Have you had "The Talk"?

Myra Christopher
Marshall Scott

The third annual National Healthcare Decisions Day is set for April 16, 2010 in Kansas City and all over the country.

The day is designed to help individuals and families make practical preparations for end-of-life decisions, including the designation of someone to speak for you when you can no longer speak for yourself.

Lorell LaBoube of The Bioethics Channel talks about it with Myra Christopher of the Center for Practical Bioethics and Marshall Scott of Saint Luke's South Hospital in Overland Park, KS.

Podcast: 11 minutes 31 seconds

Screening for Breast Cancer -- KC's Response

RosemaryFlanigan
March 29, 2010

I have to tell you about our panel discussion last Wednesday night on the U.S. Preventive Services Task Force (USPSTF)’s updated recommendations concerning screening for breast cancer in the general population—the study that has clogged the blogs.

Terry Rosell and a physician at St. Luke’s drew together three doctors of differing specialties, including a breast imaging specialist who adamantly opposed the study on grounds of ethics—no authority, inexpert in skills required—a nurse, a representative from the Susan G. Komen for the Cure group, and our own Summer Johnson, AJOB editor, to discuss the ethical implications of the statement.

There was disagreement about the recommendation itself, about the study itself and about its communication to the public! But throughout the evening, the discussion was civil and enlightening.

How can one use an “evidence-based” study and its statistical findings in the one-on-one physician/patient relationship? That was the key question. Women have a right to the information which USPSTF provided (whether legitimate or not) but the interpretation of that study—or of any other—is of paramount importance. And what kind of policy decisions might be made on the basis of such studies is worrisome.

Even more worrying is the number of women who are not taking advantage of the screening process at the present time, no matter their age.

I hope some of our Center staff will report to you the insights that were of particular interest to them, but I was heartened that, to my knowledge, the Center and St. Luke’s have been the first group to present a reasoned discourse, civilly conducted, to a general audience. It is possible to argue ethics without vituperation!

Doc, Will You "Friend" Me?

Summer Johnson, PhD

March 26, 2010

What are the ethical bounds of using social networks for the existing patients under a doctor's care?

According to a recent study by Harvard researcher David Brendel, the "friending" process between doctors and patients was explored to find an ethical way for the physician-patient relationship to remain intact via social networking.

Read more on bioethics.net: Doc, Will You "Friend" Me?

Health Reform: Common Sense? Or Govt Intrusion?

John Carney

March 24, 2010

Access to healthcare for many in this country is not a right. But that doesn’t mean we act irresponsibly. As good citizens we have responsibilities to obey the laws of the land, respect our flag and country, and pay our taxes that provide community safety and security.

Now, after years of debate we add another: get health insurance; or if not, pay a penalty for the more expensive alternative designed for disasters and catastrophic illness. Is this common sense or government intrusion?

Personal health is commonly viewed as a private matter. Anything that hints at government involvement rankles our sense of autonomy, independence and freedom of choice. It’s a matter of principle.

Health insurance by extension is also a private matter. If I’m healthy, I shouldn’t be forced to pay for something of no value to me. But personal responsibility is not only about what’s good for me. As in the example paying for police and fire protection, I don’t only behave well because it is good for me; I do my part because it benefits my community.

So how does mandated coverage help me?

Health insurance works only if people who aren’t sick participate. If the only time I buy insurance is when I need it, the notion of insurance fails and is replaced by a pre-paid purchasing plan.

Why can’t that work?

Because virtually none of us have saved enough (nor could save enough) and others of us would rather eat and pay rent than save for some unforeseen future event that we pray never happens. So while my personal health is just that; my responsibility to be a good citizen is more than personal.

It means I, along with everybody else, pay for insurance that protects whichever us is unlucky enough to face disaster and isn’t ruined in the process. Personal responsibility goes beyond a “what’s in it for me” mentality to an understanding of “what’s good for me is good for us”.

If I could guarantee you that I would never need access to expensive healthcare that I couldn’t afford, I would land solidly on the side that the individual mandate is government intrusion. But I can’t. That would be foolish. I may not like the mandate, but it does make sense.

Not only for me personally, but all of us - individually and collectively. It’s one of those personal responsibility things that grown ups have to do. It makes me a better citizen and a person of character. And who knows, someday it may just save me and my family from financial ruin.

