What is an ethical issue in medicine?

[mechtel]

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I've been asked this at two different interviews and both times said something along the lines of "Ethics is at the heart of medicine and doctors face many ethical dilemmas. One that comes to mind is Euthanasia. Although doctors have an obligation to relieve suffering, there is a greater obligation not to harm a patient. Therefore, my opinion is that Euthanasia should not be practiced by physicians."

I was wondering if anyone has any comments on my answer or any alternate ways to approach such an open ended question. It seems like an ethics question that is intended to be "easy" and not stressful. I seemed to do much better answer specific ethical dilemmas than to simply name one. It seems so open ended. Should I even take a side in the ethical issue I mention? What are some other "good" ethical issues in medicine?

 

[Rendar5]

I've been asked this at two different interviews and both times said something along the lines of "Ethics is at the heart of medicine and doctors face many ethical dilemmas. One that comes to mind is Euthanasia. Although doctors have an obligation to relieve suffering, there is a greater obligation not to harm a patient. Therefore, my opinion is that Euthanasia should not be practiced by physicians."

I was wondering if anyone has any comments on my answer or any alternate ways to approach such an open ended question. It seems like an ethics question that is intended to be "easy" and not stressful. I seemed to do much better answer specific ethical dilemmas than to simply name one. It seems so open ended. Should I even take a side in the ethical issue I mention? What are some other "good" ethical issues in medicine?

health insurance, treating those who cannot afford to pay, treating illegal immigrants, dealing with confidential issues, DNR/DNI issues, what to do when conflict between family members on what to do, when to call child protective services and so on and so forth.

 

[BerlinDude]

I don't really understand your question. What is an ethical issue in medicine? There's lots - patient confidentiality, informed consent, right to refuse care, futile care, mandatory testing, etc. Is that what you are asking about?

 

[Pedie Packs]

I would probably take a side... the question seems more geared towards your ability to analyze a tough situation and take a stand, with concrete reasoning.

As long as you're not offensive and too personal, I think it's okay to pick a side.

 

[teenmachinery1]

I don't think your euthanasia answer was very good. Your premise seems off:

"Although doctors have an obligation to relieve suffering, there is a greater obligation not to harm a patient. Therefore, my opinion is that Euthanasia should not be practiced by physicians."

I hope it came out better at your interviews. However, you're in good company with opposing euthanasia. I believe the AMA does not support euthanasia and officially outlines as such somewhere... in the place where they outline such things..

anyways, there's my two cents.

👍

 

[Depakote]

One prevalent issue you might consider discussing is futile medical care, which consumes a large portion of health resources and medicare dollars each year.

These are scenarios where the patient is towards the end of their life and ill with multiple medical conditions. Yet aggressive, expensive and painful treatments are prescribed and pursued. Often it is the patient's families requesting the care (occasionally it is physicians believing they can fix the problem with an unrealistic goal).

The ethical issues: How much care should we be providing? Do we need to ration these resources? If so, who decides who gets them? How can you objectively decide and state whether care is futile or not? Then how do you convince the patients family that the best course of action is to pursue comfort measures?

 

[teenmachinery1]

One prevalent issue you might consider discussing is futile medical care, which consumes a large portion of health resources and medicare dollars each year.

These are scenarios where the patient is towards the end of their life and ill with multiple medical conditions. Yet aggressive, expensive and painful treatments are prescribed and pursued. Often it is the patient's families requesting the care (occasionally it is physicians believing they can fix the problem with an unrealistic goal).

The ethical issues: How much care should we be providing? Do we need to ration these resources? If so, who decides who gets them? How can you objectively decide and state whether care is futile or not? Then how do you convince the patients family that the best course of action is to pursue comfort measures?

i heard this brought up in the great (sarcasm) health care debate we're having right now, and I'm actually not convinced that this is an issue right now. Someone also wrote, i think in NYT, about this topic and I found him unpersuasive. He was also interviewed on NPR like 2 weeks ago..

The main problem I have with this line of argument is exemplified in your first sentence. First off, you presume the medical care to be futile. This is actually the word that you used. I would hesitate before I claim to know in broad terms, futile vs. non-futile medical procedures.

I say - leave it up to the doctors, the patient (if poss.), and family.

Second, The argument is framed in terms of costs in dollars and resources vs. the procedure's efficacy and I find that a very odd way to think as a physician.

