Refusing Medical Care for Children: Religious Freedom or Child Abuse?

I read yesterday in Cleveland’s main newspaper about the tragic passing of a 14-year-old girl.  She had cancer.   Why would this tragedy have been reported on Page 1?   As sad as a loss of a child is from a medical condition, this is generally not of interest beyond the family, friends and loved one.  This case was different.  The parents refused the chemotherapy that her doctors advised.  They wanted their daughter treated with herbs and feared that standard medication would worsen their daughter’s already precarious condition.   The parents believed that chemotherapy would violate their religious beliefs.

The parents sought another medical opinion from Cleveland’s other premier tertiary care center, which affirmed the original medical advice.

About 2 weeks ago, the parents received a court order mandating that their daughter receive chemotherapy.  Shortly afterwards, the daughter, who was already on a ventilator,  developed serious medical complications and died.

This case is a tragedy for all involved, as well as for the community at large.  I was so disturbed about reading the details about a desperately ill child with overlying tensions between parents, who I believe loved their child, and the medical and legal professionals. 

  Courts Practicing Medicine Guarantee Pain and Heartache

Yes, I believe that parents have rights over their children’s medical care including the right to refuse treatment, one of our bedrock medical ethical principles.  This is why we secure permission from parents before performing medical tests and treatments on their kids. 

But, I do not believe that this right is absolute, and there is no simple standard formula that we can rely on to guide us..

It depends upon the stakes.   Refusing Nexium for your child’s heartburn is not quite the same as refusing surgery for a burst appendix.   It also depends upon the age and maturity of the child.  A 17-year-old Jehovah’s Witness may be capable of making an informed decision to refuse a blood transfusion.  I doubt that a 3-year-old Witness has this capability.  Should Jehovah Witness parents of a 3-year old be permitted to refuse a blood transfusion that the doctors feel would save his life?   Can a parent refuse recommended vaccinations for their children believing them to be harmful?  If the child becomes infected with a vaccine-preventable condition, what about the health risks to others who might be exposed to them?   Where do the individual’s rights end and the community’s rights begin?

Do children who have not reached an age of maturity and understanding have innate rights that merit protection that may override their parents' rights to direct their children's medical care?    

While it’s best if the family and the medical team agree on a plan, I realize that this is not always possible.  When the stakes are life itself, the issues become raw and agonizing.  The sure sign of a system failure is when the courts become involved. 

TSA Under Fire for Quiet Skies Program: A Lesson for Doctors?

Consider these behaviors.   A newborn calf nurses from his mother.   A robin places a worm into the gaping mouths of her offspring.   Cats know how to hunt.

These behaviors are examples of instinct.  The creatures do not even understand why they engage in these acts.  They are inborn behaviors. 

Animal Instinct

Humans have instincts also.   Unlike most professional standards and qualifications, instincts cannot be easily quantified or tested.  But, under certain circumstances, they are invaluable assets. 

We learned last week that the Transportation Security Administration (TSA) has been pursuing a program called Quiet Skies, when passengers who have met certain criteria are monitored for various behaviors that might suggest that closer scrutiny is warranted.   I am making no comment here on the merits of the program, but I am supportive of TSA using instincts of air marshals as a tool to evaluate threats.   Some have criticized this as an infringement on passengers who are not under actual suspicion or been charged with a crime.   But, if we strip instinct and suspicion from the armamentarium of our security services, then what is it exactly that makes these folks actual professionals?  Do we want ‘box checkers’ or real pros?

Of course, most of the time suspicions will not be borne out.  This does not mean, however, that the tool is invalid or that the target should feel victimized.  Before, we cry ‘discrimination!”, let’s consider what the stakes are here.  This is not an improper search of your car trunk; it’s blowing up an airplane.

I related to this issue since seasoned physicians rely so often on our instincts and sixth senses about our patients.   Every physician has said or thought throughout his career, ‘something is not right here’, even if all of the objective data seem to line up.  I think patients understand this and want their doctors to use their intangible skills along with their stethoscopes.   Frankly, it is these skills, in my view, that are amply present in our very best physicians. 

While you can’t teach these skills, doctors over time do develop them.  While younger physicians have much to teach us experienced practitioners,  we have a few things to offer them, at least that’s what my instincts tell me. 

Where Have All the Republicans Gone?

For a few decades, I have assisted tens of thousands of patients in making medical decisions.  While the stakes may be higher in making a medical decision, the process is the same as would be used in making any decision.   Gather the facts.  Weigh the options.  Consider the respective risks and benefits.  If applicable, consider additional issues that may tilt the decision, such as cost, family or professional impact, personal priorities or cultural norms. 

Obviously, two individuals may share identical medical facts but decide differently – and both decisions may be sound and correct.

Our politicians and government officials should use the same process when faced with a political decision or a vote.  But, they don’t.   Sure, they engage in a risk-benefit analysis, but in a rather twisted manner.

