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02/15/2017

Beyond the Destination LVAD

There are many forms of life sustaining treatment available to patients thanks to advances in medical technology. When a person’s physiology weakens or fails, devices may be attached or implanted to take over for organs that can no longer bear the workload of processing, moving, or taking in the elements needed to keep a body alive. Conceptually, this is appealing to a society that is as averse to death as are those of us here in the US. But we still struggle to accommodate the range of needs that crop up when function is compromised. As an ethicist, the general trend in my work suggests that the more advanced the technology, the more questions it raises when it comes time to talk about halting the mechanical support. Among the more advanced tools for sustaining physiological function is the Left Ventricular Assist Device, or LVAD, which maintains the circulatory function for persons with severe heart failure.

There is little doubt that individuals who are eligible for the device can experience remarkable quality of life gains whether they move on to receive a heart transplant or receive the implant as a destination treatment. Recipients of LVADs can typically return to their daily activities, and enjoy a level of independence not previously possible for persons with otherwise lethal heart conditions. However, these patients are not just like everyone else when complications arise. Decisions about how best to manage long term care for persons who have LVADs can be unexpectedly complex, most notably when the patient lives outside a major metropolitan city center. In particular, securing services when such patients suffer non-cardiac health complications after having the device implanted can be difficult. Consider a patient who is stable with a destination LVAD who develops end stage renal disease and requires hemodialysis. Outpatient dialysis centers can be fearful about safely managing the ongoing dialysis treatment for a patient when they do not have experience with ventricular assist devices. The same may apply to residential care centers when a patient needs a period of rehab for an injury unrelated to the heart failure diagnosis. Perhaps the most challenging circumstance involving resources for LVAD patients who experience age related cognitive decline and need nursing home level care due to confusion, impulsivity, and routine self-care deficits. There are no clear restorative goals, but the need for custodial care can quickly exceed what was once possible at home, but the LVAD is usually unfamiliar to small town nursing homes and can be a barrier to securing long term residential care.

This issue raises an important justice question for LVAD candidates. Should consent for LVADS, when known to be destination devices, include information about the limitations in assuring other types of services? If so, how do we assure that this information is delivered in a way that does not discriminate against patients from more remote areas while favoring those who live near facilities that routinely care for LVAD patients? 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

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02/06/2017

A message of hope for inclusivity and equality

For many US citizens, as well as people around the world, the last few months have been difficult and disappointing given the results of the US presidential election. As a feminist bioethicist, I am particularly concerned about how the Trump administration will treat vulnerable and oppressed groups, such as women, individuals in the LGBTQ community, people of color, individuals with disabilities, Muslims and other religious minorities in the US, and poor individuals. I am also concerned that the Trump administration will erode people’s access to healthcare and that this will disproportionately affect these vulnerable and oppressed groups. Already, we have seen that one of Trump’s first actions is to start the process of repealing the Affordable Care Act.

It is easy to be disheartened during these challenging times, but I recently attended two events that gave me hope. First, on Friday, January 20, I attended and co-organized the fifth annual Capital District Feminist Studies Consortium Conference which was held at the Albany College of Pharmacy and Health Sciences. When we chose the date for this conference in the summer of 2016, we didn’t realize that we had scheduled the conference for Inauguration Day. Had the presidential election turned out differently, this may have affected our turnout, but as it stands, we had approximately 80 people in attendance, which is great for a local conference. A feminist conference was the perfect place to be on this Inauguration Day. In order to address some of Trump’s antifeminist and other biased comments and actions, the organizers put together an invited panel titled "Feminist Work in Non-Feminist Surroundings: Survival in Challenging Times." I participated in this panel to discuss why I had created the Capital District Feminist Studies Consortium in the first place and why its existence is so important moving forward. The other panelists – a lawyer, an artist, and a historian – also spoke about the need for women in public spaces and for feminist resistance.

The following day, Saturday, January 21, I attended the Women’s March in New York City, which also gave me hope. Though tired from a full day of participating in and moderating the conference, I was invigorated by the large (over 400,000 people) and supportive crowds (filling the streets of New York City According to estimates. Furthermore, there were sister marches in all 50 states and around the world. Approximately 5 million people marched in around 670 marches, making this the world’s largest demonstration. That so many people came together surrounding a message of inclusivity and equality is incredible and powerful.