👎

 

[Depakote]

i heard this brought up in the great (sarcasm) health care debate we're having right now, and I'm actually not convinced that this is an issue right now. Someone also wrote, i think in NYT, about this topic and I found him unpersuasive. He was also interviewed on NPR like 2 weeks ago..

The main problem I have with this line of argument is exemplified in your first sentence. First off, you presume the medical care to be futile. This is actually the word that you used. I would hesitate before I claim to know in broad terms, futile vs. non-futile medical procedures.

I say - leave it up to the doctors, the patient (if poss.), and family.

Second, The argument is framed in terms of costs in dollars and resources vs. the procedure's efficacy and I find that a very odd way to think as a physician.

👎

Feel free to trim it down however you like, futile care is a significant ethical dilemma you will have to face at the provider level. You'll have patients families that "want everything done" for grandma... so does this mean you are going to run a full code on a frail 85 year old woman when you know she has no chance for a meaningful recovery?

 

[teenmachinery1]

Feel free to trim it down however you like, futile care is a significant ethical dilemma you will have to face at the provider level. You'll have patients families that "want everything done" for grandma... so does this mean you are going to run a full code on a frail 85 year old woman when you know she has no chance for a meaningful recovery?

The whole point is you don't know. There are indeed frail 85 year old grandmothers who end up alive on the other end of a whole multitude of invasive and risky procedures.

These moments are exactly the moments when you don't want to start weighing dollars and cents over possible health outcomes.

I mean- Can you imagine-->

Doctor: "There is ever the slightest chance that your grandma can come out of this alive and enjoy several more years with all her loved ones. But... may I remind you that we ARE talking about a $65,000 procedure here... !"

 

[Schemp]

The whole point is you don't know. There are indeed frail 85 year old grandmothers who end up alive on the other end of a whole multitude of invasive and risky procedures.

These moments are exactly the moments when you don't want to start weighing dollars and cents over possible health outcomes.

I mean- Can you imagine-->

Doctor: "There is ever the slightest chance that your grandma can come out of this alive and enjoy several more years with all her loved ones. But... may I remind you that we ARE talking about a $65,000 procedure here... !"

The fact is, money is an important concern, even for physicians. To say that the quality of your care should be your only concern is, I think, naive.

Ultimately medicine is a business like anything else, and has to at least break even if it's going to continue providing care. You can't have a system operating at a loss every single year and expect it to be sustainable.

I think it's extremely important that people not lose sight of the ultimate goal of medicine - keeping people healthy - but we need to be realistic while we do so. If we just provide every possible procedure for everyone it might benefit, we would be bankrupt in a very short period of time. Rationing happens and we need to face it honestly and openly, otherwise we'll never find a way to do it in the most efficient and humane way possible.

 

[Depakote]

The whole point is you don't know. There are indeed frail 85 year old grandmothers who end up alive on the other end of a whole multitude of invasive and risky procedures.

These moments are exactly the moments when you don't want to start weighing dollars and cents over possible health outcomes.

I mean- Can you imagine-->

Doctor: "There is ever the slightest chance that your grandma can come out of this alive and enjoy several more years with all her loved ones. But... may I remind you that we ARE talking about a $65,000 procedure here... !"

If I honestly believed a patient would significantly benefit from invasive care I'd be all for it, we wouldn't be having this discussion. But that's not the population we're talking about here and despite the fact that money is a real issue on the national scale, that's not why these decisions should be made, just something you should keep in the back of your mind...

You'll see it eventually, these are bad situations to begin with and sometimes hospice is the best thing you can do for a patient and their family.

 

[teenmachinery1]

The fact is, money is an important concern, even for physicians. To say that the quality of your care should be your only concern is, I think, naive.

Ultimately medicine is a business like anything else, and has to at least break even if it's going to continue providing care. You can't have a system operating at a loss every single year and expect it to be sustainable.
QUOTE]


Couldn't disagree with you more. Respectfully, of course.

👍

 

[teenmachinery1]

If I honestly believed a patient would significantly benefit from invasive care I'd be all for it, we wouldn't be having this discussion. But that's not the population we're talking about here and despite the fact that money is a real issue on the national scale, that's not why these decisions should be made, just something you should keep in the back of your mind...

You'll see it eventually, these are bad situations to begin with and sometimes hospice is the best thing you can do for a patient and their family.

