Thursday, August 27, 2009

Medical Ethics and Organ Donation: Greasing the Slippery Slope

Organ donation is a white hot medical ethics issue. In the last month alone, there have been two scandalous reports alleging criminal and immoral donation practices. First, we read about a man, a rabbi no less, arrested for trafficking in kidneys. He referred to himself as a ‘matchmaker’, not quite the Fiddler on the Roof image of the wizened Yenta character who arranged marriages. The second story exploded after an article appeared in a Swedish newspaper that accused the Israel Defense Forces (IDF) of harvesting organs from wounded or killed Palestinians. Unlike the arrested rabbi, the Israeli Prime Minister vociferously denied the scurrilous charges.

I suspect that the rabbi is guilty, by his own statements, but I do not believe the diabolical allegations against the Israelis. Charges of this nature should never be publicized in the absence of sufficient evidence.

The reason that organ trafficking exists is because there is a shortage of available organs. We need a legal and ethical way to increase the limited supply of kidneys, livers, hearts and other organs and tissues. Thousands of Americans die every year waiting for an organ rescue. This perennial shortage has stimulated new thinking among bioethicists, politicians and the medical profession. Some of these ideas are welcome, others are controversial and a few are downright dangerous.

All agree that educating the public and encouraging organ donation is a critical strategy. If a person dies and takes viable organs with him to the grave, then others will follow after him who could have been saved. There are some who advocate a new system where consent to donate organs would be assumed unless the person opts out of the program. This would dramatically enlarge the donor pool as everyone would be a potential donor unless the person actively joined the ‘Do Not Donate’ list, similar to what most of us have done to avoid dinnertime telemarketers.

KevinMD reported a proposal in South Carolina where inmates who donated organs would have their sentences reduced. China has a more ghoulish prison program of obtaining the gift of life. It harvests organs from executed prisoners 'with their consent', and has been accused of timing executions to meet recipients' medical needs. China has just announced a voluntary organ donation program to compete against a thriving black market industry. Since 2003, only 130 Chinese citizens have offered to donate their organs, while each year, one million Chinese need one.

Bioethicists are now revisiting the issue of offering compensation to organ donors to provide an incentive to donate. Drafts of a bill advocating this approach are now circulating in the U.S. Senate. While direct cash payments are not being considered, and are currently illegal, insurance benefits and funeral expenses may be offered. In the past, ethical policy dictated that donors should be motivated by altruism only, and should not receive material gain. This categorical prohibition may be cautiously relaxed. Compensation for organs creates many avenues to exploit donors, so any legislation or policy changes would need to be carefully crafted with appropriate ethical safeguards.

Harvesting organs at the end of life poses the most intense ethical challenges. There is a conflict between the individual whose life may be ending and a desperately ill person who needs a new organ to live. The latter person may be a young executive while the potential donor may be tethered to a respirator with limited or absent higher brain function. Bright ethical lines are necessary to protect the patient who is under our direct care and to guard the healing mission of the medical profession. One life should never be sacrificed to save another.

I do not believe that any measure should be taken to hasten death. Additionally, I am very concerned that today’s zeal for organ donation creates a real risk that over time we may view critically ill or moribund individuals as organ donors, rather than as living patients to be treated. If this occurred, then physicians and nurses would be distracted from their professional responsibility to be solely focused on their patients’ interests. It might also pressure families to pull the plug prematurely. I worry also that the definition of death may be diluted in order to enlarge the organ donor pool. What if we decided that those who are in a chronic vegatative state –legally alive today – were now dead? It doesn’t take much imagination to see where this mission creep could lead to.

These are vexing ethical issues. I admit that I might have a different view if one of my kids needed a new liver to survive. However, while the views of those who need organs are valuable and should be heard, it is important that ethical policies be fair and just for society, rather than address the interest of an individual. If we let our emotions for a a child, for example triumph over sound ethical policy, then we steepen the slippery slope that we are already standing on. If we don’t have sturdy ethical guardrails to prevent our descent, then we risk the soul of the medical profession.

