Minor's-right-to-privacy --- by Pam Haws

In the state of Alabama, the age of consent for medical treatment is 14. A 14 year old has nearly the same rights to treatment and privacy as does an adult, when it comes to health matters.

I recently brought our 15 year-old son to the large children's hospital in Huntsville, AL for an outpatient test called a barium swallow. When we checked in, the registrar totally ignored me and turned all her direction and attention to our son. She also gave him a piece of paper and said, "If you want your mother to know the results of your tests sign this paper." My son's eyes lit up with a smile when he realized that it was up to him if I could know the results of his test or not. I interjected that I was the one paying for the test and that if I don't get to know the results, then the test wouldn't be done and we'd leave right now. He signed the paper without problem.

If a parent brings their 14 year old into the office or hospital for a pregancy test or screen, it is up to the child if the parents can know the results or not. I find this very wrong. A 14 year old can also go to the the health department and get a "brown bag" full of condoms--no questions asked, get BCP, or even an abortion without her parents knowing about it legally. Yet this same child cannot vote, drive themself to the doctor, support themself financially, and barely knows enough to function in society. How can teenagers be legally allowed to make such vital decisions without parental involvement? How can they be allowed legally to hide vital information from their parents?

As concerned parents of 5 children, we care about our kids and want to be involved in our children's lives. Sometimes the restrictions we place on them seems unfair to them and they may rebel. But it is done for their "own good." Most people don't have children to just let them run wild and do eveything they want to. Everybody knows how difficult it can be to raise teenageers and giving them this control over their health could be very detrimental for rebellious or "scared" teens. I feel it is better to have laws that support a parent's role and authority until they are adults, not take away from it. (I also feel at the same time that there should be assistance for teenagers that are in an unsafe home environment where devastating disclosures might cause physical harm.)

I think most parents are concerned about their children and want to be a part of any hard decisions they may be going through. But if the parent doesn't know that they are addicted to drugs, then how can they help their child? If a 14 or 15 year old is pregnant, how can parents help their child cope or make difficult decisions when they don't even know she is pregnant? Where is the child turning to for help if not the parents--some strangers at planned parenthood or their peers? I think it is a parental right to be able to know any health issues or test results when they are living under your roof, you are providing for their sustenance, and you are responsible for their welfare.

A parent is responsible for their children, but the law allows the child to hide vital information from the parent. This does not seem logical or proper or in the best interests of a minor child. I think this law in Alabama should be changed from age 14 to at least 17, preferably to age 18 where one is normally considered "adult." How do you feel?

Maternal-Fetal Conflict

In this blog entry, I would like to address maternal-fetal conflict and personal beliefs, which many physicians encounter throughout their career. Respecting the patient’s beliefs and values is an important aspect of the medical profession. An effective therapeutic relationship between the patient and the physician is based on a bond of trust, known as fiduciary relationship.

We know that patients bring cultural, religious and ideological beliefs into their relationship with the physician. Failure to take the code of professional ethics seriously can undermine the patient’s ability to trust the physician. It may also encourage persons with non-mainstream cultural or religious beliefs to avoid seeking medical care.

In caring for pregnant women, the health of two patients, who are individually viable, must be considered. Most pregnant women will accept some risk to their own health in order to promote fetal health. However, ethical issues arise when women refuse medical therapy which could be life-saving for her fetus. Ethical principles of beneficence and nonmaleficence come into conflict when what is required to benefit one will cause harm to the other.

In general, the legal status of a fetus is determined by the pregnant woman or both parents. US courts have ruled that “a child has a legal right to begin life with a sound body and mind.” This creates a legal duty, on the part of a pregnant woman, to protect the health of her fetus. Refusals of hospitalization, intrauterine transfusion, or surgical delivery have been legally challenged on the grounds of an obligation to the fetus. Failure to fulfill that duty is subject to charges of abuse or liability for damage to the fetus.

As a physician, what would you do if maternal decisions are based on specific beliefs? Suppose your patient is a pregnant woman who presents with preterm labor, at 28 weeks gestation. Her contractions are successfully stopped with terbutaline (an asthma medication that is commonly used to treat preterm labor). However, she later states that she does not believe in medical interventions and will not follow treatment. She also tells you that God will not allow her, and that He had communicated this to her.

PATERNITY RIGHTS FOR RAPIST?

Paternity Rights for Rapist

A recent law in South Dakota, we can only assume, was passed to protect the rights of the unborn child. The South Dakota Women's Health and Human Life Protection Act (HB1215) makes it illegal for women to have abortions unless their lives are in danger; regardless of whether they were raped or victims of incest. This same law also gives that rapist or molester, parental rights once he has served his time.
What lawmakers have failed to recognize is that by their efforts to protect the child, they have taken away the rights of women; especially those who have been victimized and traumatized, and given them to criminals. More specifically, men who attack and violate women are given rights they don't need or deserve. In the end, it is the child who will suffer most. Obviously, recidivism rates among rapist were not a consideration for these lawmakers. Additionally, the pathology of the sexual preditor that makes him so dangerous is often due to his need to exert emotional control and dominance. Is this not patholotrophic for the sexual preditor.
It's sad to say, but it's another case where the rights of everyone else supersedes the rights of the person who will be most affected by the entire situation, the victimized woman. It is unthinkable that in the year 2006, a male dominated world is still controlling women's lives as if they were property. This is a personal decision that can and should only be made by the person who has to live with that decison everyday and eventually die with that decision.
Of significant note, is the bills definition of fertilization which is defined as the period in time in which the egg and sperm are united. This definition leaves questions regarding the legality of emergency contraception. Based on the physiology of the reproductive systm, an ovulating women may in fact be pregnant at the 24 hour mark. Does this mean that emergency contraception would not be an alternative for the rape victim?
Lawmakers argue on the grounds that they are advocates in defense of the innocent victims who cannot speak for themselves, the unborn fetus. However, I pose this question. Who are the advocates for the original victims, the women who suffer the humilitation and physical burden of the most emotionally devastating vicious crime? It should be a crime against humanity to make such a law that does not give a victim of a sex crime the freedom of choice.

Removal of a Ventilator

Removal of ventilator in a conscious woman due to non payor source is inhumane and unethical.

Frantz Francois

Tirhas Habtegiris (1978- December 14, 2005) was a legal female immigrant from Eritrea ( East Africa ). She was a 27 year old terminal cancer patient at Baylor Regional Medical Center in Plano, Texas. The patient was removed from the respirator because she did not have any medical insurance and her family was unable to pay the hospital bills. Ms Tirhas Habtegiris was given a ten days notice, and then , with the bills unpaid, withdrew her life support on the eleventh day despite her last wishes to allow to see her mother for the last time. Her wishes were not granted, the respirator was removed, and it took Ms. Habtegiris about 15 minutes to die.
From my perspective view I think it is very wrong from the Baylor regional medical center to decide to end up someone life because she does not have any proof of coverage. This is very wrong to give a patient only ten days to find alternate placement when your are on respirator and without any coverage. That is not sufficient time. The hospital could not even wait for the mother of the dying patient to arrive from Africa to comfort her for the last time. In this country, you do not have no money or insurance: you are nothing, you are not a human being.
This is very immoral and unethical. We are talking about a conscious woman, not in a vegetative state, removed from a ventilator, dying while knowing that she is suffocating to death, after being allowed only ten days to find alternatives. Could you imagine what it must be like to know that you are dying for fifteen minutes. Reflect on a conscious person knowing that life-givingair was being cut-off. Sit quietly for 15 minutes and contemplate how hopeless and horrifying that must feel.
Ms. Tirhas was awake , alert, and aware of what was about to happen, and her last wish was not granted. Just to allow her to die in her mother’s arms. That was very cruel.

Paying Organ Donors

In United States, it is estimated that more than 80,000 people are on organ transplant waiting list. Out of this number more than 5,000 die waiting for an organ because there are not enough organs for transplant. According to the United Network for OrganSharing (UNOS), about 16 of those on organ waiting list die every day. For the past three decades organ donation system has depended only on altruism; that is people decide to become organ donors because they are driven by the passion to help their fellow human beings. The traditional effort to get people to become donors is through education and public campaign. Organ transplantation is a big business in Medical Centers. Every transplant center wants a share of the profit. For example, the estimated cost for heart transplant during the first post transplant year is between $393,000.00 and $480,000.00. Due to the shortage of organ donors and the long list of people waiting for organ transplant the AmericanMedical Association set up a panel to study and come up with a recommendation on ways to increase organ and tissue donation. One of the recommendations suggested by some members of the panel is to offer money to living donors and to family members of dead donors. Paying people to donate organs is not ethical and not morally right. It will open doors for people to donate their organs if they are in need of money. This means a healthy person would risk his or her life for the sake of money. No study has been done to examine the quality of life of living organ donors. Financial incentives to organ donors and/or their family will lead to abuse. For example, a family member of a dying person will pressure him or her to sign on for organ donation because of the financial gain that will come after the person passes away. If money is involved, it may lead to who pays more gets the organ. This could be a recipe for people to start buying and selling organs. It will also erode the moral believe that organ donation is a gift of life and should never be bought or sold. The society as a whole and especially the medical community have moral obligation to assess potential organ donors and prohibit any donation that might arouse moral and ethical concern.

