Love in a Time of Pandemic

Last month’s story of Italian priest Don Giuseppe Berardelli giving up his ventilator so a younger patient could use it was an attention-grabber. The truth of the matter was a bit different, but the end result was, somewhat predictably, unchanged. Berardelli did refuse a ventilator, due to medical reasons. At the hospital, sometime in the night of March 15-16, the beloved, jovial, and accessible 72-year-old priest died from the coronavirus. He was one of at least 60 priests who succumbed to the SARS-CoV-2 virus during one month in Italy.

Physicians and dentists in Italy who have lost their lives to the coronavirus are listed here. In a similar vein, Medscape Medical News is maintaining (and adding to) a list, “In Memoriam: Healthcare Workers Who Have Died of COVID-19.” These are not the only victims, however. The frontlines are multitudinous, from people who work as clerks or deliverers of goods, to first responders, to all those caring for the ill (personally or professionally). These are exposed to increased risk of contracting the virus, and possibly dying from it. But these are not the first, nor will they be the last, to incur risk in such a manner.

History has much to teach us about staying at one’s post in difficult times. One of the prime examples is Martin Luther, who stayed in Wittenberg in 1527, in the midst of a bubonic plague outbreak. In response to multiple queries, he wrote a tract, “Whether One May Flee from a Deadly Plague.” His conclusion was that, unless someone can accomplish your duties in your absence, your presence is required.

  • Preachers and pastors: “For when people are dying, they most need a spiritual ministry which strengthens and comforts their consciences by word and sacrament and in faith overcomes death.”
  • Mayors and judges: “To abandon an entire community which one has been called to govern and to leave it without official or government, exposed to all kinds of danger such as fires, murder, riots, and every imaginable disaster is a great sin.”
  • Public servants like city physicians and city clerks: These “should not flee unless they furnish capable substitutes who are acceptable to their employer.”

Citing Matthew 7:12, Luther concluded that “we are bound to each other in such a way that no one may forsake the other in his distress but is obliged to assist and help him as he himself would like to be helped.”

Luther did not neglect the complementary side of the issue: prudent care of our bodies. He wrote, “I am of the opinion that all the epidemics, like any plague, are spread among the people by evil spirits who poison the air or exhale a pestilential breath which puts a deadly poison into the flesh.” Therefore, Luther recommended that one keep one’s distance from those ill (if they did not require help), set up hospitals to care for the sick, “help purify the air, administer medicine, and take it.” Luther, like the priests and health care professionals referenced above, provides a strong example of love in a time of pandemic.

More—with trepidation—on COVID

Let us stipulate at the outset: first, that so much—far too much? –is being written on the COVID-19 outbreak, and wisdom is a precious commodity; second, that although your correspondent is an MD, he is as bewildered as anyone by the storm of reports, claims, data, projections, arguments; and third, that whatever public comity may appear to pertain now, in due time we likely will be at one another’s throats with blame about who should have been better prepared or done what when, and there will be plenty of blame to go around.  Our leaders, national and regional, are especially to blame, but the evidence abounds that too many of us took this too lightly throughout January and February.

This being a bioethics blog, however, a few comments about some ethical issues in an outbreak, from a 2018 paper on the subject.  The paper in question raised three major topics: ethics of treatment research, triage, and the duty (by doctors and other health professionals) to provide care.

The last point first: it is well established that the covenantal duty of doctors in particular is a willingness to efface self-interest for the interests of the patient.  There is no dispute that this duty is being followed faithfully by the doctors, nurses, and others who are caring for people sick from COVID-19.  But a related duty of society is to do what it can to limit the risk to the caregivers themselves.  This is clearly pressured by, for example, the limitation on personal protective equipment (PPE) supplies.  We owe it to the medical community to provide them with what they need.

Next, triage:  try as we might, and fail as we might (and always seem to) to prepare in advance for a possible outbreak, surprise never fails to assert itself, and shortages of things that really matter loom.  At this writing, I have no idea whether New York City’s capacity to care for the sick is destined to, or is already, hopelessly overrun “under any scenario,” as Gov. Cuomo said this morning, or whether we can take any comfort in the assertion this evening by Dr. Birx that “there are still ICU beds and ventilators” in New York.  In early March, an infamous discussion at the American Hospital Association projected as many as 1.9 million people needing ICU care nationwide, and about half of those needing ventilator care, and it is further widely said that the typical ICU stay, even for someone relatively young, is 2-3 weeks.  Numbers far fewer than that would outstrip our national capacity, it appears.   Then again, the real shortage may not be ventilators, but the doctors to manage them.

