Should a Confessed Killer Get a Second Chance from a Donor Liver?

Summer Johnson, PhD

July 30, 2010

Arthur Caplan in his MSNBC column discusses over a confessed killer receiving a liver transplant.

Of course, getting into the business of allocating organs according to a person's societal worth is messy stuff, but there is something just intuitively obvious about this case that suggests that this patient, no matter now medically needy, perhaps should not have received the liver ahead of, um, whoever else was on the list.

For more click here.

Mental Health and the End of Life

Brian Carpenter, PhD
July 23, 2010

Dying is hard enough work without depression and other mental health disorders interfering with achieving end of life goals.

Washington University’s Brian Carpenter, PhD talks about it in this edition of the Bioethics Channel.

Link: Podcast, 8 minutes 11 seconds

Ice Cream and End of Life

Rosemary Flanigan

July 28, 2010

Myra has us all reading Atul Gawande’s August 2nd piece in the New Yorker. Remember, he’s a physician, so when he says, “Modern medicine is good at staving off death with aggressive interventions—and bad at knowing when to focus, instead, on improving the days that terminal patients have left,” I know he’s pointing his finger at the medical profession.

But I think we “recipients” of today’s medicine share equal blame.

We are too often not ready to hear that our time is almost up. And under what conditions are we able to let go? One story he tells is that of a daughter who hears her father say, “As long as I can eat chocolate ice cream and watch football on TV, I am willing to stay alive.”

And the daughter, of course, is the surrogate, so place those instructions into the mix when one tries to ascertain the “breakpoint discussion” when “dying” is the operative word.

Dr. Gawande cites the LaCrosse, Wisconsin story (which many of us know) where, since 1991 the entire city has been flooded with injunctions to have the “caring conversation” and it has worked! (By 1996 85% of the residents there who had died had written advance directives!)

So I think of the 26 year history of the Center and all the words we have addressed on end-of-life issues to thousands of our citizens, and I wonder why Kansas City isn’t another LaCrosse.

And it’s not just physicians who are slow to recognize that the end is near; it’s we who savor that chocolate ice cream!

But we can’t stop addressing that the end is inevitable.

Link: What should medicine do when it can’t save your life?, Atul Gawande, The New Yorker

Presidential Bioethics

Barbara Atkinson, MD

Summer Johnson, PhD
July 27, 2010

The Presidential Commission for the Study of Bioethical Issues met for the first time July 8th and 9th in Washington DC. In this edition of The Bioethics Channel, host Lorell LaBoube visits with two individuals who attended that gathering – one as a member of the commission, the other as an observer.

Barbara Atkinson is Executive Vice Chancellor of the University of Kansas Medical Center, where she also serves as executive dean. Summer Johnson is executive editor of the American Journal of Bioethics and director of graduate studies at the Center for Practical Bioethics.

Link: Podcast, Presidential Bioethics, 8 minutes 51 seconds

Could Posthumous Egg Donation Ever Be Morally Acceptable?

Summer Johnson, PhD
July 26, 2010

A recent report from the New England Journal of Medicine about a surviving husband to have the eggs of his dead wife harvested in order to create a posthumous child has raised the question of gender equity in the posthumous harvesting of gametes.

Luckily, the medical team did not accede to his request.

The pull that the husband must have felt not to "lose" his wife must have been incredible, but the answer was not to put her through a medically inappropriate procedure, keeping her alive unnecessarily and harmfully to try to result in a reproductive act that neither she nor he would have wanted under ordinary circumstances.

For more click here.

A Code of Silence

Summer Johnson, PhD

Blog.Bioethics.net

July 23, 2010

No doubt it is difficult to stand up to a peer and especially a friend and tell them that they have a problem and that they are putting patient's lives at risk, but better that then knowingly letting them do it, violating medical ethics, and being culpable in the process.

For more click here.

Sister Rosemary Retires

Rosemary Flanigan
Myra Christopher
July 22, 2010

It’s an announcement few wanted to hear but everyone understands. Rosemary Flanigan, PhD, is retiring from the Center for Practical Bioethics.

Sister Rosemary talks about her 24 years with the Center as a board member and staff in this edition of the Bioethics Channel, along with Myra Christopher, the Center’s president and CEO.