Emotional Health Responsibility

EMOTIONAL HEALTH RESPONSIBILITY

Tiffany Preer

Emotional Health ResponsibilityPlastic surgery is supposed to enhance a person’s physical features and provide the person with some sense of physical comfort. An article in the New York Times (www.nytimes.com/2006/09/26/health/26impl.html) explained the results of a Canadian study on breast implants and suicide which I found to be very interesting but quite disturbing at the same time. It states that women who opt for breast implants have a higher rate of suicide due to feelings that stem from low self-esteem. Honestly, I cannot see a direct correlation between breast implants and suicide but I do see a connection between suicide and low self-esteem. If the woman has low self-esteem when she decides to have the implants then there might be an increased risk of suicide but all women who get breast implants are not suicidal.

Women choose breast implants to physically “enhance” themselves which should result in a better feeling about one’s physical appearance and perhaps, increase a person’s self-esteem. If the surgery did not go as expected, I can see how the implants could affect her self-esteem. It is a good idea to have a psychological evaluation before plastic surgery is considered to make sure that the patient is mentally and emotional capable of safely undergoing the surgery. However, prospective patients that have been admitted to psychiatric facilities or those who have psychiatric disorders should not be deemed as poor candidates for surgery. In this case, the plastic surgeon should consult with the psychiatrist or treating physician. Should a surgeon share some of the responsibility for the patient that commits suicide after receiving breast implants? A surgeon that has addressed all of the mental and emotional complications of the procedure and has cleared the patient for surgery, does not have any responsibility to the suicide. On the other hand, a surgeon that hastily clears a patient without investigating their mental and emotional status, should share some of the responsibility toward the suicide. In my opinion, this case is like that of a physician who places a patient of a drug that knowingly affects their liver and neglects to monitor the affects on the liver which may result in serious damage to the liver and a decreased liver function. Isn’t the physician responsible then? Shouldn’t the physician have monitored the affect that the drug had on the liver on a regular basis to avoid such a result? In the latter case, the physician is definitely responsible and will probably find themselves in a malpractice suit. In the case of the plastic surgeon, I am not sure what consequences they should face but I don’t think that their medical license should be suspended or anything like that, maybe a fine would be good.

Ethical issues in whistleblowing

Blog Entry
Roland Njoh

Whistleblowing involves an individual speaking out to the general public or an individual about a situation which they think is unethical and may be causing them direct or indirect harm.
According to Fost, physicians and healthcare workers are more likely to discuss medical error with their peers than with the patient involved.

A decision to blow the whistle is often not an easy one to make. Careful consideration about career advancement opportunities and professional relationships are evaluated. The target of the accusation always suffers even though some accusations may be futile.

The author elaborates on the principle most greatly cherished by healthcare professional “Do unto others as you would have them do unto you; treat your colleagues the way you would want to be treated." He further explains the flaw of the Golden Rule by questioning the actual meaning of the word “others”, does it imply fellow physicians, or does it patent to the patient?

There will always be differences in the manner in which every healthcare provider practices but the ultimate goal is to provide patients with the best possible care available. It is the duty of every healthcare provider to be proactive on blowing the whistle when gross negligence is observed. At that point, it will be the sole responsibility of the patients to decide whether or not to file a law sue for compensation. In some cases, a law sue is imperative in other to manage the acquired disability secondary to negligence.

I agree with the author on the point that it is our ethical decision to report gross negligence to the patient involved and to make sure that such healthcare providers are given the necessary help to ensure that such an error does not happen again.

Reference:Fost Norman (2001): Ethical Issues in Whistleblowing. University of Wisconsin Schoolof Medicin. JAMA. 286:1079: http://jama.ama-assn.org/cgi/content/full/286/9/1079

Mental Illness in Children

Roselyn Burton

After reading the NY Times article Living with Love Chaos and Haley, October 22, 2006, It made me stop and think about the effects of mental health disorders in children and their families.Mental health disorders in children is a very emotional subject. Over at least 6 million are diagnosed every year. One wonders if a lot of children who have been labeled as “slow” and “developmentally challenged” don’t just have a mental disorder. These often go undiagnosed for a long time, because it is very hard for some families to face the fact that their “little girl” or “boy” could have a mental disability. Often people say these children will grow out of it and that they are just going through a phase. But this phase just never seems to end.Mostly the reality of it is that there is still a big stigma associated with mental disorders. People are embarrassed especially parents to tell friends and family that their child have a mental disorder. Because of the lack of education of the society as a whole, some people think that their child will contact this also, if they associate with these children, .as if this is something that is contagious. While others feel that it is the fault of the parents for not training their children the right way. These children tend to have outbursts at any time and shut down when they cannot handle their situation anymore. Some people tend not to understand But what is especially sad is that some “teachers” don’t understand and don’t take the time to fully understand. Not recognizing that this is a true medical condition. Also controversial is the use of drug treatment in these children. Some argue against it as tolerance develops to the drugs very easily. Drug therapy seems to work for“a little while”, while the side effects from the drugs wreak havoc on these little bodies.But one of the most gruesome problems is the effect on the families that have to live with these children. The other children in the family often begin to feel neglected and sometimes to the extent, that they begin to “thread lightly”, so as not to be a bother to their parents. Then they begin to feel that if they were not around their parents would have more time to spend with their sick sibling and sometimes try to hurt themselves. The parents then blame themselves and begin to wonder what they did wrong, to cause this to happen to their children. Even though it is not their fault. This becomes a vicious cycle.I believe more effort and funding need to be put into research for mental disorders in children and more education and awareness need to be promoted, to help erase the stigmas so that these families don’t remain isolated and these children and families can get the help they need.

Is Tort Reform a Good Idea?

Tort reform is a controversial subject and has been one of the most debated policy issues in recent times. It is a result of too many frivolous lawsuits being filed that cannot be reasonably supported under the existing legal precedent. It takes a broader rhetorical definition to describe successful tort lawsuits that are seemingly without merit, or where the judgments seem too high relative to the harm. Advocates generally argue that the present tort system is too expensive, and that the system is not even-handed because the amount of per capita tort costs varies significantly from state to state.
One common ground in the tort reform debate is the inconsistencies of the legislatures. Many want no limits of any type of private litigants. Examples when they talk about pitiful little plaintiffs victimized by doctors and hospitals and pill-makers, not to mention store owners who have slippery floors, and how “artificial” it would be for the Legislature to impose caps of any kind.
“How can a legislator say how much the life of a child is worth?” is the typical somber intonation. Truth is legislators do that all the time. And up until 20 years ago, their firm position (from which they've been forced to retreat only slightly) is that the life of a child is not worth a penny, at least if the child perishes due to the negligent act or omission of any state agency or employee.
Before 1982, “sovereign immunity” was ironclad law in the state of Mississippi. The parents of a lad struck by a speeding bread truck could sue the bakery for money damages. The parents of a lad struck by an alderman speeding in a city car would find the courthouse door locked. No suits for damages were allowed against state or local governments if the allegation was negligence.
The Supreme Court, not the Legislature, has worked to change all that. In a case decided 20 years ago, Pruett vs. City of Rosedale, the justices made clear the injustice had gone on long enough. If the state or its employees were negligent, the state should pay. Lawmakers were told to create a mechanism to do so. Cities and counties were told to do what bakeries do: Buy insurance.
None of this happened quickly, of course. The Legislature dithered and delayed and danced around, failing to pass the Mississippi Tort Claims Act for at least another decade. And guess what? When they finally did start allowing state and local governments to be sued, they included all sorts of stipulations and of course, caps. That's right. If a child is killed by the negligent act of, say, a school bus driver, the family may now get damages. But not more than the amount of the school district's insurance coverage.
So the answer to the somber question “who is deciding the value of a child's life?” Well, in Mississippi the lawmakers are, at least when the government is being sued.
And guess what else? It's still not clear, but if a private doctor cuts off the wrong leg of a patient, the sky's the limit on suing for the dastardly deed. But if the doctor is a state doctor, working at a state medical center, the damages will be “capped”.
One important perspective is that plaintiff's attorneys are real industry in many states. The Legislature, though, is all for caps and shields for themselves. But set any such limits in the real world? Not a chance. Isn't it funny how the ones who write the laws don't have to abide by them?

Right to Live

When I was in nursing school, I worked as a nursing assistant. During my last year of school, I was blessed with a private duty case, taking care of a 86 years old lady. She was full of life, though mildly fragile. She lived in an assisted living facility, never had any children, but has a niece who was her power of attorney. One faithful morning, she took a fall, laid on the floor for hours until I got there. when I found her she was oriented, in a lot of pain, but unable to ambulate. I called for help, and she was sent to the emergency room. She had suffered a fractured hip, and the niece declined surgery. From the hospital, she was then admitted to the infirmary, at the assisted living where she lived.

