Bioethics/bioethical Issues brought up in interviews

[Snakes]

I've read a number of different threads about bioethical and medical ethics issues being brought up in MS interviews and it seems like it's an area in which a lot of pre-meds have significant questions. I was thinking perhaps people could share specific bioethical questions that have been brought up in their individual interviews or MMIs and we could discuss ways to approach them. If you want to give the name of the specific school at which you interviewed, that might also be helpful for future interviewees (but certainly not a requirement). Alternatively, if there's a specific issue you think might be interesting to discuss, post it here. I'm certain a number of these ethical issues must be repetitive in how they are asked and approached by MS adcoms. For instance, was the ACA a common theme? Or were you given a specific medical scenario and asked "what would you do given X and Y circumstances"?

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[Bilboraggins]

Someone posted this in another thread but I can't remember which one. It should serve as a good overview of some topics. http://depts.washington.edu/bioethx/topics/index.html

 

[LizzyM]

What I'd like to ask: you are an attending physician and you can choose to have hands on care of a patient in your US hospital with Ebola or defer to your subordinates and the nursing staff to provide the hands on care while you supervise from a distance. (Appropriate safety gear is provided, you have been trained to use it, and its use is mandatory.) Which would you choose and why?

 

[The Milkman]

What I'd like to ask: you are an attending physician and you can choose to have hands on care of a patient in your US hospital with Ebola or defer to your subordinates and the nursing staff to provide the hands on care while you supervise from a distance. (Appropriate safety gear is provided, you have been trained to use it, and its use is mandatory.) Which would you choose and why?

I wish you would interview me, this would be an interesting conversation with today's current events!

 

[Snakes]

What I'd like to ask: you are an attending physician and you can choose to have hands on care of a patient in your US hospital with Ebola or defer to your subordinates and the nursing staff to provide the hands on care while you supervise from a distance. (Appropriate safety gear is provided, you have been trained to use it, and its use is mandatory.) Which would you choose and why?

How much can you "defer" care to your subordinates and nursing staff? How isolated is an attending physician from ordinary hands-on care for a typical (non-ebola infected) patient? It seems to me like there still has to be a rapport/relationship between attending and patient, and that requires some sort of contact that can't be negotiated away. (And which of your subordinates/nursing staff will respect you after you decide you aren't putting yourself at any risk whatsoever?) It seems to me that implicit in the job is patient contact.

Interestingly enough, when I have been hospitalized in the past, my contact with attendings has been minimal anyway. They mainly come in, consult, speak with me for a few minutes, and then leave. None of them were hanging my IV's or coming into contact with my body fluids.

I don't see any possible way it can be negotiated away in certain specialties, like surgery or in the ED, even if you don't care about the integrity of the doctor/patient relationship. Who will work with you if you aren't willing to take the same risks that everyone else takes? And in other specialties, I'm not sure why there would be a reason to do so, because the type of patient contact that spreads ebola, they're not doing anyway.

 

[Goro]

Check out the Interview Feedback section of these forums.

A classic one is "A patient with terminal cancer asks you for a lethal drug combination so they can commit suicide." This activity is legal in your state. What do you do, and why?"

Another common one is a "A 14-15 year old girl comes to see you about having an abortion. What do you do and why?"

 

[m.a.r.r.]

What I'd like to ask: you are an attending physician and you can choose to have hands on care of a patient in your US hospital with Ebola or defer to your subordinates and the nursing staff to provide the hands on care while you supervise from a distance. (Appropriate safety gear is provided, you have been trained to use it, and its use is mandatory.) Which would you choose and why?

I assume that there are certain tasks that nurses are trained to do that doctors aren't (starting IVs?) and there are certain things that doctors have to do that nurses aren't trained to do (physical examinations). I don't think the roles of the doctor and nurses should change at all, they should just all be wearing the appropriate protective gear.

 

[NotAnOperator]

Check out the Interview Feedback section of these forums.

A classic one is "A patient with terminal cancer asks you for a lethal drug combination so they can commit suicide." This activity is legal in your state. What do you do, and why?"

Another common one is a "A 14-15 year old girl comes to see you about having an abortion. What do you do and why?"

Those are great questions. I'm still premed for another couple years but I'm intrigued.
With the first question, short answer is I would not give or administer a lethal drug combo simply because when I am a physician, my goal(s) is to preserve and better human life. While it is definitely an individual opinion whether death is better than life (or ones' own timing rather than the disease's), my goal as a medical doctor stays the same: to PRESERVE first and foremost, and to BETTER the quality of that preserved life. Preventing death is the absolute reason I'm pursuing medicine therefore it would go against everything I believe to kill someone or give them the means to kill themselves. They can find another doctor if they really want to go that way but it will not be me.

As for the abortion question, I would never do an abortion either. It's my personal belief (not religious) that human life begins at conception. Killing a fetus results in preventing a person from entering this world which is the same as killing a person in my eyes. Like I said in the previous answer, my goal is the preservation and betterment of life, not ending or preventing it. Whether death is better or worse than the child's quality of life is not my decision. Once we get into that mindset, we will have a meter on quality of life and if that quality is not at a certain place, a life becomes warranting of death (handicap, mentally handicap, chronic diseases, poor, etc).
I also have personal reasons regarding the abortion argument: my father fought to have me aborted and my mother was very close to doing it. It makes me sad that I was almost not given a chance to show my worth to the world. It also makes me driven knowing I luckily get to show my worth. I feel the person that fetus could one day be will feel the same. Agreeing that abortion is NOT ending human life is agreeing that my own life does not matter. One day my wife and I hope to have children and I will love them from that first positive hcg to the day I die. Different stages in life do not translate into the value of life. A butterfly may be more beautiful and more important to some but the egg and the caterpillar and the chrysalis are what makes the butterfly everything it is, will be, and can be.