Hospice = $$$$$

👎

 

[Schemp]

The fact is, money is an important concern, even for physicians. To say that the quality of your care should be your only concern is, I think, naive.

Ultimately medicine is a business like anything else, and has to at least break even if it's going to continue providing care. You can't have a system operating at a loss every single year and expect it to be sustainable.
QUOTE]


Couldn't disagree with you more. Respectfully, of course.

👍

Okay, but you picked the most poorly-worded sentence fragment of my entire argument. Do you disagree that a hospital or other care provider can operate at a loss indefinitely and continue to exist?

The point is that they have to take common business principles into consideration because their two options may often be to a) provide all possible care for a short period of time (until they inevitably close or lay off caregivers), or b) operate more efficiently, denying care in some cases, but stay open. I mean, the latter is the system we currently operate in and we still struggle to stay in the black. How can you honestly expect that we provide every available procedure to anyone who might benefit from it?

 

[Schemp]

I should note that I'm not necessarily saying it's physicians who should be looking at things this way. Someone needs to be on the side of the patient, and more often than not that should be the physician. By the same token, someone else (often an administrative person who has the expertise to make such calls) needs to look at things fiscally because money is a real thing that you can't ignore just because it's uncomfortable or may seem immoral.

It'd be great if we could provide top of the line care and every alternative to every person, but this is clearly untenable in the foreseeable future. We have to do the best we can with what we've got while we concurrently work to improve the underlying system.

 

[Depakote]

Hospice = $$$$$

👎

Weren't you just the one making the argument that money shouldn't influence decisions about patient care?

Anyway, hospice is covered by medicare, medicaid and generally covered by private insurance.

 

[teenmachinery1]

Weren't you just the one making the argument that money shouldn't influence decisions about patient care?

Anyway, hospice is covered by medicare, medicaid and generally covered by private insurance.

That was supposed to be an ironic response.

 

[teenmachinery1]

Okay, but you picked the most poorly-worded sentence fragment of my entire argument. Do you disagree that a hospital or other care provider can operate at a loss indefinitely and continue to exist?

The point is that they have to take common business principles into consideration because their two options may often be to a) provide all possible care for a short period of time (until they inevitably close or lay off caregivers), or b) operate more efficiently, denying care in some cases, but stay open. I mean, the latter is the system we currently operate in and we still struggle to stay in the black. How can you honestly expect that we provide every available procedure to anyone who might benefit from it?

"..you picked the most poorly-worded sentence fragment of my entire argument."

I agree that I picked the most poorly-worded sentence fragment in your argument.

"Do you disagree that a hospital or other care provider can operate at a loss indefinitely and continue to exist?"

This is an example of an either-or fallacy. Either we don't go to extreme medical life-saving/prolonging procedures or providers "operate at a loss indefinitely and (dis)continue to exist."

👎

Also, this came out a week ago. This is definitely an ethical issue one can bring up!

http://www.telegraph.co.uk/health/healthnews/6127514/Sentenced-to-death-on-the-NHS.html

 

[chman]

I just saw a good one on the discovery health channel.

A man walked into an ER. He claimed he was suffering from severe anxiety. The doc was not buying it and figured he had a drug problem. With more investigation the doc found out said patient was a pilot due to leave on a flight in a few hours.

This is an ethical issue for a number of reasons. First, it would be unethical to give drugs to an addict, but at the same time said addict could go into severe withdraw and potentially die.

The other issue is that if the doc let the patient walk out the door to fly a plane, either high or in withdraw, that puts others at risk. But it is the doc's responsibility to respect confidentiality.

The doc ended up threatening to tell the airline and the patient went to a detox facility.

That is just an example.

Other issues could include the subjects of abortion, gene therapy, artificial fertilization, the right to not receive care, care for the uninsured, etc.

 

[Schemp]

"Do you disagree that a hospital or other care provider can operate at a loss indefinitely and continue to exist?"

This is an example of an either-or fallacy. Either we don't go to extreme medical life-saving/prolonging procedures or providers "operate at a loss indefinitely and (dis)continue to exist."

👎

http://www.telegraph.co.uk/health/healthnews/6127514/Sentenced-to-death-on-the-NHS.html

I'm confused. Either you operate at a loss or you operate at a profit/break even. What is fallacious about those two options? The level of rationing that takes place is much less black and white, but it comes down to whether you're losing money or not.