She had a gastrostomy tube placed due to poor eating before she left the hospital. While at the infirmary, she continued with feeding via the tube, and was slowing progressing. Then the niece came to town, and decided that all the feedings and medications should be stopped immediately. The doctor agreed, and so it was done. While taking care of this lady, I could not figure out how that could have happened. How one can come and say stop feeding a person, and so shall it be. After a week of no food, no water, just swabbing her mouth to keep it moist, I saw a human being wasting away. It was very painful for me to take care of this woman at this state. I thought to myself, if this woman had bore her own kids, this would not have happened. I didn't think this woman would want to die that way. For three weeks as this woman lingered in suffering, I wondered how this can be allowed. The fall didn't mean imminent death, surgery at her age, maybe not, but i didn't think death needed to be forced on her this way. Finally she died in suffering, and that thought hunted me for years. There was still quality of life in the woman. Bedrest, continued tube feeding, would have probably help this woman regain her strength at to some extent, but death, that was unimaginable to me.

This experience shape my life, and my thoughts in how I feel about life and death issues. Then I started working as a nurse on a vent unit where patients were taken off the vent, and die just like that. I wondered whether this was a common practice. I wondered how family could make those decision in natural vs unnatural death.

I finally gave up thinking how wrong it was to let someone die when they have certain condition until I had a 58 yrs old female with ALS as a patient. This woman planned the day she wanted to be taken off the vent, what, when and how she wanted it done. Most of all this woman stated she has had a good life, she know how her illness will progress for the worse, and she didn't want to get to that point. She loved her kids, and grand kids, and didn't want to put there lives on hold. In all my experience, this was the first time I met with such bravery. It was hard for me to accept her decision, but this woman was extremely happy about the choice she mad. She was finally taken off the vent, and she only lasted 3 hours.

Everyday, I hear people say, I will never want to live this way. My question is whose choice is it? God or man. I cannot answer this.

When I was in nursing school, I worked as a nursing assistant. During my last year of school, I was blessed with a private duty case, taking care of a 86 years old lady. She was full of life, though mildly fragile. She lived in an assisted living facility, never had any children, but has a niece who was her power of attorney. One faithful morning, she took a fall, laid on the floor for hours until I got there. when I found her she was oriented, in a lot of pain, but unable to ambulate. I called for help, and she was sent to the emergency room. She had suffered a fractured hip, and the niece declined surgery. From the hospital, she was then admitted to the infirmary, at the assisted living where she lived.

She had a gastrostomy tube placed due to poor eating before she left the hospital. While at the infirmary, she continued with feeding via the tube, and was slowing progressing. Then the niece came to town, and decided that all the feedings and medications should be stopped immediately. The doctor agreed, and so it was done. While taking care of this lady, I could not figure out how that could have happened. How one can come and say stop feeding a person, and so shall it be. After a week of no food, no water, just swabbing her mouth to keep it moist, I saw a human being wasting away. It was very painful for me to take care of this woman at this state. I thought to myself, if this woman had bore her own kids, this would not have happened. I didn't think this woman would want to die that way. For three weeks as this woman lingered in suffering, I wondered how this can be allowed. The fall didn't mean imminent death, surgery at her age, maybe not, but i didn't think death needed to be forced on her this way. Finally she died in suffering, and that thought hunted me for years. There was still quality of life in the woman. Bedrest, continued tube feeding, would have probably help this woman regain her strength at to some extent, but death, that was unimaginable to me.

This experience shape my life, and my thoughts in how I feel about life and death issues. Then I started working as a nurse on a vent unit where patients were taken off the vent, and die just like that. I wondered whether this was a common practice. I wondered how family could make those decision in natural vs unnatural death.

I finally gave up thinking how wrong it was to let someone die when they have certain condition until I had a 58 yrs old female with ALS as a patient. This woman planned the day she wanted to be taken off the vent, what, when and how she wanted it done. Most of all this woman stated she has had a good life, she know how her illness will progress for the worse, and she didn't want to get to that point. She loved her kids, and grand kids, and didn't want to put there lives on hold. In all my experience, this was the first time I met with such bravery. It was hard for me to accept her decision, but this woman was extremely happy about the choice she mad. She was finally taken off the vent, and she only lasted 3 hours.

Everyday, I hear people say, I will never want to live this way. My question is whose choice is it? God or man. I cannot answer this.

The BioEthics Cafe -- Essays from the Edge of Paradise

The Last Word

It is of interest to note that after reading an article in the New York Times, Hawaii passed a law stating the medical professional may decide if a “do not resuscitate order” should be carried out. It is usually a “do not resuscitate" order for a reason, this is the wish of the patient. Although this law was passed, I believe that if a medical professional does not respect the wish of a patient, there will be trials to determine if the decision is ethical.

When a person has an advance directive and does not want to be resuscitated, there should be specific guidelines. I don’t want to suffer through a terminal illness for years, however if I am in a car accident with a medical necklace or bracelet that says do not resuscitate and surgery may save my life, then by all means resuscitate me. This may be one of the times when the medical provider may intervene and speak with a family member and educate them on the prognosis if surgery is done.

Education is the key in understanding advance directives and there are times when a person may make a decision and not be totally aware of what the facts involved. It is our duty as health care providers to explain this to all of our patients when they come to our offices or facilities. Do you feel comfortable not resuscitating a person knowing that the may not have been properly informed when their decision was made.

Mythology and Abortion

Mythology, Abortion, and the cold hard facts.

What the heck is going on in our society? The topic of abortion is made complicated by emotionally charged discussions that are clouded with confusing and conflicting information which is misrepresented at times by the opposing sides of the debate to augment their argument or opinion. Frequently, in open forums and societal debates considerable mythology (noun: myths collectively; the body of stories associated with a culture or institution or person) appears to surround this topic. For clarification in academic fields, a myth is a sacred story concerning the origins of the world or how the world and the creatures in it came to have their present form. In saying that a myth is a sacred narrative, what is meant is that a myth is believed to be true by people who attach religious or spiritual significance to it. Use of the term by scholars does not imply that the narrative is either true or false. I recently read an article that discussed the topic of abortion on demand. I was challenged to reexamine my convictions.
The mother of all abortion debates is Roe vs Wade. In this Supreme Court decision the majority of the justices obviously sided with Roe which resulted in the legalization of abortion on demand. Yep, from conception to seconds before your first breath abortion is allowed. Many people believe erroneously that abortion is only legal in the first three month of first trimester of pregnancy. This myth was faithfully propagated in public debate by newspapers, magazines, pollsters, and others by framing the argument with the pretense “In the first trimester of pregnancy…” implying that abortion was somehow legislatively restricted in the second and third trimesters. In Roe vs Wade a window was left open to allow individual states to legislate restrictions during the second and third trimesters. However, in Doe vs Bolton the window was lost when the whole wall was knocked down. Medical determination of the health of the patient eviscerated any legal recourse.
The most startling aspect of the whole process is that the “legal precedence” was more “legal activism” then constitutional law. The concept of a “penumbra” (the gray area between light and complete shadow) of legal rights within the Bill of Rights has been recognized and used in determination of constitutional rights in many cases. The justices in defense of their positions either concurring or dissenting unquestionably recognize marriage and its particularities and uniqueness in conjugal intimacy as an entity warranting penumbral privacy protection. Dissention arose with the decision to uphold contraception rights of individuals, the court made the sweeping conclusion that abortion was a form of contraception and that abortion was a constitutional liberty. To this day Roe vs Wade is not argued or defended by its own merits but rather secondary constitutional avenues which address governmental encroachment on individual rights.
So what is the debate? Where will the cult of unrestricted “individual rights” lead its followers to worship? Will the communal cult of “responsibility of actions” who recognize no man as an island and that individual actions have a ripple effect on all humanity concede to the shady mythological god of penumbral rights who no one has seen, heard, or read? Should impregnated men (this is the future) or women be allowed to continue to terminate their progeny on demand or should some restriction on this form of birth control be implemented? Are human persons uniquely endowed with unalienable rights such as life liberty and the pursuit of happiness at any cost? Will the minority cult of “well what about in the case of ….” Continue to lead the majority of “well, yeah but something ain’t right.” As long as faithful propagators in the camps of “the individual willed that he crawl from primordial ooze therefore the individual is solely determinant of his destiny” and “the individual was created to exist in harmony in community with other persons as a prelude to his eternal destiny with the Master Planner” exist it is unlikely that the debate will subside.

Pharmaceuticals for the Elderly

I recently read an article on the New York State Department of Health website pertaining to the Elderly Pharmaceutical Insurance Coverage (EPIC). EPIC is New York State sponsored prescription plan for senior citizens who need help paying for their prescriptions. Over 360,000 seniors already belong and are saving, on average, over 80% of the cost of their medicine.