Just my 98 cents on these two hot topics. I respect all opinions, disagreeing or agreeing, and am not looking for a heated debate.

 

[Porkloins]

Those are great questions. I'm still premed for another couple years but I'm intrigued.
With the first question, short answer is I would not give or administer a lethal drug combo simply because when I am a physician, my goal(s) is to preserve and better human life. While it is definitely an individual opinion whether death is better than life (or ones' own timing rather than the disease's), my goal as a medical doctor stays the same: to PRESERVE first and foremost, and to BETTER the quality of that preserved life. Preventing death is the absolute reason I'm pursuing medicine therefore it would go against everything I believe to kill someone or give them the means to kill themselves. They can find another doctor if they really want to go that way but it will not be me.

As for the abortion question, I would never do an abortion either. It's my personal belief (not religious) that human life begins at conception. Killing a fetus results in preventing a person from entering this world which is the same as killing a person in my eyes. Like I said in the previous answer, my goal is the preservation and betterment of life, not ending or preventing it. Whether death is better or worse than the child's quality of life is not my decision. Once we get into that mindset, we will have a meter on quality of life and if that quality is not at a certain place, a life becomes warranting of death (handicap, mentally handicap, chronic diseases, poor, etc).
I also have personal reasons regarding the abortion argument: my father fought to have me aborted and my mother was very close to doing it. It makes me sad that I was almost not given a chance to show my worth to the world. It also makes me driven knowing I luckily get to show my worth. I feel the person that fetus could one day be will feel the same. Agreeing that abortion is NOT ending human life is agreeing that my own life does not matter. One day my wife and I hope to have children and I will love them from that first positive hcg to the day I die. Different stages in life do not translate into the value of life. A butterfly may be more beautiful and more important to some but the egg and the caterpillar and the chrysalis are what makes the butterfly everything it is, will be, and can be.

Just my 98 cents on these two hot topics. I respect all opinions, disagreeing or agreeing, and am not looking for a heated debate.

What about if the patient is 80 years old and in incredible pain, but is able to cogently express that he would rather die than go through expensive, invasive, or painful treatments (would his life really be 'bettered' by these)?

As for abortion nothing wrong with having your particular point of view on it, but I think you're neglecting part of the question (how does the girl being 14 yo change the situation?)

Not trying to start a heated debate - just interested in talking some of these out! (For later use huehue)

 

[CLE216]

Those are great questions. I'm still premed for another couple years but I'm intrigued.
With the first question, short answer is I would not give or administer a lethal drug combo simply because when I am a physician, my goal(s) is to preserve and better human life. While it is definitely an individual opinion whether death is better than life (or ones' own timing rather than the disease's), my goal as a medical doctor stays the same: to PRESERVE first and foremost, and to BETTER the quality of that preserved life. Preventing death is the absolute reason I'm pursuing medicine therefore it would go against everything I believe to kill someone or give them the means to kill themselves. They can find another doctor if they really want to go that way but it will not be me.

As for the abortion question, I would never do an abortion either. It's my personal belief (not religious) that human life begins at conception. Killing a fetus results in preventing a person from entering this world which is the same as killing a person in my eyes. Like I said in the previous answer, my goal is the preservation and betterment of life, not ending or preventing it. Whether death is better or worse than the child's quality of life is not my decision. Once we get into that mindset, we will have a meter on quality of life and if that quality is not at a certain place, a life becomes warranting of death (handicap, mentally handicap, chronic diseases, poor, etc).
I also have personal reasons regarding the abortion argument: my father fought to have me aborted and my mother was very close to doing it. It makes me sad that I was almost not given a chance to show my worth to the world. It also makes me driven knowing I luckily get to show my worth. I feel the person that fetus could one day be will feel the same. Agreeing that abortion is NOT ending human life is agreeing that my own life does not matter. One day my wife and I hope to have children and I will love them from that first positive hcg to the day I die. Different stages in life do not translate into the value of life. A butterfly may be more beautiful and more important to some but the egg and the caterpillar and the chrysalis are what makes the butterfly everything it is, will be, and can be.

Just my 98 cents on these two hot topics. I respect all opinions, disagreeing or agreeing, and am not looking for a heated debate.

For the physician assisted death question, one could argue that preserving life in the case of a terminally ill patient is actually doing more harm than good. I think as a physician your role is to find what's best for each individual patient. If patients have reached the logical conclusion (they are in a good state of mind) that ending their life is what is right for them and their family, I think they should have the right to do it. I read a figure recently that something like 40 years ago, most people died in their homes, but now a lot of people die in the hospital. Death is a normal process of life. I think physicians need to move away from the whole "prevent death in 100% of cases" to more of mindset that realizes death may be a good option for some patients. How would you like your last days to be? Anyway, if you look into numbers in Oregon where it is legal, only about 1/500 people actually utilize Physician assisted death. We actually need to do a better job at end of life care because physician assisted death is not that commonly utilized. Finding out what is most important to each individual patient and forming a plan with them is the best way to go about death. Some patients will want to be kept alive at all costs and want doctors to do everything possible. Others will prefer to die at home surrounded by family.

About abortion, you say "Whether death is better or worse than the child's quality of life is not my decision". To me, it seems like you are valuing your opinions more than your patients. Don't you think women know best what is right for them and their situation? Do you really think forcing a woman to bring a baby into this world that has a mother who may not be in a good place to raise it is a good idea? What about birth defects? Again, forcing someone to bring a baby into the world that may have a terrible quality of life is actually doing more harm in my opinion.