These concerns also arose in the first Ebola outbreak a few years ago, and much-discussed principles of allocating scarce resources apply.  First and foremost is to try to alleviate the shortage through the best possible resource management.  Failing that, if hard choices must be made, then the likelihood of achieving clinical success is a top criterion.  But that requires clinical judgment that may be uncertain, requiring a lottery system, or a registry (as is done for organ transplantation).  Perhaps most controversial is to make an attempt to prefer treating people who are judged, if treatment succeeds, to have more life to live or more potential lifetime contribution to society to offer.  In that case, who decides, and how one decides, become very dubious judgments to make.

In the moment, there may not be enough critical care resources to go around, and doctors have to make a hard choice to treat one person but not another.  Physicians in Italy are reported to have faced exactly this choice this month.  Another principle, easy to say but hard to follow (talk is cheap!), is that triage “should not be a bedside decision,” that is, the treating doctor should not be forced to make a choice, but a previously-settled decision process should be applied.  I do not know whether that was or is possible in Italy, or in New York, or elsewhere in the U.S. or the world during this outbreak.

If we indeed are committed to care for and conserve our most precious care resource, our doctors, then that, in addition to limits on the number of available beds, might be adduced in favor of a so-called “universal” or “unilateral” decision that resuscitation (CPR) of some patients—which will increase the risk of the doctors and nurses getting infected—simply will not be attempted if their heart stops, regardless of whether the patient desires the attempt.  I know of no evidence that this is being done anywhere, but it is the subject of some speculation in the press.  The proper process is for a careful end-of-life conversation to happen between doctor and patient, before being confronted with the need, so that the patient’s wishes and the doctor’s professional recommendation can be considered.  But if that did not happen for people seriously ill with COVID-19, it may be too late when the illness strikes.  Those of us “of a certain age” are wise to consider this question in advance—viral outbreak or no.

Finally, the ethics of experimental treatment during a disease outbreak are governed by a well-defined regime of human subject research.  The key principles follow the Belmont principles reviewed by Mark McQuain on this blog on March 17, and include that risks to subjects must be limited as much as possible; that the necessary research risks not be excessive compared to the potential benefit to the subject at hand or society at large; that informed consent be properly obtained and documented; and that vulnerable people or those less advantaged not be denied access to potentially promising treatment nor be disproportionately placed at risk or have their vulnerabilities taken advantage of.

In the case of this present outbreak, research ethics also require that experimental treatments be properly studied in adequately designed clinical trials.  Implications, IMO, include that people be randomly assigned to treatment alternatives.   It is true that “off-label” use of drugs that are available for other uses is legal when prescribed by a licensed physician, and such off-label use is not on its face evidence of malpractice.  However, society stands to benefit by collection of data about the COVID-19 disease and outcomes of treatment, and so even off-label use should be done in a clinical trial, not in a “right to try” approach.  Because COVID-19 can be so severe, and the need for treatment is so great, I am inclined to think that random assignment to a placebo is a suspect requirement, I must admit that the need to learn more about the natural course of COVID-19 infection probably requires a placebo group in most, if not every, clinical trial.  There is not enough prior knowledge to rely on comparing a past group with a current, treated group, to conclude whether a new treatment works.  But requiring a placebo further requires that the trial get done fast and carefully, so results are as clear as possible, and made pubic immediately.  We should have no doubt at all that everyone doing the trials wants that.

I note that the public registry of clinical trials includes several in the U.S., including a national, 3000-person study of whether hydroxychloroquine may prevent disease in people exposed to others with COVID-19 disease.