Inspired by these two events, I will continue moving forward with hope, which will strengthen and support me as I continue to work, both in my professional and personal life, towards justice for all people, and particularly those who are vulnerable and oppressed. I hope you will join me.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

 

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01/30/2017

A Necessary Retelling of the Smallpox Vaccine Story

A curious confluence of events unfolded Tuesday night. Just hours before President Obama uttered the powerful “science and reason matter” in his farewell address, Robert F. Kennedy Jr. announced that the incoming president had tapped him to head a committee on vaccine safety.

RFK Jr. is not a pediatric immunologist nor an epidemiologist, but a vocal “vaccine skeptic.” Although the PEOTUS dialed back on the purported appointment shortly after social media erupted, a tweet from March 28, 2014 makes his analysis of the history and science of vaccines clear: Healthy young child goes to doctor, gets pumped with massive shot of many vaccines, doesnt feel good and changes – AUTISM. Many such cases!

As a child I devoured books on the history of medicine. One of my favorite stories was how Edward Jenner developed the first vaccine, testing an approach that had been used for centuries. Knowing his story made me understand why my little sister had to shriek her way through shots for the “childhood diseases,” while I’d suffered through chickenpox, mumps, and both types of measles. My pediatrician predicted I’d end up deaf and brain damaged after a month with measles.

Now I think the tale of Edward Jenner needs retelling, for those who may not have heard it.

VACCINES 101

A vaccine is a pathogen, or part of one, whose presence in a human body is sufficient to evoke an immune response, yet not complete or active enough to transmit the illness. When the vaccinated person encounters the wild pathogen, the protective antibody response is immediate, thanks to immune memory. Conquering polio provides a dramatic vaccine story, which DNA Science covered here.

Vaccines aren’t just biomedicine, but bioethics too. The herd immunity that arises at the population level protects us all, illustrating the principle of beneficence: action that is done for the benefit of others. Vaccinate enough people against a particular pathogen, and it can’t find enough sensitive people to rampage through a population. In practical terms, when parents refuse to vaccinate their children, other children can die. Yet vaccines are not entirely risk-free; no medical treatment or procedure is. Most reactions are due to allergy or the necessary revving up of the immune response — here’s a list from a reliable source, the CDC.

THE DISCREDITED DR. WAKEFIELD

The vaccine-autism link arose from a paper published in The Lancet in 1998, in which English physician Andrew Wakefield described “a pervasive developmental disorder” in 12 children. The large, red word “RETRACTED” appears on the first page. The study had no controls and a tiny sample size, but case reports are ok in the medical literature given appropriate caveats. What wasn’t ok (among many other problems) was that Dr. Wakefield was being paid by attorneys representing allegedly harmed children. When this news surfaced, The Lancet, in February 2010, again fully retracted the paper — in case anyone missed the earlier discrediting.

Apparently the president-elect did not get that memo.

But he’s certainly old enough to remember how polio vanished after kids started lining up at school to receive vaccines. Maybe they didn’t do that at the military school his parents sent him to (see “Confident. Incorrigible. Bully: Little Donny was a lot like candidate Donald Trump” from the Washington Post.)

And so in the interest of educating the new administration on the history of vaccines, here is the story of Edward Jenner and his testing of the smallpox vaccine that has rid the world of this terrible disease. (It’s from my first textbook, with apologies to McGraw-Hill. I plagiarize myself for the greater good.)

JENNER’S STORY

“Vaccine technology dates back to the eleventh century in China. Based on the observation that those who recovered from smallpox never got it again, people would collect the scabs of infected individuals and crush them into a powder, which they inhaled or rubbed into pricked skin.

Dr. Edward Jenner

In 1796, the wife of a British ambassador to Turkey witnessed the Chinese method of vaccination, and mentioned it to an English country physician, Edward Jenner. Intrigued, Jenner had himself vaccinated the Chinese way, and then thought of a different approach.