 

[Porkloins]

For the physician assisted death question, one could argue that preserving life in the case of a terminally ill patient is actually doing more harm than good. I think as a physician your role is to find what's best for each individual patient. If patients have reached the logical conclusion (they are in a good state of mind) that ending their life is what is right for them and their family, I think they should have the right to do it. I read a figure recently that something like 40 years ago, most people died in their homes, but now a lot of people die in the hospital. Death is a normal process of life. I think physicians need to move away from the whole "prevent death in 100% of cases" to more of mindset that realizes death may be a good option for some patients. How would you like your last days to be? Anyway, if you look into numbers in Oregon where it is legal, only about 1/500 people actually utilize Physician assisted death. We actually need to do a better job at end of life care because physician assisted death is not that commonly utilized. Finding out what is most important to each individual patient and forming a plan with them is the best way to go about death. Some patients will want to be kept alive at all costs and want doctors to do everything possible. Others will prefer to die at home surrounded by family.

About abortion, you say "Whether death is better or worse than the child's quality of life is not my decision". To me, it seems like you are valuing your opinions more than your patients. Don't you think women know best what is right for them and their situation? Do you really think forcing a woman to bring a baby into this world that has a mother who may not be in a good place to raise it is a good idea? What about birth defects? Again, forcing someone to bring a baby into the world that may have a terrible quality of life is actually doing more harm in my opinion.

I don't think it's productive at all to argue about that side of the abortion question... either people think life starts at conception and thus it's murder (in which case I think it would be completely reasonable to refer her to a different physician) or they don't think it's any worse than killing a few cells in the lab (I personally think it's somewhere in between). Do you go around killing kids on the street if you see they have birth defects? That's essentially what you're asking this guy to do.

 

[CLE216]

I don't think it's productive at all to argue about that side of the abortion question... either people think life starts at conception and thus it's murder (in which case I think it would be completely reasonable to refer her to a different physician) or they don't think it's any worse than killing a few cells in the lab (I personally think it's somewhere in between). Do you go around killing kids on the street if you see they have birth defects? That's essentially what you're asking this guy to do.

Yeah I see where you're coming from.

 

[Catalystik]

What I'd like to ask: you are an attending physician and you can choose to have hands on care of a patient in your US hospital with Ebola or defer to your subordinates and the nursing staff to provide the hands on care while you supervise from a distance. (Appropriate safety gear is provided, you have been trained to use it, and its use is mandatory.) Which would you choose and why?

And whatever your answer might be, it would be nice to see it backed up with some facts based on science rather than the fear-mongering information provided by mass media. Digging a little deeper and being conversant on the issue would be a good demonstration of scientific curiosity.

 

[touchpause13]

I'm in Ethics now and I just wanted to say in my class there is a pretty wide spread of beliefs in terms of these topics (another one is genetic testing - when do you test, what do you do with incidental findings, etc)

At least from my perspective I think as long as you can present thoughts in a well-reasoned and scientifically literate manner, it doesn't particularly matter what side of the fence you fall on. Don't just repeat buzzwords you have heard in the media, actually take the time to tease out your thoughts and be able to express them in a rational manner. For these I doubt that "no, because it's murder or yes because it's not murder" is going to cut it as a complete answer.

 

[PlaqueBuster]

My 2 cents on the questions above:
1. Physicians and nurses are trained differently and the care they provide is very different. As a physician I would do everything to help the ebola patient recover even if it means I would need to be in the room and doing lab work. However, if a more qualified individual can provide better/appropriate care then I would defer to that individual so that the patient is receiving the best care.
2. I think it is important to know the age of the terminal patient. Next, you should evaluate the mental state of the patient making this decision . Finally, it would be critical to address the patient and their family about this decision to make sure that everyone is comfortable with this decision. Death with dignity is important, and as a physician I believe it is your resposibility to honor the patient's decision if lethal injection is legal in your state and if the patient is making a rational decision.
3. Even though confidentiality should always be exercised, I would discuss the abortion with the girl's parents or guardians before making a decision because she is a minor. I also think that it is important to understand how far along the young girl is into her pregnancy and whether an abortion can be done. Finally, if there is no harm to the patient, I would be ok with the abortion.

 

[ridethecliche]

Re: Terminal patient.

If physician assisted suicide is what that patient wants, I would talk to the patient, their family, and social work/responsible legal channels to get it under way. Potentially see if the patient wanted some time to think it over and or to spend time with loved ones before making a decision.

Re: Abortion.

My patient is the girl. I'd do what's right for here. There are no long term side effects of an abortion, other than those imposed by society. Of course, STD testing, abuse, etc etc would also be discussed. She's still a minor which is why the parental thing is hard, but this is something that depends on which state you live in. Some don't require disclosure.

http://www.plannedparenthood.org/health-info/abortion/parental-consent-notification-laws

Re: Ebola.

Why isn't both a reasonable answer? You instill confidence in both your patient and staff if you're bold enough to actually do what you're trained to instead of shirking responsibility.

 

[touchpause13]

Just a Sidenote- it depends on the state but legally you don't have to disclose to a minors parents about an abortion.

 

[PreciousHamburgers]

Terminally ill: First do no harm. Forcing someone to live hopelessly with pain is harm. The patient has a right to die with dignity. Make sure they fully understand the situationa nd their prognosis, and that they have talked to their family about this.

Abortion: Life does not begin at conception. Life began once, about 3.5 billion years ago, and has been continuous since then. When people say "life begins at conception," they are arguing when a human becomes 'ensouled,' so to speak. That is a religious view. Ultimately, because of the girls age, she is not a consenting adult, and I would initially feel compelled to contact her parent(s)/guardian, after speaking with her and making sure this is not incestuous rape, or something like that. I would have to make sure I followed any state laws as well.

I would obviously elaborate more, but that is what it would boil down to.