Sunday, August 23, 2009

Medical Ghostwriting: Spooks in the Ivory Tower

We have spent many dinner discussions with our kids discussing plagiarism. This infraction was verboten even when I was student back when, according to our kids, ‘I used to take the dinosaur out for a walk’. While I don’t think the offense is more serious today, it is much more prevalent. Educators report that there is an epidemic of it in our schools and universities. Perhaps, the practice even crosses national boundaries, which might mean that we are in the midst of a plagiarism pandemic. Unlike ‘swine flu’, there’s no vaccine available for this disease.

Of course, the offense is so much easier to commit today, with expansive information on any imaginable subject available with a keystroke. I’m sure I could cut & paste a 10 page term paper on nearly any topic during half-time of a televised football game.

Some of these rule-bending kids grow up to be adults who still misunderstand the importance of owning work that appears under their name. Joe Biden, historians Doris Kearns Goodwin and Stephen Ambrose and the infamous former New York Times reporter Jayson Blair are well known examples of folks who ‘borrowed’ without permission or attribution.

Regrettably, doctors are not immune to the affliction. I’m not referring to community physicians who do honest work each day seeing their patients. The sickness seems to have a predilection for a minority of academic physicians in our nation’s most prestigious medical schools. These are our leaders who are charged to serve as models of integrity and personal rectitude. They lecture widely about emerging medical developments. They meet with legislators to educate lawmakers and to influence health care policy. They are the prime authors of medical journal articles that are read by physicians like me who aim to stay current in our professional fields.

We now learn that scores of published journal articles over past years weren’t written by the stated authors. These articles were ghostwritten by writers hired by drug companies who prepared slanted drafts that favored their pharmaceutical employers’ interests. Disclosure to the readers of this improper practice was absent or too dilute to matter. How did these purported authors justify this misconduct? Weren’t their ethical compasses spinning wildly?

In response, medical schools, universities, medical editors and drug companies are establishing new policies to reclaim their ethical credentials. This is a limp PR response to a pattern of unethical activity that should never have occurred. Academicians and all parties involved shouldn’t need to consult a 3-ringed binder to determine if presenting a paid writer’s article as someone else’s work is proper. They should already know right from wrong, like the rest of us do. Rules, regulations and laws are more necessary for enforcing infractions than for teaching ethical behavior. Most of us don’t have to consult law books to determine if embezzlement or theft is acceptable.

If an academic physician happens to be reading this post, and is unsure if he should sign off on the drug company’s journal article on his desk, consult my kids first for some plagiarism pointers. True, they’ve never published anything, but I would trust their advice on this issue. Why? Their work is always their own.

On Halloween, many of us used to dress up as ghosts as we prowled our neighborhoods in search of treats. Now, we have ghosts masquerading as doctors. This time, we’re the ones who have been tricked.

Ghost image from

Sunday, August 16, 2009

Medical Futiliy: Aiming for a ‘Hole-in-One’

Consider this hypothetical vignette. Tiger Woods accepts my challenge to play 18 holes. Obviously, the gallery would be packed with golf enthusiasts who would cancel job interviews, vacations and even worship services in order to witness this historic competition. Spectators would be permitted to place bets at even money. Perhaps, my mother would bet on me, but no other sane person would. They would properly conclude that even my best performance against Tiger’s worst would be inadequate. There is nothing I could do to change the outcome. All of my efforts would be futile.

Futility cannot be proved with mathematical certainly. After all, Tiger could develop acute appendicitis on the fairway and have to forfeit. He could be arrested. Lightning could strike. Killer bees could take him down. Nevertheless, the overwhelming odds are that I would be vanquished and humiliated.

Medical futility is a more serious issue that exists in every physician’s office and hospital in the country. Examples can be mundane such as a physician prescribing (or a patient demanding) antibiotics for the sniffles or a viral infection. This treatment is futile; it does no good. Medical futility is usually a controversy that involves end of life care when treatments are initiated or continued that won’t change the outcome. Many of these patients may have already ascended a few rungs up the ladder to the next world.

