnosis may support that patient’s right to decide.

None of this is apt to garner many recoveries of cognitive ability, however. May it then not raise false hopes in that regard, or impact negatively reasonable decision making in the vast majority of cases where meaningful recovery is unlikely and allowing natural death may be the best of bad choices.

Brain Activity and Vegetative States

The New England Journal of Medicine’s publication of Willful Modulation of Brain Activity in Disorders of Consciousness has already started a stream of headlines of how this relates to the Terri Schiavo case and how, maybe, possibly we should rethink the meaning of vegetative states.

Our coverage of this debate begins with Dr. Christian Sinclair, who opined back in August about a Journal of Medical Ethics discussion on the implications of functional MRI imaging on the withdrawal of life prolonging treatments for vegetative patients.

Later today, the Center will record a Bioethics Channel podcast on this subject with Glenn McGee, PhD, the John B. Francis Chair in Bioethics.

Stay tuned.

L2

The PVS, fMRI, Radiolab, & 'Murder', Pallimed, August 5, 2009

Bioethics Center recognized for patient advocacy

Award presented during annual meeting of American Academy of Pain Medicine

The American Academy of Pain Medicine has awarded the Center for Practical Bioethics their Patient Advocacy Award for an outstanding contribution to the field of pain medicine.

AAPM President Rollin Gallagher will present the award to Myra Christopher, Center president and CEO, during opening activities of the annual meeting on February 4.

According to the Academy, “the Patient Advocacy Award recognizes activity of an individual in advocating for appropriate evaluation and treatment of patients suffering from pain. This award was created to honor those healthcare professionals whose deeds reflect their recognition of the importance and impact of the specialty of Pain Medicine.”

Links:

Center Balanced Pain Policy Initiative
Video, Seeking a Balanced Pain Policy, 7 minutes 38 seconds

How we THINK about end of life decisions

Rosemary Flanigan

February 2, 2010

Thanks to you good doctors, nurses, and men of God for getting into the discussion about how we THINK when it comes to end-of-life decisions.

Mike the pastor said it well: “. . .belief and emotion trump Consumer Reports almost every time.” And that must make it so difficult for clinicians at the bedside.

In a NY Times article, the author asks her father if he wants to be intubated; he nods his head, and then “One nurse grunts and rolls her eyes dramatically. The other mutters, “Oh, brother—here we go again.”

That must be a microcosm of dailyness in the ICU: families’ responding from belief and/or emotion and clinicians from a totally different knowledge base.

So do I still want knowledgeable nurses empowered and flooding the end-of-life scene? YES!

I may be condemning them to hours of frustration, but they are well equipped to make the breakthroughs that I also hear happening every day. And chaplains as well, the only people in hospitals today (at least in my judgment) who have time.

A Dying Man and Sophie's Choices

John Carney
February 2, 2010

I want to express my sympathies to Alicia on the death of her father. I’d also like to extend my apologies to her and posthumously to him – for making them responsible for decisions that should have never been theirs to make.

Dying is hard enough work for patients and families without our making it harder by throwing every mechanical obstruction we can in its path. That is not the art of medicine, it is technological abandonment. He died tethered to machines, she supposes, because he chose to.

Is that really true? We in health care conspired to allow his dying a death unimaginable a few decades ago. It was not only a “mistake” as she suggests, but it was preventable, for it is not a dying man’s job to make Sophie’s choices.

We are not allowed to torture a beleaguered soul out of a false notion of patient self determination. When a medical intervention cannot serve the purpose it was designed for, cannot approximate an acceptable standard or achieve a goal of care we should not impose it.

We have no obligation to offer, recommend or even suggest care that patients cannot benefit from, and we should avoid putting patients on “mechanical paths to death.”

At some point, supporting this daughter and her father requires that we face the inevitability of his dying with them, compassionately, honestly and ethically. Yes, it would have been wrong of her to tell us that he didn’t want to be intubated when he did, but that decision should not have dictated all others.

It was her job to tell the truth when asked about her father’s treatment preference - especially given that particular intervention’s success previously. But it is our job to ensure that we honor preferences in meaningful and reasonable ways.

We are obliged to offer patient centered care, not patient directed care. Prolonging his dying six months served whom? Autonomy run amok is as disrespectful of the patient as is paternalism.

Yes, Alicia, your role was to support your father, and our role was to support you. You may have upheld your part of the bargain, but unfortunately we let you both down by allowing our “support” to create unforeseen burdens while misusing valuable resources in the name of acceptable.

Link: An Ill Father, a Life-or-Death Decision, Alicia von Stamwitz, New York Times
January 25, 2010

Terri Schiavo Lives On

John Carney

January 29, 2010

12 minutes 43 seconds

Terri Schiavo’s name doesn’t appear in the headlines much these days. But her story continues to ripple through state legislatures across the country, as they try to wrestle with end of life issues.

In this edition of the Bioethics Channel, host Lorell LaBoube visits with John Carney, vice president for aging and end of life at the Center for Practical Bioethics, about legislative efforts to address issues raised by the story of Terri Schiavo.

Link: Terri Schiavo Lives On, The Bioethics Channel