Posts Tagged ethics

More on When Labelling Patients Causes Patients to Die

In the comments WhiteCoat (of WhiteCoat’s Call Room fame) strenuously objects to my take on the Anna Brown case:

Wow.

Someone on my blog suggested that I check out this post after I just posted about this story yesterday.

To all of you who think “something more should have been done,” what should that “something” have been? She had multiple tests and exams performed for the same complaint – including sonograms which showed no blood clots the day before she died. She was having the same pain in her legs since she was hospitalized the week before. Gold standard test for DVTs is ultrasound. Do we repeat the ultrasound every day? Every hour? What other testing was “necessary”?

TorontoEmerg – think of all the patients you see with back pain requesting narcotic pain medications. Do you order serial MRIs on them to rule out the possibility of cauda equina? Or tumor? If so, what is the medical basis for the testing? If not, why? I’m assuming you don’t. When you miss the one patient who has a tumor and becomes paralyzed, you’ll be harangued because “obviously” the patient had something wrong and you neglected to address it. Yet once you tell the patients that they won’t be receiving any narcotic pain medications, many of the patients in severe pain stand up, curse at you, and storm out of the emergency department.

You say that Ms. Brown was “unable to walk.” The article showed that a nurse saw her standing the same day that she couldn’t walk. How many patients do you see who come to the emergency department and can’t get out of their car when they arrive? That’s a “red flag” that something is wrong. Do you order a million dollar workup on all of them? How many patients do you see who have had dozens of normal CT scans for their chronic abdominal pain? Is that proper medical care? I could go on and on, but you get the point.

The problem is that your post suffers from horrible hindsight bias. You knew the outcome and now you’re bashing the people who treated Ms. Brown because they didn’t have the ability to look into the future to see what would happen.

Yes, the outcome was horrible. Yes, there were miscues and miscommunication. I’m sure that Ms. Brown was “labeled” as someone trying to game the system. Society “labels” every aspect of our lives every day. President Obama is “liberal.” Ron Paul is “crazy.” Pit bulls are “dangerous.” Doctors are “rich.” Baby pandas are “cute.” Doing so doesn’t make us bad, it makes us human. Someone who was articulate and polite to the providers and to the police may have been treated differently. One of my readers said this was the “perfect storm” of events leading up to Ms. Brown’s death.

To say that Ms. Brown didn’t receive proper care or that her complaints were ignored is just wrong. I’m betting if you ordered all the testing you think Ms. Brown should have received on all of the patients who walked through the doors at your emergency department, *you’d* be the one being ridiculed.

I appreciate WhiteCoat taking the time to post such a lengthy reply. He fully explicates many of his points on his blog. I won’t editorialize much here, because I think his perspective is important to how we discuss cases like Anna Brown. I don’t share his point of view for a number of reasons, but I do agree with him that labelling people makes us human. The trouble starts, for me at least,  when we allow our interior — and often unrealized — biases to influence our care.

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A Nasty, Medically Unnecessary, Coercive Procedure

This is just grostesque:

A Republican supermajority has muscled two of the most restrictive anti-abortion bills in years through the Virginia House, despite bitter yet futile objections from Democrats, with one GOP delegate deriding most of the procedures as “matters of lifestyle convenience.”

You want to put what where?

[SNIP]

And the ultrasound legislation would constitute an unprecedented government mandate to insert vaginal ultrasonic probes into women as part of a state-ordered effort to dissuade them from terminating pregnancies, legislative opponents noted.

“We’re talking about inside a woman’s body,” Del. Charnielle Herring said in an emotional floor speech. “This is the first time, if we pass this bill, that we will be dictating a medical procedure to a physician.”

The conservative Family Foundation hailed the ultrasound measure as an “update” to the state’s existing informed consent laws “with the most advanced medical technology available.”

The Oklahoma legislature passed a similar law a couple of years ago. Full disclosure, in case you didn’t know it: I dislike abortion, but I’m strongly pro-choice. Even if you are strongly against abortion on moral or religious grounds, I would like to know how a medically unnecessary, coercive, invasive procedure can be ethically justified in order for a patient to receive health care? (I think we can safely dismiss the Family Foundation’s reasoning as spin.) And if the patient is a 13-year-old rape victim, how is this not despicable and evil?

Another question I would like to ask: if you’re a health care professional, would you excuse yourself from participating or facilitating in enforcing this law?

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At Veterans Affairs, Confidentiality is Meaningless

This story has been bouncing around the last day or so, but the more I think about it, the more disturbing I find it:

Confidential medical and financial information belonging to an outspoken critic of Veterans Affairs, including part of a psychiatrist’s report, found its way into the briefing notes of a cabinet minister.

Highly personal information about Sean Bruyea was contained in a 13-page briefing note prepared by bureaucrats in 2006 for then minister Greg Thompson, a copy of which was obtained by The Canadian Press.

The note, with two annexes of detailed information, laid out in detail Bruyea’s medical and psychological condition.

[snip]

The privacy documents show 614 people within Veterans Affairs accessed Bruyea’s computer file between 2001 and 2010, records that are kept in a password-protected computer database. Of those, 156 exchanged varying amounts of personal information, according to a trail of internal emails.