While physicians must not hasten death, we should not provide futile care. This expends resources, generates unrealistic hopes and demoralizes the medical professionals who are caring for the patient. Why is it done? It is often demanded by families who insist on more medical care and consultations. Sometimes, this is a guilt reaction. Often, they simply cannot accept the outcome. They deny. Or, they may think that the doctors are wrong. These families all know the rare anecdotes of folks who awaken from long comas ready to play chess. Since doctors cannot be 100% sure of anything, they press on hoping for a miracle. Finally, since hospital bills are usually paid by third parties, patients and families have every reason to pursue medical care against all odds.

Medicine is an imperfect discipline. If a patient or a family expect an inviolable guarantee that our advice is correct, then we can never satisfy them. Our job, as physicians, is to empathize and to guide them toward a rational plan. While the views of the family are important, our professional obligation is to serve as the patient’s advocate. When our medical judgment and experience convince us that surgery, a respirator, antibiotics or a colonoscopy are futile, we shouldn’t permit them. Patients should not receive treatments that medical professionals overwhelmingly feel would offer no benefit. In addition, is it fair for others to pay for futile care?

Of course, physicians should approach these issues delicately, but patients and families must be discouraged from pursuing a futile path. These bedside discussions can be difficult and consensus is not guaranteed. But, the goal is worth the effort.

Golfers, have you ever hit a hole-in-one? While this outcome is never impossible, would you bet large sums of money on it? If so, then you might also bet on me in my imaginary contest against Tiger. If you did, all your prayers for my victory would be futile. We can’t win at golf or practice medicine when our only hope for success is divine intervention.

Sunday, August 9, 2009

Medical Ethics –vs- Medical Politics: What Patients Should Know

Medical politics has dominated the news for months. Each day, we read about the machinations of various congressional committees and our legislators who are dueling over health care reform. We learn about deals that the president has forged with various medical industry stakeholders. We watch as many liberal Democrats angle to put the ‘Blue Dogs’ in a secure kennel. We read about town hall meetings across the country being disrupted by folks who are accused of being right wing tools. Too much politics and too little policy.

There is another genre of medical politics that is not covered by the press, but should be of interest to every one of us who seeks health care. This is the politics that exists in every doctor’s office and directly affects your medical care. I was never taught about any of this during my medical training. I learned about it on the job, and much of it isn’t pretty.

As a younger doctor, I assumed that physicians chose consultants for their patients based on their medical skill. In other words, if my doctor sent me to a cardiologist, it meant that my physician believed that this specialist was the best available within a reasonable driving distance. While nearly all physicians I work with today choose competent specialty consultants, there are many other invisible influences present that affect these referrals, none of which are known to the patient.
The fundmental operative rule is that a doctor refers to a colleague who refers back to him, particulary in medical private practices. This is acceptable, provided that both physicians are highly qualified practitioners. However, if a questionable gastroenterologist refers heavily to an excellent surgeon, should the surgeon refer back to him if there are more qualified gastroenterologists available? Should the surgeon risk an important referral source by not reciprocating? I know what the ideal answer should be, but these conflicts may not be so cleanly resolved in the real world.

Another force influencing referral behavior is the physician’s practice type. For example, employed physicians, particularly in large medical groups and teaching institutions, are strongly ‘encouraged’ to refer within their own group. I’ve been there. Conversely, private pracitioners tend to refer to other private physicians to support this practice model, which is increasingly under threat.

We physicians feel that we are uncorruptible. None of us believes (or will admit) that we can be bought or unduely influenced. Yet, many doctors entertain colleagues at social gatherings, country clubs and sporting events, not so much for their stimulating company, but more to cultivate personal relationships to keep the referral pipeline well lubricated. I’ve never done this, but I’ve seen this tactic from a distance, and it works. This is the primary strategy of pharmaceutical representatives who, until the practice was curtailed, gave doctors free food, honorariums and assorted labled office trinkets. Such largesse, from a drug company or a doctor, generates a subtle feeling of obligation on the recipient.

In my own gastroenterology practice, there are physicians who consult me in one hospital, but not in another where the internal politics are different. For many years, this differential treatment by consulting physicians vexed me, but I have come to accept it as a reality that I cannot change.

I am not immune to these forces and admit that various considerations enter my mind when I am choosing specialists for a patients.. So, I am both a victim and a perpetrator of medical politics.

