Swine Flu: A Test of Ethical Planning

John Lantos, MD
April 28, 2009

Swine flu is coming!! Swine flu is coming!! What will we do? Will there be enough face masks? Enough ventilators? Enough vaccine? Enough antiviral medication? Who will be quarantined? How many schools will close? Will this squelch the economic recovery? Obliterate civil liberties?

The questions are already swirling, even though, to date, there are fewer cases of swine flu in the United States than there are of tularemia or of people struck and killed by lightning. (In 2007, 47 people in the United States were killed by lightning strikes.)

We don’t yet know whether or not this outbreak will be The Big One that public health experts have been predicting or not. Epidemics are notoriously difficult to predict. Let us hope it will not be.

If it is The Big One, it will be a good test of prospective ethical planning. Over the last five years, bioethicists around the world have been proposing moral frameworks for responding to a pandemic. (Check out the links below.)

Most of these documents are non-specific in their recommendations, identifying “values frameworks” or “necessary tradeoffs,” but not confronting the hard questions of politics and emotions that would take over in a real epidemic.

If and when the long-predicted pandemic arrives, it will be a test not only of our public health system but also of the value of prospective ethical analysis. We will see whether responses follow previously agreed upon moral frameworks or, instead, follow previously enshrined political power structures.

I hope it will be the former. I suspect it will be the latter.

Links:

http://www.phen.ab.ca/pandemicplanning/index.asp
http://www.who.int/ethics/influenza_project/en/index.html
http://www.ehman.org/pandemic.html
http://www.pandemicflu.gov/
Obligatory Topical Swine Flu Post, Journal of Medical Ethics Blog
April 28, 2009

Matching Physicians with Patients in Need

Tyler Brundige, MD

Jill Watson, Metropolitan Medical Society
April 24, 2009

Four years ago it was an idea. Two years later, it became a reality. It's the Northland Care/MetroCARE program, a specialty care network for the poor and uninsured in the Kansas City area.

Jill Watson of the Metropolitan Medical Society and Dr. Tyler Brundige talk about the program in this edition of The Bioethics Channel.

Judging Virtuously

Rosemary Flanigan
April 24, 2009

I am so lucky-I was invited this week to an ethics committee which was reviewing the Baby K case-remember, 1992, the anencephalic baby born in DC; the mother refused to give permission for a DNR order and the baby lived for 2 ½ yrs, going back to the hospital for ventilator support.

There were 7 of us there and an excellent analysis unfolded without a single reference to an ethical principle. The entire discussion hinged on virtue. I have always found that the argument from virtue is the most difficult to make.

Problem # 1: Before one has acquired virtue and is thereby able to judge virtuously by oneself (and thus be one's own ethical standard), one must following the guide of a person already virtuous.

And problem #2: in our culture it is oftentimes difficult to distinguish character traits that are virtues from those which are impressive because of certain contemporary cultural phenomena.

Oh, did I tell you that all 7 of us are female and 6 of them were mothers. I think that fact was important. There was careful weighing of the mother's feelings and desires over against what was best, in their argument, for Baby K.

Sensitive alternatives were proposed aimed towards respect for autonomy, beneficence and justice without those words being mentioned.

Seats Remain for Annual Dinner May 7

Tables are filling up fast for the Center’s Annual Dinner on May 7. We’re also celebrating the 25th Anniversary of the Center that night, so you won’t want to miss it.

For information on buying a table or attending as an individual, click here.

If you cannot attend but would like to contribute to honor the Center’s 25th Anniversary, please click here.

Shifting Ethics: Act Centered to Virtue Centered

Rosemary Flanigan

April 22, 2009

Over the week-end I was thinking of another article I had read—Richard Gula, a moral theologian who has written in the bioethics field for years. In it, the author sees moral theology shifting from act-centered to virtue-centered.