 

[touchpause13]

Another thing to consider. Sorry I keep coming up with stuff here -
Don't assume that a family has the child's best interest in mind. Not everyone grows up in happy, healthy, non-abusive situations. That just goes with anything dealing with minors, elders, people with disabilities, etc. In med school you will learn how to screen for abuse, but it's just something to keep in mind now when considering such ethical decisions. A minor child could be pressured to have an abortion by parents because the fetus in question is the result of rape by the father. Or on the other end the parents could be extremely religious to the point that they would kick the girl out of the home if they found out she had an abortion. Just remember who your patient is.

 

[Snakes]

Abortion: Life does not begin at conception. Life began once, about 3.5 billion years ago, and has been continuous since then. When people say "life begins at conception," they are arguing when a human becomes 'ensouled,' so to speak. That is a religious view.

You are using the term "life"--which has multiple meanings--to mean only one thing, and it spoils your analogy. By your definition of life, no individual life matters (I'm not talking about a fetus here). Also, not all people think life begins at conception because they believe that is when the soul is created, nor is it always a religious view. You can believe that human life begins at conception, implantation, at the end of the first trimester, at the end of the 2nd trimester--whatever--and still believe that a woman's right to control her body supersedes the rights of the fetus.

Also, at some point in time, we are going to be able to grow a human fetus to term in a box or in a goat or in a monkey. What interesting questions will be raised then.

 

[PreciousHamburgers]

You are using the term "life"--which has multiple meanings--to mean only one thing, and it spoils your analogy. By your definition of life, no individual life matters (I'm not talking about a fetus here). Also, not all people think life begins at conception because they believe that is when the soul is created, nor is it always a religious view. You can believe that human life begins at conception, implantation, at the end of the first trimester, at the end of the 2nd trimester--whatever--and still believe that a woman's right to control her body supersedes the rights of the fetus.

Also, at some point in time, we are going to be able to grow a human fetus to term in a box or in a goat or in a monkey. What interesting questions will be raised then.

I didn't make an analogy. And I can still believe human life has value without believing in a soul.

 

[PreciousHamburgers]

Maybe if you don't give her an abortion she will try and do it herself and end up killing herself. People who grew up with safe and legal abortions seem to have little to no idea why Roe v. Wade was so important and necessary.

 

[Snakes]

And whatever your answer might be, it would be nice to see it backed up with some facts based on science rather than the fear-mongering information provided by mass media. Digging a little deeper and being conversant on the issue would be a good demonstration of scientific curiosity.

So "Run and hide" would probably be an inappropriate response...

You know, interestingly enough, all joking aside, it's been nurses who have been the ones who have contracted the virus here in the U.S., treating infected patients. All of the doctors who have been treated here contracted the virus outside of the U.S. In terms of fear of infection, it's the nurses who (from n=2) seem to have the most to fear--which is probably why they are protesting. http://news.yahoo.com/u-nurses-protest-strike-over-ebola-measures-110348906.html

 

[musicalfeet]

For the terminally ill question:

Perhaps actual attending physicians can better answer my thoughts. I recall reading a pamphlet while volunteering at the ICU that talked about end-of-life care. As physician-assisted suicide is NOT legal where I'm from, this pamphlet attempts to educate patients and their families about their options. A big one that appealed to me was comfort care. It talked about how the hospital can try to make the patient as comfortable as possible, and in the least amount of pain while they pass/live the remainder of their life. Now, I'm not sure what that entails or looks like, but from that pamphlet, it looked like a damn good alternative to physician-assisted suicide. My mom's always talked about how she wants to "die with dignity" via physician-assisted suicide if she ever became terminally ill, and I've been trying to sway her more towards the comfort care direction (if/when we ever get to that point..right now it's all hypothetical).

If comfort care is what I'm imagining it to be, I don't see why physician-assisted suicide is necessary. The patient can choose not to pursue aggressive care to prolong life, but rather care to minimize pain and suffering for the time that they do have left.

 

[blackroses]

For the terminally ill question:

Perhaps actual attending physicians can better answer my thoughts. I recall reading a pamphlet while volunteering at the ICU that talked about end-of-life care. As physician-assisted suicide is NOT legal where I'm from, this pamphlet attempts to educate patients and their families about their options. A big one that appealed to me was comfort care. It talked about how the hospital can try to make the patient as comfortable as possible, and in the least amount of pain while they pass/live the remainder of their life. Now, I'm not sure what that entails or looks like, but from that pamphlet, it looked like a damn good alternative to physician-assisted suicide. My mom's always talked about how she wants to "die with dignity" via physician-assisted suicide if she ever became terminally ill, and I've been trying to sway her more towards the comfort care direction (if/when we ever get to that point..right now it's all hypothetical).

If comfort care is what I'm imagining it to be, I don't see why physician-assisted suicide is necessary. The patient can choose not to pursue aggressive care to prolong life, but rather care to minimize pain and suffering for the time that they do have left.

To put this in the kindest way possible, I don't think comfort care is anything like you're imagining for most patients. For many, they will be in a great deal of pain, so the comfort care will include large doses of narcotics, leaving the patient extremely hazy and possibly feeling sick (a reasonably common side effect of narcotics). Additionally, narcotics are not always enough to control pain - some pain will persist at the same level despite high doses of narcotics. There are also many other factors to consider. The patient will likely be kept in a hospital or nursing home, not at their own home. They will likely have an IV and some monitoring equipment. They may very well be unable to move under their own free will, so will need someone to assist with personal hygiene and things like toileting.

For some patients, comfort care is an excellent option. Others, however, would prefer to be aware and strong enough to say goodbye to their loved ones and give them a hug before they die. They would prefer to die in their own home, without experiencing the indignity of needing someone to clean up soiled sheets, without being surrounded by tubes and wires, and before they have to experience uncontrollable pain. For those patients, physician-assisted suicide IS comfort care.

