Opinion : Informed Consent and Error disclosure

Submitted as a position paper for my Med. and Society ethics class:

To respect a patient's rights as discussed previously, informed consent must be received from a patient or the patient's family. While few would argue that consent is a bad idea, the extent to which that consent is informed can be more controversial. In a patient-physician relationship, there is an inherent imbalance of knowledge that clearly favors the physician. The patient will never be able to close the knowledge gap completely, yet the extent to which they are informed of their situation, (the treatment options and possible outcomes) dictates the extent to which they can make the best choice. Problems can arise when patients are unable to grasp the facts of the situation or are unable to make a reasoned or logical choice. More importantly for physicians however, is when problems arise because they have not communicated all the facts, especially when these omissions are important to or may sway the patients choice. Along with the case of non-disclosure of medical errors, this leads to a state of ignorance on the patient's behalf, which can have negative ramifications in both treatment outcomes and especially in legal liability.

It is assumed that in all cases that the physician's goal is to minimize the patient's ignorance and his personal liability. Therefore, I propose a guideline that I will call the George W. Bush disclosure rules, in honor of the president's foreign policy. The rules can be summed up as: 1) Take the moral high ground, 2) stay the course, and 3) damn the consequences (have faith that those consequences will be better than the alternative outcomes would have been).
For part one, we will depart with the President's actual practice and state that the moral high ground is always to tell the entire truth. There should be no manipulating, distorting, or omitting relevant facts. The patient should be told the diagnosis, all the treatment options, and all the outcomes without any interpretation unless that interpretation is specifically requested. The physician's role in this stage will be as an educator, and full disclosure will fulfill his duty to the patient and allow a truly informed consent to be made.

For the second part, the physician must stay the course as far as telling the full truth and complying with the patient's decision. Several mitigating factors may arise as discussed in the text, such as family's wishes, physician's prejudices, economic considerations, or public safety, yet the physician must not allow these influences to effect delivery of the truthful full disclosure. The physician will need courage to deliver the whole truth in some cases, and must accept the old platitude that "truth hurts". It must be held evident that none of these circumstances are more important that the patient's health and human rights. If the patient chooses a treatment that the physician feels is not in their best interest, than the patient's rights are the chief concern and the physician must still comply with the patient's wishes to the best of his abilities.

The most difficult part of the plan may be to accept any consequences and have faith that the right thing was done. Consequences from an error disclosure could damage reputations and consequences from letting the patient choose a non-optimal treatment could be premature death. Full disclosure is always the best policy considering the big picture however; as reputations are made by difficult choices and patient deaths are often inevitable. Second guessing decisions will cause stress and not fix the past, and therefore should be avoided as useless. If applied consistently, the George Bush disclosure rules should minimize physician legal liability and empower patients. These rules are easy to remember and almost universally applicable. They provide a clear and decisive guide through the often conflicting and controversial issue of informed consent and disclosure.

Opinion : Patient Autonomy and Physician Paternalism

Submitted as a position paper for my Med. and Society ethics class:

When a major disease or condition is diagnosed, there are often several treatment options, each with their own strengths and weaknesses. The important question that arises is who gets to chose the ultimate course of treatment, the patient, or the physician. This question is complicated by two other issues in medical care, knowledge and responsibility.

It is usually safe to assume that the physician knows more about the treatment than the patients, and is in a better position to make a logical and rational choice, yet there are pertinent life circumstances affecting the choice that are only known to the patient. While it is always optimal to reconcile these differences with communication, this process can never be perfect. The question now becomes how should the physician explain the choices to the patient (objective vs. subjective) and how to evaluate patient comprehension.

As far as responsibility, a physician can certainly be held legally liable for their decisions, yet it is the patient who ultimately has to live with the consequences of any treatment decision. It is hard to argue that a patient could be responsible for a decision when they don't completely understand the facts however. Physicians also have trouble accepting responsibility after getting overruled by a patient and carrying out a treatment option that they know is not optimal.

