Tuesday, January 27, 2009

Medical Ethics, Bloggers and The Ethics of Integrity

I was in the doctor’s office. There was no nurse or attendant to act as a witness. The doctor spent a great deal of time examining my breasts. I wasn’t sure it was necessary but he had a white coat, a stethoscope and a degree on the wall. He kept going over my areolas and examining my nipples. The room was cold. I was uncomfortable.

Finally he told me to put my blouse back on and wait in the next room.  I was confused, did something just happen or is it my imagination?

As I sat in the waiting room, I felt ickier by the second. I grabbed my handbag and ran out of the place.  I kept searching my mind to find out what I had said or indicated to him that he could do that kind of thing. Worse, I didn’t feel I had the right to tell him he was way out of line.

The reality of course is that I had done nothing wrong. I was programmed to trust the situation. I had been told that doctors can do no wrong. He was a man with a medical license AND he was a creep. These days I bring my distrust through the door with me, ask questions and have primarily female physicians, if possible.

Why Do We Need Medical Ethics?

We need a common ground of acceptable and responsible behavior, particularly in a setting where humans may be required to expose themselves physically or emotionally. There has to be an understood foundation of trust, communication and respect.

Some people are having trouble with the concept. Denise Tanton in her post on Blogging for Choice briefly mentioned and provided a link to a story about a court case concerning a Nurse Practitioner who is charged with removed a patient IUD without consent. From the Courthouse News Service this is a little more of the story:

A clinic nurse first removed her intrauterine birth-control device without permission, the patient claims in a federal action, then told her that "having the IUD come out was a good thing," because "I personally do not like IUDs. I feel they are a type of abortion. I don't know how you feel about abortion, but I am against them."

Invasion of a person’s body autonomy, decision making abilities and disrespect for individual belief systems will have me searching for my invisible baseball bat. As I viewed the American Nursing Association Code of Ethics what this woman has allegedly done was a violation of the nursing ethics code, particularly section 2.2 where it talks about nurses dealing with conflicts of interests, both personal and professional.

If there was just one core ethical standard for the practice of medicine and providing heath care maybe our decisions would be easier. I regret to inform you that there isn’t one clear standard or code. There are dozen of them. For example, there is the World Medical Association’s International Code of Medical Ethics. This is a selection:

A PHYSICIAN SHALL always exercise his/her independent professional judgment and maintain the highest standards of professional conduct.

A PHYSICIAN SHALL respect a competent patient's right to accept or refuse treatment.

A PHYSICIAN SHALL not allow his/her judgment to be influenced by personal profit or unfair discrimination.

A PHYSICIAN SHALL be dedicated to providing competent medical service in full professional and moral independence, with compassion and respect for human dignity.

I like the Australian Medical Association Code of Ethics because they leave nothing to the imagination. Particularly these sections:

Ensure that doctors and other health professionals upon whom you call to assist in the care of your patients are appropriately qualified.
Make sure that you do not exploit your patient for any reason.
Avoid engaging in sexual activity with your patient.
Refrain from denying treatment to your patient because of a judgement based on discrimination.
Respect your patient's right to choose their doctor freely, to accept or reject advice and to make their own decisions about treatment or procedures.

A stated code of practices or medical ethics reminds medical professionals that trust is given because of education, skills and the nature of the work. It is more of a goal . You want those medical professional to know the Hippocratic oath or their respective ethics code but it isn’t binding. Laws concerning medical licensing are more explicit and legally effective.

Certainly the various medical professions work very hard to remove the blighters. Medical journalists and science writers do help to keep an eye on the lower forms of life. Medical Ethics bloggers also contribute to protecting the community as well.

Medical Ethics Bloggers

It is not just medical professionals that we need to keep an eye on. There are ethical issues about the intersections of medicine, technology and religion. There is also an increasing vocal population of providers who are invoking their faith based right to deny services. Medical Ethics Bloggers covers a wide topic area but these are folks you should know.

Maggie Mahar at The Health Beat Blog and a contributor to TheHealthcareBlog.com

Maggie writes about medical industry practices and asks thoughtful questions about living wills, media incorrectly identifying and reporting health care reform issues (remember CNN firing all their science reporters?) and the important things like the necessity of doctor – patient communications. Her post on Do Non-Profit Hospitals Deserve Their Tax Breaks? talks about the legacy names of formerly religious and charitable hospitals that are shielded from taxation. Some are located in areas that provide little or no charitable healthcare services to low income populations. There are additional issues of non-profit hospitals circumventing their tax status and questions who is providing the bulk of low and non-income health care.

Jessica Arons at RH Reality Check

In December 2008 Former President GW Bush President Bush issued an order known as The Right of Conscious Rule. It allows medical facilities, doctors, nurses, pharmacists and other health care workers to refuse to participate in any way in morally "objectionable procedures." Jessica Arons post on HHS Provider Conscious Rule Puts Public Health In Danger has an extensive write up on the potential effects of such an order can have on the medical profession.

Nancy Walton, Ph.D at The Research Ethics Blog

Nancy and co-blogger Chris MacDonald look at the ethical aspects of using human subjects to test new medicines, procedures and the process of controlling the level of risk for those participants. Nancy wrote a clarification update about a misrepresented article by the Associated Press. The article stated that there was a research project on Autism in young children in which some of the children would receive treatment and some would not.  The report was inaccurate:

Dr. Greenspan wrote to me this week and indicated that, although the AP report is out there, it is completely inaccurate. He is not conducting (nor would he ever conduct) studies on children at risk of or diagnosed with autism in which no treatment was offered.

Nancy also has a post on an infamous research experiment conducted in the 1960s.

For most of us who work or teach in the area of research ethics, when we talk about experiments like Milgram's, typically to initiate a classroom discussion on whether or not "bad ethics" necessarily implies "bad science", we usually end by saying something definitive like, "But most ethics review boards would never allow Milgram's work to be done today.

Well someone has replicated the research with “modern controls” to prevent abuse. Those of us old enough to remember seeing it on 60 Minutes had the shivers for days. You can read more and watch for her review of the article when it is published in American Psychologist.

For every medical decision there is an opinion. Medical Ethics bloggers can give you are perspective that your local TV news reader can’t begin to wrap their mouths around.  As always I invite your comments.

For More Information:

You can compare the classic version of the Hippocratic Oath with the modern one created by by Louis Lasagna, Dean of the School of Medicine at Tufts University.

If you would like to know the exact language of the Right of Conscious Rule you can read a copy from U.S. Dept. of Health and Human Services. It is a 42 page document.

Download an information sheet on what a Nurse Practitioner is and the level of her responsibilities from the American Academy of Nurse Practitioners.

This post originally appeared on BlogHer where I am a Contributing Editor.

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