You've yet to acknowledge that some rationing is necessary, so should I assume you think it isn't?

 

[teenmachinery1]

I'm confused (agreed). Either you operate at a loss or you operate at a profit/break even. What is fallacious about those two options (this question doesn't even make sense)? The level of rationing that takes place is much less black and white, but it comes down to whether you're losing money or not (are you a uw asian business student perchance?).

You've yet to acknowledge that some rationing is necessary, so should I assume you think it isn't?

I hate to spell it out but I suppose I will. You're confused because you think providers will either have to stop going through extreme, costly lengths to save grandma or face operating at a loss. Your premise is wrong. Your logic is fallacious.

I worry about you UW.

👎

oh right... and as for: "You've yet to acknowledge that some rationing is necessary, so should I assume you think it isn't?"

I'm sorry but I don't speak Rush Limbaugh.

👎

 

[chman]

I hate to spell it out but I suppose I will. You're confused because you think providers will either have to stop going through extreme, costly lengths to save grandma or face operating at a loss. Your premise is wrong. Your logic is fallacious.

I worry about you UW.

👎

oh right... and as for: "You've yet to acknowledge that some rationing is necessary, so should I assume you think it isn't?"

I'm sorry but I don't speak Rush Limbaugh.

👎

Who is UW?

 

[greatnt249]

Better yet, how do some of you find it so difficult to quote a post?

 

[teenmachinery1]

Who is UW?

lol- the university of washington.

👍

 

[teenmachinery1]

Better yet, how hard could it possibly be to quote a post?

yeah i noticed that but, meh.

People make mistakes that aren't necessarily related to the difficulty of a certain task or their intelligence.

 

[Schemp]

I guess taking you at your word when you said "respectfully" was my mistake. Sorry about that.

To answer one of your question though, I'm a UW biochem major. I'm also quite liberal and think we should do everything we can to extend patients' lives within the confines of our financial situation. I used hyperbolic examples because I wanted to establish SOME idea of what you were for or against, but clearly you're not interested in that, you just want to make sarcastic, insulting comments. I guess that's what I get for trying to be reasonable on a message board! Lesson learned. 👎

Enjoy your fantasy world. Feel free to PM me when you find a cache of limitless resources with which to fund this utopian health care system you have in mind. I'd genuinely love to be involved with it.

 

[Bacchus]

Rude awakenings, rude awakenings, I smell some rude awakenings in the future.

 

[mechtel]

I just saw a good one on the discovery health channel.

A man walked into an ER. He claimed he was suffering from severe anxiety. The doc was not buying it and figured he had a drug problem. With more investigation the doc found out said patient was a pilot due to leave on a flight in a few hours.

This is an ethical issue for a number of reasons. First, it would be unethical to give drugs to an addict, but at the same time said addict could go into severe withdraw and potentially die.

The other issue is that if the doc let the patient walk out the door to fly a plane, either high or in withdraw, that puts others at risk. But it is the doc's responsibility to respect confidentiality.

The doc ended up threatening to tell the airline and the patient went to a detox facility.

That is just an example.

Other issues could include the subjects of abortion, gene therapy, artificial fertilization, the right to not receive care, care for the uninsured, etc.

Thank you all! I found this quite helpful. I would prefer to mention a topic such as patient confidentiality that often does not make the news than an issue like Euthananasia. I think this demonstrates a greater command of the ethical issues actually faced by physicians on a daily basis.

I will look into the medical ethics literature before my next interview, but I was wondering if anyone had come across any good articles on the issue of confidentiality. When should a doctor breach confidentiality? What are some other angles to consider?

Thank you!

 

[austinap]

I guess taking you at your word when you said "respectfully" was my mistake. Sorry about that.

To answer one of your question though, I'm a UW biochem major. I'm also quite liberal and think we should do everything we can to extend patients' lives within the confines of our financial situation. I used hyperbolic examples because I wanted to establish SOME idea of what you were for or against, but clearly you're not interested in that, you just want to make sarcastic, insulting comments. I guess that's what I get for trying to be reasonable on a message board! Lesson learned. 👎

Enjoy your fantasy world. Feel free to PM me when you find a cache of limitless resources with which to fund this utopian health care system you have in mind. I'd genuinely love to be involved with it.

