Tuesday, June 26, 2012

Failure to Use the Anatomic Names for Female Genitals: Ethical Illegitimacy?

I was a bit surprised and perplexed when I found and read an Essay in the current May-June 2012 issue of the Hastings Center Report, one of the major ethics journals.  Sarah Rodriguez and Toby Schonfeld wrote the Essay titled "The Organ That Must-Not-Be-Named: Female Genitals and Generalized References". It is all about the observation that in various public presentations, the vagina is referred to as "it"  or  "the v" or the female genitalia, presumably the vagina, as "down there" and failure to specifically name the vulva,clitoris, mons or the vagina itself.

My concern with the Essay is whether this is really a vital ethical issue and whether TV's hiding the anatomic names from their advertisements of women's products is worth an ethical dialogue as hoped for by the authors in their final paragraph excerpted here: "Our purpose is to encourage not a monologue about the vagina, but rather a dialogue. Part of this discourse involves recognition on the part of women, men, their doctors, and advertising companies that female genitalia, like male genitalia, are multiply constituted, diverse, and, of necessity, named. We must start using words like vagina in order for the words to become normalized and for the speakers of the words to be empowered and respected—something Betty Ford did for “breast” in the 1970s."

I think there are so many more significant ethical issues around us in this world and the way humans are treated that printed space and reading time should be better applied to them. Go to the link above and read the free full Essay and then return and share your opinion regarding my concern.  Oops! Well, I guess we will have started the authors' dialogue.  ..Maurice.

Graphic: Image from Wikipedia modified with Picasa 3.

Monday, June 25, 2012

Doctor Spying on a Patient's Blog

How would you feel, as a patient, if without your knowledge, your doctor found your blog and was monitoring it for additional information about you?  If you would be upset about that, why? If the doctor told you in advance that he or she was going to look but asked your permission, how would you respond? Do you think that your doctor has every right to look at your open blog as any other visitor? Do you think that your privacy is being intruded upon by the doctor looking at or following your postings on your blog? Would it make any difference if you had a mental illness and your doctor was your psychiatrist? 

In the June 2012 issue of the American Medical Association's Virtual Mentor, the topic of psychiatrists monitoring their patients' blogs is brought up with a scenario and followed by a commentary by psychiatrist David H. Brendel, MD, PhD under the title "Monitoring Blogs: A New Dilemma for Psychiatrists". The first paragraph of the commentary follows.  Go to the link above and read the entire article and then return and answer my questions. Your responses will be worth while to this topic since Dr. Brendel can only express his concerns speaking as a psychiatrist but you can provide feedback to us from any patient's point of view. ..Maurice.

Internet technologies in the twenty-first century have provided countless opportunities and potential pitfalls for professional practice in areas as diverse as medicine, law, politics, business, and academia. These technologies have especially serious implications for psychiatry, where emotional complexities, boundary issues, and privacy concerns are of particular concern in the relationship between clinician and patient. In the course of routine clinical practice, psychiatrists nowadays must grapple with questions about whether to exchange e-mails with patients, to participate in social networking sites such as Facebook, and to perform Internet searches in order to learn information about patients. Each of these uses of Internet technologies in psychiatry has received growing attention in the professional literature [1-3]. The case scenario raises the question of whether clinical psychiatrists ought to read and monitor the websites or blogs of some of their patients.

Graphic: From Colocation America. com via Google Images.

Sunday, June 24, 2012

Bad Smell vs Good Smell: Can the Smell of a Decision Determine Its Ethics

In life, most of us can smell and make some
interpretation of the source and significance
of the smell. The odor may often be the 
first sign of something bad such as an un-
expected fire or something good such as 
a favorite pie baking in the oven.

Can we carry the analogy of smell to the interpretation of our initial casual observations or by hearing the explanations by others for the basis of their decisions or actions and then go on to develop a firm conclusion as to whether what was decided or what was done was ethical? Can one "smell" the good and the bad of a decision? And with that smell can we accept that smell as a basis for a conclusion?  Can we accept the smell as the basis for whether or not to further investigate the decisions or actions? A "bad smell" requires a thorough investigation of the facts, whereas a "good smell" is evidence enough of a "good". I would argue that it takes more than the presenting odor to establish any final conclusion. Whether a smell is good or bad, I think is in the nose and mind of the beholder and it takes an analysis of as much of the facts as available to reach a reasonable conclusion about the ethics. I bring this topic up because I think it is very easy and I think it often occurs that we "rush to judgment" about someone's behavior or someones decisions or actions.  Criticism or ethical conclusions without all the facts is unwarranted.  Or, perhaps..our lives are too busy with not enough time or interst to develop the facts and it is just easier to go by our noses. What do you think? ..Maurice.