Dr. Flanigan's final official act as a staff member of the Center is the Flanigan Lecture scheduled for August 3 at 7 pm. For more information and to register for this free lecture, visit www.practicalbioethics.org.

Link: Podcast, Sister Rosemary Retires, 14 minutes 3 seconds

Annie's Father and Genetics

Rosemary Flanigan

July 21, 2010

Remember the case I told you about that the Nurse Practitioners used last week in their Ethics Forum at their annual meeting?

Let me summarize it: a fourth pregnancy, two normal sons then an 8 year old girl with congenital adrenal hyperplasia. Genetic testing is proposed and the parents told that information gained from that could be used to test the fetus to determine if prenatal treatment is indicated.

Both girl and parents contribute blood, and the lab director calls the primary care physician (or it could be nurse practitioner) to say that DNA analysis identified both mutations in Annie and that Mrs. G was found to be a carrier for one of them but no mutation was found in Mr. G.

Hence, “he could not be Annie’s biological father.”

The NPs reportedly were more inclined to tell the husband she was not his child while some of them wanted to protect the wife’s privacy and have HER tell him. But interestingly a large portion of the Forum time was doing some basics in genetics.

YES!! In my one brown bag so far I have found that MY basic genetics needed a boost. I had originally seen the case as “Whom to tell?” or “Whom to tell first?” by the general practitioner or the nurse practitioner (which will increasingly be the case as the tests proliferate but numbers of genetic counselors don’t keep pace).

But it is so much more than that.

It is knowing enough that one can understand genetic principles, appreciate the benefits, limitations and risks of genetic knowledge and be able to explain them, be conversant on disease as a combination of genetic risk and environmental exposure which makes individual outcome a probability, not a certainty—and on and on.

Have any of you had a idea or two about this case? THANKS.

Bioethics Summer Reading

Rosemary Flanigan

July 20, 2010

The new Hastings Center Report came through our mailbox and it contains “four essays through the lens of literature.” Wouldn’t you know-- two of them were written by Kansas Citians: Martha Montello and John Lantos.

What a treat!!

Martha shows failure (Jodi Picoult’s novels) when the author raises the issues but doesn’t really address them through the unfolding of the story; John shows how often science seems to offer both redemption and doom (cure but at what price?) through the telling of the story.

These are wonderful essays to read and they raise the use of “the story” in ethical analysis. How often do we recount an example, tell a story, as we break open a case? If the “story” is apt, it sheds light on a certain perspective—as do all of our arguments. But how much more beguiling—and more easily recalled—is the “story” from the reasoned-out argument?

Martha says, “Fiction, John Gardner once said, is a moral laboratory. Through well-crafted narratives, a reader examines how a singular person, situated in a specific context, might live a life. A novel that pursues this kind of inquiry with integrity and passion may not only capture the particularities of experience, but also the very processes by which we reach moral understanding and make our choices.”

And John adds that the true story as well as the novel can illustrate new knowledge and offer us new possibilities—in any case, they can “enlarge our imagination.”

“Narrative ethics,” as this kind of analysis has come to be named has much going for it, but the two essayists remind us to read carefully.

FDA REMS: A Pain Policy Balancing Act

Myra Christopher

July 19, 2010

The Food and Drug Administration is moving forward on Risk Evaluation and Mitigation Strategies (REMS) for Extended-Release and Long-Acting Opioid Analgesics.

What do those strategies mean for people in chronic pain, and what does it mean for physicians who wish to prescribe such medications?

Myra Christopher, president and CEO of the Center for Practical Bioethics, explains in this edition of The Bioethics Channel with Lorell LaBoube.

Link: Podcast, FDA REMS: A Pain Policy Balancing Act, 14 minutes

Respecting Living and Allowing Dying

Rosemary Flanigan

July 16, 2010

An editorial from the March, 2010 Journal of the American Geriatrics Society by Daniel J. Brauner, MD from the Pritzker School of Medicine, University of Chicago, was entitled, “Reconsidering Default Medicine.”

So instead of writing orders negatively (Do Not. . . .) how much better it would be to stress something like “comfort feeding only.”

So far so good.

