the glory and the horror

This CNN article highlights a continuing question in the realm of medical ethics and philosophy of medicine. The basic question is whether or not parents have complete and inalienable rights to decide what is in their child’s best interest in terms of their health care. In this case, the child has Hodgkin’s lymphoma, a very treatable condition, although chemotherapy is never easy.

However, compared to many other malignancies, the prognosis is very good, and the treatment regimens are well-understood with significant data to support current treatment regimens.

But it appears that the family does not believe that pursuing futher allopathic medical treatment (conventional western medicine) is in the child’s best interest, and instead have chosen to pursue other treatment courses, namely a Native American modality (or so says the article).

So does the State (or Society) have a compelling case in “protecting” the child from his parents wishes? Where, if at all, do the parents’ rights to make decisions for the minor end?

This has been debated in the ethics literature in the past, and there are arguments that go back and forth. However, this is the real thing, with a real child’s life and well-being at stake.

Do you invoke the authority of the state and force the family to return the child for treatment?

I just wanted to highlight a new rule that the Department of Health and Human Services is considering implementing to protect the right of conscience for health care providers.

You can read more about it at The Center Blog, which my friend Isaac contributes to.

I think it is very important that the right of conscience, in general, and specifically in medicine, be preserved in the US. It is better to be free to live according to your conscience, and it would be nice to not have your medical license revoked simply because you are opposed to abortion or some other procedure.

BBC NEWS | Science/Nature | No consensus on IPCC’s level of ignorance

An interesting perspective by a scientist on the IPCC and the nature of knowledge in atmospheric science as it pertains to global warming.

A recent New England Journal of Medicine article from the 8 February 2007 issue tried to understand and characterize the nature of conscience as it plays a role in clinicians and their willingness to disclose information and refer to other clinicians who do not have similar moral objections. It reports that many (86% of 1144 surveyed) physicians believe they are “obligated to present all options” while a slightly smaller number (71%) believed they were obligated to “refer the patient to another clinician who does not object to the requested procedure.”

This brings up an interesting point because that leaves 14% who do NOT believe they are obligated to present all options, and 29% who would NOT refer to a willing clinician. I can imagine that the attitude of such physicians is one where they see the controversial procedure/action as such an evil, that even their referral to another clinician would be seen as being complicit in a moral evil. I’ve even considered such a position for various things.

A recent Ph.D. dissertation from a graduate student at Rice recently dealt with the issue of complicity, and in particular, his position comes down to one where complicity is defined quite broadly, but with an important factor that may not be present in the situations brought up by the survey – a “pro” stance (I haven’t read the dissertation yet, but am just paraphrasing that from some other sources)

This brings up an interesting point. If I don’t cause something to happen, but help it happen by referring the patient to someone willing to do it, yet I maintain I do not have a “pro” stance, is that complicity with a moral evil?

Our new Constitution is now established, and has an appearance that promises permanency; but in this world nothing can be said to be certain, except death and taxes.

- Benjamin Franklin, Letter to Jean-Baptiste Leroy, November 13, 1789

These past few weeks have seemed to prove his statement so true. During my last call, I saw 4 patients die in the MICU, 2 of whom hadn’t been in the ICU more than 24 hours. One of them was a tough one, as the guy had just come in at 5 am in the morning, talking and actually appeared kinda put out that he was in the hospital, and by noon, we had already coded (i.e. attempted resuscitation) him twice, and he had died.

The other part of the statement is also true, but not nearly as stressful or emotionally tiring. We’ve also seen (and paid) our property tax bill, which was more than we thought it would be. Suffice it to say that when you don’t pay state income tax, you’re bound to pay somewhere else.

When dealing with the relative certainties of death, it’s one thing when we have attempted everything within our power to resuscitate. It is clear that we have reached the limit of medical science when we have thrown the kitchen sink at the patient and nothing has worked. The question is whether or not we are always obligated to do so.

When a patient has suffered a significant injury to the brain, usually in the form of a prolonged period of decreased/minimal, or even absent blood flow to the brain, permanent damage occurs in the brain, and repair of such anoxic tissue (i.e. tissue that has been deprived of oxygen) is minimal to non-existent. When the entire brain is subjected to such stresses, it does not do well. We may be able to recover some level of minimal function, such as primitive reflexes, or maybe the patient will breathe on her own, but that does not mean that recovery of more complex functions is likely, or even possible.