Graphics:  I photographed the images of the artwork of Francis Xaver Messerschmitt found in the 2009 Auction Catalog of Koller Auktionen, Zurich Switzerland.

Friday, June 22, 2012

Telling Bad News: Should the Doctor "Say It Flat Out"?

In my previous blog threads, the issue of a physician telling the patient "bad news" has been rather fully discussed (see links below to those threads).  It always was and always will be a challenge for any physician to communicate this diagnosis since  often the doctor doesn't know how much and how quickly the patient can understand and accept the information.  It also means that the doctor has to find the right words to be informative, supportive and yet empathetic to what the patient may be about to experience.  In the attached video clip from the John Wayne movie "The Shootist", the doctor played by James Stewart finds this challenge as he must tell the "bad news" word to John Wayne who comes for a consultation.  The confrontation of the news by both parties is beautifully played out in this segment of this movie, which, by the way, has been an educational worthy segment for medical students to review. It shows how the patient helped the doctor with the doctor's first challenge with  the words "say it flat out". What the doctor should say after the diagnosis is revealed is the second challenge in doctor-patient communication. If you were the patient, would you be a John Wayne and have your doctor "say it flat out"?  ..Maurice.

Previous "Telling Bad News" blog thread links:

Video Clip: Downloaded from Turner Classic Movies website.

(A Truism)"If You Can't Leave Your Mark, Give Up": Is Procreation That Mark?

I came upon that classic truism "If you can't leave your mark, give up" and then I wondered about procreation as a way to follow the truism. Is there a human necessity for us to find ways to bring a child into the world in order to leave our mark in the world for the future? Of course, for those who can "automatically" procreate, this may not always be the basis for the creation of an offspring.  But for those who can't have children for one medical or biologic reason or another is this need to leave a mark so pervasive as to encourage the single or couple to attempt procreation through one method or another with the help of fertility clinics and the current science of creating an embryo along with implantation and delivery rather than adopting a child? Is instilling our genes into the genetic pools of the future essential to ensure that our life has left that mark? Is this the basic motivation of those who enter a fertility clinic for help? I would like to read the answers from all my visitors with regard to these questions but particularly from those who have utilized fertility clinics .  ..Maurice.

Graphic: Photograph I took of a wooden bench at Yosemite Falls, Yosemite National Park, CA, June 2012.

Wednesday, June 20, 2012

Coerced Medical Care: Is That Ethical?

Coerced medical care means that the patient will or is having or has received medical care not by their own autonomous decision but because the legal system has decided, after consultation with the patient's doctors that such care must occur.  Dr. Julie Cantor discusses the matter in a New England Journal of Medicine free full text article in the June14 2012  issue.
The first paragraph sets an example:

Samantha Burton was 25 weeks pregnant when her membranes ruptured. Burton's obstetrician admitted her to Tallahassee Memorial Hospital (TMH) and prescribed continuous inpatient bed rest. But with two young children and a job to consider, Burton found the prospect of a 3-month hospital stay overwhelming. She decided to go home. When she tried to leave, authorities barred her exit.

Go and read the Journal article and then return with you own views regarding such legislative, medical or legal actions taken upon patients.
Under what circumstance do you find that a law or court decision should override any voluntary medical decision by the patient? Is it ethical to deny a competent patient's informed and autonomous decision?  Is there a difference if the issue is regarding a communicable disease versus a pregnancy? ..Maurice.

Saturday, June 9, 2012

Munchausen by Internet: Should We Believe Everything Our Visitors Tell Us Here?

On many of the threads on my blog, my visitors describe their own medical conditions and their experiences with the disease and with their healthcare providers. Probably more common, of course, are visitors to online chat or websites which deal with and provide support for specific illnesses and encourage discussion.  The general personal anonymity of the postings encourage free discussion of one's described illness and experience.  Often there may be a outpouring of sympathy by the other participants to the site. Unfortunately, it has been discovered and documented that these personal narratives of one's illness are fabricated by the writer for their own psychological reasons. And this condition has been named: "Munchhausen by Internet". An excellent description  of this behavior is described in the Wikipedia presentation "Munchhausen by Internet" from which the following portions are copied below. Go to the Wikipedia link and read the entire article including noting the resources. What do you see as the ethical implications of such behavior on the internet and the effect of such made-up life experiences might have on large numbers of innocent but ill visitors struggling with their own concerns? ..Maurice.