Politician contemplating a vote:  “What is the risk to me if I vote for or against?”

Same politician contemplating a vote:  “What is the benefit to me if I vote for or against?”

In other words, our politicians focus much more on their interest than on ours.  Perhaps, that’s why their approval ratings are underwater.

Consider how the establishment GOP have been responding to the president’s steady stream of rhetorical and behavioral malfeasance.  In general, the responses have included silence, acquiescence, tolerance, deflection and even outright defense.  Yes, there are occasional murmurs of discontent, but these seem more aberrational than a coherent broadside.

'Hear no evil, see no evil, speak no evil.'

Interestingly, the GOP individuals who have been consistent critics of the president are from those who are not running for reelection.  Thus, it may be that these folks discovered their principles only when they became unshackled from a future campaign and election - not exactly a profile in courage.

Even some senate Democrats who are up for reelection in 2018 have been very reluctant to criticize the president as they are from red states who support Trump.  

Here’s a different way to approach the risk-benefit equation for politicians who won’t express their outrage.   What do they risk by speaking their mind?   They would not be risking their health or their freedom.  They would not be risking a financial catastrophe.   They would not be risking the respect of their colleagues or their own self-respect.   Yes, they might be risking their job.  The worst outcome of calling out a demagogue is that the voters would toss them out.  Is that such a cataclysmic event that is worth one's personal integrity?   And all of them are so readily employable, although the prospect of leaving the public trough seems downright unbearable to them.

Consider the benefits of speaking true.   I won’t insult my readers my listing them, as they are self-evident.

If you suspect that I didn’t vote for Trump, then you are correct.  And, if you suspect that I voted for Clinton, then you are wrong.

There are circumstances when it is sensible to keep one’s thoughts to himself.   Maybe the issue is not that important or the stakes of speaking out are disproportionately high.   This is not the case for current legislators who look away.  The stakes to the nation and to themselves do not justify their silence.

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Doctors and the Opioid Epidemic

I am against all forms of bodily pain, both foreign and domestic.  I wish the world were pain free.  When I am suffering from even a routine headache, I want immediate relief just like everyone else.  The medical approach to pain control has changed dramatically even during my own career.  When I started practicing a few decades ago, the strategy was pain reduction.  We gave narcotics for very few indications such as kidney stones, heart attacks and severe abdominal pain after a surgeon evaluated the patient.  (The reason for this was so the surgeon could obtain an accurate assessment of the patient’s belly before pain medicine masked the findings.) 

The new goal is pain elimination which I believe is one factor that has fueled the overconsumption of opioids, although there are other factors present.  I admit that I am opining on this as an individual who is blessed to be pain free.  I do not pretend or suggest that if I were afflicted with a painful condition, that I would not want whatever it might take to bring me relief.  In medicine and in life, the world looks very different when you are a victim.   Your view on health care reform, for example, might ‘evolve’ if you or a loved one is suddenly uninsured. 

But patients’ rising expectation of eliminating pain and the medical professions willingness to join in this mission has exacted a great societal cost.  I am not blaming anyone here.  Of course, patients want pain to go away.  Of course, physicians want to relieve suffering.  Isn’t a doctor’s mission to make his patient feel better?

Could this really result from a doctor's prescription?

The consequences of this approach have exploded.  Narcotics and opioids are addictive agents.  Any individual who takes these medicines over time risks addiction, which is a new disease.  In fact, the addiction may very well be a more severe illness than the original medical condition. When OxyContin (oxycodone) came on the scene in 1995 the drug company recommended it as first line treatment for chronic pain as well as for musculoskeletal pain, two conditions that today would not be initially treated with opioids.  Over a decade later, the pharmaceutical company accepted a guilty plea in federal court and admitted that it trivialized the drug’s addictive properties, along with other deceptive practices. 

Consider this sobering statistic.  The United States is about 5% of the world’s population yet consumes about 80% of the world’s oxycodone supply. 

When a doctor is prescribing opioids to a patient, which may be entirely appropriate, the physician and the patient must be mindful of how carefully this must be monitored and the addictive risks of prolonged use.   We must guard against creating a new disease – which may be fatal – which may result from unrestricted or inadequately monitored pain medication use. 

Ohio announced new rules recently that would limit opioid prescription for only 7 days for acute pain.  While I generally resist politicians interfering with medical practice, with thousands of overdose deaths in our state every year, I understand their need to intervene.  

Many heroin addicts today can trace their affliction back to a doctor’s prescription, which was given for the right reasons. 

The medical profession and the scientific community needs to triple down on research to develop new drugs and techniques that attack pain but leave patients protected from the ravages and misery of drug addiction. 

