Tag: internal medicine

Bioethics Blogs

Choosing Wisely in Intensive Care Medicine – DGIM Recommendations

The German Society for Internal Medicine (DGIM) has released recommendations for intensive care medicine.

Among their positive recommendation is “early evaluation of patient consent.”

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Confronting Medicine in the Holocaust & Beyond

By Hedy S. Wald

Galilee, Israel, May 7-11, 2017. I was privileged to be at the Second International Scholars Workshop on “Medicine in the Holocaust and Beyond.” Why so meaningful?  Why so needed? 140 purposeful, passionate scholars from 17 countries delved into the past history of medicine at its worst in order to inform the future.  From 1933-1945, presumed healers within mainstream medicine (sworn to uphold the Hippocratic Oath) turned into killers (1).  Yes, medical ethics in Nazi-era medical school curricula existed, yet included “unequal worth of human beings, authoritative role of the physician, and priority of public health over individual-patient care”(2).  In Western Galilee College, (Akko), Bar-Ilan University Faculty of Health Sciences (Safed), and Galilee Medical Center and Ghetto Fighters’ Museum, (both in Nahariya), historians, physicians, nurses, medical and university educators, medical students, ethicists and more gathered to grapple with this history and consider how learning about medicine in the Holocaust can support healthy professional identity formation with a moral compass for navigating the future of medical practice with issues such as prejudice, assisted reproduction and suicide, resource allocation, obtaining valid informed consent, and challenges of genomics and technology expansion (3)…

The conference, in essence, served as a lens for the here and now, reinforcing my contention (and others’) that history of medicine in the Holocaust curricula including confronting the Nazi physicians’ and scientific establishment’s euthanasia of “lives unworthy of life,” forced sterilizations, horrific experimentation on their victims, and medicalized genocide (leading to the destruction of a third of the European Jewish population and many others) is a “moral imperative” in healthcare professions education (1,4).

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

FDA Advisory Committees and Industry-Funded Patient Advocacy

Cross-posted on Objective Intent and Notice & Comment.

Industry funding of patient advocacy organizations recently has received attention from media and researchers.  For example, one 2017 study in the New England Journal of Medicine found that over 80% of patient advocacy organizations with annual revenues of at least $7.5 million reported receiving industry funding; another study in JAMA Internal Medicine found that approximately 65% of patient advocacy organizations with a median annual revenue of about $300,000 reported receiving industry funding; and a post on the Hastings Center’s website (and an earlier JAMA Internal Medicine editorial) reported that one pharmaceutical company funded an advocacy organization that, in turn, recruited other patient advocacy groups to speak in favor of the company’s drug when the FDA was considering approving it.  This last story highlights one area where the rubber meets the road with respect to FDA and patient advocates’ conflicts of interest: advisory committee meetings.

Advisory committees play an important role at FDA, including for new drug approvals.  Often when FDA is considering whether to approve a new drug, it will ask an advisory committee—a group of outside experts—to provide the agency with advice on various scientific questions about the drug.  At a typical drug-related advisory committee meeting, the drug company and FDA will each take a turn presenting the scientific evidence about the unapproved drug, then there will be an open public hearing at which any interested member of the public may speak, followed by the advisory committee’s discussion of, and vote on, the questions that FDA has posed to it. 

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

In Defense of a Physician’s Right to Conscientious Objection, Part 2

Guest post by Cheyn Onarecker, MD

Today, I am continuing my comments on the recent editorial against conscientious objections from the New England Journal of Medicine (subscription required). My previous objections to the elimination of protections for conscientious objections included: 1) the importance of maintaining the traditional balance that has always existed between the needs of the patient and the physician, and 2) the fact that medical societies make decisions on the acceptability of certain procedures that are influenced by society and do not represent the views of a large percentage of its members. I will now add a couple more reasons.