Bioethics and the COVID-19 National Emergency

What a difference a couple of days can make. In the last blog entry, Steve Phillips discussed the problems that fear and panic are causing as we deal the many unknowns of the COVID-19 pandemic. While the current incidence, prevalence, and mortality of COVID-19 lags behind that of seasonal influenza (as well as past influenza pandemics caused by novel influenza strains), the eventual morbidity and mortality remain unknown. This uncertainty has caused public panic, which has lead to significant disruption of life, as we know it. A national emergency was declared in the US last Friday, calming some fears but reinforcing others. Using the four Principles of Bioethics as a simple outline, the following are some of the bioethical implications of the current COVID-19 pandemic I have recently considered – there is certainly space to add others.

Autonomy: The highly infectious nature of the new virus and the risks for the population as a whole place severe restrictions on individual autonomy. An individual is really not free to do whatever he or she wishes to do at this time. Measures to blunt the rate of infection spread have limited travel and will eventually cause some to be quarantined, perhaps against their will. Necessary public health measures will conflict with individual health decisions and desires. Do all individuals have a right to be tested for COVID-19 (particularly now that the test will shortly be free of charge) because they have a right to know or demand to know, or will we defer to protocols of best practice in the face of currently limited test availability, all of which are admittedly our best statistical utilitarian “guesstimates” for the benefit of the population as a whole?

Justice: The details of the pending National Emergency legislation are still not well known as of this writing but will apparently provide financial support to individuals and businesses affected by COVID-19 and this is certainly good, given the considerable disruption already caused by the fear and panic related to the disease, and the projected future impact of the actual illness itself. It is interesting to me that one result of this legislation may be that, with accurate testing, an individual or business will get federal benefits for having COVID-19 related problems but may not for similar influenza related problems. This is despite the fact that from an individual morbidity and mortality standpoint, particularly on a global basis, both COVID-19 and influenza both can end up causing severe health and secondary financial consequences. Asked differently, does justice require federalizing other viruses (or diseases) that, on a case-by-case basis, cause similar individual financial disruption as we will see from COVID-19?

Beneficence: I believe most people want to be helpful to others and do the right thing. Any desire to help others is somewhat counter balanced by lack of knowledge of exactly how infectious is the COVID-19 and therefore what risks do we assume for ourselves and for our immediate family in any benevolent activity in which we engage. Deciding how to help others without harming oneself will become clearer as the public health data grows.

Non-maleficence: Our natural tendency for self-preservation in uncertain times has resulted in a rush to hoard food and supplies, causing a severe strain on supply of these resources. Supply chains in a global “just-in-time” inventory structure are much more fragile as a result of COVID-19 than many had anticipated. Important medications, medical supplies, standard foodstuffs and infant needs are suddenly in short supply and are concerning; recent news videos of fights at your local Cosco over the last role of toilet paper are concerning for other reasons. Calls have gone out asking citizens to “hoard less”; hopefully these pleas will not fall on deaf and selfish ears.

For the Christian, wisely loving our neighbors may be the best ethical guideline and will look different in various regions and will likely change over time as we get a better understanding of COVID-19. I echo the many prayers for the health and safety of all affected by this pandemic and an extra measure of the Lord’s wisdom and strength for those in public health rising to meet and resolve this national (and worldwide) emergency.

The Non-Binary Doctor-Patient Relationship

Today’s blog entry continues another aspect of what Neil Skjoldal began yesterday. Shoshana Rockoff, writing in Yeshiva University’s The Commentator wrote about the changing landscape of physician private practice ownership and how that may be changing the doctor-patient relationship for the worse. She reflects on her grandfather’s private optometry practice when she describes the solid personal relationships that developed with his patients over his some 30 years of private practice. She worries what the future of that doctor-patient relationship will look like as both hospital systems and private equity firms, looking to make a profit, swallow up a growing number of practices. Her editorial is found here.

My personal practice experience is not too dissimilar. I began in private practice 30 years ago as a rehabilitation physician taking care of mostly inpatients who had recently suffered a stroke, spinal cord or head injury. I saw outpatients in my daily clinic that had the chronic neuromusculoskeletal sequelae of these problems. The chronic nature of their diseases resulted in my getting to know my patients fairly well, an attribute that I very much enjoyed.

What I did not enjoy was negotiating my reimbursement rates with the insurance system, something I was never trained to do in residency. As a solo practitioner, I had no clout with the large insurance carriers and my rates went down every year. Eager to pay back my student loan debt, I had also accepted a stipend to be the rehabilitation hospital’s medical director, which was my first experience with conflict of interest – I was responsible for making sure that only medically appropriate patients were admitted to the hospital while working with the administration of the hospital to maintain its financial viability at a time when insurance companies were beginning to aggressively assert their financial ability to reduce costs. It is rare, if not impossible, to wear two conflicting hats well, particularly at the same time.

