Tag: medical specialties

Bioethics Blogs

The Tale of the Ethical Neonatologist – And Why There Shouldn’t Be a Legal Right of Conscientious Objection

Doctors have values. These are sometimes described as their conscience. Those values can conflict with what has evolved to be medical practice. Where that practice is consistent with principles, concept and norms of medical ethics, their values should not compromise patient care. The place for doctors to express their values and seek to revise the practice of medicine is at the level of policy and law, not at the bedside. Because conscientious objection can compromise patient care, there should be no legal right to conscientious objection to medical practice that is consistent with medical ethics. Personal values (“conscience”) can be accommodated by employers under standard labour law as occurs in Sweden and Finland, or candidates selected for medical specialties who have values consistent with ethical medicine, or new professions developed to provide those services.

Doctors may have very defensible values. But just because their values are reasonable does not imply they should be accommodated by medicine. Consider the Conscientious Neonatologist.

The Conscientious Neonatologist

Peter is a thoughtful, reflective specialist caring for premature babies in intensive care. He is a vegetarian for 20 years. He became deeply concerned about the welfare of animals during his university years. He believes in “animal liberation”. Neither he nor his family consume meat or use animal products for clothing.

In his job, he must prescribe “surfactant” – a substance to help the lungs of premature babies function better. The standard, and most effective form is derived from the lungs of pigs. However there is a new artificial form. He considers this a more “ethical” product and considers using it in his medical practice.

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 the Journals – June 2016, Part II by Anna Zogas

We have three special issues to conclude our highlighting of new articles in June! Here they are:

  • Surveillance and Embodiment: Dispositifs of Capture, in Body & Society
  • Perspectives on patienthood, practitioners and pedagogy, in Medical Humanities
  • Childbirth and Reproduction, in Sociology of Health & Illness

And, if you’re looking for more to read, the first part of this month’s roundup is here.

Body & Society

Surveillance and Embodiment: Dispositifs of Capture
Martin French, Gavin JD Smith 

This article provides an introduction to a special issue of Body & Society that explores the surveillance-embodiment nexus. It accentuates both the prevalence and consequence of bodies being increasingly converted into ‘objects of information’ by surveillance technologies and systems. We begin by regarding the normalcy of body monitoring in contemporary life, illustrating how a plurality of biometric scanners operate to intermediate the physical surfaces and subjective depths of bodies in accordance with various concerns. We focus on everyday experiences of bodily intermediation by surveillant dispositifs, and consider the broader political, epistemological, and ontological significance of these processes. We then point to the substantive intersections and divergences existing between body and surveillance studies. We conclude with an overview of the five articles appearing in this special issue. We describe how each contribution creates a template for imagining what a body is, and what a body might become, in a culture defined by proliferating data sharing behaviours, systems of codification, and practices of intermediation.

Surveillance, Privacy and the Making of the Modern Subject: Habeas what kind of Corpus?
Charlotte Epstein

In this article I consider how our experiences of bodily privacy are changing in the contemporary surveillance society.

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

Cassandra Crawford’s Phantom Limb: Amputation, Embodiment, and Prosthetic Technology by Seth Messinger

Phantom Limb: Amputation, Embodiment, and Prosthetic Technology

by Cassandra S. Crawford

NYU Press, 2014, 314 pages

The title of this important book gives only the slightest hint of the extraordinarily complex account that Crawford has produced about the biopolitics of limb absence and other forms of acquired limb loss, the meaning of phantom sensation and phantom pain, and the work of scientific knowledge-making in constructing experience and persons. Crawford organizes her book both as a history of biomedicine’s overall construction of limb loss and as a series of disciplinary encounters between different medical specialties struggling over how to delimit and explain the experience of limb loss.

In the United States, amputation and phantom sensation became a concern to biomedicine as a result of the mass injuries and limb loss sustained by soldiers during the Civil War. This period produced one of the first large-scale attempts to offer prosthetic limbs to people with limb loss, and as the manufacture and utilization of prosthetics increased, an interest in the biomedical needs and challenges experienced by prosthetic users also grew rapidly. This was also a period of increased attention to neuroscience and the linkages between nerves and the self (Phineas Gage’s accident with a railroad spike happened in 1848).

Silas Weir Mitchell, an American physician and neuroscientist, treated Civil War casualties and was the first to seriously study the phenomena of phantom limb sensation. He prepared detailed reports about sensations experienced by persons with limb loss and the potential clinical effects those sensations might have on prosthetic utilization. From this initial clinical attention Crawford explores how different clinical specialties have constructed limb loss and sensations associated with 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

27th Annual Dorothy J. MacLean Fellows Conference on Clinical Medical Ethics

The MacLean Center at the University of Chicago has prepared another world class conference on clinical medical ethics.  It is November 13 and 14.  It is free.