I agree with you wholeheartedly, except that I wouldn't call a health system where every measure is taken to prevent death "utopian". I think this is really something that our society has lost sight of - dying is part of life.

I don't think it's reasonable or good to take all measures to prevent death in all cases. Anybody that's seen a family fight to keep an elderly patient on life support even when there is little chance they will recover at all (and if they do, they will have a very poor quality of life) would likely agree. We all want to save everyone, but there has to be a limit. Many times, 'futile' is the right word. Finding where that line is at is the ethical issue.

 

[Jolie South]

I agree with you wholeheartedly, except that I wouldn't call a health system where every measure is taken to prevent death "utopian". I think this is really something that our society has lost sight of - dying is part of life.

I don't think it's reasonable or good to take all measures to prevent death in all cases. Anybody that's seen a family fight to keep an elderly patient on life support even when there is little chance they will recover at all (and if they do, they will have a very poor quality of life) would likely agree. We all want to save everyone, but there has to be a limit. Many times, 'futile' is the right word. Finding where that line is at is the ethical issue.

Any system that does that is also bordering on being unethical from a patient's rights perspective. We aren't considering the patient's rights to dignity and his/her wish to abandon treatment when it is prolonging a life that he/she would not want to live.

 

[akinetopsia]

People need to be clear with their wishes - I remember reading about a hospital that is very proactive as far as counseling goes for end of life, and recommend people to make living wills while they are competent and let their wishes be known.

It's naive to think futile care isn't a big part of the spending. What makes it futile is that a lot of these patients' families may not know their wishes, so their first instinct is to do everything. If a highly invasive, expensive procedure has an 8% chance of being successful, some families want to do it. It's their loved one so they automatically assume they will be lucky and in that 8% even though the statistics are stacked against them.

Teenmachinery, let's make an assumption that frail 85 year old successfully made it alive through a bunch of expensive, invasive and risky procedures. What is her quality of life going to be like at that point?

As far as an ethical dilemma I can think of, what about this: a young 25 year old male is in a high-speed MVA, colliding with a pick up on his motorcycle. He ends up brain dead and on a ventilator, and his license doesn't identify him as an organ donor but he didn't make his wishes clearly known to his family regarding organ donation. His father and mother heard him say he would donate and update his license, his siblings heard the opposite from him. He was otherwise a healthy 25 year old male. Do you address it with the family?

 

[austinap]

Any system that does that is also bordering on being unethical from a patient's rights perspective. We aren't considering the patient's rights to dignity and his/her wish to abandon treatment when it is prolonging a life that he/she would not want to live.

True, but many patients also don't consider their own dignity at times either. Often times it becomes an issue of whether the patient is in the right state of mind at the time they're requesting (or denying) certain treatment. Also frequent are cases where the patient doesn't have a living will, and the family decides that they want to do everything possibly to try to save their loved one, even if the chances of it working are slim to none.

 

[chman]

lol- the university of washington.

👍

I realize this. What I was getting at was when you said, "I worry about you UW, when we were not even in a dialog together. But o.k, you can worry.

 

[Jolie South]

True, but many patients also don't consider their own dignity at times either. Often times it becomes an issue of whether the patient is in the right state of mind at the time they're requesting (or denying) certain treatment. Also frequent are cases where the patient doesn't have a living will, and the family decides that they want to do everything possibly to try to save their loved one, even if the chances of it working are slim to none.

What I am discussing is families that only consider that they want more time with Grandma without thinking about whether Grandma would want the treatment when she is in a persistent vegetative state or in a coma. I think common sense and compassion go a long way when there isn't a definitive directive or written documentation of the patient's wishes.

While the patient's wishes aren't always completely known, it is often clear that the family's wishes are overriding any other factors in decision making. The ethical standard is substituted judgment, not "family desires."

 

[brooklynblunder]

I just saw a good one on the discovery health channel.

A man walked into an ER. He claimed he was suffering from severe anxiety. The doc was not buying it and figured he had a drug problem. With more investigation the doc found out said patient was a pilot due to leave on a flight in a few hours.

This is an ethical issue for a number of reasons. First, it would be unethical to give drugs to an addict, but at the same time said addict could go into severe withdraw and potentially die.

The other issue is that if the doc let the patient walk out the door to fly a plane, either high or in withdraw, that puts others at risk. But it is the doc's responsibility to respect confidentiality.