Because none of us is getting out of here alive.

Link: Podcast: Health Reform: An Ethical Analysis, The Bioethics Channel, 19 minutes 17 seconds

Health Reform: Hope & Foreboding

Terry Rosell, DMin, PhD

March 24, 2010

What happened Sunday evening, March 21, 2010, in the U.S. House of Representatives was shameful, on the one hand, and incremental justice-making, on the other.

Shameful? I’m referring to legislators’ behaviors that engaged bumper-sticker sloganeering (“Cornhusker Kickback”), childish repetitiveness (“. . . this flawed bill”), name-calling (“Baby-killer”), and tit-for-tat posturing for the party leadership. Instead of true debate—involving reasoned response to an opponent’s arguments—this process involved overt partisanship that had little to do with healthcare legislation and everything to do with political will to power.

My 18 year old son, with vocational aspirations that might include law and politics, watched the C-Span coverage with me for awhile. In the midst of “debate,” he turned to me with wide eyes, clearly disappointed, and asked, “Is this for real? Do they really act this way in Congress?” I felt ashamed of my generation of lawmakers.

Or of some. Others in Washington last weekend chose to work more reasonably toward an incremental change in the way healthcare insurance works in a system that has been flawed or broken far too long. Our infamous three tiers (the Haves, Have-Somes, and Have-Nots) are shifting to something more like two, with fewer of us being left out entirely. Fixing insurance gaps and abuses is a big deal, and those who struck a deal to do so are to be commended—or mostly so.

I regret that all of this divided down party lines, and that a few “Tea Party” demonstrators outside the Capitol treated disrespectfully and even criminally several of our most distinguished legislators. I worry that legislation passed will get hung up in further stalling tactics, court cases, state constitutional amendments, and legislative challenges. I anticipate a backlash from those already raging against this show of democratic process, such as it is, who fear that they will lose if others gain, who desperately grasp at power and control.

While this major step toward a more just healthcare system gives many of us hope, it also leaves me with a sense of foreboding that we have not seen the end of Congressional and civilian incivility. With midterm elections just around the corner, the shameful behaviors witnessed in Washington recently may be just the beginning. I hope not.

Link: Podcast, Health Reform: An Ethical Analysis, The Bioethics Channel, March 23, 19 minutes 17 seconds

Health Reform: Not perfect, but a start

Rosemary Flanigan
March 23, 2010

Healthcare is a right. Rights come about when a claim is made to a vulnerable item in a society, which item is a means for responsible action. The right of persons to food, clothing, shelter, and adequate employment is well known.

These rights belong to persons simply because they are persons, not as a matter of contract or merit or law. When one considers the vagaries of nature as it affects people’s health and well-being rendering some people dependent on healthcare, how can one deny that such people ought to assert their right to such care as needed.

Our healthcare “system” has been in need of reform for many years. Imagine a wealthy society that permits over 47 million of its citizens to be without health insurance. This is not merely a financial problem nor even a political one; such a “system” presents us with a moral problem—a problem of justice. And ours is a country that promises “liberty and justice for all.”

When I was a young Sister, no religious group that I knew had health insurance; we either paid for our care or received charity care. Then in the early 70’s, the federal government offered to include us in Social Security and hence into Medicare and Medicaid—at a price. And we borrowed the money to secure it. I cannot imagine living without insurance in today’s world.

The reform is not perfect. There ought to be universal coverage, but this bill is a step towards that. The status quo is intolerable; we must escape from individualistic thinking to broadening our concept of persons as beings-with-others, social beings, and face the responsibilities we have for one another.

Links:

*Podcast: Health Reform: An Ethical Analysis, The Bioethics Channel, 19 minutes 17 seconds

*Immediate effects of health reform bill, Kaiser Health News, March 22
*House Passes Historic Healthcare Reform, MedPage Today, March 21
*Health reform a hot topic in bioethics circles, Wall Street Journal, March 19

To Screen? Or Not to Screen

In November 2009 a report that questioned the merits of routine mammography screening sparked a firestorm of protest, from women’s advocacy groups and medical professionals alike.

But is that criticism deserved?

Dr. Jeff Wieman of the Saint Luke’s Cancer Institute and Terry Rosell of the Center for Practical Bioethics talk about the report and a March 24, 2010 forum in Kansas City examining the issues around this controversy.