Panel 1: Ethics and Healthcare Economics 

  • Moderator: Mark Siegler
  • The True Cost of Hepatitis C Therapy (Andrew Aronsohn, The University of Chicago)
  • Ethics of Sustainability (Stacy Lindau, The University of Chicago)
  • Are There Ethical Standards For Health Insurance Companies? (David Rubin, The University of Chicago)
  • What’s Wrong With Healthcare Rationing (Peter Ubel, Duke University)
  • An Economic Analysis of Medical Ethics (Anup Malani, The University of Chicago)


Panel 2: Topics in Clinical Ethics 

  • Moderator: Lainie Ross
  • Ethical Issues in Organ Transplantation: Risk of Living Kidney: Donation in African-Americans (Dick Thistlethwaite, The University of Chicago)
  • When Altruism Goes Awry: Living Kidney Donors in End Stage Renal Disease (Lainie Ross, The University of Chicago)
  • How We Disagree: Unexpected Lessons on Professionalism from the Maintenance of Certification Debate (Lois Nora, American Board of Medical Specialties)
  • The Chart (David Schiedermayer, Medical College of Wisconsin)


Panel 3: Surgery 

  • Moderator: Peter Angelos
  • Surgical Ethics and the Future of Surgery (Peter Angelos, The University of Chicago)
  • Aligning patient preferences with high risk surgical treatments (Gretchen Schwarze, University of Wisconsin)
  • Pallative Reconstructive Surgery (Lawrence Gottlieb, The University of Chicago)
  • Ethics in the Operating Room (Alex Langerman, The University of Chicago)
  • Research on Organ Donors (Tracy Koogler, The University of Chicago)


Panel 4: Quality 

  • Moderator: Daniel Sulmasy
  • Quality Attestation in Clinical Ethics: Stepping Up (Eric Kodish, Cleveland Clinic)
  • Ethics of Hand Hygeine (Emily Landon, The University of Chicago)
  • From Ethics to President in Oklahoma (John Schumann, The University of Oklahoma-Tulsa)
  • Adherence to Altered Standards of Care in a Public Health Crisis (Valerie Gutmann Koch, IIT Chicago-Kent College of Law)
  • Religion & Workplace Discrimination: Findings from a National Survey of Muslim Physicians (Aasim Padela, The University of Chicago)


Panel 5: Decision-Making/Disparities

  • Moderator: Monica Peek
  • Improving Shared Decision-Making with LGBT Racial and Ethnic Minority Populations (Marshall Chin, The University of Chicago)
  • Joint Deliberation as a Patient/Doctor Ideal (Daniel Brudney, The University of Chicago)
  • Shared Decision-Making Among African-Americans (Monica Peek, The University of Chicago)
  • Gender and Socioeconomic Disparities in Caregiving for Fragile X Syndrome (Harold Pollack, The University of Chicago)


Panel 6: Excellence in Ethics and Patient Care 

  • Moderator: Mark Siegler
  • Scaling Innovation: Lessons from Maternal, Newborn & Child Health (Peter Singer, University of Toronto)
  • Treating Moral Injuries of Veterans & Their Families (Niranjan Karnik, Rush University)
  • The Political Obstacles Toward Developing a Private Market in Organs (Richard Epstein, The University of Chicago)
  • On Making a Difference One Paragraph at a Time: From Oncologist to Guardian Coilumnist (Ranjana Srivastava, Monash Health)
  • Excellence in Ethics (Richard Gunderman, Indiana University)


Panel 7: The Past and Future of Clinical Ethics

  • Moderator: Marshall Chin
  • History and Ethics: U.S.

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

The Unique Challenge of Healthcare Reform in the US, and Why it Might All Fall Apart

Those of us who aspire to eventually having an affordable,
quality, accessible healthcare system for all citizens, or even for most
citizens, must first face an obvious but under-discussed challenge that
uniquely American: The major players in the US healthcare system—including
private insurance companies, pharmaceutical companies, medical device and
equipment makers, medical specialties and sub-specialties, healthcare
organizations and their executives and shareholders, and all of their lobbyists—are
motivated by their own economic self-interests first and foremost. Which means
our aspirations must be viewed as a long-term struggle.