I eventually joined a larger, multispecialty (mainly orthopaedic surgery) physician-owned group practice, where I remain today. Being part of a larger group allows us to negotiate more favorable reimbursement rates than my earlier experience but now from the dwindling number of consolidating insurance companies, who, along with the federal government Medicare and Medicaid programs, dictate those rates. My reimbursement rate has still gone down every year, now at a slower rate. A solo practice or small group private practice has no similar negotiating power with the insurance system. This is, if not the main reason, at least a significant reason that many of my colleagues who were in small physician-owned practices have decided to be acquired by large hospital systems or sell a portion of their assets to equity firms, who naturally exert some influence on future medical business decisions.

Economic decisions have not been isolated to the doctor side of the equation. Individual patients and smaller businesses that provide insurance to their employees lack the negotiation power with these same insurance providers and, over time, have had to settle for insurance coverage that contractually pays for fewer benefits at gradually increasing cost to those same patients or small businesses. Only very large companies or unions have any negotiation power to obtain better insurance benefits at less cost. The recipients of government sponsored insurance programs, such as Medicare and Medicaid, have the least direct costs but also the least direct say in their medical benefits, and these programs presently dictate medical reimbursement for well over one-third of the US population.

I think Ms. Rockoff is correct that it is getting harder to maintain the same doctor-patient relationship that her grandfather and his patients enjoyed decades ago. I think the primary reason is that both doctors and patients have allowed third parties into that relationship, largely for economic reasons, a process that began even before her grandfather started his practice.

I am blessed to be part of a physician-run multispecialty group that remains committed to a (Judeo-Christianized) Hippocratic doctor-patient relationship. I know many of my corporate-employed colleagues desire and work to maintain the same relationship with their patients. Many non-medical business people running corporate practices want that type of relationship with their physician.

The real question may be how to have a doctor-patient relationship when the relationship is no longer binary, and likely never will be again.

Withdrawing life-sustaining treatment from an infant and rights of conscience

The is currently a legal (and ethical) debate in Texas over the treatment of a one-year-old infant, Tinslee Lewis (see articles in the Hastings Center Bioethics Forum and the Fort Worth Star-Telegram). Tinslee was born prematurely with a congenital heart defect and subsequent severe lung disease. She has had multiple surgeries and is on a ventilator in ICU. In October Cook Children’s Hospital, physicians, and ethics committee made a decision to remove her from the ventilator in spite of her mother’s desire to have the ventilator continued. This was done in accord with Texas law which allows a hospital to stop life-sustaining treatment of a child against the wishes of the child’s parents if the treatment is futile. Tinslee’s mother went to court and obtained an injunction to keep the hospital from withdrawing the treatment. In January the court decided in favor of the hospital that the treatment could be withdrawn, but that decision was appealed and is now being heard in a Court of Appeals. There are two issues at stake. One is who should be the final decision-making authority for Tinslee. The other is whether the current Texas law is constitutional.

The hospital says that treating Tinslee with the ventilator is causing suffering without medical benefit and that her physicians have a right to decline to participate in such treatment. They support the current Texas law which would allow the hospital to stop the treatment. Tinslee’s mother says that her daughter is not suffering and has actually recently improved. Her lawyers say that the current Texas law is unconstitutional. The two sides have been joined by interesting supporters. The hospital has been joined by the Texas Catholic Conference of Bishops and several other groups including a pro-life group and a disability rights group who argue that the current law provides protection for patients and protects rights of conscience for physicians. Tinslee’s mother has been joined by the Texas Solicitor General and the Texas Attorney General who are seeking to overturn the current Texas law.

The basic ethical question is whether rights of conscience apply in this situation. The physicians and hospital say that they believe that continuing the ventilator is wrong because it is causing suffering without medical benefit and they should be able to refuse to provide a treatment they believe to be wrong because of a right of conscience.