Münchausen by Internet is a pattern of behavior in which Internet users seek attention by feigning illnesses in online venues such as chat roomsmessage boards, and Internet Relay Chat(IRC). It has been described in medical literature as a manifestation of factitious disorder or factitious disorder by proxy.[1] Reports of users who deceive Internet forum participants by portraying themselves as gravely ill or as victims of violence first appeared in the 1990s due to the relative newness of Internet communications. The pattern was identified in 1998 by psychiatrist Marc Feldman, who created the term "Münchausen by Internet" in 2000. It is not included in the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR).
The development of factitious disorders in online venues is made easier by the availability of medical literature on the Internet, the anonymous and malleable nature of online identities, and the existence of communication forums established for the sole purpose of giving support to members facing significant health or psychological problems. Several high-profile cases have demonstrated behavior patterns which are common among those who pose as gravely ill, victims of violence, or whose deaths are announced to online forums. The virtual communities that were created to give support, as well as general non-medical communities, often express genuine sympathy and grief for the purported victims. When fabrications are suspected or confirmed, the ensuing discussion can create schisms in online communities, destroying some and altering the trusting nature of individual members in others.
The term "Münchausen by Internet" was first used in an article published in the Southern Medical Journal written by Marc Feldman in 2000. Feldman, a clinical professor of psychiatry at theUniversity of Alabama at Birmingham, gave a name to the phenomenon in 2000, but he co-authored an article on the topic two years earlier in the Western Journal of Medicine, using the description "virtual factitious disorder".[2] Factitious disorders are described in the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR (DSM) as psychological disorders involving the production of non-existent physical or psychological ailments to earn sympathy. These illnesses are feigned not for monetary gain or to avoid inconvenient situations, but to attract compassion or to control others.[3] Chronic manifestation of factitious disorder is often called Münchausen syndrome, after a book about the exaggerated accounts of the adventures of Baron Münchhausen, a German cavalry officer in the Russian Army, that was written by Rudolf Erich Raspe.[4] When another person's symptoms are caused, such as a child or an elderly parent's, it is called factitious disorder by proxy, or Münchausen syndrome by proxy.[5]
Feldman noted that the advent of online support groups, combined with access to vast stores of medical information, were being abused by individuals seeking to gain sympathy by relating a series of harrowing medical or psychological problems that defy comprehension.[1] Communication forums specializing in medical or psychological recovery were established to give lay users support in navigating often confusing and frustrating medical processes and bureaucracy. Communities often formed on those forums, with the goal of sharing information to help other members. Medical websites also became common, giving lay users access to literature in a way that was accessible to those without specific medical training. As Internet communication grew in popularity, users began to forgo the doctors and hospitals often consulted for medical advice. Frequenting virtual communities that have experience with a medical problem, Feldman notes, is easier than going through the physical pain or illness that would be necessary before visiting a doctor to get the attention sought. By pretending to be gravely ill, Internet users can gain sympathy from a group whose sole reason for existence is support. Health care professionals, with their limited time, greater medical knowledge, and tendency to be more skeptical in their diagnoses, may be less likely to provide that support.[1][6][7]People who demonstrate factitious disorders often claim to have physical ailments or be recovering from the consequences of stalkingvictimizationharassment, and sexual abuse. Several behaviors present themselves to suggest factors beyond genuine problems. After studying 21 cases of deception, Feldman listed the following common behavior patterns in people who exhibited Münchausen by Internet:
  • Medical literature from websites or textbooks is often duplicated or discussed in great detail.
  • The length and severity of purported physical ailments conflicts with user behavior. Feldman uses the example of someone posting in considerable detail about being in septic shock, when such a possibility is extremely unlikely.
  • Symptoms of ailments may be exaggerated as they correspond to a user's misunderstanding of the nature of an illness.
  • Grave situations and increasingly critical prognoses are interspersed with "miraculous" recoveries.
  • A user's posts eventually reveal contradictory information or claims that are implausible: for example, other users of a forum may find that a user has been divulging contradictory information about occurrence or length of hospital visits.
  • When attention and sympathy decreases to focus on other members of the group, a user may announce that other dire events have transpired, including the illness or death of a close family member.
  • When faced with insufficient expressions of attention or sympathy, a forum member claims this as a cause that symptoms worsen or do not improve.
  • A user resists contact beyond the Internet, by telephone or personal visit, often claiming bizarre reasons for not being able to accept such contact.
  • Further emergencies are described with inappropriate happiness, designed to garner immediate reactions.
  • Other forum members post on behalf of a user, exhibiting identical writing styles, spelling errors, and language idiosyncrasies, suggesting that the user has created fictitious identities to move the conversation in their direction.[1]

Wednesday, June 6, 2012

"Difficult Patient": What is your definition and ARE YOU ONE?

