Tag: internal medicine

Bioethics Blogs

Three New Articles on Medical Futility Conflicts

Here are three relevant articles from the latest Journal of Clinical Ethics (Winter 2016, Volume 27, Number 4).

A Survey of Physicians’ Attitudes toward Decision-Making Authority for Initiating and Withdrawing VA-ECMO: Results and Ethical Implications for Shared Decision Making
Ellen C. Meltzer, Natalia S. Ivascu, Meredith Stark, Alexander V. Orfanos, Cathleen A. Acres, Paul J. Christos, Thomas Mangione, and Joseph J. Fins


Objective:  Although patients exercise greater autonomy than in the past, and shared decision making is promoted as the preferred model for doctor-patient engagement, tensions still exist in clinical practice about the primary locus of decision-making authority for complex, scarce, and resource-intensive medical therapies: patients and their surrogates, or physicians. We assessed physicians’ attitudes toward decisional authority for adult venoarterial extracorporeal membrane oxygenation (VA-ECMO), hypothesizing they would favor a medical locus.


Design, Setting, Participants: A survey of resident/fellow physicians and internal medicine attendings at an academic medical center, May to August 2013. 


Measurements: We used a 24-item, internet-based survey assessing physician-respondents’ demographic characteristics, knowledge, and  attitudes regarding decisional authority for adult VA-ECMO. Qualitative narratives were also collected. 


Main Results: A total of 179 physicians completed the survey (15 percent response rate); 48 percent attendings and 52 percent residents/fellows. Only 32 percent of the respondents indicated that a surrogate’s consent should be required to discontinue VA-ECMO; 56 percent felt that physicians should have the right to discontinue VA-ECMO over a surrogate’s objection. Those who self-reported as “knowledgeable” about VA-ECMO, compared to those who did not, more frequently replied that there should not be presumed consent for VA-ECMO (47.6

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

Study Finds No Safe Level of Smoking

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Many Americans who’ve smoked cigarettes have been successful in their efforts to quit. But there’s some bad news for those who’ve settled for just cutting back: new evidence shows there’s no safe amount of smoking. One cigarette a day, or even less than that, still poses significant risks to your health.

A study conducted by NIH researchers of more than 290,000 adults between the ages of 59 and 82 found that those who reported smoking less than one cigarette per day, on average, for most of their lives were nine times more likely to die from lung cancer than those who never smoked. The outlook was even worse for those who smoked between one and 10 cigarettes a day. Compared to never-smokers, they faced a 12 times greater risk of dying from lung cancer and 1½ times greater risk of dying of cardiovascular disease.

The findings, reported by Maki Inoue-Choi of NIH’s National Cancer Institute, Rockville, MD, and colleagues, come from an analysis of data from the NIH-AARP Diet and Health Study. The study is evaluating the effects of diet and lifestyle on cancer risk over many years in a large group of seniors from across the country.

The study began about 20 years ago, when a team of NIH researchers mailed questionnaires to 3.5 million members of AARP.  More than a half million people answered the original survey. Since then, these respondents have completed two follow-up surveys about their lifestyle and behaviors, including their smoking patterns from ages 15 to 70.

As published in JAMA Internal Medicine, the latest analysis included more than 290,000 seniors who answered a survey conducted from 2004 to 2005 [1].

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

‘Dear Plagiarist’: A Scientist Calls Out His Double-Crosser

December 13, 2016

(STAT News) – It’s a researcher’s worst nightmare: Pour five years, and at least 4,000 hours, of sweat and tears into a study, only to have the work stolen from you — by someone who was entrusted to confidentially review the manuscript. But unlike many sordid tales of academia, this one is being made public. Dr. Michael Dansinger, of Tufts Medical Center, has taken to print to excoriate a group of researchers in Italy who stole his data and published it as their own. Writing in the prestigious Annals of Internal Medicine — which unwittingly facilitated the episode by farming the paper out for review and then rejecting it — Dansinger calls out the scientists who published their nearly identical version in the somewhat less prestigious EXCLI Journal.

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

Low-Value Treatments, Prescriptions Common, Survey Finds

December 7, 2016

(Medscape) – Overuse of antibiotics, aggressive nonpalliative end-of-life care, chronic pain medications, and dietary supplements offer patients the least value despite widespread use, according to a research letter published in the December 6 issue of the Annals of Internal Medicine. The letter reports findings from a survey conducted by the American College of Physicians, which defines “high-value” interventions as those whose potential benefits outweigh the potential harms and costs.

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

Bioethicists Urge Caution in Teaching High Value Care

Calling for an “unwavering focus on the primacy of patient welfare,” a pair of medical ethics scholars urges careful consideration of how the concept of high-value care (HVC) should be integrated in medical education.

 

The JAMA Viewpoint published December 6 states, “if primacy of patient welfare is to truly remain fundamental to the profession, instilling commitment to this principle should be the most critical ethical value instilled in cultivating professional identity.”

 

If ‘value’ is considered the ratio of health benefits achieved per unit of cost, value can be increased in several ways: increasing health benefits, decreasing costs, or accepting less health benefit as a trade-off for cost savings.