The doc ended up threatening to tell the airline and the patient went to a detox facility.

That is just an example.

Other issues could include the subjects of abortion, gene therapy, artificial fertilization, the right to not receive care, care for the uninsured, etc.

when physicians believe that an patient might cause harm to an individual or a group of people, he/she has the right to report the patient to authorities.

somewhat.. like the patient with hiv/aids but refuses to tell the partner. or the prisoner who is hiding a gun compared to the prisoner who is just doing drugs recreationally (you dont have to report the druggie, in case he might open up to you about info about more malicious things or whatnot)

other ethical issues are physicians giving the lethal injection vs a technician. abortion. blah blah blah

healthcare is probly the best debate and the one that you are definitely going to get asked on

 

[Jolie South]

This is not accurate. I would urge you to read about the exceptions to HIPAA and the two Tarasoff decisions.

Not to mention that Tarasoff isn't law everywhere. Some states, mine in particular, are more restrictive.

 

[Long Dong]

Coverage for all, how the hell are we gonna pay for it. And all this talk about the Mayo model. Mayo has already limited the number of medicare medicaid peeps they can see because they lose about 30% on these patients. If the current public option now (care/caid/VA) can't do a good job/keep its promise now how's it gonna do it when trying to cover more peeps.

 

[kami333]

As far as an ethical dilemma I can think of, what about this: a young 25 year old male is in a high-speed MVA, colliding with a pick up on his motorcycle. He ends up brain dead and on a ventilator, and his license doesn't identify him as an organ donor but he didn't make his wishes clearly known to his family regarding organ donation. His father and mother heard him say he would donate and update his license, his siblings heard the opposite from him. He was otherwise a healthy 25 year old male. Do you address it with the family?

Parents come before adult siblings in next of kin hierarchy.

 

[Rendar5]

Parents come before adult siblings in next of kin hierarchy.

true case:
drunk guy gets into an accident. Needs a transfusion or he will die. His mom says he's a Jehovah's witness and would not want blood products at all. His sister says "this is bull, he's not a jehovah's witness, doesn't believe in that stuff and is effectively estranged from his mom". What do you do? (btw, the truth is, he ultimately did not receive the transfusion, he died, and the sister was correct. There was not enough time for this stuff to play out for the truth to be uncovered)

 

[lord_jeebus]

True story

An 80-something woman is admitted for sepsis, which resolves with treatment. However, during her hospital stay she is diagnosed with AML (acute myeloid leukemia). She elects to undergo induction chemotherapy.

After induction chemotherapy, she rapidly develops neutropenic fever and eventually severe septic shock. (at this and all subsequent stages of the story, all involved physicians agree that her prospects for meaningful recovery are virtually zero) She is intubated for respiratory failure, put on continuous dialysis for renal failure. She also develops shock liver, which resolves, and an ST-elevation myocardial infarction, leaving her with poor cardiac function. Pressors are administered to maintain blood pressure and are eventually weaned.

Her family insists on the most aggressive care possible, and over 3 months she undergoes tens of painful line placements and changes, bone marrow biopsy, and remains on a ventilator. When sedation is weaned, she shows no evidence of being able to follow commands or attempt to communicate.

Other complications like deep vein thrombosis also develop.

The family, although otherwise friendly, make no secret that they intend to sue everyone if they find that the patient is not receiving "the most aggressive care possible," and they keep meticulous records of everything down to the names of dieticians and at what time each medication has been administered.

The family insists on a repeat bone marrow biopsy, and when it shows that the initial induction chemotherapy was unsuccessful, insists on reinduction chemotherapy. Hematology/Oncology agrees, and as a consequence the patient again develops severe septic shock. Over her last days she repeatedly codes and is given full CPR including electric shocks and chest compressions which break her ribs.

All this is done at the expense of the US taxpayer - 100 days of ICU physician, nursing, and respiratory therapist care; very expensive antibiotics for increasingly resistant organisms; two courses of chemotherapy; consultants from cardiology, nephrology, infectious disease, oncology, hepatology, and palliative care; 100+ images read by board-certified radiologists; and many more costly yet futile expenses. Based on the bills I have seen for shorter ICU cases, I am sure this bill was in the seven-figure range.

Cost aside, how much torture (and I believe that prolonged ICU care can be exactly that for a confused patient who does not understand why they have a tube in the throat, a tube in their nose, and a tube in their urethra or why they get stabbed repeatedly for lines and biopsies) should the patient have been subjected to when physicians knew that meaningful recovery was impossible?

