Bioethics Exam

In keeping with the evaluation-obsessed spirit of the time, here is a little bioethics test. No multiple-choice fill-in-the-bubbles here, no simple true/false; but bioethics usually isn’t so simple, is it? So it’s OK if you don’t have a No. 2 pencil, you can still take today’s exam!

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1. The patient-physician relationship depends on trust, and close observation, and appreciating subtleties, and giving one’s full attention to another person. So, who thought that making the doctor spend the office visit typing into a computer was actually a good idea???

2. Why does the NRA know better than physicians in Florida what they should be saying to their patients in the exam room?

3. What is just and right about a medical insurance system in which people have to stay in jobs they hate because of the fear of getting sick, and which bankrupts many people who get a serious illness? Give examples to support your answer.

4. If doctors have huge malpractice premiums, which they pay for by charging patients more for medical care, then essentially patients are paying doctors so the doctors can protect themselves from patients. Does this make sense? Explain.

5. Compare and contrast: Why should taking one’s own life be considered a more dignified death than any other? Is there really any dignity in death itself, or is it in the way that we face it?

6. Why should doctors be trusted more than anybody else with the right to kill someone?

7. If all of these prenatal genetic tests weren’t developed and marketed for specifically eugenic purposes, then just what were they developed and marketed for?

8. Is there any evidence that “evidence-based medicine” (aka statistic-based medicine) is better than whatever we did before?

9. Is abortion the problem, or is it the symptom of a lot of other problems?

10. In the DSM-V (the latest version of the official guidebook to diagnosing psychiatric illness), grief over the death of a loved one that lasts longer than two weeks can now be considered a disease and treated with medications. What will be the next normal human experience to be turned into a disease?

EXTRA CREDIT:

11. What does it mean to be human? Who gets to decide?

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Since this is an ethics blog, you’re on your honor to score yourself fairly. Good providence!

Guidelines for malpractice reform?

A bill with bipartisan support was introduced in Congress this week that would grant physicians increased protection from malpractice suits if they can demonstrate that they followed established clinical guidelines in the case over which they are being sued.

I am all for malpractice reform, but I’m a little uncomfortable with this one. Clinical guidelines in medicine can be very helpful, as long as they are treated as just that: guidelines. Every patient is different, and there are very few “One-size-fits-all” tests or treatments in medicine. Unfortunately, clinical guidelines are often treated as “One  size fits all.” Guideline recommendations are appropriate for some patients and not for others. Unfortunately, too many of the people who are making decisions for doctors these days (administrators, bean-counters) think guidelines are a good way to standardize doctors’ behavior (which will work fine as soon as they find a way to standardize the patients). So while I applaud the intent of the proposed bill, I fear that it will be an excuse to scare more physicians into toeing the guide-line

Another problem lies with guidelines themselves. Guidelines are considered one way to help physicians practice “evidence-based medicine.” However, there is reason to believe that a fair amount of the evidence upon which these guidelines rest is questionable at best. One cause for this is the undue influence of pharmaceutical companies upon guidelines, which takes at least two forms. Many of the studies on which guidelines are based were funded by the pharmaceutical companies, and there is extensive documentation of a long history of data-tampering to make study results appear to favor a particular sponsoring company’s expensive new drug. Many medical journal publishers are taking steps to correct this, but the fact remains that a lot of questionable data is being used to guide guidelines.

And then there are the guideline-writing bodies themselves. Take the recent update to the cholesterol guidelines, for example: if fully implemented, the pool of patients eligible for treatment with cholesterol-lowering medications will expand by 13 million patients. Seven of the fifteen people on the committee that wrote the guidelines have either current or past ties to the companies that make cholesterol-lowering medications. I am certain that none of the committee members consciously tried to do any favors to the particular drug companies that pay them honoraria. But I am not so certain that unbiased judgment can be maintained under such conditions. (As an aside, it is no wonder that clinical guidelines have been called particularly lucrative marketing tools for pharmaceutical companies. Think of it: a drug rep can only visit a limited number of doctors’ offices in a limited geographical area, but a clinical guideline — !! Potentially thousands of prescribers across the country!!)

So, while I am all for real malpractice reform, and I understand the good faith behind the bill that’s been introduced, I am concerned that the potential harms outweigh the potential benefits. We might need a little more guideline reform before we embrace this malpractice reform.