I don’t think that any of this is evil. In most instances, patients still receive competent medical care. The public, however, should be aware that their doctors may be weighing concerns unrelated to their health. Patients have a clear right to ask their doctors directly why they have selected a certain specialist over others, and they deserve a response.

Tip O’Neill, the former Speaker of the House is credited with coining the adage, all politics is local’. He wasn’t referring to the medical profession, but I think his maxim fits us quite well.

Sunday, August 2, 2009

Emergency Room Medicine: Model for Excellence or Excess?

The concept of medical excess is very difficult for ordinary patients to grasp. The medical community has worked hard for decades teaching them that more medicine meant better medical care. The public has learned these lessons well. Physicians who sent their patients for various diagnostic tests or specialty consultations were regarded as conscientious and thorough. Patients approved of doctors who prescribed antibiotics regularly for colds and other viruses believing that something beneficial was being done for them.

We can’t expect a patient to know if a CAT scan a physician orders is medically necessary. From a patient’s perspective, a test is medically necessary if the doctor orders it. However, physicians, with professional training and experience, know whether medical testing is urgent or optional. Isn’t that our jobs?

Of course, the practice of medicine often resides in the murky gray area where there is no single correct answer. In these instances, there can be several rational medical options available. Often, different medical studies examining a clinical question reach opposite conclusions. Sometimes, the medical issue at hand hasn’t been scientifically studied so there is no authoritative medical evidence to rely on. In these examples, differing medical recommendations are to be expected.

The bulk of excessive medical care I witness is not within the nebulous medical arena described above. These unneeded medical tests and treatments are black and white, not gray. It occurs every day in every doctor’s office, including mine. The most dramatic example of it, however, is the care rendered in our emergency rooms. The volume and expense of care given there routinely is absolutely astonishing. It is wasting a fortune of money and exposing patients to the risks and anxieties of extensive testing, even for minor medical conditions. Whenever one of my patients sees me in the office to review a recent ER visit, I try to disguise my amazement, as I look through all the lab results, x-ray reports, CAT scan interpretations and EKG tracings – often performed for some innocent complaint that has already resolved on its own. While this patient may believe that this medical pile on was great care, it wasn’t.

A serious risk of this buckshot-style medicine is that any one of the ultrasounds, CAT scans or other tests will detect an irrelevant and innocent abnormality that drags the patient to a brand new avenue of medical adventure. These new ‘abnormalities’, found by accident, create anxiety, cost money and mean more medical testing. This vicious circle is no merry-go-round carnival ride.

Why do ER physicians practice this way? Are they dumb? Hardly. In general, they are extremely capable and well trained. They perform well under pressure that can rival the tension found in any operating room. They make decisions routinely that determine whether a patient survives or succumbs. They have all of the necessary tools to practice judicious and conservative medicine, but they don’t.

They claim that the ER is a different medical universe, unlike primary doctors’ offices. They argue that they can’t miss serious diagnoses like heart attacks, strokes and blood clots to the lungs, all of which can be fatal. They need to test extensively because they have only one visit with the patient to get it right. Additionally, they point out that some of their patients may not follow up afterward with their primary physicians, even though they are advised to do so. Understandably, these physicians fear lawsuits against them if a patient they saw deteriorates after discharge. This latter reality motivates them to test patients aggressively.

I reject these arguments. In fact, the same ones could be applied to patients I see every day in my office. ER physicians should practice the same style of medicine that we all were taught to do during our medical training. Take a thorough history, perform an examination and then make appropriate recommendations. As a gastroenterologist, I see patients with chest burning in my office several times a week. The medical history allows me to determine if the chest discomfort is innocent or suspicious. In most cases, these patients don’t need a stat cardiac work up. Yet, if this same patient were seen in an ER…

Physicians, being members of the human species, are not perfect. It is not our task to test for every conceivable diagnosis in one visit. If an ER physician, or any doctor, thinks his patient’s abdominal discomfort is from constipation, then treat it accordingly and arrange for proper follow-up in the office. Don’t start a scan attack just because you can’t exclude appendicitis with 100% certainty. When we shoot for perfection, we are target our own profession.

I don’t think that the ER needs a different playbook. It just needs to play differently.