PATIENT CHOICE & THE ETHICS OF HEALING

In this Sunday’s NY Times oncologist Mikkael A. Sekeres describes his dealings with a Jehovah’s Witness patient, dying from leukemia and with profound anemia, who refused blood transfusions. 

The article raised important moral/ethical/medical and spiritual issues.  What is the role of the physician/medical establishment in advising and administering treatments to someone who refuses them? It was clearly a difficult time for the medical and nursing staff who cared for the patient as well as for the patient and his family of devout believers.  Dr Sekeres respected his patient’s wishes, tried to work around his refusal to be transfused, and ultimately witnessed his death. Afterwards there were discussions regarding whether or not more could have been done to save him.  Sekeres ultimately concludes that “our responsibility must be to our patient’s goal more than to our own…”  I agree. 

The difficulty arising from these issues is that not all physicians and medical teams do agree with this assertion.  On a daily basis we see physicians and family members forcibly take charge of medical decision making despite the expressed wishes of patients.   We see living wills, advanced directives continuously being ignored.

All this is complicated by patients themselves in a clearly weakened mental and physical state,  who seem to “change their mind” when it appears that their lives are imminently threatened by disease and death. 

Many bioethical issues arise from these real life situations.  Why should patients be the ultimate arbiters of their own fate? What about withholding medical treatment of treatable disease states? What about euthanasia either passive or active? At what point do we accept a patient’s decisions? And when (if ever) is it OK to override them?  How do family emotions and disagreements play into last minute alterations in end of life planning? 

Would professional teams of medical staff/ ethicist / spiritual leaders etc offer a sounding board for such difficult times?  The impact of such personal decisions have profound economic implications for the totality of health care as well.  When nearly half of all ICU/CCU patients in any given hospital should probably not be there (according to independent physician/nursing assessments)  the financial burden of health care costs loom large.  As stated I applaud Dr. Sekeres approach and attitude in this patient’s case.  While we are trained to save lives at “all costs” it should remain in the hands of individuals how they live and ultimately how they die.

THEY HATED THE WARS IN IRAQ & AFGANISTAN — Is This The New Excuse For Radical Islamic Barbarity?

Forgive me if I don’t get it. 

The Chechnian brothers who committed the Boston Marathon atrocities  ( I choose not to name them once again ) have been analyzed by the liberal media as being outraged by US wars against Iraq and Afghanistan.  Their actions at the Boston marathon somehow become “undertandable” by those who seek rationality in the barbaric actions of Islamic fundamentalists.  If only we “understood” them better then these religious fanatics would desist from a their heinous acts of maniacal slaughter.  ( An Obama policy).  If only we realized how distressed they were by our political support of Israel.  If only we understood that attacks on Iraq and Afghanistan would trigger such a response.  If only… if only….    But why should we?  I personally believe our involvement in both of these wars was utter folly.  I shudder to ponder the next time our military leaders decide to send our best young men and women into harms way for some inane and insane military venture without an exit strategy. 

Yet I strongly reject any attempt to “understand” or somehow “justify” jihadist attitudes and actions in this 21st  century.  There is NO JUSTIFICATION FOR THE SLAUGHTER OF INNOCENTS.  Do I need to restate this?  When Americans or Israelis kill innocent civilians in the prosecution of military actions theiy immediately apologize.  It is never their intention to do so.  Do we not understand the profound ethical/moral/spiritual/metaphysical distinction here? 

INTENTION IS EVERYTHING!!

The purposeful destruction/ wounding/ killing of innocent civilians can NEVER be justified.  To even suggest that there is any legitimacy to these jihadist claims is horrific and reprehensible. To even offer an explanation is to infer that we should understand the reasons or motivations for such actions.  Civillized people disagree with each other– passionately and frequently.  Do we ever excuse such barbaric behavior?  Never. 

And God forbid we ever do so.

THE TRANSFORMATION OF HEALTH CARE — A Difficult Transition

The status quo in health care is changing.  That is painfully obvious to both patient (ie everyone) and healthcare providers (formerly known as “doctor”).  It has to do with both economics and  the philosophy of health care in this country. 

Everyone understands that the cost of health care has been rising for many years now.  Ironically that rate of increase may have stabilized somewhat.  But the causes are often misunderstood. 

Healthcare technology is always changing, evolving and hopefully improving.  Innovation costs money.  Is that a shocking revelation to anyone?  New drugs are expensive to bring to market.  Our aging population is surviving with chronic diseases longer than ever.  There are millions of poor citizens who cannot contribute to these costs and yet are never refused the health care that they need. 

Enter the beaurocrats/ politicians/ PhDs in social planning/ economists etc. etc.  Each has their own solution for fixing the problem. 

What may ultimately be the greatest casualty in this health care debate  is the time-honored patient-doctor relationship.  Some cynics will claim this was always an illusion.  Some will claim that physicians were always interested in generating income on the backs of those who relied on them. 

Those who direct public policy have come down hard on physicians as the source of much of the problem.  They insist that we don’t practice according to established guidelines, that we order tests, call consultants and overdo everything out of greed.  They imply that defensive medicine is an excuse for lining our pockets with income generating tests and procedures.  They dismiss the impact that malpractice claims have on physician attitudes towards their patients or the overutilization of defensive practices. They refuse to consider binding arbitration approaches to medical malpractice disputes and deny the role of lawyer PACs and their influence on the process. They insist that electronic medical records leads to better health care for all.  They tout the benefits of electronic medical records while every physician and every patient understands the absurdity of such a claim.  They insist that patients do not need options in the medications we prescribe but that one generic per diagnosis will be sufficient.  They believe physicians need oversight when our clinical judgment impels us to order a test or call in a consultant when this does not conform to some their own templates of care.  They believe that salaried physicians will see as many patients and keep later hours than those who receive compensation for what they actually do.

They deny the power of the sacred place which is the relationship between patient and doctor behind the examination room door.  They insist that social media contacts and skype approaches will easily and cheaply substitute for such face to face encounters.  

The system awaits young physicians who are seeking full time 9 to 5 types of pracitices.  They have no interest in getting called at night or on weekends for their patient’s problems.  Those who get sick after “banker’s hours” will find themselves in ERs or medimerge facilities, essentially on their own.

In short they are forcefully molding the transformation of health care as we have known it.   To point out that this will  be a difficult transiton is an understatement.  

I will very likely leave practice a better and more knowledgeable physician than I was 5 years before, one year, before, even one day before I retire.  My experience and sense of awareness grows each day I stay around.

In other words I will be leaving before I should or need to.  Yet when I do (I am turning 65 next month) it will be out of a deep sadness and frustration about the state of affairs involving our health care system.

Sorry to inject such negativity but, let us pray for some infusion of sanity into a system bound for inferiority.