Third, it is impractical and unreasonable to demand that persons considering a career in medicine should be prepared to violate their moral convictions. When the Church Amendment was passed in 1973, allowing physicians to be exempt from performing abortions, there was no outcry from the AMA or any other medical society denouncing the law or declaring that rights of conscience were unethical. Since then, the number of laws and provisions to protect conscience rights have increased, not decreased. Philosopher Mark Wicclair explains that modern medicine, in general, has accepted the right of conscientious objection, and no young person entering medicine today believes that their moral and religious convictions are incompatible with a career in medicine. In fact, the AMA issued a directive to medical schools to excuse students from performing activities that violate their ethical beliefs. Not only that, but how would physicians be able to predict that someday their chosen specialty would develop a controversial treatment?

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

When Ideology Trumps Reason, Do The Life Sciences Resist or Capitulate?

by Craig Klugman, Ph.D.

The world of the life sciences and medicine is being changed radically in 2017. The proposed Trump budget cuts funding for the CDC, NIH, NSF, NEH, NEA, EPA, and PHS will radically change how science is done, how much science is done and by whom. The US is withdrawing from the Paris Climate Treaty. Cuts to social security that traditionally pays for medical residents have also been proposed. The American Health Care Act will take affordable health insurance away from 23 million people. For the rest of us, the AHCA means higher premiums and less coverage. At the same time, we live in an era of “fake news,” “leaks,” incendiary tweets, and loyalty as the sign of someone’s worth. What might be the impact on medicine, the life sciences and bioethics in the Trumpian era? Will the dominant political ideology affect the practice of science and medicine in more ways than economics? Can ethics help steer a course around ideology?

One change that has already occurred under Trump is an anecdotal decrease in the number of immigrants (documented and undocumented) who are seeking medical care under concern that they will be deported if they show up to hospitals and doctor’s offices. In one case, a woman was forcibly removed the hospital where she was to be treated for a brain tumor and brought to a detention center.

Certainly, there is a U.S. history of medicine following the ideology of the government. Forced sterilization, the Tuskegee Syphilis study, the US radiation experiments and the Guatemala Syphilis studies were all government financed research created to prove a particular ideology: In these cases, species-level differences between the races and that a nuclear war was “winnable.”

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Medical Students Can Handle the Truth; Their Mentors Should be More Open About It

By Shannon Tapia

Medical School is rough.  Fortunately there is a recent movement to make medical education more humane.  The movement to bring humanity, ethics, and love back into the molding of our future physicians is crucial. Personally, I felt my medical school was on the forefront of this push.  Perhaps it was because we had Jesuit priests for attendings and the hospital’s motto of “We also treat the human spirit” filtered into the treatment of students.  Whether it was something about myself or my medical school, I was fortunate to never experience the depression, competitive urges, burnout and isolation that is so prevalent during American medical school years…

But there is an underlying and hidden truth that is never spoken about, or at least wasn’t to me, in medical school.  As students we are warned how tough medical school is and furthermore how absolutely draining residency is.  When we’re in the thick of either in even the most uplifting programs and schools, we are monitored for burnout, offered services to prevent it, and given support in ways students and residents of the 20th century never were. More frequently now, we are prepared for these harsh realities.  But what we’re not told, ever, is that even if and when we make it through medical school and residency/fellowship to attending physicians we may well find it’s not greener on the other side.  We may still first experience burnout when we’re supposed to be summiting our Everest Mountain of medical training. As many mountain climbers will tell you, often the way down from the peak is just as hard if not harder than the climb up.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics News

How Are Doctors Expected to Talk about Patients?

Zack Berger writes, “:Every week I precept (teach and supervise) in the residents’ internal medicine clinic at the Outpatient Center of Johns Hopkins Hospital, on Caroline Street in Baltimore, Md. The patients are mostly Baltimoreans, mostly African-Americans, though an increasing number are Spanish-speaking immigrants”

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Widening Gap in U.S. Life Expectancy

Caption: Life expectancy at birth by county, 2014. Life expectancy into 80s (blue), 70s (green, yellow, orange), 60s (red).