Healthcare in American is simply unfettered capitalism at
work. Let me hasten to add, this is not to say that all of these entities don’t
do some remarkable work—I owe my life to the U.S. healthcare system as do
millions more. But the fact remains that much of the extravagantly high costs
of medical care in the U.S. healthcare system has nothing to do with improving
or adding quality care for patients and producing good outcomes. Rather it’s a
reflection of how these key players pursue their own entrenched financial
interests, while creating narratives to the public that the services they provide
is essential for quality healthcare. Interestingly, over time, this bloated,
inefficient system has been generally accepted by the public and therefore
gained a façade of legitimacy that makes it virtually intractable to reform.

In this light, it is quite remarkable that the Affordable
Care Act (ACA) is actually less expensive than was originally forecast and
during its implementation so far overall healthcare costs are declining. These
encouraging cost considerations notwithstanding, the primary virtue of the ACA
is its very modest goal of expanding healthcare coverage for more citizens
within the confines, more or less, of the status quo US healthcare system.

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

Why Buying A Car Is So Unlike Buying Healthcare

Let’s say you are looking to buy a car. You think you might
want to buy a Volvo so you go down to the Volvo dealer and check out the new
models. But you are shocked by what you see. You realize that you really don’t
need to spend $35 to $40,000, or more, on a new car, so you decide to visit the
Subaru dealer. There you find very nice alternative models for thousands of
dollars less. You are delighted to have a new Outback for about $27,000.

The above story is how private markets and market choices
work for the vast majority of items that we purchase to meet most of our needs
as human beings. However, it has become painfully obvious that healthcare is an
area where the normal model of markets and market choices do not apply. I’ll
use a personal example.

A little over 15 years ago, I was diagnosed with colon
cancer, which left me scared and shocked, especially for someone who has no
family history of this disease and who had always exercised regularly and
maintained a healthy diet. I gladly agreed to aggressively use the most
effective technology, medications, and surgical procedures to deal with my
condition; and I never once thought of whether my treatments cost too much
money or whether I could get a better deal at another hospital. Shopping around
for a lower price on my treatments would have been simply preposterous for me
to consider at such a time. In due course I started getting statements of the
medical costs in the mail associated with my treatment from my provider, most
of which I did not have to pay because my insurance covered 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

Two Cheers for Choosing Wisely

The Choosing Wisely campaign is one of the most exciting experiments in health care in quite a while. If it lives up to its potential, Choosing Wisely could prevent some of the harm caused by unnecessary tests and treatments, while helping to bring down medical costs. But the real challenge to the campaign is whether it actually “empowers” consumers to do anything other than hurl themselves at a brick wall.

Choosing Wisely, begun in 2012, challenges medical specialties to create lists of the five most commonly misused and overprescribed interventions. Today there are more than 50 lists. Consumers Union is helping the campaign to bring its message to consumers in user-friendly form. And, indeed, the campaign is doing a wonderful job. The website (choosingwisely.org) has not only the lists, but terrific back-up resources to help laypeople understand the reasoning behind the lists. There are explanations about everything from why to avoid feeding tubes for Alzheimer’s patients, to how often one needs a colonoscopy.

True, Choosing Wisely is a work in progress. I wish dentists and orthodontists would sign on. And the current lists have been criticized for focusing on low-ticket items or on interventions performed by other specialties. Number one on the list from the American Academy of Ophthalmology, for example, is routine electrocardiograms (EKGs) before cataract surgery, a relatively low cost intervention provided commonly by primary care physicians.

The rationale for the campaign is to “educate and empower” consumers (whom they insist on calling “patients”) and to “promote conversations between providers and patients.” The goal is to help consumers choose care that is evidence-based and not harmful.

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

NRC Report: Assess Risk Empirically

One theme running throughout the NRC report is the need to replace the worthless gut reactions decried by Ezekiel Emanuel with a system that would base its judgments on the latest empirical evidence. But the report does not present a clear set of reforms that would effect this change without scrapping the current system of local IRB review.

Inexpert, Subjective Judgments

The NRC report notes the problem of subjective assessment of protocols:

To avoid subjectivity and enhance continuity within and across institutions, IRBs could draw on established scientific and professional knowledge in their determination of the probability and magnitude of research harms in daily life and in routine medical, psychological, or educational examinations, tests, or procedures of the general population. However, care is needed to avoid confusing evidence-based probability estimates with the subjective possibility that harms and discomforts of high magnitude are likely to be produced by the research. For example, IRBs could consider adopting procedures that appropriately balance the probability and magnitude of research harms, in order to avoid subjectively judging research as having a greater than minimal risk in cases where there is a very small probability that the research may produce harm of high magnitude or where there is a high probability that research may produce harms or discomfort of small magnitude.

Research Needed: To build a stronger evidence base, research is needed for identifying the probability and magnitude of harms and discomfort in daily life and the nature of age- indexed, routine medical, psychological, or educational examinations, tests, or procedures of the general population.

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.