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January 31, 2008

Doctors’ Values Are More Important Than Those of Their Patients

I have been warning anyone who will listen about the coming huge policy fight over medical futility–what I call Futile Care Theory–that allows a doctor to refuse wanted life sustaining treatment when the doctor doesn’t believe that the quality of the patient’s life is worth sustaining (or spending money on). This isn’t about asking for treatment that won’t work, but withholding treatment that will or may work. Usually futile care protocols–where they have been promulgated–allow an ethics committee to make this decision after a quasi-judicial hearing. Texas has been a big center of futilitarian advances.

There is a futile care case right now in the courts of Winnipeg. In this regard, it is worth noting–and being very alarmed about–the futile care protocol adopted by The College of Physicians and Surgeons of Manitoba, which permits the doctor to make the call, after consultation with a second physician, without even having to pass it by an ethics committee. And this is in cases in which the minimal goal of the patient is likely to be met! From the protocol:

WHERE THE PHYSICIAN CONCLUDES THAT THE MINIMUM GOAL IS REALISTICALLY ACHIEVABLE BUT THAT TREATMENT SHOULD BE WITHHELD OR WITHDRAWN, that physician must consult with another physician…

2. Where the consultation supports the conclusion that treatment should be withheld or withdrawn:

a. The physician who sought the consultation must advise the patient/proxy/representative that the consultation supports the initial assessment that treatment should be withheld or withdrawn .

b. If there is still a demand or request for treatment, the physician must attempt to address the reasons directly and with a view to reaching consensus…

c. If consensus cannot be reached, the physician must give the patient/proxy/representative a reasonable opportunity to identify another physician who is willing to assume care of the patient and must facilitate the transfer of care and…

d. Where, despite all reasonable efforts, consensus cannot be reached the physician may withhold or withdraw life-sustaining treatment, but: i) in the case of a patient/proxy who is still not in agreement with the decision to withhold or withdraw treatment, the physician must provide at least 96 hours advance notice to the patient or proxy as described below.

There you have it: Doctors think that their values should rule over those of their patients.

This is the beginning of the institution of a duty to die that we ignore at our peril. It also threatens the trust of people in medicine. My prediction: A lot of fireworks ahead!

HT: Alex Schadenberg

Stem Cell Ethics? We Don’t Need No Stinkin’ Stem Cell Ethics!

Ignoring that New Jersey voters recently rejected a $450 boondoggle bond issue to pay for embryonic stem cell research, New York State is funding the research to the tune of $600 million without even giving the people a chance to vote on the issue. And those behind the effort have no intention of letting nonsense like ethics get in the way. From a column by members of the New York Task Force on Life and the Law:

In April, with little discussion and no public input, New York passed Public Health Law Article 2, Title 5-A, creating the Empire State Stem Cell Board to oversee the funding of a $600 million, 10-year stem cell research initiative. Several other states have had major public ethical debates about stem cell research funding. New York’s statute does not delineate ethical limits on stem cell research except to prohibit attempts to bring a cloned human being to birth. Instead, the ESSCB comprises a funding committee and an ethics committee, with the ethics committee legislatively charged to make “recommendations to the funding committee regarding scientific, medical, and ethical standards.”

Even this minimum level of checks and balances is apparently too tough for the funding committee:

The ethics committee is extremely diverse in its views about these substantive issues. Nonetheless, we unanimously recommended to the funding committee that while this first RFA could permit research on existing human embryonic stem cell lines under current national or international guidelines, funding should not cover the creation of new embryonic stem cell lines or undertake the controversial activities listed above until the ethics committee had the opportunity to deliberate and make solid recommendations. The ethics committee made clear that this brief moratorium did not represent its considered substantive judgment, and that it would make definitive recommendations within six months. What mattered to the ethics committee was that ethics mattered.

On Dec. 13, the funding committee rejected the ethics committee’s call for a temporary moratorium, arguing that it would “send the wrong message to scientists.” On Jan. 7, Gov. Eliot Spitzer announced that the first round of funding had been awarded.

So the blank check mentality continues among the powers that be without risking direct approval by the people or even taking time to consider appropriate ethical checks and balances. After all, we mustn’t give “the scientists” the wrong idea that ethics matter.

Japan: Ministry to widen ban on stem cell research

In a pre-emptive move to avert a debate over ethics, the education ministry will temporarily ban research to produce reproductive cells from induced pluripotent stem (iPS) cells, sources said.