Years ago, as a young adult in college and so many others of my friends (being dropped from our parents health insurance at the age of 18), have experienced being without basic health insurance coverage, due to the high cost to obtain and maintain. Despite so many years have come and gone, there is still not enough resources allocated for young adults in this complex society, only for individuals <18>65. I think that rationing health care for the elderly might become necessary to eliminate those restrictions on health care for other groups, but would encourage conflict between generations.

In the past few years, an increasingly large share of health care is going to the elderly vs. young adult. For example the federal government spends six time as much providing health benefits and other social services to those >65 as it does to those over 18. In addition to wasteful spending of hundreds of millions on an inflated defense budget.

I think government has the social obligation and responsiblity to help the elderly live out a natural life span but not to help medically extend life beyond that point. A government system based on the above would immediately create a balance in medical care benefits for the other neglected generation.

Euthanasia

Euthanasia
Euthanasia is the practice of terminating the life of a person because they are perceived as living ahttp://www.blogger.com/i.g?invID=6937264264295004718&hl=enn intolerable life, in a painless or minimally painful way either by lethal injection, drug overdose, or by the withdrawal of life support. Euthanasia may be active or passive; and, types include physician assisted suicide, voluntary, involuntary and mercy killing. Euthanasia has both legal and ethical ramification.
Euthanasia is a controversial issue which its legality has being argued for years. For illustration, in 1997 U.S. Supreme Court ruled on a case between Washington v. Glucksberg. The question presented in this case is whether Washington’s prohibition against causing or aiding a suicide offends the Fourteenth Amendment to the United States Constitution. The court holds that it does not. Even though, the Due Process Clause protects individuals’ liberty, in addition to freedom protected by Bill of Rights. The protection includes rights to marry, to have children, to direct the education and upbringing of one’s children, to marital privacy, to use contraception, to bodily integrity, and abortion.
Euthanasia is a controversial issue because of conflicting religious and humanist views. There are a number of conflicting beliefs about euthanasia. Different aspects of euthanasia are supported by different people. Some people argue against euthanasia based on the belief that only God should choose when someone dies. However, individuals’ right to autonomy must also be examined. Autonomy is a concept found in moral, political, and bioethical philosophy. Within these contexts it refers to the capacity of a rational individual to make an informed, uncoerced decision. One can also define autonomy as the right to be self-determined. In medicine, respect for the autonomy of patients is considered obligatory for doctors and other health-care professionals. This ethical principle is also supported legally. The 1990 Patient Self-Determination Act (PSDA) encourages all people to make choices and decisions now about the types and extent of medical care they want to accept or refuse should they become unable to make those decisions due to illness. This is called advance directives. Hence, this law supports individuals’ right to autonomy including right to die.
In summary, euthanasia is one of the ethical-legal dilemmas that the society must address. Although the voice of the supporters for the movement has being soften due to conviction of Dr. Kevorkian, the issue is not about him but upholding and protecting the individuals’ right to autonomy. The Due Process Clause can also be applied, that is right to refuse unwanted lifesaving medical treatment.

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Should people sell their organs?

Growing up in a poor country I witnessed first hand people lining up at the hospital to sell their blood and organs for money to support their families. Evidently the O blood type made out the best as it is the universal donor! Even though donating blood is a much less invasive procedure and your body automatically replaces itself it still is a personal decision for each individual to make.
I admire people who are willing to take personal risks to save the lives of others, These people should be able to get a reward or payment of some kind. There are two primary arguments in favor of allowing the sale of organs. First is the fact that a person's organ belongs to them and they should be able to do with them as they wish. The second is that there is a huge shortage in organs available for transplants so if paying money for them will result in saving more lives then this can be justified.
The removal of live organs is difficult and painful for the donor. like any surgery the process itself is dangerous. It is possible the person undergoing surgery will not wake up and if they do make it through the surgery there is still a chance of post-operative infection wich could potentially kill. The donor should also be provided with proper health care and counseling before and after the organ removel.
In selling organs for money the one problem that needs to be addressed is the sale through underground markets and the donor and tehir vital organs are treated as commodities. Hown can we impose stricter regulations on theses " vendors" that are making money off the donors?

Assisted Suicide

In Depth Assisted Suicide –“The Fight for the Right to Die”, CBC News Online Sept 27 2004. CBC online September 27, 2004 at HTTP:www.cbc.ca/news/background/assisted/sucide/ is the web site.

The article discusses the age old controversy of does a person have the right to end their life. In this article, Sue Rodreges, dying already of a terminal illness, suffering and wasting away was fighting for the right to die. She fought in the Canadian courts arguing that to deny here this right was not constitutional. She based this argument around the premise that it curbed her personal life freedoms. However, this was not accepted by the Canadian supreme court and here case was lost. This court decision however, has not lead to the end of this controversy.

As the article continues, the fight for personal choice to end a life with help is becoming a well supported ideal. It is gaining support not only in Canada, but in many countries. The support is been seen that there may even be a possible motion for a change to the Canadian law as this concept has gained support.

The opponents of this fight however, argue that old frail people may be cohersed into choosing such an option for the wrong reasons. There is fear that if legal people may make the decision to end a light for as much as to limit financial debt and not for medical or personal suffering reasons. This poses a moral and legal dilemma which continues to rage on.

As this controversy rages many people have decided to help no matter the consequences of the law. This has a result of court cases which have exonerated and convicted people of aiding in assisted suicide. The outcomes of the trials have been more based on jury opinion and decision then case law.

In closing regardless what country, the controversy rages with little end in sight due to strong opposing views each with the morals of society trying to be achieved. The right answer may not exist.

Anorexia and Forced Hospitalization

Anorexia Nervosa and Forced Hospitalization

Jessica Peluso

Should a physician be allowed to hospitalize a patient suffering from anorexia nervosa against his/her will? Anorexia nervosa is a multifactorial psychiatric disorder that manifests as a very low body weight and distorted body image. More than 90% of the cases are seen in young women (typically teens to young adulthood). Long term mortality can be as high as 10% resulting from starvation, suicide or electrolyte imbalance.

Consider a young teenage girl (18 y/o) whose mother has come to you requesting your assistance in dealing with her malnourished child. The patient is described as a 5’6”, 75 pounds who was 120 pounds six months prior. The patient’s lab work reveals some electrolyte disturbances. However, the patient denies that she is anorexic and is refusing any treatment.

Of course the problem arises in determining whether autonomy should supersede beneficence. This can be a very difficult situation because the patient is refusing treatment and to enforce her into something she is unwilling to do would infringe upon her ability to exercise autonomy. However, the patient’s body (suggested by the lab work) and family are obviously crying out for help. Would it be considered assisted suicide if nothing was done to deter this behavior?

Unfortunately this situation was all too real for me and my family. I suffered from anorexia nervosa from 16-22 years old. During that time I dropped down to 75 pounds at my worst and was hospitalized three times many times with mixed emotions. I, too, never admitted to being anorexic and many times my hospitalizations provided me with ways of becoming a “better” anorexic. The fear of gaining weight was real. More importantly, though, gaining weight was a fear greater than just pounds. The fear of gaining weight for me, as for many others, meant giving up control. It was not until I learned about a “miracle” named Madelyn (my first child) that I decided to deal with this life threatening issue.

I can honestly say that I believe that the physician should have the ability to exercise his /her judgment in these situations to promote life even if it means sacrificing the patient’s autonomy. I can say that when I was wrapped up in this disease, my state of mind was altered as I believe many of these patients with similar situations are. If the provider does nothing, I believe we are allowing suicide to occur in front of our eyes. Even if it means multiple hospitalizations, I believe, life needs to be promoted so that hopefully, eventually, these patients may also be given a chance for a “miracle”.

References:

http://www.cpa-apc.org/Publications/Archives/CJP/2002/april/briefCommunicationTreatmentResistance2.asp (Accessed 10/06)

Cord Bood Banking

Cord Blood BankingCord blood is a topic of great interest to me. When I had my children I was given a pink form with numbers on it one being the medical record number the other number of a cord bank. I was told blood was collected from my newborns umbilical cord i never asked why and I was not told how important it could be. What is cord blood? It is the collection and storage of stem cells found in a newborns umbilical cor. It offers lifesaving treatments for the newborn or a family member. we see how stem cell research is a major issue that scientists are pondering with in laboratoris worldwide as couples and families try to concieve or save alredy born children all possible with cord blood banking.Cord blood is collected after the baby is born but before the placenta is delivered.A needle is injected into the umbilical vein and the blood is collected it takes about 2-4 minutes.The collected blood is stored in a cryopreservation chamber a specialized freezer where cells are stored at -196 degrees celsius ,-321 degrees F.Cord blood can be used to treat over 40 life threatening diseases including a wide range of cancers,genetic diseases, immune deficiences and blood disorders.I was drawn to this topic because earlier this week in a medical journal this topic was spoken about. Until this time i never understood the clinical importance of why the newborns blood is collected and that the number on the form is phone number if you as a parent need to access your cord blood for e.g in illness your doctor can do so with this information.

