GOP Candidates on Advance Directives

This from the GeriPal Blog yesterday.

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Are you encouraged that the candidates have at least some healthy respect for Advance Directives and the right not to have CPR performed upon them? Are you dismayed by some of the statements about judicial review for end of life decisions?

I for one am hopeful as the language used in this debate is very different than the language used during the debates about health care reform (in particular the provision to pay for advance care planning consultations).

Link to blog here.

IOM Report and NEJM

Alleviating Suffering 101 — Pain Relief in the United States

Philip A. Pizzo, M.D., and Noreen M. Clark, Ph.D.
New England Journal of Medicine
January 19, 2012

The magnitude of pain in the United States is astounding. More than 116 million Americans have pain that persists for weeks to years. The total financial costs of this epidemic are $560 billion to $635 billion per year, according to Relieving Pain in America, 1 the recent report of an Institute of Medicine (IOM) committee that we cochaired.

Links:

Alleviating Suffering 101 — Pain Relief in the United States, New England Journal of Medicine, January 19, 2012

Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, Institute of Medicine

What’s Next? The IOM Report on Pain, Myra Christopher, The Bioethics Channel

Part II: Undocumented Organ Donor

Here are some responses to yesterday’s post on this subject.

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Response 1: I cannot think of any compelling moral reason not to use the living donors for this person regardless of their alien status as long as no one is burdened against their will. This is to say if the insurance is willing to pay for the donors as well as the recipient (including follow-up for complications) and if the donors are giving fully informed consent then what would be the argument against doing so. It is a gift and alien status really is of no consequence if the burdens are accepted.

The policy of the Organ Procurement and Transplant Network (OPTN) 6.2 clearly states that a resident alien cannot not be discriminated against for transplantation if they fulfill all of the other requirements for transplantation. I can understand recipient not getting the transplant (though I may not agree with it) but cannot see how being a donor would disqualify.

Response 2: Seems to me that, if one eliminates the reimbursement issue, what you are left with is this question: Are people without the "proper" paperwork somehow of lesser status as human beings, and thus entitled to a lesser standard of care?

I hope the answer to that is obvious.

Response 3: The other side of the coin is not whether the “donee” is entitled to the same standard of care. It is whether the “donors” of organs are in the same vulnerable position as prisoners, and therefore not ethically allowed to donate organs.

The donors are in the unique situation of assuming significant risks with no benefits from the procedure and therefore should be entitled to greater protection from coercion.

Undocumented and Organ Donor?

Consultation for ethics response pertains to a case in which a resident alien (documented) with end-stage renal failure, recently listed with UNOS for a deceased donor kidney transplant, presents to the kidney transplant program two or three potential living donors who are undocumented immigrants.

Question put to Ethics is: Ought the transplant program evaluate and accept undocumented persons as living donors of a kidney?
Note: This transplant program, and others asked, typically have not transplanted (recipient) undocumented persons. Public insurance apparently is not available without legal immigration status; although for a documented person/patient recipient of an organ, public insurance (or private, if they have it) is apt to pay medical expenses both for recipient and donor.

Are there nonetheless compelling moral grounds for not using as living donors persons without papers--or for doing so?

MLK and the Center for Practical Bioethics

In March 1965, Rosemary Flanigan was among a group of Catholic nuns who traveled to Selma, Alabama to advocate for civil rights. The trip came shortly after "Bloody Sunday" on March 7, 1965, when 600 civil rights marchers were attacked by state and local police with billy clubs and tear gas.

Sister Rosemary shared her experience and her thoughts during an event sponsored by the Center for Practical Bioethics on January 19, 2009. The next day, the first African American in US history was sworn in as President of the United States.

Sisters of Selma – Bearing Witness to Change
Sister Rosemary Flanigan
Father Norman Rotert

A Sister of Selma Celebrates Martin Luther King’s Birthday
Sister Rosemary Flanigan
3 minutes 02 seconds

A Priest Reflects on Dr. Martin Luther King
Norman Rotert
3 minutes 13 seconds

Hospice in American Prisons January 30

Nationally, about 3,300 men and women die in American prisons each year. A decade ago, most died alone and in pain. Today, thanks to the creative leadership of a few prison wardens and superintendents, there are seventy five active hospice programs in this country.

They believe the provision of hospice care for dying inmates transforms lives: the life of the dying inmate and the life of the inmate caregiver.

Find out how during a special program January 30th at 5 pm at the Community Christian Church in Kansas City, MO.

Serving Life, a documentary about the hospice program at Angolo Penitentiary in Louisiana, will be shown followed by discussion and review of a traveling photo exhibit about the program.

For more information and to register click here.

Part II: Does parsimonious equal ethical?

It might be that the American College of Physicians would be wiser to not use what amounts to a technical term better understood by an audience they're mostly not addressing in this document.

Read in context, I think it should not be difficult for most readers to get the meaning intended. The full quotation from this article is as follows:

"Physicians have a responsibility to practice effective and efficient health care, and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available."

Seems pretty clear to me.

Given the number of very expensive, situationally ineffective, even risky or harmful, and oftentimes unnecessary-but-for-"defensive medicine" scans and interventions that are ordered so long as someone (Medicare/Medicaid/Tri-Care/insurance) will pay . . . I'm having a hard time getting too worried about ACP finally using the "p" word with physicians.

It appears to me, rather, that it is Gottlieb who gets it wrong here, if quoted accurately: "I mean, that really implies that care should be withheld." Does it? Or is he constructing a straw man?

Even if we correct his misuse of the term "care" (surely he means to say "treatment"), the only real implication I see is that of encouraging a wiser, more equitable use of healthcare resources.

While we might not want to put that responsibility fully on the shoulders of clinicians--the rest of us as patients and parents/families, politicians and other policy makers, have as much or greater responsibility to choose and use wisely--physicians too need to get on board so that fewer trains to nowhere good never leave the station.

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

Does parsimonious equal ethical?

The American College of Physicians recently released an updated ethics manual calling for physicians to practice "parsimonious" care.

That prompted a practical discussion of what this means among the list serv discussion group at the Center for Practical Bioethics. Here’s a sampling, edited for length:

I was not uncomfortable with the ACP use of the term parsimony or parsimonious practice. I am used (to) the term as it is often referred to as "Occam's Razor" or lex parsimoniae and as applied to medical practice I see it as referring to avoiding expensive and not so useful testing or testing for the sake of testing and perhaps even, shudder the thought, reducing ineffective medical treatment.

Traditionally and at least within the context of philosophy, the terms has always referred to the use of an economy of assumptions, a minimalist approach to thought and practice, and, of course if used in particular fields, the terms will usually assume a more narrow and more focused meaning. It is certainly not a neologism but a definition that may have a more specifically focused connotation. Many logicians refer to this practice as using "precise definition.

Parsimonious does not mean ethical. It is a shame that the statement does not simply say “medical care congruent with professional standards and the patient’s goals and values.”

Wow. My Webster’s dictionary has as one of the definitions of parsimonious….”frugal to the point of stinginess.” Also parsimony has as one definition….”economy in the use of means to and end.” Hmmm, how do we define “end”?

What do you think? More commentary later.

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