I think that rights of conscience for physicians and other medical providers are very important. However, there is a significant moral difference between the usual understanding of rights of conscience in which physicians refuse to engage in actions they believe to be inherently morally wrong. A physician who refuses to be involved in abortion or euthanasia does so because he or she believes that such actions are inherently wrong. The physicians in this case do not believe that treating an infant with a ventilator is an inherently wrong action. It is quite likely that these same physicians recommended the use of the ventilator and encouraged Tinslee’s mother to see this a treatment that was good for Tinslee and which they could make as painless and comfortable for her as possible. The decision to stop the treatment which they once recommended is a judgment based on their values that the burden of the treatment has become more than the benefit of the treatment. That is significantly different from a refusal to participate in a treatment which the physician believes to be inherently wrong. The burden of being on the ventilator is no different than it was when it was started. The ventilator continues to be effective in performing its function of supporting respiration. What has changed in the physicians’ minds is whether the benefit of extending this child’s life is worthwhile. That is a decision that should be made based on the values of her mother, not the values of the physicians.

New technology, old moral problem

Many of our discussions in bioethics are about whether the things that are possible to do with advances in medical technology are things that we ought to do. However, some of the moral concerns in medicine are much more basic. They have to do with the idea that dates back at least to the Hippocratic oath that physicians should use their knowledge for the benefit of the people they treat. Patients should not be used by physicians in ways that are harmful to the patient in order to increase physicians’ income.

Medscape recently reported on a study presented at the American Society for Reproductive Medicine 2019 Scientific Congress which looked at how well fertility clinics across the US complied with the Society’s online advertising policy. They found that many clinics were not following the policy. The major concern was that there were a significant number of clinics that were advertising success rates without revealing the additional information needed to make that rate meaningful. The most serious concerns had to do with clinics that advertised high success rates without revealing that they also had higher than recommended rates of transferring more than one embryo per cycle and had significantly higher than expected rates of twin pregnancies. It is well known that twin pregnancies have a higher risk of complications for both the mother and the babies. Transferring more than one embryo increases the chance of achieving pregnancy and live birth with a cycle of IVF but also increases the likelihood of twin or other multiple gestation pregnancies and the risk to the mother and babies. By transferring more than one embryo in situations in which it is not generally considered justified, these clinics are increasing the success rate that they advertise to obtain patients by doing something which causes harm to their patients.

When the physicians at a fertility clinic prioritize their income above doing what is best for the people they are treating, they have gone beyond unethical business practices. They have abandoned one of the main things that makes the practice of medicine a moral profession.

Dementia and the value of human life

Recent public reporting of some cases in Canada of people with dementia whose lives have been ended by euthanasia have caused me to think about the value of human life in those who have dementia. Canadian law requires the person whose life is ended by euthanasia to have mental capacity for informed consent, intolerable suffering, and a foreseeable death. It was initially thought that patients with dementia would not be candidates for euthanasia under the Canadian law because of the requirement for mental capacity, but now there euthanasia providers who have concluded that there are some patients with dementia who have sufficient symptoms from their dementia to qualify as having intolerable suffering but still have adequate decision-making capacity. The discussion there has focused on whether person who is at the stage of dementia that causes intolerable suffering can still have adequate mental capacity. I have a different concern.

When we try to define intolerable suffering in the context of euthanasia it appears to mean that the person who is requesting euthanasia has decided that the effects of an illness have reached the point that the illness has made his or her life not worth living. When we talk about intolerable suffering and euthanasia the first image that comes to mind is a person with excruciating and untreatable pain, but it turns out that pain is not the most common reason for people to request euthanasia. It is more commonly requested due to a loss of control and increased dependency. This is not surprising since we live in a society that places high value on independence and autonomy. However, is independence really what makes human life worth living or is that a widely believed but untrue fiction in our society? Aren’t we all dependent? As children we are dependent upon our parents. As we go through adulthood, we are dependent on spouses and friends. As we age, we become dependent on our children and neighbors. Loss of independence makes us more clearly human, not less human. The impairments of old age, whether they be physical or mental, make it harder for us to deny our dependency, but loss of control (which is what loss of independence is) and increased dependency should not be seen as something that makes life not worth living. It draws us deeper into the relationships that are an essential part of being human.