THERAPEUTIC CLONING

Imagine brain stem cell cloning from one embryo to alleviate or erradicatelon-standing pathologies which have ended a multitude of lives? What would it be like to end diabetes mellitus, leukemias, tissue dysplasias, glaucomas, immnosupressive disorders, arthitis and hypertension. For one medicine's focus would have to change.
What would it take to find enough production beta cells, abort tissue or fluid autoimmune destruction, abort optic nerve atrophy or even graft it? Or even allow for control of vasdilation and vasoconstriction of vessels thru the natural physiologic process without pharmacological aid?
The regulation of benefit for the wide variety of individuals would have to fall on a governmental agency, private agency or who would be in control of the multiple how's? How would the medical perspective influence handle patient selection? What about those transplant wating list patients with diseased organs? Reimbursement: private or public? If it would resemble anything like our present system what an oppurtnity for colossal confusion and frustation!
Mal-beneficience vs benefit to humankind. Faiths of all creeds vs the premise to benefit all. Conservatives alleging "play god " and obstruct science. Radicals advance science and aid humankind as whole. What about the middle of the these cross-roads? Are we not on top of the list as a industrialized nation? Are we not a culture with a meltdown from several other roots? And we profess the pursue of liberty and happiness to all. And if we have created human form in the laboratory already? What about pursuing technology for therapeutic cloing exclusively?
An opthalmic perspective on therapeutic cloning goes without elaborating on the idea about grafting or regenerating optic nerve fibers for open angle glaucoma. What about regenerating macular degeneration or annihilating diabertic macular edema? As sad as it is truth our patients are losing sight despite our best intentioned efforts to prevent these pathologies. Yes, of course we have pharmaceutical agnets to increase/reduce introcular flow, laser beams to interfere with the trabecular meshwork and its outpour of intraocular flow. And last but, not least we have valves transplanted to scleras to obtain a definite device to control introcular pressure. However, we are still encountering endstage glaucoma and BLINDNESS. What about our present early prophylaxis for macular degeneration: sunglasses, vitamins and wide brim head coverage. Someone tell me that therapeutic cloning for the retina would not alleviate this pathology? Our worst case scenario surgery or intravitreal injections to absorb and reduce inflammation. And diabetic retionpathy: laser vs intravitreal cortisone or other anti-inflammatory agents.
Advances, most definitely, however full resolution a dream!

Physician-Assisted Suicide vs.Euthanasia

The first thought that come to my mind " two topics one result, intentional death.By definition Physician assisted suicide refers to a practice in which the physician provides a patient with a letal dose of medication, upon the patient's request, which the patient intends to use to end his or her own life.In Euthanasia generally means that the physician would act directly,for instance by giving a lethal injection,to end the patient's life.As a health care provider since fourthteen years ago in a durable medical equipment industry, I had the opportunity to visit ( in hospital or home) a lot of patient with mechanical ventilators,enteral nutrition ( feeding tube),patient with quadriplegia that developed other problems and others with "terminal illness".But the intentional termination of life is not ethically justifiable.A degree of acceptance by the patient.Acceptance doesn't mean that the patient likes what is going on,and it doesn't mean that the patient has no hopes; it just mean that he can be realistic about the situation.A medical undrestanding of the patient's disease.One great physician does not equal great care,it takes a coordinated system of providers.Death is not usually an individual experience;it occurs within a social context of family,significant others, friends and caregivers.
I don't want to enter in some issues but arguments like respect for autonomy; justice; compassion and individual liberty are not ethically justifiable offer to physician assisted suicide and euthanasia.Furthermore,the physician's duty to alleviate suffering may,at times, for many people justify the act of providing assistance with suicide.Remember the traditional duty of the physician is preserve life and we have,as a health care providers a social and moral responsability .

My Take On The Missouri Stem Cell Initiative

By: Ray Manuel U. Paguntalan

Sunday morning as me and my family was coming out of church, my oldest daughter asked, “hey dad! What is that amendment number 2: Vote NO To Stem Cell Initiative?” After explaining to her what the stem cell is all about, my daughter (who is a very conservative person by the way) quickly dismissed the idea as absurd and unethical in the eyes of God. I too, felt the same way and somehow agreed with her …. But let’s back up a bit and think about it for a while, I asked her…… is it really?

(The nation’s eyes are focused on the senatorial race in Missouri mainly because of the two senatorial candidates who both have the stem cell issue as one of their main campaign agenda. Senator Jim Talent is anti-stem cell while Claire McCaskill is pro- stem cell. Each candidate has expressed their views and has reasons for supporting or rejecting it.)

Stem cells are primitive cells that can be manipulated and coaxed into developing into the 220 different human body cells. Scientists have found ways of developing these stem cells into most types of human cells, such as blood, brain, heart tissue, nerve cells, bones, etc. These researchers are confident that they will lead to treatments to many diseases such as bone loss, broken bones, brain damage due to oxygen starvation, severe burns, some forms of cancer , diabetes, Lou Gehrig's disease, heart disease, hepatitis, incomplete bladder control, Huntington's, leukemia, lupus, muscular dystrophy, multiple sclerosis, osteoarthritis, Parkinson's, spinal cord injuries, and stroke!

There is not much ethical concern related to the adult stem cell research as long as there is consent obtained. However, I read that stem cell lines from adults have limited usefulness compared to the stem cell line from embryos. During the time when a woman undergoes in-vitro fertilization, she is given medication to help her produce at least a dozen mature eggs which are then fertilized by sperm. She then gets 2-4 eggs implanted on her womb (2-5 days after fertilization) in the hope of getting pregnant. So what happens to the other embryos? They are frozen for future use (which I read is very expensive), used for research, or destroyed.

So if we leave the rest of the embryos to die or destroy them (which at times happen in fertility clinics), are we guilty of murder? What if we use it for research (once the stem cell is extracted, the embryo dies)? Is that also murder? This is what it’s all about anyways, right? Pro-life people give emphasis on the stem cell research as unethical, but believe or does not really argue much on the ethical issues on discarded embryos in fertility clinics. They apparently believe that leaving the embryos to die is letting it take its normal course of dying and does not constitute to murder.

I believe this is just plain hypocrisy. How can one address one as such devious act and not consider the other? One can certainly not make an excuse for one, though done with different process, the outcome is still the same. Wouldn’t you think that if someone is anti stem cell research should also be anti in-vitro fertilization? Isn’t it more prudent to go after the source than just focusing on its end results? After all, isn’t that where it all started? I guess the argument there is….
In-vitro fertilization was discovered to bring in life and can’t be seen as unethical due to its full benefits to life. So where do we actually draw the line?

After some major brainstorming, I guess I got my daughter confused. Don’t worry, I told her. I’m confused too myself. More so that I am to vote soon on this issue. I always consider myself as pro-life, but also believes in pro-choice. I guess I’ll just have to sort this thing out. After all, I have till November to figure this out.

Fetal Abuse

Fetal Abuse (blog entry by Christine W. #AI107304-9FM)

We have heard of spousal abuse, child abuse - even animal abuse. Many laws exist to protect these different victims. Most of these laws have been in practice for a number of years. I had not heard of the term 'fetal abuse' until recently. However, one could say it is a new name for an old problem.

What is society to do with a pregnant woman who will not take responsibility for the health of her unborn child? In the recent past, the majority of women that fell into this category would have been those who continued to drink alcohol even though they knew it would harm their unborn son or daughter. Now, with illegal drugs being available almost anywhere and creating new addicts on a daily basis - there are now many more ways for the pregnant woman to jeopardize the health of the fetus.

At what point should the law step in? This behavior certainly seems to quality as child abuse. Do we arrest her and put her in jail? Do we charge here with a criminal offense or just a misdemeanor? Or do we force her to participate in a rehab program?

Well, guesss what - states are already enacting laws that allow these women to be arrested. In recent months, pregnant women have been arrested and jailed in South Carolina, New Mexico, Arizona, Alabama, Colorado, Georgia, Missouri, North Dakota and New Hampshire (among other states) claiming that pregnant women can be considered child abusers even before they have given birth.

South Carolina has been the toughest so far. Their Supreme Court declared in 1997 that drug-using pregnant women can be prosecuted criminally - and sentenced to as many as 10 years in prison. The attorney general there says that he will only prosecute pregnant women that use illegal drugs - not alcohol. (However, alcohol is still the leading cause of preventable mental retardation in infants.) It was the Medical University of South Carolina in Charleston, that started a program of testing pregnant women for drug use, and turning over their findings to police. It was done as a 'last resort' because they were seeing more and more pregnant drug users.

So, will this solve the problem? Many say absolutely not. Public health and child welfare groups say that most of these women want to stop using, but cannot; and threat-based approaches will not deter women from using drugs but will only prevent them from seeking prenatal care and any voluntary treatment programs that could be abailable for them.

And then one has to consider the health risks both mother and child face if she is forced to give birth in prison. Whil researching this, I read some shocking and extremely sad stories of women giving birth in prison. Sometimes the conditions would be deplorable. Sometimes the women would be left alone by custody to have the child without help from anyone. Although international law and treaties signed by the United States prohibit the shackling of pregnant and birthing women, Amnesty International USA reports that only two states - Illinois and California - have banned this practice here at home in the United States.