The material appears to have been shared with an additional 243 individuals, including both Liberal and Conservative political staffers, through briefing notes and emails during the 2006 transition between governments. [Toronto Star]

In health care, there is a term of art  — “circle of care” — which describes the health care professionals directly involved with a patient’s treatment, and by implication, those who have direct access to confidential information related to her or his care. For example, if you are hospitalized, your circle of care would include your primary nurse, your physician, and maybe some others — the physiotherapist, perhaps, or the social worker. Generally speaking, you can’t access the health records of any person outside the circle of care without explicit written consent of the patient. Papers need to be signed and so on.

I understand Veterans Affairs might need to request access to confidential medical records to assess benefits and treatment. What I’m having difficulty with is imagining circumstances where a cabinet minister, hundreds of bureaucrats, three senior civil servants, and staffers and various other flaks should have access to confidential medical information without permission. How is the Minister of Veterans Affairs part of the circle of care? Or, for that matter, a staffer in the PMO?

It’s disgraceful enough that the health care information of any Canadian, let alone a veteran, was used for political purposes. But the real scandal is the safeguarding within Veterans Affairs to protect confidential medical records of veterans. Apparently, there isn’t any.

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Physicians and Torture

Torture is a health care issue. Especially when physicians are complicit, as they evidently were during the Bush administration, in the CIA’s Office of Medical Services, where they facilitated torture of prisoners: [via The Daily Dish: the original JAMA article is behind a paywall.]

An important new study came out today. It’s from the Journal of the American Medical Association about the deep and unethical involvement of CIA doctors and psychiatrists in pioneering torture techniques for the Bush-Cheney administration. . .

The CIA Office of Medical Services

  • purported to subject some techniques to “medical limitations,” but those claimed limitations imposed no constraint on use of torture, e.g., allowing weight loss up to serious malnutrition, noise up to level of permanent hearing damage, exposure to cold water right up to development of hypothermia, shackling in upright sitting or horizontal position for 48 hours (and longer with medical monitoring);
  • placed no medical limitations at all on the use of isolation, hooding, walling, cramped confinement or stress positions except in some cases avoidance of aggravation of pre-existing injury;
  • ignored medical and other literature on effects of these forms of torture, and instead cited sources like NIH web site, wilderness manuals and WHO guidelines.
  • recognized dangers of certain enhanced methods but nevertheless approved them, e.g., that waterboarding risks drowning, aspiration pneumonia, and laryngospasm; sleep deprivation can degrade cognitive performance, lead to visual disturbances and reduce immune competence acutely; prolonged standing can induce dependent edeme, increased risk for DVT, cellulitis.

I spent a considerable amount of time yesterday trying to imagine circumstances where health care professionals in a supposedly free society could justify their participation in torture of their patients. Because there is no way around this bald fact: those being tortured were patients of these physicians. They assumed care; they took up responsibility for their treatment and well-being.

I came up empty. I suppose one could make the argument that physician participation mitigates the worst effects of torture, as if having waterboarding (for example) supervised by medical personnel somehow minimizes poor outcomes and creates and justifies acceptable practice. In short, it’s all routinization and normalization: torture as a medically prescribed treatment. But do we really want torture to be medically “administered” to ensure acceptable outcomes?

There are certain ethical touchstones all health care professionals must abide by: beneficence, non-maleficence, autonomy and justice. We must work for the patient’s good. We must not do harm. We must respect the patient’s choices in accepting or rejecting treatment. We must ensure patients are treated equally without regard to externalities. It’s hard to see which of these principles isn’t grossly violated.

“Conduct disgraceful and dishonourable to the profession” is the traditional formulation when health care professionals are found guilty of misconduct. I guess it would apply here.

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Even in Disaster, Breast is Best

Another consideration on the disaster in Haiti. The International Lactation Consultant Association points out the worst thing you can do is send infant formula:

Interventions to protect infants include supporting mothers to initiate and continue exclusive breastfeeding, relactation for mothers who have ceased breastfeeding, and finding wet nurses for motherless or separated babies. Every effort should be made to minimize the number of infants and young children who do not have access to breastfeeding. Artificially fed infants require intensive support from aid organizations including infant formula, clean water, soap, a stove, fuel, education, and medical support. This is not an easy endeavor. Formula feeding is extremely risky in emergency conditions and artificially fed infants are vulnerable to the biggest killers of children in emergencies: diarrhea and pneumonia.

As stated by UNICEF and WHO, no donations of infant formula or powdered milk should be sent to the Haiti emergency. Such donations are difficult to manage logistically, actively detract from the aid effort, and put infant’s lives at risk. Distribution of infant formula should only occur in a strictly controlled manner. Stress does not prevent women from making milk for their babies, and breastfeeding women should not be given any infant formula or powdered milk.

The trouble is, the intuitive response would be to send formula. It would help some poor infant, somewhere. Better than doing nothing, right? Unfortunately, in cases of disaster, a strictly utilitarian response is necessary, in order to save us, and more importantly, to save the people we are purporting to help, from our best impulses to do good.

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