This brings us back to the question of what role a physician should play in choosing the treatment options for their patients. I believe that a physician should make every attempt to educate the patient on the condition and the treatment options. They should not withhold any possibilities or outcomes and should explain when the literature is ambiguous or contradictory. Physicians should say what they think is the proper course of action only if they thoroughly explain their choice. They should also give other opinions if requested by the patient. If a patient makes an irrational choice, the physician should explain why this is the case, but should not resist implementing that treatment or putting the patient in any type of duress. If the patient chooses says at the beginning that the physician should just do whatever he feels is best, the physician should still explain what this is and what the risks are, as well as why he would choose that treatment over others.

If the physician is an effective communicator, than the patient will be making an informed decision about their health. If the patient chooses to disagree with the physician, hopefully they will be able to communicate the reasons that decision. Once a consensus has been reached, the physician will take responsibility for the effective delivery of services, and the patient will have to live with the outcome. If the patient chooses to go against the physician's advice, than they are mitigating the physician's responsibility for the outcome of the treatment, although not the treatment itself. These guidelines allow for a patients rights while making the physician's responsibilities clear.

Global hunger vs. Global obesity

This article amazes me. Couldn't of said it better myself. The sad part is that there are people who are still starving.

Opinion : Osteopathic Medicine

Submitted as a position paper for my Med. and Society ethics class:

Osteopathic medicine presents an alternative to the standard (allopathic) medical practice. Its in tenets include a holistic musculoskeletal focus and a type of healing called osteopathic manipulation (OM). It is not quite on the level with allopathic medicine, however and has some serious problems that would keep me from ever pursuing it as a career.

First, modern osteopathic medicine is little more than allopathic medicine with the simple addition of the OM techniques. When the practice was established in the 1800's, the move away from laboratories to hands on healing may have made a lot of sense by offering patients more tangible results. This is simply not the case with modern medicine however, as the advent of antibiotics, chemical therapies, genetics, imaging, etc. have proved that scientific techniques provide much more effective healing. To stay relevant, the osteopathic practice adapted by adopting theses techniques. This raises the question, what is the point of having an "alternative" set of physicians if they are doing the same thing?

This question gets to the real problem with current osteopathic medicine. Its education system exists mainly as a way to help less qualified students get into a medical school. In both personal experience and in the assessment offered by Dr. Howell, many of the students who apply to and enroll in DO schools do so because they were unable to gain admission to allopathic schools, not because they believe in a holistic approach to medicine. The Osteopathic schools also continue to reinforce this by admitting weaker candidates and letting their students take allopathic residencies after 3 years. Dr. Howell sites the AOA's own studies that most of its members do not use their specialized OM skill. While the holistic approach may have merit as a treatment option when used by a skilled practitioner and OM may have therapeutic value, Osteopathic medicine will not be respectable until it ceases to be a backdoor entrance for less qualified people to become physicians.

Dateline 9/15/06

I have been very busy lately with studying and work. The IMS program isn't so bad. I have gotten used to watching lectures on a telecast and I am doing well. I hit the average on the first 2 tests and was in the honors range on the last biochem exam. I have an advising appointment next week to help determine what the next step will be after this program.

My main problem with philly so far has been the complete lack of businesses near where I live (other than dive bars as it would happen). There is a convenient store a few blocks down that is about the only store in about a 5 block radius of this apt. The nearest barbershop is a 20 min walk away, the nearest sit down restaurant (an olive garden) almost as far. The Reading terminal market is nearby but it cannot replace a supermarket (miles away). You would think they could but some ethnic stores or something near the international parkway...Anyway this is a beautiful and cheap neighborhood, so I will stop complaining.

I got a workstudy job as an office asst. in the office on the first floor of my building. Every few shifts I actually need to assist someone, making this job slightly more labor intensive than my BU job, but I do get a computer and get to split the workload with another person (not sure why they though this office needs 2 people). Anyway, back to studying.