Thursday, April 24, 2008

Can Medical Ethics Taken to the Extreme be Detrimental?

I believe it can. Here’s a recent example.

An 18-month old child with a rare and always fatal disease had been on life support in a Texas hospital for five months. The Texas physicians, with the agreement of the hospital ethics committee wanted to discontinue life support because the child had no chance of recovery. His death was imminent and certain. Texas has a Futility Law that provides for a limited time period before the hospital, with the agreement of the ethics committee, can discontinue all but supportive care. His mother wanted life support continued and with the help of others, appealed to the courts to prevent the Texas Futility Law from being activated in this case. The child died before the judge’s final ruling.

Dr. Robert D. Truog, Professor of Medical Ethics and Anesthesia (pediatrics) Harvard Medical School, wrote about this case in a perspective article in the New England Journal of Medicine. (1) In Dr. Troug’s view, since the child was severely neurologically impaired and could not perceive pain, the doctor’s claim that he was having a painful death was not valid. But what about the indignities suffered by this child with feeding tubes, constant IVs, multiple blood tests and the ventilator tube to keep him breathing? The physician’s concern about the dignity of the child’s death was of little concern to Dr. Troug, the child’s mother and others who joined in the legal battle.

These are extremely unfortunate and painful situations that require delicacy and understanding, but I believe, must be addressed with a sense of reality. If, indeed, the total weight of medical knowledge shows that a patient will not benefit from therapy, then providing such therapies because of patient/family demands, means physicians are not to express or develop judgment, but must rather use their skills as technicians at the bidding of others.

There is no doubt that some form of due process should be in place to insure against human misjudgment and provide fairness to the patient/family. But Dr. Troug’s view that the judicial system is the only source of due process is an extreme view that says honesty and fairness is impossible in a medical setting. I share Dr. Troug’s respect for the need to be fair to minority views, but that fairness does not, in my opinion, extend to family desires that are totally inconsistent with the reality of the situation. This is just the sort of situation that would benefit from a nationwide system of appropriate care committees (See my March 1,2008 post about Appropriate Care Committees for more details.) The courts are not the places to decide medical issues.

Dr. Troug’s conclusion that physicians are incapable of dealing kindly but appropriately with end of life situations along with ill-conceived judicial opinions (2), have had a serious negative impact on American medicine. This has led to over 550,000 deaths in ICUs yearly with its overuse of technology and procedures, lack of spirituality at tremendous cost to our society (3).

In my opinion, physicians must learn how to deal fairly with the many difficult and sometimes tragic situations they confront on a daily basis, but cannot relegate conflict to others, especially to the courts. Doctors must learn to use the profession’s ever increasing treatment options wisely for the benefit of their patients and for our society. A family’s demand for treatment does not relieve the physician of responsibility to deliver care within the confines of medical knowledge and with the best interest of the patient at heart.
1. Troug, RD. Tackling Medical Futility in Texas. New England Journal of Medicine 2007;351:1-3 (PMID 17611201)
2. Annas, GJ. Asking the courts to settle standard of emergency care – the case of Baby K. New England Journal of Medicine 1994;330:1542-1545 (PMID 8164726)
3. Angus, DC, Barnato AE, Linde-Zwirble, WT, et al. Use of intensive care at the end of life in the United States: an epidemiologic study. Critical Care Medicine 2004;32:638-643 (PMID 15090940)

Friday, April 4, 2008

The Health Care Mess - Medical Society Responsibility

The American College of Physicians (ACP) recently presented an elegant model of primary care in the Annals of Internal Medicine. (1) They also made other suggestions that would greatly improve health care in The United States. What they failed to do, however, is discuss why primary care is in such a shambles and what their role should be as a professional organization. Primary care is the backbone of any successful health care program. Patients and their primary care physician – what we used to call the family doctor – can build relationships that bring much better care in the long run. Why? Because the primary care physician knows the patient as a “person” not just a jumble of symptoms and diseases. That’s of the utmost importance when it comes time to make decisions about care, and for a physician to use judgment about what’s appropriate for a particular patient.

Approximately one-third of care is inappropriate to the tune of $600 billion dollars a year. (2) That’s a lot of money that could be directed to primary care, provide universal access and make our health care system less of a burden on our economy. The ACP should take a leading role in addressing the excessive use of technology that frequently does not benefit the patient, particularly patients at the end of their lives. (3) If the primary care system was strong, there would be a vital link between the patient and the hospital that would facilitate much better decisions about what would be in the patient’s best interest.

The plain fact is that hospitals and physicians make more money with expensive procedures whether they help the patient or not. A classic example is using coronary artery stents in patients in whom medications alone are equally efficacious. (5) The growth of specialty hospitals and procedurists is a result – not more physicians practicing primary care. At this time there’s just not enough prestige and money in it.

Most of the overuse of technology and procedures occurs in large teaching hospitals. (4) What kind of message does this send to young physicians in training? Does it teach them to build relationships with their patients? To use their judgment to decide what would benefit a patient the most? Or does it teach them to throw every procedure they can into the mix and bill handsomely for it?

Medicare has attempted to adequately fund primary care. However, because of the excessive funding for specialists and procedures, their efforts have failed. (6) If the American College of Physicians is serious about its goal of excellent primary care for all, then it must take an active role in promoting the appropriate use of our medical resources. Only with a return to a strong primary care system will we see good preventative care and the delivery of appropriate treatment for everyone.
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1. Public Policy Committee of the American College of Physicians, Ginsburg JA, Doherty RB, Ralston JF Jr. et al. Achieving a high-performance health care system with universal access: what the United States can learn from other countries. Annals of Internal Medicine 2008;148:55-75 (PMID 18056654)
2. Garson A Jr., Engelhard CL. Health Care Half Truths; Too Many Myths, Not Enough Reality. New York: Rowan and Littlefield; 2007, Page 17
3. Barnato AE, McClellen ME, Kagay CR, Garber AM. Trends in inpatient treatment intensity among Medicare beneficiaries at the end-of-life. Health Serv Res 2004;39:363-375 (PMID15032959)
4. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucus FL, Pinder EL. The implications of regional variations in Medicare spending, Parts I&II. Annals Intern Med 2003;138:273-298 (PMID 12585825 & 12585826)
5. Mitka M. Cardiologists get wake-up call stents. JAMA 2007;297:1967-1968 (PMID 17488954)
6. Ginsburg PB, Berenson RA. Revising Medicare’s physician fee schedule – much activity, little change. N Engl J Med 2007;356:1201-1203 (PMID 17377156)