Links:

Podcast: The Ethics of Mammography Screening, The Bioethics Channel, March 18, 12 minutes 53 seconds

Overview of forum March 24, 2010

Pain Contracts for Opioids

Rosemary Flanigan

March 18, 2010

In 2009, the FDA announced that they would require the manufacturers of opioids to come together and develop a single Risk Evaluation Mitigation Strategy (REMS) and further suggested that “pain contracts” might be required as a component of such.

Our Myra Christopher has expressed serious ethical concerns about the universal application of pain contracts although they are growing in popularity among physicians.

Recently, the Center collaborated with the American Academy of Family Physicians to develop a CME program on the treatment of chronic pain for their AAFP LIVE! Initiative. Over the past few months, Myra has helped at five conferences across the country to deliver this curriculum. Approximately 1500 providers attended.

The use of pain contracts is raised in the curriculum and has been a point of discussion at all five conferences although there is NO data that points to the efficacy of these contracts. And the only legal action that has resulted from their use has been an action against a physician for not following the terms of the agreement.

Although Myra believes that these documents can be helpful in the care of complex chronic pain cases when the patient has difficulty managing their medications, she is very concerned about their universal application and believes they are corrosive to the therapeutic relationship between the provider and patient.

Her fundamental concern is that these contracts shift the locus of concern from the patient to the provider and violate the covenant between the healthcare professional and the pain patient.

Would you, my thoughtful discussion participants, express your judgments regarding these pain contracts?

Cancer Reporting in the Media - Guess what they report on?

March 18, 2010

Interesting take on how the media reports on cancer from our friend Christian Sinclair at Pallimed.

As a former reporter and current PR professional, the results of this study aren't all that surprising. Reporters, believe it or not, are looking for positive, compelling stories to tell. A successful battle against cancer fits the bill. The negatives involved with fighting cancer are less inviting to share for both the reporter and the patient/family.

Thanks Christian and keep it coming.

Lorell LaBoube
Director of Communications
Center for Practical Bioethics
llaboube@practicalbioethics.org

Link: Pallimed: A Hospice & Palliative Medicine Blog: Cancer Reporting in the Media - Guess what they report on?

Part 2: Commemorating Nancy Cruzan

Rosemary Flanigan

March 16, 2010

As we talk about the 20th anniversary of Nancy Cruzan some of us are saying that the case points to a social, not an individual, ethic; that it’s NOT all about autonomy but it explores character ethic—and character ethics is tied to the relationships that formed us.

What ought to be the character of a populace facing the inevitability of dying in a technologically driven age? Cruzan can be used as a narrative, as a bit of history, to illustrate the issue (I have never conducted a “Caring Conversation” that I have not used Quinlan and Cruzan as stories pointing to the need for a “conversation” with our loved ones).

No one, so far, has lauded the forms, the documents—maybe one of you sees the worth of Cruzan in states’ and federal responses; certainly, the Patient Self Determination Act, for example, is a significant social response.

So, please, you can’t plead ignorance and I don’t think you can plead non-influence. So what does “Cruzan” mean to you?

Eleanor Clift on Healthcare Reform

March 12, 2010

10 minutes 39 seconds

Seems not all that long ago that healthcare reform not only seemed possible, but probable. Now the prospects are unsettled.

In this edition of the Bioethics Channel, Eleanor Clift talks about the political maneuvering that has made passage of healthcare reform so challenging.

Ms. Clift will be the keynote speaker at the annual dinner of the Center for Practical Bioethics on April 13.

Link: Podcast, Eleanor Clift on Healthcare Reform, The Bioethics Channel, March 12

"Lawsuit Urges Payment for Bone Marrow Donors"? Nonsense.

Tarris Rosell, PhD, DMin
Rosemary Flanigan Chair at the Center for Practical Bioethics

March 12, 2010

An article in USA Today asks, “Should people be paid to donate bone marrow?”

Journalist Rita Rubin reports on a lawsuit filed by a stem cell transplant physician and other plaintiffs against U.S. Attorney General Eric Holder. They contend that the government ought to make a legal distinction between bone marrow and solid organs so as to allow compensation of up to $3,000 to persons willing to sell their marrow for stem cell transplants.