There are a series of articles in the current May 2012 issue of the American Journal of Bioethics which offers perhaps a redefinition of the expression often used in medical practice "the difficult patient". In addition, the discussion also involves how to handle such characterized patients including mediation of the doctor-patient relationship, perhaps formally with the utilization of a clinical ethicist.  The journal articles were all written by  thoughtful professional ethics scholars and although they all, most likely have been or will be patients, I wanted, with this thread, to read how my visitors as patients and "scholars" in other ways, would define or redefine the "difficult patient" in you own terms and then tell us whether you think you are one!  ..Maurice.

Graphic: "Difficult Patient" retrieved from Google Images.

Saturday, June 2, 2012

Do You Want to be Autopsied?

Routine hospital autopsies, performed by pathologists, in the past was a not an uncommon result after a patent died in the hospital.  Families were routinely asked for permission for the autopsy.  In recent years, routine autopsies far less frequent.  According to a recent report by the CDC (United State Center for Disease Control) written by  Donna L. Hoyert the key findings were as follows:

  • The percentage of deaths for which an autopsy was performed declined more than 50 percent from 1972 through 2007, from 19.3 percent to 8.5 percent.
  • External causes accounted for 9 of the 10 most frequently autopsied causes of death.
  • The percentage autopsied declined with age after ages 15–24: from 60 percent at 15–24, to 11 percent at 55–64, to less than 5 percent at 65–74.
  • In 1972, 79 percent of autopsies were performed for deaths due to disease conditions and 19 percent for deaths due to external causes. By 2007, the respective percentages were 46 percent and 50 percent.
  • While the age distribution of deaths shifted to older ages from 1972 through 2007, autopsied deaths were increasingly concentrated in the age groups 1–34 and 35–64.
An autopsy, the medical examination of a deceased person, may confirm clinical findings, provide more complete information to describe cause of death, or uncover conditions not recognized clinically prior to death (1). Two types are performed in the United States: a) hospital or clinical autopsies, which family or physicians request to clarify cause of death or assess care, and b) medicolegal autopsies, which legal officials order to further investigate the circumstances surrounding a death (2). The autopsy rate, or percentage of deaths that received this final assessment, was stable from the 1950s until the beginning of the 1970s, when the autopsy rate began to decrease (3). This report uses mortality data from the National Vital Statistics System (NVSS) over a 35-year period to examine changes in the autopsy rate and in the distribution of those autopsied by age and cause. Variation in autopsy patterns has implications for which deaths may have a more complete and conclusive cause-of-death determination.
Read the full study.  To answer the question, why are autopsies not as popular now as it had been in th past, George Lundberg, M.D. writing in KevinMD suggest the following from the view of each participant except, of course, the deceased patient:
  1. Pathologists don’t like autopsies because they can be unpleasant, smelly, time-consuming, unappreciated, often not specifically paid for, and they take time away from other tasks viewed as more important, appreciated, pleasant, and lucrative.
  2. Clinicians do not like autopsies because it is uncomfortable to face a family that has lost a loved one. The physician must confront a level of failure because of the death, a tarnishing of the doctor-as-god image. Autopsy surprises might lead to an unhappy family, quality assurance committee concerns, possible litigation, and even a report to the state medical board.
  3. Hospital administrators do not like autopsies because they prefer not to dwell on unfavorable results of hospitalization. They claim difficulty finding the money to pay for them and can never make a profit from autopsies. They often have little medical or scientific background that would encourage curiosity and they tend to do mostly what licensing and accrediting agencies require; these remain strangely silent.
  4. Third-party payers do not like autopsies because they are an expense, and are performed on people who are already dead.
  5. Families of patients do not like autopsies because they are ill-informed about their value, afraid that it might cost them money, and some feel that the deceased person has already been through too much of an ordeal in dying.
The value of any professionally carried out autopsy might reveal not only some unexpected or unknown cause of death but also could provide the medical profession and future generations with knowledge of disease never previously described. In these days of modern technology from MRIs to genetic analysis, there is always room for the old fashioned but information-yielding autopsies. Permitting  an autopsy could be looked upon as a altruistic action for the future living even though, unfortunately, the patients themselves will no longer be benefited. 

So  the question for this thread: "Do you want to be autopsied?" And the answer is:____________. 
(You might also explain your answer.)  ..Maurice.

Graphic: From Wikimedia Commons: "The Anatomy Lesson of Dr. Nicolaes Tulp"  Rembrandt, 1632