So, is rehabilitation the answer? It has been around for a while. Would this problem have been worse without it? The educational materials about the dangers of drug and alcohol use while pregnant is certainly available. And we know society supports rehab programs - is there enough money out there to do this successfully though? Is education at a very early age possibly part of the solution? I wish I had the answer, or even part of it.

(I would like to acknowledge Lynn M. Paltrow; Vince Beiser; Julie Ehrlich - authors of various articles that I used for this blog.)

Ethical Issues Associated with Bariatric Surgery

John Alioche’s Blog Entry
Ethical Issues Associated with Bariatric (Weight Loss) Surgery
October 21, 2006
The United States is experiencing an epidemic of obesity. Under the widely used classification developed by the National Institutes of Health, 34% of the adult population is "overweight" (BMI 25-29.9) and another 27% meet criteria for "obesity" (BMI>30). The overall prevalence of obesity has increased more than 75% since 1980. Obesity is associated with increased type II diabetes, cardiovascular disease (especially hypertension), osteoarthritis and multiple conditions. An obesity-related process called "Syndrome X" or "metabolic syndrome" that includes insulin resistance, abdominal obesity, hypertension, and diabetes and lipid abnormalities.
Bariatric surgery is a textbook example of an area of health care calling for evidence based management of utilization and ethically guided deliberation about coverage policies. At one extreme bariatric surgery can be seen as a life saving, medically necessary intervention that potentially reverses the inevitable trend to sometimes fatal medical conditions. At the other extreme it can be seen as a technical fix for a subjectively distressing result of choices with regard to eating and exercise. The surgery has risks and represents a significant cost (approximately $15-20K). In the past year alone the number of patients that are having Bariatric Surgery has doubled.
Bariatric surgery has risk. Mortality from the surgery itself is less than 1% but post-surgical leakage into the abdomen or malfunction of the outlet from the stomach pouch can require further surgery. Vitamin deficiencies, gallstones, and osteoporosis are among the other complications that can occur. With regard to the basic objective of weight reduction the surgery is not foolproof-some patients ultimately regain the weight they lost, through varying combinations of enlargement of the stomach pouch and return to compulsive patterns of eating.
1. In a culture that is deeply conflicted in its approaches to weight and obesity, how can we best pursue the mission of "improving the health of the population we serve and the health of our society?
2. Should we seek cost effective opportunities to support "upstream" services aimed at shifting the trajectory of obesity earlier in the clinical course with the objective of reducing suffering and medical morbidity and possibly obviating the need for surgery itself? or Encourage optimal education so that members can make well-informed decisions about surgery with full understanding of and commitment to the lifelong post surgical requirements?

Children of lesser gods

I have been contemplating the value of human life, wondering if life is innately of value, or is some life more valuable than others. Is the life of the alcoholic as important or as valuable as that of the school teacher of pharmacist? Are nurses more valuable than rapist? who places value to human life, and are there different levels of humanity? Should people be ascribed value based on occupation or social contribution, education or wealth, the argument seams always to be framed in camps that are in conceptual opposition. You are either a bleeding heart liberal or a hard nose conservative but reality often times is much less polorized.

The question is how can we not label people; This I venture to say is impossible. The problem with labeling is that it has the potential to affect the quality of care that is delivered based on the value that we placed on the patient. As a human being the concept of all being equal is designed to provide the platform upon which care is provided and although this may sound great, in reality we know that there is no such thing as people being equal. Equality is a socio political construct, designed to maintain the social compact, in which people co exist feeling good about themself despite all their shortcomings. The equality philosophy is a lie. We are never equal from birth to death, we are born with different capacities to learn and grow, with different needs and desires, different strength and weakness.

As health care providers, we need to be mindful of these labels and try to find some unifying quality among patients in order that we provide compassionate care to all. This may require that we embrace a work philosophy which can sustain us through difficult and trying days, for some they may need to call upon their faith, for others, it may come from a strong desire to live up to a professional code, for in a profession in which we are at constant risk for becoming apathetic and desentisized to the suffering of those we treat. It is important that we keep a constant check of our humanity, or we may find ourselves treating some patients as though they were children of lesser gods.

Putting Judith Jarvis Thomson's argument to the test

Blog entry # 2: Elsie barthelemy

Putting Judith Jarvis Thomson’s argument to the test
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Judith Jarvis Thomson’s analogy regarding a pregnant woman’s right to unhook herself from a fetus later amended by Jane Thomas , I feel places the woman as the sole decision maker .I feel that all parties involved should equally take part in the decision making when such a drastic outcome such as “ ABORTION” is entertained.

A woman cannot conceive alone. So far, science has yet made this leap. Conception thus far is accomplished by two parties whether each one play either an active or passive role toward such an accomplishment. Even in the instance where the natural process of conceiving by sexual intercourse is bypassed to be replaced by unison of a donor egg and sperm in a Petri dish. One thing cannot be changed that is the creation of the origin of such a conception that is the starting ingredients: sperm and egg. Therefore both parties supplying the ingredients should have equal right to its product unless one decides to give up this right.

So far the argument made by both Judith J Thomson and Jane Thomas only supports the woman as the sole decision maker. The male donor/ parent must be taken into account as well. I do understand that a woman carries the unequal burden of pregnancy for 9 months in comparison to the male counterpart. This should not be the sole aspect taken into account when arguing such a controversial subject.

One can further argue that a man donating his sperm is doing so in the hope of accomplishing procreation even when the act is done in an immoral and illegal matter. Therefore shouldn ’t he be given his fair share of the right to choose to give up his right of fatherhood?

Now as far as the right of the embryo/ fetus, I still have some reservation . If one agrees with Joseph Fletcher’s 15 propositions of personhood , it would then be clear and simple to decide that indeed the product of conception at its earliest stage is untitled to any rights whatsoever . However, there is still a grey area in this issue of when to consider a person a person. The advent of ART’s definitely render this subject more and more complex…

So what is the final word then? I guess for a while , this will remain “THE” controversial subject for debate. I don’t believe we have yet seen the end of the ambivalence and confusion which exist when one is considering what the final true ethical, moral and legal decision regarding “ ABORTION” should really be. I myself am no exception to the rule………….

Criminal & Civil Liability for Failure to Follow Advanced Directives

Health care workers need to faced with both criminal and civil prosecutions for refusal to follow Advance Directives for Healthcare.

There has been alot of time and energy expended in our country on the issue of healthcare directives. The government as well as private institutions have provided many classes, seminars, and even attorneys to help individuals understand and prepare these directives. Many people, especially the elderly, agonize over the decisions as to whom they want to appoint thier attorney-in-fact and to express what their desires are. In accordance with most state laws, every patient mujst be questioned as the presence of Advanced Directives for Healthcare and must provide further information and assitance to the patient in procuring these directives if the patient requests. Why is then that we are constantly hearing about healthcare providers , primarily physicians, who are refusing to follow these documents.

I believe that physicians need to be arrested for battery and that the families of these patients need to file a civil lawsuit for the tort of committing a battery and that damages need to be paid. For example, a physician who intubates a patient in the Emergency Room after learning of an Advanced Directive requesting "No Intubation" and speaking with the Attorney - in - Fact who states No Intubation. The occurs many times when there are multiple family members who have different wishes. Even though every family member is important, we must lose focus of our patient. The reason the patient identified his or hers desires and appointed an Attorney - in - Fact is that the individual has made the decison for himself.

The definition of a battery is the wilful or intentional touching of a person against that person's will or by an object set in motion by that person. Intubation of the patient in mhy example is clearly the intentional touching of the patient against their will.

In order to intubate a patient, a practitioner must first obtain legal consent. The consent can either be expressed or implied. Neither of these types of consent would be present in this example. There woule be lack of express consent as the Attorney-in-Fact clearly did not give consent to the intubation and furthermore, this expression was consistent with those expressed in the Advanced Directive. Implied consent also would not apply here. While many procedures are performed via the doctrine of implied consent in the Emergency Room, the doctrine would be negated by the refusal of the Attorney-in-Fact to consent. If the patient came in the Emergency Room in respiratory distress and without an Advanced Directive, consent would be implied by the virtue of succumbing to the EMS system. However, the Advance Directive and POA clearly interfere from Implied Consent being necessary.

Criminal prosecution for Battery does not require that any harm occur so an argument by the offending practioner that no damage occured by extending the patient's life would not prevent a criminal finding of Battery with a sentence. The plaintiff in the civil action would be required to show damages and they may be difficult to prove in monetary terms but some degree of pain suffering would be present in these type actions.

Those who choose to work in areas where these issues are present must comply with law even if they do not agree. If they choose to disregard the law. they must be prosecuted. This will eventually affect their licensure as one of the questions we all must answer when renewing our licenses is whether or not you have been convicted of a crime other than speeding offenses.