 

[musicalfeet]

To put this in the kindest way possible, I don't think comfort care is anything like you're imagining for most patients. For many, they will be in a great deal of pain, so the comfort care will include large doses of narcotics, leaving the patient extremely hazy and possibly feeling sick (a reasonably common side effect of narcotics). Additionally, narcotics are not always enough to control pain - some pain will persist at the same level despite high doses of narcotics. There are also many other factors to consider. The patient will likely be kept in a hospital or nursing home, not at their own home. They will likely have an IV and some monitoring equipment. They may very well be unable to move under their own free will, so will need someone to assist with personal hygiene and things like toileting.

For some patients, comfort care is an excellent option. Others, however, would prefer to be aware and strong enough to say goodbye to their loved ones and give them a hug before they die. They would prefer to die in their own home, without experiencing the indignity of needing someone to clean up soiled sheets, without being surrounded by tubes and wires, and before they have to experience uncontrollable pain. For those patients, physician-assisted suicide IS comfort care.

Ah..in that case, the patient's comfort and well-being should come first. I suppose they try to make it sound better than it is in the pamphlet to console the patients and their family (precisely because it's not legal where I live; so really they don't even have that option on the table).

 

[Mad Jack]

Cloning humans is always wrong, but if asked what you would do in a human cloning scenario, the appropriate answer is to kill and bury it then act as if nothing happened. It didn't have a soul anyway.

 

[Snakes]

If comfort care is what I'm imagining it to be, I don't see why physician-assisted suicide is necessary. The patient can choose not to pursue aggressive care to prolong life, but rather care to minimize pain and suffering for the time that they do have left.

Atul Gawande has just written a new book about how the U.S. medical system fails patients at the end of their lives, especially the elderly. It's called "Being Mortal" if you want to check it out.

To put this in the kindest way possible, I don't think comfort care is anything like you're imagining for most patients. For many, they will be in a great deal of pain, so the comfort care will include large doses of narcotics, leaving the patient extremely hazy and possibly feeling sick (a reasonably common side effect of narcotics). Additionally, narcotics are not always enough to control pain - some pain will persist at the same level despite high doses of narcotics. There are also many other factors to consider. The patient will likely be kept in a hospital or nursing home, not at their own home. They will likely have an IV and some monitoring equipment. They may very well be unable to move under their own free will, so will need someone to assist with personal hygiene and things like toileting.

These things are all true. I can think of a couple of situations also where a disease involves progressive neurological decline that I wouldn't want to be around to deal with and for which comfort care would really be moot. Alzheimer's Disease for one.

 

[Snakes]

I didn't make an analogy. And I can still believe human life has value without believing in a soul.

I agree with your second point.

 

[ridethecliche]

Yeah, some of you kids have never seen terminal cancer patients with Mets everywhere on such high doses of painkillers like dilaudid and morphine that they can barely figure out where who they're talking to and where they are.

It's not really comfortable in the least and some of them would rather reduce the painkillers, spend some time with their family, and then end the pain because it is ungodly painful to watch your entire family watch you decline while holding on to false hope.

The act and decision is the very opposite of cowardly.

 

[touchpause13]

Cloning humans is always wrong, but if asked what you would do in a human cloning scenario, the appropriate answer is to kill and bury it then act as if nothing happened. It didn't have a soul anyway.

Krieger is that you?

 

[Mad Jack]

Krieger is that you?

...no?

 

[NotAnOperator]

What about if the patient is 80 years old and in incredible pain, but is able to cogently express that he would rather die than go through expensive, invasive, or painful treatments (would his life really be 'bettered' by these)?

As for abortion nothing wrong with having your particular point of view on it, but I think you're neglecting part of the question (how does the girl being 14 yo change the situation?)

Not trying to start a heated debate - just interested in talking some of these out! (For later use huehue)

Terminally Ill patient: I agree that sometimes ending ones life would be more comfortable or happy for the patient than living. I've always said that if I was ever in a position where I could not live life the way I want than I rather seek death. However, I don't believe this is a physicians job. This is very different from physicians/life or death but try to hear the underlying point: someone loves trees and makes a profession from tree planting. They understand more about trees than most anyone else in the world. Massive amounts of special paper is required from special trees and no one is more qualified to obtain this massive amount of special wood than the tree planter. Should we expect the tree planter to incorporate the chopping of trees in his practice simply because he's an expert on trees? It is not his job, it is not why he chose his job, it is the sole purpose he began his job in the first place to grow trees, not cut them.
What I'm getting at is I'm not saying it's wrong that some people chose death over life or that death shouldn't be warranty if the patient chooses, I'm asking why should we force a physician to sleep at night knowing he/she killed someone, whether it was against their will or not. Taking a life can be an extremely traumatizing ordeal, even when the taking of that life is justified. This is why we often see our troops come home with PTSD, not because they consider themselves murderers or because they did something wrong. They know they had to kill to defend their life or the life of an innocent but the act of taking someone's life or giving someone the means to take it (calling in airstrikes) can haunt that person forever and ultimately destroy their life. Personally, I do not want to be haunted by that as a physician. If another physician can do it and help ease someone's suffering and feels it is the right thing to do, good on them, that's great. But as for me, I will not be using my future medical license to end a person's life. I see nothing wrong with physician assisted suicide, but I feel with such a tremendous act that arguably is not even the physician's job, the doctor should definitely have a say in it because this effects them as well as the patient and family.