“When virtue ethics shifts the attention from acting to being, it does not do away with moral theology’s interest in action. Moral problems will not go away. After we have pulled the plug or dropped the bomb, what happens to the decision-maker? Virtue ethics takes seriously the proposition that who we are affects what we do, and what we do affects who we become.” (Richard M. Gula. 2009. (Richard M. Gula. 2009. “The Shifting Landscape of Moral Theology.” National Pastoral Life Center.)

And I thought: the same holds true with young people in medicine or in law or in teaching or wherever! They have been taught how to do whatever it is they do—but what they need, and continue to need, is the virtuous mentor showing them the “character” of medicine or law.

Idealism doesn’t have to die; moral fatigue is not a given. But without the example of good people trying to act well, virtuous practitioners, their splendid knowledge might have little effect on who they become.

Congratulations! You've had The Talk

On April 16, tens of thousands of people across the Kansas City metro area wore buttons, filled out healthcare powers of attorney, and most importantly – they had “The TALK.” More than 100 organizations held events – in libraries, hospitals, schools, places of worship, and homes.

THANK YOU to all for helping make Kansas City Healthcare Decisions Day a rousing success! We will see you in 2010. And let’s keep talking!

Links:

Making Your Wishes Known for End of Life Care

Participating Organizations

Advance Directives, Living Wills, and End-of-Life Issues, KCUR Radio with Bill Colby and Dr. Karin Porter-Williamson

'The Talk' needed as we learn how, when to die, Bill Colby, Kansas City Star, April 13, 2009

Hospital Ethics Committees -- Then & Now

Hospital ethics committees evolved in the late 1970s and into the 80s.

In this edition of The Bioethics Channel Rosemary Flanigan talks about how hospital ethics committees began and their future.

Conscience and the Practice of Medicine

John Lantos, MD
April 17, 2009

What are we, as a nation, going to do with the pesky issue of conscience clauses? Or, more interestingly, how are we going to think about the more profound issue of conscience itself and its role in the practice of medicine?

When should professional obligations override individual moral qualms? Do we risk turning doctors into moral automatons if we insist that there is no role for individual conscience in clinical decisions?

Controversies about conscience raise more questions than answers, generate more heat than light, and like debates about medical futility or universal coverage, lead to stable stalemates between protagonists who held relatively well-defined positions. And, like those other long-standing controversies, there is a relatively broad middle ground about which most people actually do agree.

In some situations, conscience clauses are widely accepted. No doctor or nurse has to participate in an abortion procedure. That has been true for thirty years. In other situations, conscience clauses would be intolerable. A Jehovah’s Witness trauma surgeon could not withhold blood transfusions. The real question is where to draw the boundaries between conscience claims that are acceptable and those that are intolerable.

Two solutions for many conscience problems would solve many problems. One is full disclosure. If a health professional has an uncompromising, conscience-based limitation on his or her practice, he must disclose that to each and every patient at the outset of their doctor patient relationship.

Second, medical interventions that could be provided without the complicity of a health professional should be.

Links:

Medical pros seek freedom to follow their consciences, Detroit News, April 13, 2009

Conscience vs. Conscience, Stanley Fish, New York Times, April 12, 2009

Conscientious Objection Gone Awry — Restoring Selfless Professionalism in Medicine, New England Journal of Medicine, April 10, 2009

Social Justice On Edge

Rosemary Flanigan
April 16, 2009

John Carney sent to several of us here at the Center a recent article in the Journal of the American Medical Association April 8), “The Ethical Foundation of American Medicine.”

The co-authors, one of whom is a physician, contend that the mantra of the BIG FOUR (beneficence, nonmaleficence, respect for autonomy and justice) have become unbalanced: “In a market-driven environment, fiscal independence seems to have become as important as autonomous decision making in practice, and concomitantly, attention to social justice may be decreased.”

Yes, yes, that’s been said before and if Kathleen Sibelius ever gets confirmed, she is going to have to do something about reimbursement patterns for Medicare and Medicaid, for instance.But the point that jarred me was this one: “. . .the percentage of Americans who agree that the higher the income, the more the individual should expect to pay in taxes to cover the cost of care for individuals who are less well off decreased from 66% in 1991 to 51% in 2003 and to 39% in 2006.”