Americans are living longer than ever before, thanks in large part to NIH-supported research. But a new, heavily publicized study shows that recent gains in longevity aren’t being enjoyed equally in all corners of the United States. In fact, depending on where you live in this great country, life expectancy can vary more than 20 years—a surprisingly wide gap that has widened significantly in recent decades.

Researchers attribute this disturbing gap to a variety of social and economic influences, as well as differences in modifiable behavioral and lifestyle factors, such as obesity, inactivity, and tobacco use. The findings serve as a sobering reminder that, despite the considerable progress made possible by biomedical science, more research is needed to figure out better ways of addressing health disparities and improving life expectancy for all Americans.

In the new study published in JAMA Internal Medicine, a research team, partially funded by NIH, found that the average American baby born in 2014 can expect to live to about age 79 [1]. That’s up from a national average of about 73 in 1980 and around 68 in 1950. However, babies born in 2014 in remote Oglala Lakota County, SD, home to the Pine Ridge Indian Reservation, can expect to live only about 66 years. That’s in stark contrast to a child born about 400 miles away in Summit County, CO, where life expectancy at birth now exceeds age 86.

Earlier studies suggested that Americans living in some parts of the country were living more than a decade longer than others [2].

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

E-H-ARRGH: The Frustrating Costs and Benefits of the Electronic Health Record

April 28, 2017

by Jami Starr, MD, Clarkson University Bioethics Policy Certificate 2017

E-H-ARRGH: The Frustrating Costs and Benefits of the Electronic Health Record

 The concept of electronic medical recordkeeping was first introduced in the late 1960’s but it did not really become established until this century. Electronic Health Records (EHRs) are expected to provide a number of benefits, including: ability to track data over time, monitoring use of interventions (i.e. vaccinations), and identifying patients in need of preventive screening. Data are forthcoming as to how effectively EHRs meet these goals. What is clear, however, is that it is third party payers profit from EHRs as a result of improvements in claims processing.

The use of EHRs carries implicit hazards with respect to confidentiality. It seems no cyber security system today is impenetrable.  We have witnessed multiple breaches in the past few years involving government agencies, major retail chains, and financial institutions. If a hospital database were hacked, not only would pertinent demographics be exposed (social security numbers, insurance policies, etc.) but also personal information about diagnoses, socioeconomic circumstances, and the like.  While this is a risk with paper medical records as well, the rapid and potentially widespread dissemination of information though a computer data system is far more menacing in scope.  In most clinical settings where EHRs are employed, paper charts have been eliminated and patients do not have an option as to how personal data are maintained.  Vulnerability has been increased de facto by reliance upon this new medium.

Aside from the issues related to cyber security, there are start-up costs related to productivity, burnout and physician-patient relationships.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

How to make Nazi doctors

Most people who go into medicine have as at least part of their motivation the desire to help other people. I’m sure this was as true in 1930’s Germany as anywhere else. So how did a cadre of Nazi doctors come not only to commit crimes against humanity, but also to defend the moral correctness of their conduct when placed on trial for those crimes? The answer is complex, but one way was through the teaching of medical ethics.

An article in the April 18th Annals of Internal Medicine tells a cautionary tale for teachers and learners of bioethics. Entitled “Lectures on Inhumanity: Teaching Medical Ethics in German Medical Schools Under Nazism,” the article details how the Nazi party developed a curriculum for teaching ethics in medical schools that “was intended to explicitly create a ‘new type of physician’ . . . trained to internalize and then implement the Nazi biomedical vision . . . shifting the focus of ethical concern and medical care away from the individual patient and toward the general welfare of society or the people.” The curriculum included lectures in racial hygiene, the science of heredity, population policy, military medicine, and the history of medicine. Only long-standing members of the Nazi party were appointed lecturers. The lecturer at Berlin University, Rudolf Ramm, wrote the ethics textbook used in the curriculum, which emphasized physician paternalism in practicing their moral obligation to rid society of certain groups, and asserted that every (Aryan) person in Germany had a moral duty to stay healthy.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.