And as for the abortion question, I am definitely considering the 14 yo girls position as well. With an OB patient, whether 1 week pregnant or 38, I believe you're dealing with 2 patients, two equal human lives. I come to my conclusion by the same process I used in my earlier post: preserve life first, better quality of life second. My job is to preserve both lives, 14 yo girl and 1 week old unborn. Therefore, taking one life in order to better the quality of another is against what I believe is fair and just for both patients.
If a 15 yo girl came in with a child who was already born and told you she has no family support, her life is miserable and she can't take care of herself or the baby, would you end the baby's life to better the 15 yo pt? Absolutely not. When one believes life begins at conception (which a lot of people do), one sees the unborn life just as they see the born. We are to be the patient advocate, even if the patient doesn't have a voice of their own.

Good questions, I hope my answers give you some insight into my thought process and I respect any disagreements you may have.

 

[NotAnOperator]

Terminally ill: First do no harm. Forcing someone to live hopelessly with pain is harm. The patient has a right to die with dignity. Make sure they fully understand the situationa nd their prognosis, and that they have talked to their family about this.

Abortion: Life does not begin at conception. Life began once, about 3.5 billion years ago, and has been continuous since then. When people say "life begins at conception," they are arguing when a human becomes 'ensouled,' so to speak. That is a religious view. Ultimately, because of the girls age, she is not a consenting adult, and I would initially feel compelled to contact her parent(s)/guardian, after speaking with her and making sure this is not incestuous rape, or something like that. I would have to make sure I followed any state laws as well.

I would obviously elaborate more, but that is what it would boil down to.

Not arguing with your view but I believe life begins at conception and I have no religious ties or affiliation.

 

[NotAnOperator]

Maybe if you don't give her an abortion she will try and do it herself and end up killing herself. People who grew up with safe and legal abortions seem to have little to no idea why Roe v. Wade was so important and necessary.

I don't believe in practicing medicine based on the "what if the patient (or pt legal guardian) completely ignores all medical advice and does xyz. All a provider can do is treat and give medical advice and education to the patient and or guardian as best they can. We can't give every patient who stubbed their toe morphine just in case they may decide to amputate their leg at home if they don't get the narcs.

 

[NotAnOperator]

For the physician assisted death question, one could argue that preserving life in the case of a terminally ill patient is actually doing more harm than good. I think as a physician your role is to find what's best for each individual patient. If patients have reached the logical conclusion (they are in a good state of mind) that ending their life is what is right for them and their family, I think they should have the right to do it. I read a figure recently that something like 40 years ago, most people died in their homes, but now a lot of people die in the hospital. Death is a normal process of life. I think physicians need to move away from the whole "prevent death in 100% of cases" to more of mindset that realizes death may be a good option for some patients. How would you like your last days to be? Anyway, if you look into numbers in Oregon where it is legal, only about 1/500 people actually utilize Physician assisted death. We actually need to do a better job at end of life care because physician assisted death is not that commonly utilized. Finding out what is most important to each individual patient and forming a plan with them is the best way to go about death. Some patients will want to be kept alive at all costs and want doctors to do everything possible. Others will prefer to die at home surrounded by family.

About abortion, you say "Whether death is better or worse than the child's quality of life is not my decision". To me, it seems like you are valuing your opinions more than your patients. Don't you think women know best what is right for them and their situation? Do you really think forcing a woman to bring a baby into this world that has a mother who may not be in a good place to raise it is a good idea? What about birth defects? Again, forcing someone to bring a baby into the world that may have a terrible quality of life is actually doing more harm in my opinion.

My reply to porkloins along with the statements others on here have brought up kind of clear my point of view. I understand and respect your opinion on the issue, I just have a different one.

 

[ridethecliche]

I don't believe in practicing medicine based on the "what if the patient (or pt legal guardian) completely ignores all medical advice and does xyz. All a provider can do is treat and give medical advice and education to the patient and or guardian as best they can. We can't give every patient who stubbed their toe morphine just in case they may decide to amputate their leg at home
if they don't get the narcs.

Not a legitimate comparison. If you don't understand why, you're beyond help.

 

[NotAnOperator]

Not a legitimate comparison. If you don't understand why, you're beyond help.

And if you can't grasp the underlying point of the whole reply, you're the one beyond help. Sometimes comparisons are used to prove a point rather than providing a situation with equal values.

 

[alpinism]

For the terminally ill question:

Perhaps actual attending physicians can better answer my thoughts. I recall reading a pamphlet while volunteering at the ICU that talked about end-of-life care. As physician-assisted suicide is NOT legal where I'm from, this pamphlet attempts to educate patients and their families about their options. A big one that appealed to me was comfort care. It talked about how the hospital can try to make the patient as comfortable as possible, and in the least amount of pain while they pass/live the remainder of their life. Now, I'm not sure what that entails or looks like, but from that pamphlet, it looked like a damn good alternative to physician-assisted suicide. My mom's always talked about how she wants to "die with dignity" via physician-assisted suicide if she ever became terminally ill, and I've been trying to sway her more towards the comfort care direction (if/when we ever get to that point..right now it's all hypothetical).

If comfort care is what I'm imagining it to be, I don't see why physician-assisted suicide is necessary. The patient can choose not to pursue aggressive care to prolong life, but rather care to minimize pain and suffering for the time that they do have left.

To put this in the kindest way possible, I don't think comfort care is anything like you're imagining for most patients. For many, they will be in a great deal of pain, so the comfort care will include large doses of narcotics, leaving the patient extremely hazy and possibly feeling sick (a reasonably common side effect of narcotics). Additionally, narcotics are not always enough to control pain - some pain will persist at the same level despite high doses of narcotics. There are also many other factors to consider. The patient will likely be kept in a hospital or nursing home, not at their own home. They will likely have an IV and some monitoring equipment. They may very well be unable to move under their own free will, so will need someone to assist with personal hygiene and things like toileting.