Buying and selling either organs or marrow is currently illegal. I think it should remain so.

Proponents of marrow sales want to save lives by increasing the stem cell pool. They claim this could help up to a thousand Americans who die each year for lack of a matching donor. The ends are worthy, though the numbers are speculative.

Mostly it’s the means that trouble me, along with the unintended outcomes one could reasonably expect as a sort of iatrogenic effect of this supposedly curative innovation to expand the donor pool.

The quality of marrow collected and stem cells extracted is expected to diminish even if the quantity were to increase. However, there is no guarantee that more and not fewer people actually would give up their marrow for pay. If the altruistic impulse is removed by means of compensation, we might see a net loss instead. An idea that potentially threatens both quality and quantity of a scarce resource is an idea to be shelved.

Plaintiffs argue that marrow is more similar to blood plasma than to kidneys, and that we do allow people to sell their own plasma. But this begs the question of whether we ought to have commodified blood products—or sperm and ova, for that matter. Many of us would be inclined to argue from exactly the opposite direction. i.e., since our society and virtually all others already ban sales of organs and marrow, we ought also to forbid any and all selling of one’s bodily self.

We have significant data from experiences with organs sold on the “black market” and with legal sales of plasma, sperm and eggs. What happens? In some nations, the poor sell their kidneys to shady brokers who re-sell to wealthier “medical tourists” at many times the original cost. Clinical outcomes from these transplants are relatively awful, and no one except the broker ultimately benefits.

Plasma sellers in this country get a mere $25 to $30 dollars a crack—and too many apparently use the money to buy crack or other harmful substances that result in the generally lower quality of blood collected. Sperm sellers get paid a bit more for their product, but have to lie awake at night sometimes wondering how many dozens of children they now have fathered and whether any will ever search “Dad” out.

Ova sellers reportedly are recruited from Ivy League campuses for as much as $15,000; and many of us with feminist sensibilities suspect that unsuspecting young women are in reality being pimped. It appears to me that a society is not improved by marketing of our bodies in whole or in parts.

Donation—the “gift of life”—rather than commodification of body parts, is a norm deeply embedded in the human moral community. We hardly know how to speak of this in words other than “donate.”

The journalist’s question itself is self-negating nonsense: “Should people be paid to donate . . .?” Clearly not.

Tarris Rosell, PhD, DMin
Rosemary Flanigan Chair, Center for Practical Bioethics
1111 Main St, Suite 500, Kansas City, MO 64105 (816.979.1361)
Professor--Ethics & Ministry Praxis, Central Baptist Theological Seminary
Clinical Associate Professor (Ethics), KUMC, School of Medicine
Mobile: 913.909.3863 Pager: 913.917.0152

Bending the Health Cost Curve

Estimating how much the nation will spend on health care is difficult, but in many ways, it is even more difficult to say how much the nation should spend on health care, because the answer depends on values as well as on data related to health, medical technology, and the economy.

Links:

How to Think about Future Health Care Spending, Victor R. Fuchs, Ph.D., New England Journal of Medicine, March 10, 2010

Bending the Cost Curve, The Bioethics Channel, 16 minutes 27 seconds

Implantable Cardiac Defibrillators- Hospice Role in Deactivation?

Happy to pass along viewpoints on this issue from our friends at Pallimed.

L2

Pallimed: A Hospice & Palliative Medicine Blog: Implantable Cardiac Defibrillators- Hospice Role in Deactivation?

Commemorating Nancy Cruzan

Rosemary Flanigan

March 9, 2010

2010 is the 20th anniversary of Nancy Cruzan's death and of the passage of the Patient Self-Determination Act. At the Center for Practical Bioethics we are thinking about how best to commemorate the two events.

Certainly we don’t honor Nancy’s death—there was nothing “honorable” about it, nor the circumstances of the years leading up to it and the tragic effects of those years on both Joe and Joyce Cruzan (Joe’s suicide and Joyce’s cancer—don’t tell me that stress doesn’t play a part in causing cancer—or tell me, if you think I’m wrong!)

But Cruzan led to the PSDA and that led to a nation’s trying to take some control over dying—and even to the emergence of palliative care. (O.K., hospice and palliative care would have emerged with or without Cruzan, but I see an “influence” of Cruzan there.)