Can you imagine even thinking about healthcare reform within this troubling trend—a trend that does not appear to be as pronounced in other westernized countries.The whole social justice issue stands tottering in the worlds of providers and receivers of healthcare. Maybe our former next-door-state-governor ought to hope she doesn’t get confirmed!

What a challenge.

Once a Guardian, Always a Guardian

Right? ??

Rosemary Flanigan
April 14, 2009

I told you that last week I had used the recent Hastings Center Report case with my ethics brown bag session. The case involved a fifty-nine-year-old male who was being readmitted to the hospital from a nursing home because he has gangrene of three right toes and both his heels.

He is being told that amputation is necessary: the right leg above the knee and the left heel. What does he say? “Let’s wait it out.” And his family concurs.

Well, of course, the doctors wondered at his capacity, and voila! didn’t they discover that nine years ago, the family chose not to be his legal guardian so he was appointed one. So shouldn’t the team contact the guardian?

Though we have no information about his condition during the intervening years, I was dead set against re-activating the guardian. But 2/3 of the brown baggers took it for granted that the guardian needed to be consulted. They said, “Once you have a guardian, you have a guardian unless the court revokes it.”

But I caught dear Bill Colby on the fly this morning and he said a case can be made either way.

I think my problem is: Those in the majority seemed so implacable; they had found “an answer” in the law, and someone “outside” was going to make a decision about this “waiting” option.

It was an “ethics” brown bag, and I would have hoped that the providers would have talked more to the poor patient to try to understand his “Let’s wait.” But, like so many arguments, if you think you have “the answer,” why bother with all the loosey-goosey in-between matter?

You must have experienced this in YOUR healthcare lives; isn’t it frustrating?? HELP!

Having "The Talk" April 16

Kathy Sproules, MD, Crossroads Hospice

John Carney, Center for Practical Bioethics

34 minutes

Have You Had "The TALK?"

April 16 is Healthcare Decisions Day across the country - a day to name someone you trust to speak for you during a serious illness or at the end of life.

This special edition of the Bioethics Channel comes courtesy of KMBZ Radio in Kansas City. It’s a radio program that aired April 4, 2009. Guests include Kathy Sproules, MD of Crossroads Hospice and John Carney of the Center for Practical Bioethics.

The Bioethics Channel is a free podcast. To subscribe via iTunes, click here.

Authenticity vs. Autonomy

Rosemary Flanigan
April 10, 2009

In his article in the newest Hastings Center Report, Dan Brudney dispels the notion that asking “What would the patient choose?” is asking about the patient’s autonomy or his/her best interests.

Imagine this scenario: you are the surrogate for a patient, Bill, who has lost decision-making capacity. He has no advance directive or anything equivalent. An important treatment decision needs to be made. When you are asked, “What would Bill choose to do?” you are being asked a hypothetical question.

Bill is not self-determining, so there is no question of choice here. And when you decide for him, you are making your decision in terms of the Bill you know, his values, and you try to give a response coherent with those values.

What is at stake here is his authenticity, not his autonomy (or self-determining capacity).

Dan says that clinicians will find little new in this article—and I think he’s correct. Physicians know that when they ask surrogates, “What would your loved one choose?” they are seeking a reply beyond a simple matter of choice; they are hoping for a reply which reflects the whole person of the patient, his authentic self.

The name of the foundational value matters little; that the decision reflects who Bill is matters a lot.

If any of you have read the article, tell me if the distinction was as meaningful to you as it was to me. THANKS.

Link:

Choosing for Another: Beyond Autonomy and Best Interests

Daniel Brudney

Hastings Center Report

March/April 2009

Discerning, Deliberating and Deciding

Rosemary Flanigan
April 9, 2009

On April 7 we had over 70 ethics committee members at our training workshop and it was an excellent morning. I thought Terry Rosell did an exceptionally good job (along with John Lantos, Myra, and Bill Colby, of course) leading the discussion of a case at our 8-person tables.