Does there come a point when the cost to society for futile care becomes so great that cost becomes an ethical issue?

 

[mirrorpair]

I've been asked this at two different interviews and both times said something along the lines of "Ethics is at the heart of medicine and doctors face many ethical dilemmas. One that comes to mind is Euthanasia. Although doctors have an obligation to relieve suffering, there is a greater obligation not to harm a patient. Therefore, my opinion is that Euthanasia should not be practiced by physicians."

I think you should come up with a semi-precise definition of what an 'ethical issue' is and discuss how it applies to medicine.

What I'd say is that 'Doctors have various goals in treating patients: making the patient healthier, not hurting the patient, respecting the patient's independence, quality of life, etc. When they conflict, then you have an ethical issue. For example euthanasia is a conflict between quality of life and not hurting the patient. Blood transfusions for Jehovah's Witnesses involve patient autonomy and making the patient healthier (though a previous post shows that the information we receive can further complicate issues).

I'm not giving any guidelines for solving ethical issues--just creating a framework to think about them. Your guess about solving ethical issues is as good as mine.

 

[Bacchus]

True story

An 80-something woman is admitted for sepsis, which resolves with treatment. However, during her hospital stay she is diagnosed with AML (acute myeloid leukemia). She elects to undergo induction chemotherapy.

After induction chemotherapy, she rapidly develops neutropenic fever and eventually severe septic shock. (at this and all subsequent stages of the story, all involved physicians agree that her prospects for meaningful recovery are virtually zero) She is intubated for respiratory failure, put on continuous dialysis for renal failure. She also develops shock liver, which resolves, and an ST-elevation myocardial infarction, leaving her with poor cardiac function. Pressors are administered to maintain blood pressure and are eventually weaned.

Her family insists on the most aggressive care possible, and over 3 months she undergoes tens of painful line placements and changes, bone marrow biopsy, and remains on a ventilator. When sedation is weaned, she shows no evidence of being able to follow commands or attempt to communicate.

Other complications like deep vein thrombosis also develop.

The family, although otherwise friendly, make no secret that they intend to sue everyone if they find that the patient is not receiving "the most aggressive care possible," and they keep meticulous records of everything down to the names of dieticians and at what time each medication has been administered.

The family insists on a repeat bone marrow biopsy, and when it shows that the initial induction chemotherapy was unsuccessful, insists on reinduction chemotherapy. Hematology/Oncology agrees, and as a consequence the patient again develops severe septic shock. Over her last days she repeatedly codes and is given full CPR including electric shocks and chest compressions which break her ribs.

All this is done at the expense of the US taxpayer - 100 days of ICU physician, nursing, and respiratory therapist care; very expensive antibiotics for increasingly resistant organisms; two courses of chemotherapy; consultants from cardiology, nephrology, infectious disease, oncology, hepatology, and palliative care; 100+ images read by board-certified radiologists; and many more costly yet futile expenses. Based on the bills I have seen for shorter ICU cases, I am sure this bill was in the seven-figure range.

Cost aside, how much torture (and I believe that prolonged ICU care can be exactly that for a confused patient who does not understand why they have a tube in the throat, a tube in their nose, and a tube in their urethra or why they get stabbed repeatedly for lines and biopsies) should the patient have been subjected to when physicians knew that meaningful recovery was impossible?

Does there come a point when the cost to society for futile care becomes so great that cost becomes an ethical issue?

That is unbelievable. I understand the physicians were bound to provide care. There are several things to learn here:

1) Have an advanced directive/living will.
2) Talk with your family about your expectation in case you become incapacitated.
3) Learn to accept death. America is afraid of death; other cultures embrace it.
4) Realize, as a family, the amount of resources being consumed for a rather hopeless case.
5) Realize continuous, aggressive care is not always the best thing, but comfort most definitely is.

 

[Jolie South]

True story

Good God. That poor woman.

 

[Bacchus]

true case:
drunk guy gets into an accident. Needs a transfusion or he will die. His mom says he's a Jehovah's witness and would not want blood products at all. His sister says "this is bull, he's not a jehovah's witness, doesn't believe in that stuff and is effectively estranged from his mom". What do you do? (btw, the truth is, he ultimately did not receive the transfusion, he died, and the sister was correct. There was not enough time for this stuff to play out for the truth to be uncovered)

Wouldn't you, in the case of a minor, transfer custody to the state and do the transfusion? Of course, and its been argued on SDN before, transfuse now, worry about paperwork later.