For some patients, comfort care is an excellent option. Others, however, would prefer to be aware and strong enough to say goodbye to their loved ones and give them a hug before they die. They would prefer to die in their own home, without experiencing the indignity of needing someone to clean up soiled sheets, without being surrounded by tubes and wires, and before they have to experience uncontrollable pain. For those patients, physician-assisted suicide IS comfort care.

I think the term you're both searching for is palliative care.

If you look at the research, it's a very effective way to control pain and suffering for most patients during the final stages of a terminal illness.

It can also be tailored to each particular patient regarding pain control (PO/IV/nerve blocks/etc) and monitoring levels (invasive/noninvasive/etc).

Palliative medicine has been a board certified subspecialty of internal medicine since 2006. In most developed countries, providing proper palliative care is essential to working with ICU patients.

WHO:
http://www.who.int/cancer/palliative/definition/en/
Harvard Medical School Dana-Farber Cancer Institute:
http://www.dana-farber.org/Adult-Ca...ices/Pain-Management-and-Palliative-Care.aspx

While this is a bioethics discussion (and you haven't done an internal medicine or pain medicine rotation yet), it's still helpful to have a basic understanding of how terminal illnesses are currently managed.

We like to ask interviewees terminal cancer questions from time to time, and unfortunately many people haven't even heard of palliative care let alone understand what it means.

 

[ridethecliche]

And if you can't grasp the underlying point of the whole reply, you're the one beyond help. Sometimes comparisons are used to prove a point rather than providing a situation with equal values.

No ****ing patient is going to amputate their toe because it hurts.

You threw away any credibility you might have had with that asinine statement.

There's a world out there, it might serve you well to experience it.

 

[NotAnOperator]

No ******* patient is going to amputate their toe because it hurts.

You threw away any credibility you might have had with that asinine statement.

There's a world out there, it might serve you well to experience it.

You either failed to comprehend what I wrote or just failed to read it. Let me guess, been in classrooms your whole life, maybe an online activist? I've seen and experienced much more of this world I can assure you. Grow up.

 

[ridethecliche]

You either failed to comprehend what I wrote or just failed to read it. Let me guess, been in classrooms your whole life, maybe an online activist? I've seen and experienced much more of this world I can assure you. Grow up.

Lul, no but okay. Given how you're responding though it might behoove you to spend a bit more time in one though.

Side note, I never disagreed with this statement:
"I don't believe in practicing medicine based on the "what if the patient (or pt legal guardian) completely ignores all medical advice and does xyz. All a provider can do is treat and give medical advice and education to the patient and or guardian as best they can."

Yet, you're acting as if the psychosocial aspect of medicine/treatment/etc is the same for all 'ailments' so to speak. That's really not how it works. At all.

 

[Eppur Si Muove]

Terminally Ill patient: I agree that sometimes ending ones life would be more comfortable or happy for the patient than living. I've always said that if I was ever in a position where I could not live life the way I want than I rather seek death. However, I don't believe this is a physicians job. This is very different from physicians/life or death but try to hear the underlying point: someone loves trees and makes a profession from tree planting. They understand more about trees than most anyone else in the world. Massive amounts of special paper is required from special trees and no one is more qualified to obtain this massive amount of special wood than the tree planter. Should we expect the tree planter to incorporate the chopping of trees in his practice simply because he's an expert on trees? It is not his job, it is not why he chose his job, it is the sole purpose he began his job in the first place to grow trees, not cut them.
What I'm getting at is I'm not saying it's wrong that some people chose death over life or that death shouldn't be warranty if the patient chooses, I'm asking why should we force a physician to sleep at night knowing he/she killed someone, whether it was against their will or not. Taking a life can be an extremely traumatizing ordeal, even when the taking of that life is justified. This is why we often see our troops come home with PTSD, not because they consider themselves murderers or because they did something wrong. They know they had to kill to defend their life or the life of an innocent but the act of taking someone's life or giving someone the means to take it (calling in airstrikes) can haunt that person forever and ultimately destroy their life. Personally, I do not want to be haunted by that as a physician. If another physician can do it and help ease someone's suffering and feels it is the right thing to do, good on them, that's great. But as for me, I will not be using my future medical license to end a person's life. I see nothing wrong with physician assisted suicide, but I feel with such a tremendous act that arguably is not even the physician's job, the doctor should definitely have a say in it because this effects them as well as the patient and family.

And as for the abortion question, I am definitely considering the 14 yo girls position as well. With an OB patient, whether 1 week pregnant or 38, I believe you're dealing with 2 patients, two equal human lives. I come to my conclusion by the same process I used in my earlier post: preserve life first, better quality of life second. My job is to preserve both lives, 14 yo girl and 1 week old unborn. Therefore, taking one life in order to better the quality of another is against what I believe is fair and just for both patients.
If a 15 yo girl came in with a child who was already born and told you she has no family support, her life is miserable and she can't take care of herself or the baby, would you end the baby's life to better the 15 yo pt? Absolutely not. When one believes life begins at conception (which a lot of people do), one sees the unborn life just as they see the born. We are to be the patient advocate, even if the patient doesn't have a voice of their own.

Good questions, I hope my answers give you some insight into my thought process and I respect any disagreements you may have.

I see this in a similar light. It can be easy to say that assisted suicide may help someone die in peace, but could you be the one to do it and live with that death? Whether in peace or not, assisting in death can be seen by many to still be unnatural and as a crime against nature. Even if I believed it could end the persons misery it would not be me pulling the plug

 

[NotAnOperator]

Lul, no but okay. Given how you're responding though it might behoove you to spend a bit more time in one though.

Side note, I never disagreed with this statement:
"I don't believe in practicing medicine based on the "what if the patient (or pt legal guardian) completely ignores all medical advice and does xyz. All a provider can do is treat and give medical advice and education to the patient and or guardian as best they can."