Living with dementia is difficult for the person with dementia and for those who love and care for persons with dementia, but it does not make the life of a person who has dementia not worth living. The person with dementia is still a person who has relationships that are important, even when the one with dementia can no longer remember who those people are, because the person with this dementia is still the same person. He or she is still the mother or father, sister or brother, or friend. He or she is still a uniquely created child of God. Our response to those who feel that life is no longer worth living because of the loss of cognitive abilities and independence should be to help them understand that their lives are worth living because they are valuable to us.

Sociopaths in Medical School

The NEJM recently had an interesting article calling on medical schools to do a better job identifying students who exhibit “unprofessional behavior” before allowing them to graduate. The link for that article is HERE (subscription required). While admitting that it was difficult to consistently and reliably identify such students, the authors claimed that every medical school staff annually could likely identify one or two students “whom they would not allow to care for their family.” The article goes on to describe the barriers that prevent medical schools from accurately identifying unethical behavior in their students and some of the problems associated with trying to use the limited data that is available to delay or even prevent such a student from graduating medical school.

Going so far as to label students with unethical behavior as sociopaths is admittedly hyperbole on my part for the sake of rhetoric. In my defense, the article does touch upon the fact that there are a few physicians, presumably in every class, who commit “criminal or malicious acts”. The authors then go on to ask how we might identify these individuals before they behave “unprofessionally”, ideally before they graduate medical school. I presently have no doubt that anyone who has ever attended medical school can think of at least one person in their graduating class whom they would prevent from treating their immediate family.

I heard an excellent lecture on this issue more than 15 years ago by Dr. John Patrick, former Associate Professor of Clinical Nutrition at the University of Ottawa, who now speaks worldwide on issues of medical ethics, culture, public policy and the integration of faith and science. In speaking to a group of medical students about the need for transcendence in Hippocratic Medicine in a lecture entitled “Meaning and Purpose in Medicine”, he says about the sociopaths in their midst (beginning at 38:25 in the audio):

“…you can name them in your class already, you know who they are. You could tell me in your class the two or three people who are likely to lose their licenses for immoral or bad behavior in the future. The faculty never have a clue. You know. But you have already left Christian ethics, and loyalty dominates your class, so you don’t tell us. We find out 5 or 6 years later when they lose their license. And nothing on their university transcripts but all the students are not surprised.”

I originally wondered about the veracity of this claim so, for several years, I conducted a simple survey of the first year medical students in our local medical school. For a period of time, I was the very first clinical lecturer the students heard as they prepared for their first exam on the anatomy of the spine, just 10 days after beginning medical school. At the beginning of the lecture, I asked the students to look at me directly and, without speaking or glancing at their fellow classmates, answer the following question in their head: “After being together for the past 10 days, have any of you met at least one person in your first year class to whom you would not trust to care for someone you loved?” Invariably, over half of the class smiled, many while quickly glancing in the direction of the same one or two potential sociopaths in their class.

Why is this bioethically important? Dr. Patrick contends, and I suspect many of the readers of this blog agree, while the study of medicine is a scientific endeavor, focused on the accumulation of scientific knowledge, the practice of medicine is mainly a moral endeavor. Physicians are trying to work with their patients to help them do what they “ought” to do, as agreed upon by both the physician and patient. Such an endeavor demands mutual respect and trust so there is no place for unethical behavior on the part of the physician caring for a vulnerable patient.

Sadly, as both Dr. Patrick and the authors of the recent NEJM point out, while we are fairly adept at selecting medical students who can handle the academic rigor and have sufficient self-discipline to succeed in medical school from a knowledge standpoint, we remain woefully inadequate at assessing the ethical character of those same students to make sure they have the necessary moral integrity to actually practice medicine.

Unless that can be remedied, we should expect the continued gradual replacement of rich, lifelong, covenantal doctor-patient relationships with sterile, limited, contractural provider-client partnerships.

[I encourage readers to follow the link to Dr. Patrick’s website for a wealth of audio lectures on bioethics, culture and the integration of faith and science. Begin with the above link for “Meaning and Purpose in Medicine”]

Rights of conscience and the distinction between needed and desired treatment

Rights of conscience, the moral concept that physicians or other medical providers should be able to choose not to provide or participate in medical treatments which they believe to be morally wrong, continues to be widely debated in our society. A recent article in Vox titled “He needed a gender-affirming procedure. The hospital said no.” Expresses some things that I think are misunderstandings of what this debate is about.