We see everyday as healthcare providers how the HIV epidemic becomes more prominent. SInce the begining in the 1980's thousands of people have lost their lives to this epidemic. The numbers keep rising specially in Africa where screening and treatment are a matter of luxury. With this in hand we beging to question wether HIV screening should be part of a normal physical examination. The reality is that many americans do not know they have the HIV virus do to lack of screening.
The U.S Ceters for Disease COntrol and Prevention announced the recommendation to make HIV testing a standard testing for all americans as they aim to prevent further spread of the disease and prompt needed care for the estimated 250,000 americans who have AIDS but do not know. It has been found that nearly half of the new HIV infections are discovered when doctors try to diagnose another illness and turn out to have the virus. I believe that earlier screening will allow people access to life expanding therapy, and also through prevention education, learn how to avoid the transmittion of the HIV infection.
Although this is only the beginning is a very important step in the prevention and treatment of the disease, Is a very good sign that we understand that testing should not be only for high risk groups but for every sexually active individual. Although the implementation will be challanging, requiring alot of money for testing counseling, and testing.
Identififying more HIV patients however, will place an added burden on public health programs that pay for such care, some of which are facing potential cuts under a proposal before Congress. However, more diagnosis may help win more funding, people's awareness and responsability for this expanding killer.
There is also the matter of cost. Some healthcare economists say that universal screening for HIV is a t least as cost effective as test that detect diabetes, breast cancer, and other chroninc conditions because if the virus is caught early, medicines can give patienta long, productive life. However, there are others under the impression that it will add more to the already burden health system.
I will assume that many of our fellow physicians will question wether is necessary to expand testing behond high risk individuals. However, it is the beginning for the prevention and extintion of the disease. Also, a more routine testing would avoid the problem of patients not acknowledging their risky behaviors.

HPV Vaccine- A Giant Step towards Preventing Cervical Cancer

In the United States there are currently 20 million people infected with the HPV virus and an additional 6.2 million are newly infected each year. Of every 100,000 women, 8.7 will develop invasive cervical cancer and 4000 women will die each year from this disease. In the past, prevention of cervical cancer was limited to screening Pap cytology. However, a HPV vaccine has recently been approved by the FDA and has been found to be 100% effective against the most common high-risk HPV virus strains.

In my practice as a women’s health Nurse Practitioner, I have seen the burdensome treatment and anguish of pre-cancerous conditions and the tragedy of cervical cancer caused by the HPV virus. It is my opinion that all young females should be offered and encouraged to receive this vaccine. Unfortunately at the present time no state is requiring this vaccine and few health insurance policies cover this expense. This is ridiculous.

A bipartisan group of female legislators representing the State of Michigan has introduced a bill requiring all girls entering the sixth grade to be vaccinated against the HPV virus. This is the first state to consider mandatory vaccination for this virus and should receive our enthusiastic support. It is also our obligation to help educate the public of this opportunity, inform our patients of their options and to encourage their vaccination. This vaccine should lead to a substantial reduction of cervical cancer and, hopefully, to the ultimate elimination of this disease.


www.cdc.gov/std/hpv
www.cancer.org
www.fda.gov/bbs/topics/NEWS/2006/NEW01385.html

The BioEthics Cafe -- Essays from the Edge of Paradise

The BioEthics Cafe -- Essays from the Edge of Paradise


The threat or pressure placed on physicians at the time of making a life and death decision is even more influenced by the threat of litigation. In a time of extreme stress, physicians are required to make decisions that are in the best interest of the patient and that also agree with the patient's wishes. In terms of "End of life" decisions, often every minute counts. And while the physician may have a state recognized "do not resuscitate" (DNR) order that documents the patient's wishes, there can be many members of the patient's family who surface at the 11th hour with conflicting views about what the patient wants in that situation.
For example, there was a patient in my hospital who came into the emergency room unconscious and in septic shock. She was a 76 year-old, widowed nursing home patient with four children. Her oldest daughter was her medical power of attorney. She had also signed an Advanced Directive six months prior, that stated her life not be sustained by any artificial means. She had specifically documented no intubations or CPR.
It was determined by the attending physician that this woman was in respiratory distress and needed to be intubated to prolong her life. The power of attorney, along with two other siblings reiterated the patient's wishes of no intubation. However, the physician received a phone call from the fourth sibling, her son from Washington D.C., who stated "Everything be done". The wishes of the patient and the rest of the family were not enough to convince the son to change his mind. He threatened the physician with a lawsuit.
The emergency room physician intubated the patient contrary to her wishes. While in the AICU, the intensivist would not extubate the patient because of the son's wishes despite her advanced directive. She subsequently expired 4 days later of cardiac arrest but not before a prolonged megacode to keep her alive.
Because both these physicians felt legal pressure, they did not honor the patient's Advanced Directive. They were swayed from allowing the patient to naturally pass, as per her wishes, to avoid litigation.
Unfortunately, this is becoming a trend where the DNR paperwork that comes in with a patient is not worth the paper on which it is written. While it used to be a guide that the physcian could use in directing treatment, now the patient's wishes seem to be secondary to potential legal threat. Personally, I am yet to see a physician stand up to this threat and withhold treatment in accordance with the patient's wishes. In the future it will require the hospitals and the legislature to strongly support physicians so they can provide or withhold medical care as originally intended by the patient.

Right to Die: “Mercy Killing”

Back in the old days, dying was relatively simple. Patients with untreatable illnesses opted to stay at home and live the rest of their days under hospice care. These patients wanted to live their remaining life comfortably surrounded by friends and family, then die in their own beds. These days, however, dying has become a complicated issue with the help of machines. Some people are coming up different ways of defining a “good death.” Is good death similar to the one in old days? Or is good death equivalent to be heaving out the last of breaths using respirators, dialysis machines, and force-feeding using G-tubes?

Today, most patients die in hospitals surrounded by strangers in uniforms. These strangers try their best to keep the patient alive by providing them with the best of medical machines and equipment, beds, medical staff, etc. Now, some people may find this type of death as acceptable, some however, tend to give up quickly and want to die comfortable at home. People who want to die at home may find their wishes unacceptable by family and physicians, who are entangled in a web of moral, legal and medical considerations. The main question into consideration is – should people, who want to die, request their physicians to hasten their deaths? And is it morally acceptable for physicians for physicians to do so?

This raises more questions than answers: Why decides to kill the patient? Is it the doctor? Or is it the patient (who is not always in full mental capacity)? Or is it the family members? Wouldn’t killing the patient violate the Hippocratic Oath? From a religious point of view, is it moral for one person to take the life of another person – even if the other person wants to die?

My personal point of view is that the doctor and the patient’s family (if any) decide on terminating the patient. I have first-handedly witnessed the pains of a family friend during his last stages of life. This person had a motorcycle accident and was in a vegetative state, unable to move except roll his eyes and weakly move his fingers. I noticed when a nurse was cleaning his G-tube, the patient was vigorously rolling his eyes and clenching on the bed sheet – a sign of extreme pain. The patient himself, communicating only using his eyes, wanted to die. Furthermore, the patient’s wife and doctors supported in terminating the patient, however, the patient’s sister disagreed. In the end, after dragging his life for 12 more months, the patient developed various infections in the lungs and kidneys, together with many ulcers all over the body, and died an extremely painful death. I don’t think it was worth to waste all the time and resources on a patient whose life became excruciatingly painful. So, personally, I fully support mercy killing.

Quote of the Day

To my mind, democracy is more compassionate, more harmonious, more friendly than any other system. It respects others' rights and considers others equally as human brothers and sisters. Although you might disagree with them, you have to respect their wishes.

-His Holiness the Dalai Lama From "The Pocket Dalai Lama," edited by Mary Craig, 2002. Reprinted by arrangement with Shambhala Publications, Boston, www.shambhala.com.

The Last Word

The Last Word on the Last Breath, New York Times dated October 10 presented us with the case of a 35-year old patient “ in a persistent vegetative state for 15 years…” who despite of obvious clinical deterioration was given interventions as the family requested.

Here the patient is not able to decide what he would like done. His family members have notified the medical staff of what actions are to be taken pertaining to their loved one ‘s treatment, which brings up the issue of surrogate decision. They wanted “all revival efforts” with hope. This clearly conflicts with the issue of futility in treatment and the young physician involved knew it well.

The medical staff is aware of no prevalent benefit from any further intervention for the patient based on sound physical findings. The state has no interest in prolonging the dying process based on the irreversible condition of the patient’s multiple organ failure.

The goal of treatment is to improve the patient’s condition leading to mental and physical stability. Unfortunately here it does not apply given the kidney failure, the pneumonia, the generalized infection, and the general weakening status of the body, not to mention the apparent mental deterioration without any likely recovery.

All the following could qualify as futility treatments for this patient:

1.The artificial feeding is no longer beneficial since he was losing weight;

2.Cardiac arrest is taking place;

3.The CPR will fail to resuscitate the patient;

4. The patient is not expected to regain consciousness or recover.

The family’s request for lifesaving efforts, which included CPR, does not balance with the physician’s duty to prevent unnecessary treatment on the patient. They are legally representing the patient, but at times in surrogacy issues emotions will tend to take over decisions regarding patients’ interest. The members of the family will be assured that they have authorized the medical staff to try all that was in their power to do in terms of treatments and interventions and hopefully this will prevent internal family conflicts that would make the mourning process even more difficult.