 

[Jolie South]

Wouldn't you, in the case of a minor, transfer custody to the state and do the transfusion? Of course, and its been argued on SDN before, transfuse now, worry about paperwork later.

If it's a minor, that would be the answer, but it sounds like this is an adult.

You also don't need to transfer custody to the state, at least that's not how it was presented in my ethics class.

 

[apumic]

Wouldn't you, in the case of a minor, transfer custody to the state and do the transfusion? Of course, and its been argued on SDN before, transfuse now, worry about paperwork later.

This is how EMS personnel, lifeguards, and other first responders are all trained. Unless the mother was able to provide documentation, it is generally "better" to be sued for keeping someone alive for the "wrong reason" than it would be to be sued for allowing the individual to die on false premises.

Of course, as a physician, it is far more complex b/c your standard of care is higher. This would really be a case where, for legal reasons, you would want to consult a lawyer (and EMS personnel don't do blood transfusions anyway). Speaking more to the plight of the hospital here, though, we recently had a similar case to this with a young woman whose family was JW (as was she) but was married to a non-JW. She became incapacitated and critically needed a blood transfusion (all specialists involved agreed it would have almost certainly saved her life but w/o it, all other attempts were essentially futile). Apparently, she and the husband had talked about this prior as he gave his support for the blood transfusion to be withheld as her parents/siblings had requested. The ultimate decision, however, was offered to the husband and not to the family-at-large.

 

[Jolie South]

This is how EMS personnel, lifeguards, and other first responders are all trained. Unless the mother was able to provide documentation, it is generally "better" to be sued for keeping someone alive for the "wrong reason" than it would be to be sued for allowing the individual to die on false premises.

Of course, as a physician, it is far more complex b/c your standard of care is higher. This would really be a case where, for legal reasons, you would want to consult a lawyer (and EMS personnel don't do blood transfusions anyway). Speaking more to the plight of the hospital here, though, we recently had a similar case to this with a young woman whose family was JW (as was she) but was married to a non-JW. She became incapacitated and critically needed a blood transfusion (all specialists involved agreed it would have almost certainly saved her life but w/o it, all other attempts were essentially futile). Apparently, she and the husband had talked about this prior as he gave his support for the blood transfusion to be withheld as her parents/siblings had requested. The ultimate decision, however, was offered to the husband and not to the family-at-large.

The husband is the appropriate legal decision maker in this case. The "family" is lower on the hierarchy, but he is technically required to make the decision according to her wishes using the substituted judgment standard. Without written documentation, that's obviously harder to prove.

 

[lord_jeebus]

I understand the physicians were bound to provide care.

Well, not bound to provide futile care. But do you want to deal with defending yourself in court against this family? What can you gain? How much could you lose?

I had one intensivist attending who had the balls to refuse to provide futile care and would unilaterally withdraw futile measures that had been implemented by the previous attending. Surprisingly, most families took it pretty well - but it had to be framed very carefully. He worked at a VA so he had the luxury of that layer of legal protection that most physicians do not enjoy.

 

[Jolie South]

Well, not bound to provide futile care. But do you want to deal with defending yourself in court against this family? What can you gain? How much could you lose?

I had one intensivist attending who had the balls to refuse to provide futile care and would unilaterally withdraw futile measures that had been implemented by the previous attending. Surprisingly, most families took it pretty well - but it had to be framed very carefully. He worked at a VA so he had the luxury of that layer of legal protection that most physicians do not enjoy.

My state has a legal way for physicians to do that, the Texas Advanced Directives Act.

 

[teenmachinery1]

Coverage for all, how the hell are we gonna pay for it. And all this talk about the Mayo model. Mayo has already limited the number of medicare medicaid peeps they can see because they lose about 30% on these patients. If the current public option now (care/caid/VA) can't do a good job/keep its promise now how's it gonna do it when trying to cover more peeps.

Thank god you're in the minority.

3 of 4 physicians nationwide support the public option. September 14th article summarized in the New England Journal of Medicine.

http://www.rwjf.org/healthreform/quality/product.jsp?id=48408