But what does that mean—and here an ethics committee could provide valuable insights and appropriate language for a policy, I think. If the dying infant is making sucking noises, then of course give him/her a bottle; if the dying adult waves away the spoonful of whatever, then put the spoon back in the bowl.

We in the ethics world have lifetimes of work ahead of us encouraging people both to respect living and to allow dying. And in an over-technologically driven world, that “ratio”—balance—will demand ever more sensitivity.

Are any of you aware of hospitals or nursing homes that have “Comfort Feeding Only” policies?? I would love to read some of them. THANKS.

Informing Parent of Non-Paternity

Terry Rosell
July 15, 2010

When assigning a case dilemma as part of a final exam a couple years ago, 30+ grad students in bioethics overwhelmingly opined that disclosure should be made of the non-paternity matter.

Respondents disagreed as to whom disclosure should be made, some favoring the (non)dad, some the (presumably promiscuous) mom, and others the (adult) child. The better students provided rationale for their moral sensibilities, of course. Some others didn’t do so well on that exam question…

A couple physicians, when asked for an opinion, recalled a boards exam question like this for which the “correct” answer would be nondisclosure. Some stem cell transplanters have told me that their practice, too, almost always would be nondisclosure of nonpaternity data arising from blood tests for stem cell donor compatibility.

So it may be that the popular sense of the “ought” (disclosure) is at odds with professional practice and norms (nondisclosure). We once (or twice) tried, and failed, to get money to study that hypothesis.

My own sense is that the ought (or not) of this issue is more situationally and relationally complex than can be tested in boards exam questions for which there is one supposedly right answer—and that the majority of my bioethics students’ essays demonstrated cognizance anyway of this complexity whether or not they could justify adequately their gut responses.

Spontaneous Judgments

Rosemary Flanigan

July 14, 2010

Borrowing a case study here used at a national meeting of nurse practitioners:

As genomic information becomes a part of common medical disorders, the primary care practitioner will have to assume responsibility for providing patients and families with an understanding of the risks and benefits of genetic knowledge.

So consider this case: Mr. and Mrs. G are a couple who are being referred for prenatal genetic evaluation in their current (4th) pregnancy. Mrs. G is 34 years old and currently is 9 weeks pregnant.

They have two sons, ages 12 and 10, who are healthy. Their 8 year old daughter, Annie, has a diagnosis of congenital adrenal hyperplasia (CAH). Annie has the classic salt wasting form of this disorder and is being followed by the pediatric endocrinologist at the local children’s hospital.

The gene for this particular condition is known and the parents were counseled that testing the current pregnancy could be done if the mutations in the family were identified. This information could then be used to test the fetus and determine if prenatal treatment of an affected female fetus is indicated.

Blood from Annie and her parents was drawn for direct DNA testing. The parents were informed it would take about 2 weeks for the DNA lab to complete this testing. Two weeks later, the laboratory director gives you a call. She says that DNA analysis identified both mutation in Annie, and that Mrs. G was found to be a carrier for one of these mutations.

However, no mutation was found in Mr. G, which means he could not be Annie’s biological father.
ETHICAL ISSUE: Should the primary care practitioner inform the mother/father or both of non-paternity?

Don’t skip “the answer” and then sit back looking smug. Trace your moral spontaneous judgments before we do any ethics at all. My hunch is that these will be broad-ranging—and thus there will be “meat” for several “ethical analyses.”

Want to tell us what your spontaneous moral judgments are??????? And where they lead??????

False Claims versus Medical Necessity

Rosemary Flanigan

July 13, 2010

I read an article in Trustees, the Horty Springer Publication, for March/April 2010. It is entitled, “False Claims Act Litigation and Medical Necessity: Hospitals Beware!” and tells how a small rural hospital in Minnesota recently paid almost $850,000 to the federal government to settle a False Claims Act lawsuit.

A former medical staff member filed a whistleblower lawsuit alleging another physician’s medically unnecessary services. The federal government evaluated the claim and decided to intervene. This intervention led not only to charges against the physician but also against the hospital for “deliberate ignorance” concerning these claims.

“Hospitals are between a rock and a hard place when it comes to medical necessity. When they monitor admissions, length of stay, use of diagnostic tests, and other measures related to the use of resources, some physicians will cry foul and claim the hospital is engaged in ‘economic credentialing.’