If I were this physician, I would be morally compelled to spare performing any intervention, since there is no expected recovery based on the strong clinical evidence.(Based on the AMA guidelines , another physician has to be consulted on site) . The aim of CPR, according to the American Heart Association “ …is to preserve life, restore health…” but in this particular situation there is not any “expected physiologic “improvement as evidenced by the patient’s septicemia and failing vital organs. Hospital Ethics Committees do have decision–making charts available for physicians confronted with difficult situations such as this case, and they are very helpful and simple to use. The U.S. Congress in 1985, under the “ Baby Doe Rule,” protected physicians in discontinuing any interventions aimed at prolonging a person’s life if no improvement can be foreseen. Physicians are obliged to act in their patients’ best interests at all times, let alone when aware that death is imminent and any added intervention is just prolonging death. It was time to simply let the patient be. Every individual deserves dignity and the healthcare team ought to, as always, be their patients’ best advocate in avoiding unnecessary treatment and ease suffering when all comfort treatments have been exhausted.

posted by sophie at 5:41 PM

Removal of Terri Schiavo's feeding tube violated the rights of the disabled

Theresa Marie "Terri" Schiavo (December 3, 1963 – March 31, 2005) was a woman from St. Petersburg, Florida. Her death decision was a federal matter and her husband selfishness. She was 26 when she collapsed in her home in 1990 and experienced respiratory and cardiac arrest. She remained in a coma for ten weeks. Within three years, she was diagnosed as being in a persistent vegetative state (PVS).

From my prospective view, if a person becomes incapacitated and has no written statement that expresses his/her wishes regarding health care, should the law presumes that the person wants to live, even if the person is receiving food and water though a tube. Given lack of living will, Terri Schiavo’s husband claimed that she would not want to be kept on a machine with no hope to recovery while her parents claimed that she was a devout Roman Catholic who would not wish to violate the Church’s teachings on Euthanasia. Who was in her best interest her husband who has already a girlfriend with two children out of wedlock or her parents that brought her on the earth.?

The decision of a number of Florida courts was that during two funerals earlier in her life, she discussed with her husband, brother-in-law, and sister-in-law the possibility of being profoundly disabled in the future. She indicated that she would prefer to be allowed to die naturally. It is hard to believe. She never signed a formal medical directive or a living will, which was the least thing on her mind at that age . These battles could have been avoided if Terri had had one. Perhaps the greatest effect that she has had on the American psyche is to remind citizens to consider drawing up a living will while they is still mentally alert. Otherwise, husband, brother and sister-in-law, mother and father-in-law, son and daughter-in-law or a guardian (the court) will be making decision for you.

Although, according to the Christian doctrine, death is not the ultimate evil, but eternal damnation is; to allow Terri to die would be to allow her to join with God in eternal life. Yes, but NOT when it interfered without hydration and nourishment. Pope John Paul II discussed nourishment of patients in Terri Schiavo's condition during 2004-MAR: "...the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of his suffering....we are called to provide basic means of sustenance such as food and water unless they are doing more harm than good to the patient, or are useless because the patient’s death is imminent."

Partial-birth Abortion

With the Supreme Court term beginning this past Monday, Oct. 2, it will quickly face cases on the federal law banning a procedure known as partial-birth abortion that are drawing attention from the religious community.

Court observers are eyeing two abortion cases, in which the 9^th and 8^th U.S. circuit Courts of Appeals each said the 2003 federal law banning partial-birth abortion was unconstitutional, to see if recent changes in the Supreme Court’s makeup will affect the outcome of abortion-related decisions.

In Gonzales v. Carhart, the 8^th Circuit sided with Dr. Leroy Carhart, a Nebraska abortion doctor who successfully sued to overturn that state’s partial-birth abortion ban. In 2000 the Supreme Court ruled 5-4 that the state law was unconstitutional because it lacked a provision allowing an exception in cases where the pregnant woman’s health is at risk.

Congress sought to reverse the effect of that ruling by passing a federal law banning the procedure nationwide. The bill did not include a health exception, because, the bill’s proponents argued, sufficient evidence had been heard that this particular procedure is never medically necessary.

The banned procedure involved partially delivering a live fetus and then puncturing the brain stem to kill the baby before completing the delivery. Supporters of keeping the procedure legal argue that it is usually used late in pregnancy when other abortion methods are more dangerous to the woman.

In Gonzales v. Planned Parenthood, the 9^th Circuit ruled on behalf of a San Francisco-based Planned Parenthood affiliate and its national organization that the federal law is unconstitutional because it lacks a health exception, imposes a burden on a woman’s right to choose to have an abortion and is constitutionally vague.

The legal question before the Supreme Court when it hears both cases November 8^th is whether the law is invalid because it lacks a health exception or otherwise is unconstitutional.

I believe the abortion issue is always very difficult to discuss. The main problem seems to stem from the question - When does a human being become a human being? When does life begin? Is abortion murder?

In conclusion, the basic protection which society must provide its citizens is the protection of the right to be. Our Declaration of Independence express as self-evident the truths "that all men are created equal, that they are endowed by their creator with certain unalienable rights, that among these are life, liberty and the pursuit of happiness," and that governments are instituted to secure these rights. Whether one believes in a creator or not, the responsibility of government in the matter of human life is clear. When abortion was legalized in our country, government, in effect, said that the unalienable right to life does not apply to certain beings that are, nonetheless, definitely human beings. This brings us back to the question when does life become life? For all practical purposes it made every unborn child legally vulnerable. In regards to the subject of partial – birth abortion, I believe there is no doubt that human life is being endangered. The child being aborted is a child – no questions asked.

" Don't let the bugs bite” : can genetic engineering defeat diseases spread by insects?

Reemergence of old diseases that were thought to be under control (in certain countries), was an unpleasant shock to the health care community. This illustrated an important principle that disease patterns change because of :

I. Organisms change,

II. Human activity change to create new opportunities for organisms to cause disease.

In the mid-20^th century, insecticides and other measures eliminated malaria from US and Europe. Many public health workers were optimistic over reducing the global burden of many vector-borne diseases, such as : Malaria, Chagas, Yellow fever, and Dengue fever, by spraying chemicals. With the comeback of these diseases, occurring more widely and more frequently than they have in recent decades, Frank H. Collins of the University of Notre Dame in Indiana, said in retrospect that it was naive of us to think that we could eradicate the mosquito by chemical attack. Many insect populations, especially in the tropics proved too hardy, as evident by the come back of diseases in regions that were considered free of such. Failure to control these vector-borne disease with chemicals, lead scientist to research alternate ways to target the problem.

Molecular Biologist Anthony James of University of California in Irvine has proposed; augmenting conventional measures with genetic engineering and other innovative approaches, to pare down vector population and leave others incapable of spreading disease. While controversial, the Sterile Insect Technique (SIT) has worked against disease vectors and agricultural pests.

1. Tsetse flies, the vectors of sleeping sickness, were eradicated from Zanzibar, an island of Tanzania.

2. California citrus groves were cleared of the invasive Mediterranean fruit flies.

3. Eradication of livestock parasites and flies.

SIT damages the male insects to such an extend that they can not reproduce but still compete with the wild males for mates. Entomologists are setting up research fields to study different ways to genetically modify, either the microbe or the vector insect that carry them.

Entomologist Celia Cordon-Rosales of the Universidad del Valle de Guatemala is targeting disease spreading insects, to genetically alter them or to manipulate organisms living in them. This approach remains controversial, and because the government will be tough on giving permission to release modified insects or micro-organisms in the environment, it is not too early to carry-out this project, because it involves a lot of basic research, and special precaution to ensure that potential problems with releasing the research sample, is properly secured. Cordon-Rosales' major research is with Chagas Disease. This is an insect-borne disease, that is contracted via infection with the single celled protozoa: Trypanosoma cruzi. Several insects are the vector of this disease. The bug is called “kissing” or” assassin “bug. Kissing because it has a tendency to bite people near the mouth. Chagas is prevalent in Latin America to as far North as the United States. 90 million people live in the areas where Chagas disease is endemic, 12-18 million (13-20%) people are infected of which 10-30% develop heart failure or other chronic life threatening symptoms. The mortality is approximately 50,000 people per year.

The basic research set-up is what she refers to as a ghost town, isolated from human life by fine mesh nets through which bugs can not escape. The imitation village would contain huts from straw and clay. It will be occupied by pigs in pens, and free living insects and bacteria. The mock hamlet will be encircled by a ditch, which will collect any runoff water that might permit micro-organisms to leave the site. Rosales hopes that with the results of her research project and that of her collaborators in the United States, that she will also be able to address the problem of the reemergence of Malaria, Sleeping sickness, Dengue fever and Yellow fever as well.

Posted By Ingrid Daly October 19, 2006