 

Teaching approaches that over-emphasize cost savings “could risk causing trainees to lose sight of individual patient welfare or create unintended consequences for subsequent bedside decision-making,” write Viewpoint authors Matthew DeCamp, MD, PhD, and Kevin Riggs MD, MPH

 

“Physicians must sometimes balance ethical tension between cost-saving and patient welfare. The best way to do this is unsettled among ethics scholars and practicing physicians. This lack of consensus could lead to inexperienced medical trainees misunderstanding their duty,” says DeCamp, assistant professor at the Johns Hopkins Berman Institute of Bioethics and Division of General Internal Medicine.

 

The consequences could be damaging to both the physician-patient relationship and the profession, the authors say. “[A]mbiguity regarding the primacy of patient welfare in HVC education risks patient distrust and societal backlash against what might be perceived as training future physicians to control costs at the expense of patient welfare.”

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

Interview with Dr. Marcia Angell, former Editor-in-Chief of the New England Journal of Medicine

by Mike Reaves

Dr. Marcia Angell is an American physician, author, and the first woman to serve as editor-in-chief of The New England Journal of Medicine. Dr. Angell joined the Journal’s staff in 1979, became executive Editor in 1988, and served as Editor-in-Chief of the journal until June of 2000. She is currently on the faculty of the Department of Global Health and Social Medicine at Harvard Medical School in Boston, Massachusetts. Her most popular work, The Truth About the Drug Companies: How They Deceive Us and What to Do About It (2004), is critical of big industry in healthcare and its role in research and medicine. In April of 2016, I had the opportunity to sit down with Dr. Angell for a discussion about some of the most controversial topics in healthcare economics, regulation, journalism, and politics.

I solicited Dr. Angell’s opinion on a recent decision regarding pharmaceutical companies, Amarin Pharma, Inc. v. United States. This decision holds that the First-Amendment protects off-label drug promotion by pharmaceutical companies. Dr. Angell indicated that it is difficult to prove that unethical behavior occurs in the promotion of off-label drugs because it is hard to monitor the behavior. She believes there will not be much success in the prosecution of individuals responsible for pushing these marketing strategies, and that jail time will likely be the only deterrent in an industry that incurs fines as a cost of doing business. 

I asked Dr. Angell about the Journal’s recent policy changes regarding conflict of interest. The current Editor of the Journal, Jeffery Drazen, has loosened the conflict of interest policy, which now allows authors of editorials and review articles to receive up to $10,000 from each drug company.

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

A Canadian physician’s defense of rights of conscience

A friend who teaches at the University of Toronto recently made me aware of what Ewan Goligher has written about rights of conscience in the context of the legalization of physician assisted death in Canada and the push by many there to require physicians provide effective referral for physician assisted death. Dr. Goligher is an academic physician who specializes in internal medicine and intensive care… // Read More »

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

Morning Sickness Associated with Lower Miscarriage Risk

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During the first trimester of pregnancy, many women experience what’s commonly known as “morning sickness.” As distressing as this nausea and vomiting can be, a team of NIH researchers has gathered some of the most convincing evidence to date that such symptoms may actually be a sign of something very positive: a lower risk of miscarriage.

In fact, when the researchers studied a group of women who had suffered one or two previous miscarriages, they found that the women who felt nauseous during their subsequent pregnancies were 50 to 75 percent less likely to miscarry than those without nausea. While it’s not yet exactly clear what’s going on, the findings lend support to the notion that morning sickness may arise from key biological factors that reflect an increased likelihood of a successful pregnancy.

The study, reported recently in JAMA Internal Medicine [1], was led by Enrique Schisterman and Stefanie Hinkle of the NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development. Their findings are based on a secondary analysis of existing data from the recently completed Effects of Aspirin in Gestation and Reproduction (EAGeR) trial. It found that aspirin might help in select cases but is not generally recommended to prevent pregnancy loss [2].

While other studies have looked at the effects of morning sickness on the risk of miscarriage, most have been limited to pregnancies lost late in the first trimester or thereafter. That’s one of the ways in which the EAGeR study is noteworthy. It enrolled 1,228 women who had one or two previous miscarriages and followed them for up to six menstrual cycles as they tried to become pregnant again.

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

Outside the Comfort Zone


I always feel a little nervous for the folks who sign up to
be contestants on “Dancing with the Stars” because despite any prior fame or
achievements they are spectacularly and uniquely vulnerable on the dance floor.
Stepping outside their comfort zone is perhaps what we admire about these
celebrities – they are suddenly vulnerable to a different and unfamiliar
scrutiny. Mastering new skills alongside an assigned partner we hope for the
best as the dancers put their best effort on display. There are criteria to be
satisfied (need to show enough Viennese Waltz and Foxtrot moves), and judges to
score how well they met these standards. While there is no small amount of
entertainment value to the evaluation of the contestants, what is interesting
is that the public votes too. This may be a reach, but as healthcare faces new
standards measuring quality under the ACA, we see some interesting parallels.


Like our intrepid celebrity dancers, healthcare institutions
need to adapt to an evolving set of quality measurements under the ACA. As
healthcare institutions brace for the uncertain impact of the ACA regulations
on the day to day operations and finances, those responsible for assuring the
delivery of care are focusing on not only the cost per patient, but also on
improving how patient experience care, and how the health of the community at
large can be improved. Like the dancers finding their footing, the ACA
challenges the healthcare industry to serve patients with agile and efficient
practices in order to not be left behind.

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.