But how best to commemorate the 20th anniversary? So I thought I’d ask you: What does Nancy Cruzan mean to you?

Futile CPR. Always wrong?

Rosemary Flanigan
March 5, 2010

Podcast: 13 minutes 16 seconds

Is it always wrong to perform futile CPR?

That was the question posed by Doctor Robert Truog in the February 11th edition of the New England Journal of Medicine. And that question prompted a great deal of debate in an email discussion group sponsored by Sister Rosemary Flanigan at the Center for Practical Bioethics.

Sister Rosemary talks about it in this edition of The Bioethics Channel.

Link: Podcast, Futile CPR. Always Wrong?, The Bioethics Channel, March 5, 2010

Killing? Or Letting Die?

Rosemary Flanigan

March 5, 2010

Our Ethics and Human Values Committee is discussing whether or not there is a distinction between killing and letting die. To that end, we’re reading a chapter from Dan Callahan’s Troubled Dream of Life and James Rachels’ 1975 NEJM (292:2) article, “Active and Passive Euthanasia,” in which he tries to call the distinction irrelevant.

And reviewing the articles made me think of our futility discussions.

Two issues to distinguish: 1) What justifies, medically and morally, saying that it no longer makes sense to continue life-extending treatment? And 2) What is the meaning of that judgment when it is used to stop life-extending treatment?

As we have argued over the past weeks, once a judgment has been reached about futility, it is considered acceptable by long-standing medical tradition to stop treatment. But what of the judgment by which we reached that notion? Is it, as Rachels alleges, “intending” death?

Callahan makes a forceful attack against Rachels’ attempt to negate any difference (since the end is the same: the patient is dead) by making us recall what nature is: at some point treatment will not keep us alive; we shall die, despite what others may do to us.

To think otherwise is to see the physician, not just responsible for the omitted treatment, but—“as if they were gods—to intend what nature once wrought.”

Also, Rachels’ facile eliding over the distinction collapses causality and culpability—it is not the underlying pathology that is the cause of death, he says, but the actions (or their omission) of providers. And Rachels has his followers because the tehnological imperative has so taken hold on our minds that we transfer the causality of death to the actions of physicians: Did he/she do too much?

Too little? How strange.

Analyzing "Is it Always Wrong to Provide Futile Care?"

Rosemary Flanigan

March 3, 2010

Robert Truog's "Is it always wrong to provide futile care?" in the February 11th New England Journal of Medicine prompted some excellent discussion at the Center for Practical Bioethics.

(Link: Murky path on deciding care at the end, New York Times, Feb 22)

Although "always" and "never" questions allow wriggle room, I spent time wondering how an ethical analysis helped here.

It is easy to set up the analysis; from moral principles one can see the conflict between beneficence and nonmaleficence. The arguments for the priority of nonmaleficence in this case simply flows off the tongue. Or, if you are arguing in a utilitarian framework, it is simple to show the strength of the consequences of non-intervention on the ultimate outcome.

But here, argument doesn't convince. I can see Dr. Truog even agreeing that your argument is stronger than his, yet he justifies acting as he did. So what is the point of argument?

Ethics committee members make compelling arguments in case consultations that are often rejected by patients, families or providers.

WHY OUGHT WE KEEP DOING IT? HELP!!!

When to perform futile CPR

Rosemary Flanigan

March 2, 2010

In the Feb. 11th New England Journal of Medicine Robert Truog, MD (who seems to write as often as Atul Gawande) justifies performing futile CPR for the benefit of family members—not often, of course, and never when it would cause substantial suffering or the withdrawal of resources from others would be a credible threat—but sometimes—and in instances where no “practice guidelines” might ever catch—as an act of sincere caring and compassion.

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

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

Good reflection. Life just isn’t so simple!

Audio Media from "Living Forever"

A lecture by Glenn McGee, PhD on February 24 addressed the ethical implications of wanting to live forever. Dr. McGee holds the John B. Francis Chair in Bioethics at the Center for Practical Bioethics.

The following are links to the lecture and an interview with Steve Kraske on KCUR Radio’s Up to Date.

The Ethics of Living Forever, Glenn McGee, PhD, 59 minutes 35 seconds
Up to Date, KCUR Radio, February 24, 2010