So what does that mean for the family? Many will cling to the hope of recovery, at least for a time. They will hope and pray that their loved one will regain some degree of meaningful (which is always hard to define) neurologic recovery. They pray that their loved one will remember them, will react to their presence, will interact with them. They hope for what is generally thought of as a miraculous recovery, since the doctors have all told them to expect and plan for the worst.

Sometimes, the patient continues to decline, and eventually dies of something, like an infection, or just continued deterioration caused by underlying illnesses, such as cancer or heart problems. Sometimes, patients will stabilize, but in a very tenuous state, with a thin line dividing stable (for now) and very sick. The difference can be quite the precipice, and there may not be a gradual slope from one side to the other.

What happens when a family is convinced that their loved one will recover completely? Is that simply unrealistic? Is it wishful thinking? Is it hope? Is it faith in a powerful God, who has already triumphed over death? Is it trust in a Power that knows no bounds? Is it a delusion, a fixed false belief? Is it a refusal to face what is the most reasonably expected outcome?

What sort of future are we trying to give our children?

Is this good enough? 2 years. Otherwise, it appears the baby was developmentally normal. I am personally thankful that she fought for her child. This is one of those times when technology can, does, and ought to be used to provide a life that would otherwise have been impossible.

The Irish High Court just ruled that a frozen IVF embryo is not the same as an in utero embryo. This takes the entire question of embryonic personhood to a new level. Now there’s a separate category for embryos in a uterus, and ones outside. It brings up a critical question. Does physical location fundamentally change the character of an embryo?

They seem to have caught up with the US, in saying that yes, physical location DOES change the personhood status of the embryo. Why, I’m not sure. We’re already trying to redefine personhood in terms of abilities, especially when it comes to the end-of-life, which is disturbing enough. Now physical location changes things.

This qualifies for multiple categories on so many levels.

I finally got in touch with the right people so that I can be on the ethics committee at one of the hospitals I work at. I don’t know how much I’ll be able to participate, but I will at least still be in on the process. It will be a setting in which I have not seen the ethics committee working, in that I’ve seen private and public county hospitals, and now I will see a federal hospital. There are apparently slight nuances that do change with the fact that it is a federal hospital, most notably that the policies are based on federal policy, not state or local policy. We’ll see how much that actually makes a difference.

On a related note, I got to have one of my first conversations, as an actual MD, with a patient and his wife about stopping aggressive treatment for his medical condition. He understood that without treatment, the disease would definitely progress, and at a rate that may leave him with only weeks to months to live. She supported him, but I knew it was hard for her to come to grips with the fact that this man, to whom she had been married for over 5 decades, was not far from leaving her. I almost broke down while talking to them.

It was one of those situations that I hate being in, but at the same time, I love it. I hate it because I have to tell someone that medical science may not have that much to offer them, and that the disease that they have will march inexorably toward death. I love it because it’s an opportunity to stare death in face, and see it as sweet victory.

The patient and his wife, for all that I could tell and from everything that they told me, are fellow Christians, and I was honored to pray with them while we were having these conversations. It was one of those times that I’m glad I could actually make a connection with a patient on a deeper level.

And it sure beats having to figure out who’s trying to weasel pain meds out of me/the hospital.

It has become clear over and over that I am going to reach a decision point in my training very soon. Do I pursue a more clinical track for my career, or a more academic track? This comes into play as I have to decide what to do with my one year of residency that I’m trying to land. Will I ever come back to clinical medicine, assuming I go and get that PhD after my intern year? If so, how will I maintain my clinical skills? How will I stay up to date on current therapies and the like?

The other option is actually easier, and conceivably more likely, since most PhD programs don’t officially have a clinical track. Rice does, and I could probably “create” one at a couple other places, but it would be difficult. So this question is really only a question assuming that we end up in Houston.

Oh, we would like to be in Houston. We’ve been praying for it quite specifically for a while now.

I really do enjoy the clinical practice of medicine, of sitting with patients, explaining to them what is going on, what we’re going to do about it, and how they can be a part of making things work. It’s just not enough for me.

Am I just perpetually dissatisfied with where God has me in the present?

A fascinating story found on BBC News about the sketchy history of medicine in London, and the blind eye turned to body snatchers.