The ministry is expected to make a formal decision when it convenes its Bioethics and Biosafety Commission under the Council for Science and Technology on Friday. (asahi.com)

Pope says some science shatters human dignity

Pope Benedict said on Thursday that embryonic stem cell research, artificial insemination and the prospect of human cloning had “shattered” human dignity. (Scientific American)

Op-Ed: When Health Care Becomes Personal

I do not expect health care to be perfect. I do not expect someone with cancer to have an enjoyable experience. I am not threatening to sue anyone, or even to suggest that the care my father received was anything other than far above average. But I do think that there were serious flaws, and that these flaws are systemic. (TCS Daily)

Calls to lift child embryo ban

The government is looking into calls to lift a ban on creating human or human-animal “hybrid” embryos from dying children to aid key research.

The current Human Fertilisation and Embryology Bill would not allow the procedure to take place unless the child was competent to give consent.

But critics argue many of these children die before this might happen. (BBC)

Lilly Considers $1 Billion Fine to Settle Case

Eli Lilly and federal prosecutors are discussing a settlement of a civil and criminal investigation into the company’s marketing of the antipsychotic drug Zyprexa that could result in Lilly’s paying more than $1 billion to federal and state governments. (New York Times)

Health-Care Reform to Shift Focus

The demise of California’s attempt at comprehensive health-care reform this week means that advocates of overhauling the health-care system will turn their focus back to Washington, several experts said yesterday, as an increasingly tough budget climate raises new questions about whether states can go it alone. (Washington Post)

Death of the father: British scientists discover how to turn women’s bone marrow into sperm

British scientists are ready to turn female bone marrow into sperm, cutting men out of the process of creating life.

The breakthrough paves the way for lesbian couples to have children that are biologically their own. (Daily Mail)

January 30, 2008

Pacificare HMO Hit with Big Fine

More of this please. California regulators have hit Pacificare with a huge fine. From the story:

After an unprecedented eight-month joint state probe triggered by hundreds of complaints, state health insurance regulators Tuesday slapped the PacifiCare unit of UnitedHealthcare with a record $3.5 million fine.

Regulators also will ask an administrative law judge to uphold its allegations that the company mishandled claims and levy additional penalties of up to $1.3 billion. The state accused PacifiCare of 133,000 violations from 2005 to 2007…

UnitedHealthcare officials are still in discussion with the state about the amount of the fine and contend that most problems didn’t directly affect consumers. Regulators and the physician groups disagreed, citing these problems:

- A Sacramento-area surgeon couldn’t schedule surgeries for more than six months because the insurer was slow to enter his contract in its computer system.

- More than 200 of Watson’s patients incorrectly received letters indicating that he was no longer in the insurer’s network of physicians. Watson lost about 25 percent of these patients but continued to see others without getting paid for about eight months.

- A consumer spent 11 months trying to get claims paid for his family, including an autistic child. His wife postponed EKG stress tests, fearing the family could be forced to pay for the procedures. Regulators contend PacifiCare never specified what information was needed to reconsider the denied claims.

So far, regulators have helped doctors and patients collect more than $1 million in payments from PacifiCare’s preferred provider organization and health maintenance organization plans.

HMOs are problematic because they earn profits by cutting costs, which can mean cutting levels of care. Tough regulation, along with resort to private civil litigation, are necessary checks and balances to the potential for abuse of power by bean counting executives.

Mike Wallace Had Triple Bypass Surgery

Newsman Mike Wallace is recovering from a triple bypass surgery. Why is this a matter of interest other than to wish him well? Because under age-dictated health care rationing of the kind practiced in the UK and urged upon us by some very notable bioethicists here in America, Wallace would not have been eligible for the surgery. (Forget for a moment that elites like him would almost surely not be limited by rationing protocols.) Instead, the decision to provide the treatment was based on his individual circumstances. That’s the way it should be.