Although it mentions other faith-based institutions, the article is primarily about the types of procedures which Roman Catholic hospitals in the United States do not provide under the Ethical and Religious Directives for Catholic Health Care Services. Throughout the article it is stated that Roman Catholic hospitals have refused needed care to persons seeking care in those hospitals. It also raises the concern that people may die because they are not provided necessary emergency care and care from another hospital willing to provide the care may be too far away. My main concern with this article is that there appears to be a misunderstanding about the distinction between needed and desired treatment. Among the things listed as needed care are “fertility treatment, gender-affirming care, or tubal ligations.” The article begins with the case in which a Roman Catholic hospital would not provide an elective hysterectomy to a biologically female person who identified as being male. The hospital’s reason for not providing this elective surgery was not because it was desired as a part of the person’s gender transition. They chose not to provide the surgery because of their belief that removing a healthy uterus impairs fertility in a way that should not be done.

There is a difference between desired elective treatments that people may choose to do even though there is no medical reason why they need to be done and treatment that is either life-saving or needed for other medical reasons. Such things as fertility treatments, gender affirming surgeries, tubal ligations, and abortions are elective treatments that an individual may choose to do but are not medically necessary. There is an appropriate difference between the obligation of a physician or hospital to provide medically necessary and life-saving care and the presumed obligation to provide elective medical treatments that are desired but not medically necessary.

I am not Roman Catholic, but I practiced in a Roman Catholic hospital for about 30 years. I served on the ethics committee at that hospital as well. I became very familiar with the ethical and religious directives and the type of things they direct Catholic hospitals not to do. These things are elective treatments or procedures that a person may desire, but which are not medically necessary. I also became familiar with the important role that Roman Catholic hospitals play in providing care for the poor and marginalized, many times providing care for people that other hospitals and physicians would not. Those who think that our society would be better without Roman Catholic and other faith-based hospitals are quite mistaken. If those hospitals are forced out of our society by those who would require them to do anything that anyone requests even when they believe that those things are wrong, the poor and marginalized in our society will suffer greatly.

Screening that benefits the screener

I teach it course on human diseases for students in a public health program. One of the things that we talk about is asymptomatic disease. If a disease has no symptoms the only way that we can detect it is by screening. For screening to be beneficial it needs to be able to detect asymptomatic diseases accurately and there needs to be something which can be done that will help those in whom the asymptomatic disease is diagnosed. Many times, a screening test will only be accurate if the test is used to screen a selected population which is at risk. Sometimes there are asymptomatic diseases which we can detect accurately, but the people diagnosed do not benefit because there is not something we can do to make their life better than it would be if the asymptomatic disease had not been diagnosed. Since the purpose of screening is to help people, there is no reason to do it if the people being screened will not be helped. That idea is based on the principle of beneficence. Everything that we do in medicine should be done for the benefit of the person being treated.

Some people do not follow that moral principle. There have always been some who have used the practice of medicine to benefit themselves more than those they were treating. That is why the Hippocratic physicians had to put a statement about beneficence in their oath. One of the ways that the principle of beneficence can be violated is for some people to encourage other people to do screening that will not benefit those being screened but will benefit the one doing the screening. One of the examples I see most often is supposedly low cost ultrasound screening for such things as carotid stenosis. Those doing the screening can make a significant amount of money by screening everyone who will accept their pitch but the people being screened do not benefit. It is currently not recommended to screen for asymptomatic carotid stenosis because there is no evidence that intervention is beneficial for those who are diagnosed and some evidence that intervention may cause more harm than good.

As new technology is developed it is subject to being used in a way that violates the principle of beneficence. One of the new ways to do that is with genetic screening. A recent article in the health news section of Reuters.com describes the fraudulent promotion of genetic screening to older adults in the US. Again, this is screening being done to benefit screeners who have collected huge sums from Medicare while providing no benefit to those being screened.

These abuses do not mean that we should not do screening. It simply means that screening should be done the right way. We should choose which screening tests we use and which people we screen with those tests based on how the screening will benefit those who are being screened. We should not do it to benefit those who are doing the screening.