I shall tell you about the case next week, but what Terry made us do is to consciously move together through Discerning (what’s going on? what are the facts?) to Deliberating (what responses are possible?) which in turn led us to Deciding (what are we going to do? and, most interestingly, why have we decided on this?) and finally to Doing (what? when? how?)

It moved the discussion along, towards a goal, within a time frame, and led us to resolution with an ethical basis.

I know, I know, that’s what you do at every ethics committee case consult. But for some reason, I found it refreshing to move together from facts (people love to sit on this step and they can question facts all day!) to possibles to a decision with a reason—and finally, to a plan of action.

Within our reflection on authenticity, I am glad Brian reminded us of Rebecca Dresser’s “Another Voice” at the start of the issue: if respect for a person’s authenticity is the ground of our respect for that person’s advance directive, might we not have good reasons sometimes to override specific requests stated in the AD??

Why? Because they don’t jibe with who the person really is.

Hmmmmmmmm.

Ethics Committees and Blood Transfusions II

Rosemary Flanigan
April 7, 2009

Thanks to all of you who ruminated on the suggestion that ethics committees review orders for over 7 units of blood!! Those would have to be very special ethics committees and supported by a very special medical staff!!

John Carney said 2/3 of patients who didn’t want CPR, for example, “want other measures of life-sustaining treatments.”

So the question is, “How does the hospital respond in such cases?” And I would answer, “However the patient decides”—on the POLST or TPOPP forms where they list the “other measures” they want. Of course, this demands an institutional commitment and a medical staff commitment.

BUT it certainly calls for a literate, thoughtful patient-body!!!! And isn’t that what so many of us have been about these many years?

And not just us—but our surrogates as well.

Blood Transfusions & Ethics Committees

Rosemary Flanigan
April 3, 2009

Dr. Robert Potter, who was on the staff of the Center for 10 years and is back for a visit, told us that in Portland, OR where he is retired and working with the ethics center there, it is a policy of the hospital that patients who receive 7 blood transfusions must have their cases reviewed by the ethics committee.

That fact says several things to me:

1) the respect with which the ethics committee is held by the medical staff and administration

2) the realization that 7 blood transfusions raises distributive justice concerns

3) the track record of the committee in handling both clinical and ethical aspects of this fact

Our ethics committee at Carondelet Health is not alerted, though a medical staff committee of some kind must be.

Did any of you ever hear of an ethics committee so employed??????

THANKS.

A Physician's Reflections on Bioethics

Robert Potter, MD

April 1, 2009

Dr. Robert Potter was a revered physician and medical educator in Kansas City for 30 years before moving to Oregon in 2004. In the decade prior to his departure, he served as a scholar and consultant for the Center for Practical Bioethics.

In this edition of The Bioethics Channel Dr. Potter reflects on bioethics then, now and in the future.

Link:

Podcast: The Bioethics Channel

DNR Best Practices?

Rosemary Flanigan
April 1, 2009

Remember my telling you about the patient with terminal renal cell carcinoma who is incompetent, has had a guardian appointed, and the team of 7 physicians caring for him thought it appropriate to have a Do Not Resuscitate Order.

I heard this morning that he has it!!! The ethics committee, after discussing “at length the various legal, moral, and ethical reasons both for and against instituting a DNR when the patient no longer possesses the decisional capacity to decide for himself,” concluded that the 2 physician specialists would co-sign the DNR and that the team leader would write a treatment plan to be shared with unit staff regarding what measures would or would not be taken in the event of a medical emergency.

Personally, I think that was a defensible outcome; I assume that the guardian agreed. Amazingly, during the course of all this, they were able to find family members whom he had not seen in 5 years and who were satisfied with the DNR and the treatment plan.

My peek into the future of healthcare reform tells me that there will be more DNR orders initiated and encouraged by physicians along with patient/family proposals. What my “peek” doesn’t tell me if whether or not there will be some “best practice” guidelines that will simply mandate a DNR order, regardless of physician OR patient OR family concurrence.

What do you think?