What are the ethical issues?

Moderator: Shannon Brownlee, MS, Acting Director, New America Health Policy Program

Do we need a new Hippocratic Oath, or just a new interpretation of the original?

What is the moral imperative of physicians, regardless of time or place? What are the harms of overtreatment? What are the rates of those harms? Is there an ethical difference between over-diagnosis and overtreatment? Does the Hippocratic oath demand all possible efforts at diagnosis, regardless of the Bayesian pre-test probabilities? Should we call the provision of unnecessary care a type of medical error, if only to highlight the often-unanticipated downside risk? Would this increase visibility of the problem? How does the ethical imperative of “patient-centered care” avoid avoidable care when it is driven by patient demand?

Moderator Commentary:

First, do no harm.

That’s the first admonition of a physician’s ethical code. Yet, we consistently see medical professionals giving care that offers no possible benefit to their patients, but puts the patient at risk of complications and side effects. Is that an ethical failing? Is it a greater ethical wrong to cause harm with unnecessary treatment than to miss a diagnosis or fail to deliver needed care?

This panel will address both the systemic ethical challenges of unnecessary care, and the ethical questions posed by interactions with specific patients. What is a physician’s ethical responsibility to understand medical evidence? To inform patients and families fully about potential downstream consequences of treatment decisions? How do we grapple with the problem of conflict of interest, and the use of new technology before it’s been adequately tested?

The panel will also discuss how the profession is succeeding and failing to meet its obligations, including with palliative care efforts, in medical education, and other areas.

A note: the ethical problems of avoidable and unnecessary care are different and should be debated separately from the question of rationing. Rationing refers to making choices among patients or different treatment outcomes, in order to allocate limited resources. This discussion will make a distinction between rationing and avoiding the needless harm that is inherent in needless care.

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Shannon Brownlee’s ethics panel introduction

July 09, 2012   Avoidable Care Admin   No comments

Below is Shannon Brownlee’s introductory speech from the ‘What are the ethical issues’ panel.

Thank you all for being here today – distinguished panelists and participants.

I want to tell you a story. That’s what writers do, tell stories. It’s not my story, it is Diane Meier’s, and I hope I tell it correctly. She told it to me years ago, and it haunts still, which is why I want to relate it to you.

The patient was an elderly Hispanic man. He barely spoke English, and he was dying of lung cancer when Diane met him. Mr. S., as she calls him, had watched his wife succumb to lung cancer three years earlier. When he was diagnosed with the same disease, he wanted no part of the side effects his wife had gone through. He declined chemotherapy, radiation, and surgery, saying he wanted to die at home, surrounded by his family.

The hospital sent him home, but a few months later, Mr. S. was brought in to the emergency room by his grown children. He was delirious and suffering seizures from metastases in his brain. The hospital admitted him to the neurology department, where he was stabilized.

When Diane entered his room, she found a frail, emaciated man. He had a nasogastric feeding tube, and he was thrashing was in his bed, yelling unintelligibly, and pinned down in 4-point restraints.

Diane went to find the neurology resident in charge, and asked him what was going on. The resident told her that Mr. S. had pulled out his feeding tube repeatedly, and that was why he was in restraints. And then, the young doctor looked at Diane, with enormous distress in his eyes, and said, “ ‘If I don’t keep Mr. S. in restraints, he’ll die.’ ”

There’s a concept in the medical ethics literature called moral distress — it’s a description of how one feels when you know what is ethically appropriate, but you are unable to do what’s right because of obstacles that are inherent in the situation. Moral distress was first described in 1984 in a book on nursing ethics and the term is mostly used in relation to nurses, who often feel trapped between the doctor’s orders and the suffering of patients.

Obviously moral distress is not limited to nurses. Diane’s story about the dying man haunts me because there was suffering on both ends of the stethoscope. The story of Mr. S gave me some insight into clinicians’ struggles, and it a measure of compassion – a way to integrate my own conflicting feelings about the role clinicians play in the delivery of unnecessary care.

Here is the conflict. On the one hand, it was a physician who wrote the orders for Mr. S to be put in 4-point restraints. It is, after all, always a clinician who writes an order for an unnecessary drug, who performs an unneeded catheterization, who admits a patient to the ICU when what the patient really wants is to die at home.

On the other hand, many clinicians feel trapped in a system that often pushes them to do the wrong thing. A system that makes it easy to do harm. And just like that young neurology resident, they feel a terrible distress.

Clearly the prime directive of medicine, primum non nocere, which I think would sound a lot better if it were pronounced with an Italian accent, is inadequate to the task of helping clinicians perform the balancing act that is inherent in the practice of medicine. Of balancing the potential for harm from not doing enough, which is where thinking about medical ethics has tended to dwell, against the harm from doing too much.

This leads us to many questions, a few of which I’ll name here:

1.Why do we perceive errors of commission as lesser sins than errors of omission?

2. And why do we not consider it an error, or at least unethical, to fail to inform patients about the true costs, both financial and physical, of medical care, and its limitations?

How can it be ethical to use a shiny, new, and often very expensive technology, like a robot, or a drug-eluting stent, or a new surgical technique, as a marketing tool to bring in paying customers? And how can we continue to use it without bothering to find out if it actually works?

I’ll stop there.

My request to this panel is the answer to an admittedly blunt question: Do we need a new medical ethic? Because clearly, just saying no to harm is not enough.

I won’t go into lengthy introductions. Please read this panel’s bios. Diane Meier, Howard Brody, and Jerry Hoffman are highly accomplished, recognized in their fields, but they are here today because they also have thought deeply about the meaning of professionalism. Howard Brody has the added distinction of being a bioethicist by training.

Jerry Hoffman will lead off with some overarching principles. Howard Brody will bring an ethicist’s perspective, and Diane Meier will bring us full circle to the this problem of moral distress.

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