Liberals Attack Brett Kavanaugh and Trash the Neighborhood

We live in frustrating and angry times here in America.  If you are not aware of this reality, then you are:

• a newborn
• a plant or an invertebrate
• in heaven
• comatose
• on a deserted island sans electronic devices or wifi
• living outside of the Milky Way

Peruse the front page of any newspaper or turn on any cable news channel.   You will read and hear about conflicts, outrage, investigations, accusations, threats and denials because this is what we desire and demand.  If we rejected such partisan and inflammatory reportage, the media would modify their content.   I do not accept that the media simply reports what is truly newsworthy; they produce their product to appeal to market forces.  Is Stormy Daniel's news value proportionate to the coverage she has received?  The reason that rags like the National Enquirer are successful is because we read them.

Beyond our collective appetite for darker and salacious content, we are also participants in the various tribal and cultural conflicts that are ongoing with no resolution in sight.  In other words, it's not all the media's fault.  For many interest groups and organizations, the mission is not to compromise or accommodate, but to vanquish and prevail.  Issues are viewed as a series of zero sum games – if you win, then I lose.   Of course, this is absurd. 

Ruth Bader Ginsburg was confirmed in a 96-3 vote in the Senate in 1993.   She was a known liberal, but Republicans properly supported her confirmation as she was qualified to serve.  Liberal presidents nominate jurists who are aligned with their philosophies.  Indeed, this should be a major consideration of voters when casting ballots in presidential elections.  Qualified nominees should be confirmed.  President Obama’s 2 Supreme Court Justices received Republican support, as they deserved.  Recently, Judge Brett Kavanaugh was nominated to assume Justice Anthony Kennedy’s seat.   Although his qualifications and temperament are unassailable, he has been vilified as if he is the anti-Christ.  Just because the Republicans inexcusably deprived Judge Merrick Garland of a hearing, does not justify perpetuating the dishonorable misdeed.  I wonder had President Trump nominated Moses, King Solomon or Jesus, if they would be similarly and summarily rejected by political opponents.

Moses - Clearly not Judge Material

Let me offer readers an oasis, albeit a brief one, from the chaos and the depressing morass that surrounds us.

Go and see Won’t You Be My Neighbor, a film that chronicles the life and work of one of our nation’s treasures, Fred Rogers.   He was an extraordinary human being, who inspired us with his deep humanity, compassion and love.   I found myself near tears during several moments of the film, and I continue to reflect on him his weeks later.  He was an antidote to hate and intolerance.  He made a difference.  We need him now more than ever.  See the film and you will also yearn to join his neighborhood.  

In today's era, if Fred Rogers needed Senate confirmation, could he achieve it?

Insurance Companies Protect Patients or Profits?

A patient came to see me with lower abdominal pain.  Was she interested in my medical opinion?  Not really.  She was advised to see me by her gynecologist who had advised that the patient undergo a hysterectomy.  Was this physician seeking my medical advice?  Not really.   Was this patient coming to see me as her day was boring and she was bored and needed an activity?  Not really. After the visit with me, was the patient planning to return for further discussion of her medical status?  Not really.

So, what was going on here.  What had occurred that day was the result of an insurance company practice that I had thought had been properly interred years ago. 

The Insurance Reform Hammer - Locked and Loaded.

The woman had pelvic pain and consulted with her gynecologist.  An ultrasound found a lesion within her uterus.  A hysterectomy was advised.  The insurance company directed that a 2^nd opinion be solicited.  A second gynecologist concurred with the first specialist.  The patient advised me that the insurance company wanted an opinion from a gastroenterologist that there was no gastrointestinal explanation for her pain.  In other words, they did not want to pay for a hysterectomy that they deemed to be unnecessary.

• We should applaud the insurance company for its diligence to protect the patient from an unneeded surgery.
• We should recognize that the insurance company is focused only on promoting medical quality with no concern for saving the company money.
• We should cite the insurance company for industry excellence for facilitating smooth and efficient medical care.
• We should tell the obvious truth about what is actually going on here.

This woman’s treatment plan, as recommended by two gynecologists, was halted by a bureaucrat who likely had less medical training than they did.  I surmise that not enough ‘boxes were checked’ on the submitted paperwork to permit the recommended surgery to proceed.   The insurance companies, of course, claim fidelity to a medical quality mi$$ion.  How would they like to be subjected to the same absurd level of scrutiny and oversight that they wield over us?  When the reform hammer comes down on the insurance companies,  my patient might be holding up a sign or a pitchfork, but it won't be to stand up for them.

Happy Fourth of July

Let's pause for a few moments, amidst the chaos and cacophony of a society tearing at each other, when we shout more than we listen, when we foment more than we forgive and when we hate more than we heal to recall the promise of a nation that was founded with noble ideals as it journeys to form a more perfect union. 

The Whistleblower 

”I am apt to believe that it will be celebrated, by succeeding Generations, as the great anniversary Festival. It ought to be commemorated, as the Day of Deliverance by solemn Acts of Devotion to God Almighty. It ought to be solemnized with Pomp and Parade, with Shews, Games, Sports, Guns, Bells, Bonfires and Illuminations from one End of this Continent to the other from this Time forward forever more.”

John Adams