Yet, you're acting as if the psychosocial aspect of medicine/treatment/etc is the same for all 'ailments' so to speak. That's really not how it works. At all.

So you understood my whole entire point and you understood the purpose of the comparison but you just decided to attack it because it's not very realistic? Lol I have no words. Exiting the room now.

 

[NotAnOperator]

I see this in a similar light. It can be easy to say that assisted suicide may help someone die in peace, but could you be the one to do it and live with that death? Whether in peace or not, assisting in death can be seen by many to still be unnatural and as a crime against nature. Even if I believed it could end the persons misery it would not be me pulling the plug

Just like putting a sick or injured animal to sleep, except on a much bigger and more traumatic scale. I could never be a veterinarian because I could never euthanize animals. Not because I believe a horse with two broken legs should suffer, I just don't have to heart to take an innocent life myself. I believe a terminally I'll patient who is suffering horribly should be allowed to die but it won't be by my hand.
It's such a tricky situation. Should it be federally legalized and only done by physicians who can stomach it?

This question is for anyone: do you know which specialty normally prescribes these lethal medications? Would it be pain management docs? Internal med? I hope to go into either EM or surgery most likely so as long as I'm safe in those specialties, I'm fine with it.

 

[ridethecliche]

So you understood my whole entire point and you understood the purpose of the comparison but you just decided to attack it because it's not very realistic? Lol I have no words. Exiting the room now.

I know this is challenging, but just because I agree with a statement you made doesn't mean I can't point out it doesn't really apply in the mechanism you described.

Regarding your other post, no one is forcing physicians to do this, but some do and can be referred to. At a certain point, you have to understand that patients are autonomous and can rationally come to such a decision. No one is saying it's an easy choice, but it's a choice that some patients come to and one that should be respected.

 

[PlaqueBuster]

Just like putting a sick or injured animal to sleep, except on a much bigger and more traumatic scale. I could never be a veterinarian because I could never euthanize animals. Not because I believe a horse with two broken legs should suffer, I just don't have to heart to take an innocent life myself. I believe a terminally I'll patient who is suffering horribly should be allowed to die but it won't be by my hand.
It's such a tricky situation. Should it be federally legalized and only done by physicians who can stomach it?

This question is for anyone: do you know which specialty normally prescribes these lethal medications? Would it be pain management docs? Internal med? I hope to go into either EM or surgery most likely so as long as I'm safe in those specialties, I'm fine with it.

Just to clear up some things. As a physician you are not forced by anoyone to admisister end of life treatment/care, but if you believe in this cause it is your responsiblity to advice and help your patient find the appropriate means to their wishes if they choose to die (especially if it is legalized in your state as the prompt initially mentioned). You cannot turn a cold shoulder on them and say I won't have anything to do with this even though I think it is ok for the patient to end their life without suffering. Either you are ok with patient taking their life and choose to help or you can take the stance that the physician's role is to preserve life and you would not be involved in the patient's choice of death.

You will see deaths in medicine and you just have to get used to it. You cannot go in thinking that you can save all lives. You will be traumatized by some deaths, it's how you bounce back from it that determines your mental toughness as a physician. Thats like saying I want to be a phlebotomist but I won't draw blood because I will be haunted by the sight of blood. In my personal opinion I would not use your reasoning to your conclusion if you were ever asked this question. Jusy say you will do all you can to help defer the patient to another physician that may assist them because you do not believe in patient death from a terminal illness because you value to preserve life.

 

[ridethecliche]

At my last interview, I was asked if I thought that participation in clinical trials should be mandatory.

That was a pretty interesting question as was the discussion that followed.

 

[NotAnOperator]

I know this is challenging, but just because I agree with a statement you made doesn't mean I can't point out it doesn't really apply in the mechanism you described.

Regarding your other post, no one is forcing physicians to do this, but some do and can be referred to. At a certain point, you have to understand that patients are autonomous and can rationally come to such a decision. No one is saying it's an easy choice, but it's a choice that some patients come to and one that should be respected.

You obviously failed to read anything I've written on here. I've wrote several times that I support the choice and respect it and even would advocate it if I were in a certain situation. I'm saying that I'm not willing to take or give the means to take an innocent life, whether the reasons are just or not.
Stop skimming and replying just for the sake of arguing and actually read and comprehend. I feel like every reply to you has been me rephrasing what I've already said. If you don't get it now then there's no point anymore.

 

[NotAnOperator]

Just to clear up some things. As a physician you are not forced by anoyone to admisister end of life treatment/care, but if you believe in this cause it is your responsiblity to advice and help your patient find the appropriate means to their wishes if they choose to die (especially if it is legalized in your state as the prompt initially mentioned). You cannot turn a cold shoulder on them and say I won't have anything to do with this even though I think it is ok for the patient to end their life without suffering. Either you are ok with patient taking their life and choose to help or you can take the stance that the physician's role is to preserve life and you would not be involved in the patient's choice of death.

You will see deaths in medicine and you just have to get used to it. You cannot go in thinking that you can save all lives. You will be traumatized by some deaths, it's how you bounce back from it that determines your mental toughness as a physician. Thats like saying I want to be a phlebotomist but I won't draw blood because I will be haunted by the sight of blood. In my personal opinion I would not use your reasoning to your conclusion if you were ever asked this question. Jusy say you will do all you can to help defer the patient to another physician that may assist them because you do not believe in patient death from a terminal illness because you value to preserve life.

You miss my point. I am okay with the patient taking their life, but I feel it's not the physician's job. I would refer them to another physician if they insisted but I'd wash my hands of the situation.

Fyi, I currently work in a military ER and see death on a weekly basis. I also see death in the field and I've been in positions where I've had to take life. Death doesn't bother me and I'm not a child; I know you can't save everyone, that has nothing to do with what I'm saying.