But if hospitals don’t evaluate such factors, the government may allege they violated the False Claims Act.”

Document, document, document. Since lawsuits of this nature frequently take place years after the event/s, hospital trustees were warned in the article to see that admissions and procedures were benchmarked against similar hospitals, that effective case management and utilization review plans were provided and reviewed, support adequate documentation to justify medical necessity, and make sure a solid peer review system is in place.

I shudder to think of the effects of a fine of that magnitude to that 25-bed hospital!! Ethics committee members, be part of the solution, not the problem!

Introducing "AJOB: Primary Research"

Summer Johnson, PhD

July 12, 2010

The American Journal of Bioethics launches a spin off journal.

It’s called AJOB Primary Research, and Lorell LaBoube visits with AJOB executive editor Summer Johnson about the new journal in this edition of The Bioethics Channel.

Link: Podcast, Introducing AJOB Primary Research, 6 minutes 10 seconds

Live: The Presidential Commission for the Study of Bioethical Issues

Summer Johnson, PhD

July 9, 2010

Summer Johnson, PhD, the Center’s director of graduate studies and executive editor of the American Journal of Bioethics, is onsite at the first meeting of Presidential Commission for the Study of Bioethical Issues in Washington, DC.

She is filing reports via blog at www.bioethics.net. Here are links to reports from Day 1 and Day 2.

Day 1: Puttin' On the Ritz...With the PCSBI
Day 2: Ethics Comes Early in Washington

Top 10 Podcasts -- January thru June 2010

The Center's podcast, The Bioethics Channel, continues to grow in reach and listenership. June 2010 was the best month ever for downloads of the program. And sometime in July 2010 the podcast will reach 25,000 downloads since February 2009.

It starts with good stories and good people to tell those stories. Thanks to all for making this possible.

Lorell LaBoube

Director of Communications

Center for Practical Bioethics

The End of Life Scare
Myra Christopher

A Quarter Century of Practical Bioethics
Myra Christopher

Ashley X Revisited
John Lantos and Norman Foss

Healthcare Reform: Deja vu all over again?
John Lantos

Terri Schiavo Lives On
John Carney

A Physician's Reflections on Bioethics
Robert Potter

Hospital Ethics Committees: Then and Now
Rosemary Flanigan

Why do people still suffer at the end of life?
Myra Christopher

Futile CPR. Always Wrong?
Rosemary Flanigan

Is it ethical to want to live forever?
Glenn McGee

Therapeutic Misconception at its Worst

Summer Johnson, PhD

July 6, 2010

The International Society for Stem Cell Research (ISSCR) has created a website that aims purportedly to help patients assess the claims made by stem cell companies and researchers offering cures via stem cell research.

I am usually reluctant to argue against patient education and empowerment, but this website does precisely the opposite.

It only muddies the waters and will confuse patients desperate for cures who are turning to stem cell trials as a last resort and want very much to believe that the research laboratories that they are walking into are "clinics" and the trials they are enrolling in are "therapeutic." Unfortunately, that is not yet the case. And ISSCR should just come out and say so.

For more click here.

Ethical Rules and Rules of Policy

Benjamin Sachs

July 6, 2010

There are similarities and differences between ethical rules and rules of policy when it comes to human subjects research.

Benjamin Sachs explains in this edition of the Bioethics Channel. He is an assistant professor in environmental studies and bioethics at New York University, and he wrote an article entitled “The Case for Evidence-Based Rulemaking in Human Subjects Research” in the June 2010 issue of the American Journal of Bioethics.

Link: Podcast, Ethical Rules and Rules of Policy, 9 minutes 52 seconds

POLST and TPOPP

John Carney
July 2, 2010

There is one group of patients for whom advance care planning and goals of care can be incorporated into a single document, but the form is not available in all locales. It is designed for those living with advanced disease and is called POLST (Physician Orders for Life Sustaining Treatment) or variations on that theme.

In Kansas City we are calling it TPOPP (Transportable Physician Orders for Patient Preferences). The form actually incorporates patient goals into physician order sets dealing with treatment preferences in a variety of areas (surgery, CPR - from full to no code, antibiotics, and hydration and nutrition), so while it ends up being a set of physician orders, the process requires a discussion about treatment preferences and values and thus, advance directives.