Financial Ties Are Cited as Issue in Spine Study – New York Times

As it turns out, Dr. Zigler had more than a medical interest in the outcome. So did doctors at about half of the 17 research centers involved in the study. They stood to profit financially if the Prodisc succeeded, according to confidential information from a patient’s lawsuit settled last year. (New York Times)

Brazilian carnival-goers to get access to morning-after pills

The Brazilian city of Recife is to distribute morning-after pills to women during carnival after public prosecutors on Tuesday rejected a Catholic Church lawsuit claiming the initiative promoted sex and provided “abortions.” (Yahoo! News)

Kidney Thefts Shock India

As the anesthetic wore off, Naseem Mohammed said, he felt an acute pain in the lower left side of his abdomen. Fighting drowsiness, he fumbled beneath the unfamiliar folds of a green medical gown and traced his fingers over a bandage attached with surgical tape. An armed guard by the door told him that his kidney had been removed. (New York Times)

Japan to Widen Ban on Reproductive Stem Cell Study, Asahi Says

Japan will temporarily ban scientists from making human reproductive cells from stem cells, a move aimed at heading off an ethical dispute, the Asahi newspaper reported in its English-language edition. (Bloomberg)

Centre offers genetic fix for unborn babies

BRISBANE is about to become one of the first centres in the world to offer stem-cell therapy for unborn babies with brittle bone disease, a life-shortening and disabling genetic condition. (The Courier-Mail)

Op-Ed: Nursing Landscape Could Change With New Specialty

An increasingly complex web of technology, regulations and aging patients has compelled the health care industry to create a new type of nurse trained to lead others through the maze. (Memphis Daily News)

Proposal to allow stem-cell research in Michigan submitted

The Stem Cell Ballot Question Committee in Michigan wants to authorize the use of excess or unsuitable embryos from fertility clinics that “would otherwise be discarded unless they are used for research.” In contrast to legislation designed to open up research on stem cells, the ballot proposal also affirms Michigan’s law prohibiting human cloning. (Detroit Free Press)

The Great Kidney Bazaar

The unearthing of an illegal kidney trade in Gurgaon, a Delhi suburb, could have hardly come as a surprise since India has long been notorious for being the ‘warehouse for kidneys’—a great kidney bazaar. Even less surprising was the fact that the alleged kingpin of this racket, a doctor with various aliases who had earned crores of rupees through unethical means, managed to escape when police raided his ‘clinic’. The police find it easier to catch the small time criminal, not the affluent ones. (Asian Tribune)

January 29, 2008

Medical Journal Exposes Bigotry of “Deliberate Termination of Life of Newborns with Spina Bifida”

In the Netherlands, doctors sometimes euthanize babies born with spina bifida. There (and here), doctors sometimes refuse to treat them so that they will die. But now, a new journal article calls expose these lethal actions and non actions as the bigotry (my term) that they are. Writing in Childs Nervous System (2008; 24:13-28), T. H. Rob de Jong A Dutch pediatric neurosurgeon writes:

There is no evidence that newborns with MMC and hydrocephalus do either ‘suffer’ unbearably or hopelessly and certainly not without the prospect to relieve this suffering by standard care. ‘Suffering’ itself is a nonconclusive,and in newborns, inapplicable denominator that should not be used anymore in this debate. Although they will in their future life be confronted with handicaps,sometimes very severe, their future prospects and their actual experienced quality of life cannot be predicted with such certainty at birth that their lives can be regarded as hopeless or meaningless (‘quality of life judgments’ as such being unacceptable in this decision making). Possible discomfort in these newborns can easily be treated in a straightforward way by active treatment (closure of the defect and shunting the hydrocephalus) and, when necessary,by the use of a professional pain/symptom protocol.

The decision not to treat such a newborn, when based on expected handicaps, possibly violates the ‘non-discrimination’ principle (Dorscheidt, 2006).When not being treated, they are not terminally ill because of the MMC and/or hydrocephalus per se; they are ‘terminally ill’ because of this nontreatment decision. Not being terminally ill, it is not ‘humane’ or ‘merciful’ to terminate their life, this also being not in accordance with international legislation and international medical
recommendations…

Such a child can and should be cared for in a respectful and dignified way, providing all its actual needs (which apparently is not death itself). This being the case, there is no indication whatsoever for the deliberate termination of the life of children born with MMC.

But that takes true compassion, which means to suffer with. Too often, in our utilitarian times, it is deemed better to just do away with the problem by doing a way with the patient–a false compassion.

But at last: A learned and ethical answer to the benighted drive in the Netherlands to permit infanticide against babies with spina bifida. Hooray.

Calif. Health Initiative on Deathbed

The California Senate’s health committee effectively killed an ambitious proposal to create a near-universal health-care system, dealing a major political defeat yesterday to Gov. Arnold Schwarzenegger and a setback to similar efforts nationally. (Washington Post)

 

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