It was widely known that people who milked cows contracted a mild illness called cowpox, but did not get smallpox. The cows became ill from infected horses. Since the virus seemed to jump species, Jenner wondered, would exposing a healthy person to cowpox lesions protect against smallpox?

Wrote Jenner of the horse ailment that farmers transferred to cows: ‘It is an inflammation and swelling in the heel, from which issues matter possessing properties of very peculiar kind, which seems capable of generating a disease in the human body … which bears so strong a resemblance to the smallpox that I think it highly probably it may be the source of the disease.’

A physician inspects the growth of cowpox lesions on a milkmaid.

A slightly different virus causes cowpox than smallpox, but Jenner’s approach would prove successful, leading to development of the first vaccine (from the Latin vaca for “cow”). Unable to experiment on himself because he’d already taken the Chinese vaccine, Jenner instead tried his first vaccine on 8-year-old James Phipps. On May 14, 1796, he dipped a needle in pus oozing from a small sore on a milkmaid named Sarah Nelmes, then scratched the boy’s arm with it.

Young James survived, and the smallpox vaccine was born. Eventually, the vaccine would completely eradicate the disease, although several nations maintain the virus in storage for research purposes.”

THE BIGGER PICTURE

Smallpox lesions had a characteristic central dimple, and if a person survived for awhile, the lesions grew together, covering the body. Instead of that horrific and painful disfigurement, I have a scar from my smallpox vaccine on my upper left arm. My kids didn’t even need smallpox vaccines, for the last case in the US was in 1949, and the last in the world, in Somalia, in 1977, according to the CDC.

The success of vaccine campaigns is a vivid reminder that, as President Obama said, science and reason matter. Can someone please invent a vaccine against willful ignorance? Stat.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

 

 

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01/19/2017

The Lion in Charge: Finding Strength in Uncertain Times

Aesop is credited with the first writing the familiar phrase “United We Stand, Divided We Fall.” In my brief search to find the origins of this phrase also offered a brief writing of two of the fables, which I will share here to frame my thoughts on managing the risks of ignoring cavalier, authoritarian leaders who prey on those who fail to muster the necessary strength and group support to oppose such behavior.

“The Four Oxen and the Lion:

A lion used to prowl about a field in which Four Oxen used to dwell. Many a time he tried to attack them; but whenever he came near they turned their tails to warn anther, so that whichever way he approached them he was met by the horns of one of them. At last, however, they fell [to] quarrelling among themselves, and each went off to pasture alone in the separate corner of the field. Then the Lion attacked them one by one and soon made an end of all four.” ( http://quotes.yourdictionary.com)

Let’s not be quick to dismiss this as a mere child’s story. But let’s start there. Where did most of us first learn about bullies? Probably in grade school – either as a victim, a bystander, or as a perpetrator. Tactics for dealing with the abuse may have ranged from passivity to seeking help from persons with greater authority to intervene, though this may have had mixed results. What happens when those with authority dismiss the claim, or otherwise fail to help? The abuse gets worse. What happens when the peers stand together alongside the victim? When the bystanders become active in stating “this stops and will not be allowed here – on our playground, in our group, our community”? When the bully is ‘iced out’? The power of the perpetrator recedes. As adults, employees, citizens, and those with and without social privilege we know intuitively that we have more power as a united front counteracting threats.

So that’s the idealistic answer. Confronting and sustaining the energy to hold a careless leader accountable is not easily done. A person rarely comes to a position of power in our society without having some significant skills of persuasion. Though often superficial, it may not be readily apparent because of well-honed abilities to confidently dismiss deficits in qualifications or knowledge, build collateral support with charm and social rapport, and diverting attention away from concerns when inconsistencies emerge – all with a smile or a wave of the hand. Perhaps the most dangerous of all patterns is one in which those relying on this leader to represent the well-being of all, instead creates divides by splitting dissenters against each other. Like the lion, the oxen are easily devoured once the distracted by matters other than looking out for each other.

As a democratic society, we are at risk of becoming prey. I have devoted my career to serving others who are in crisis of some kind, and providing whatever tools I have at my disposal for navigating an uncertain future, for somehow accommodating events that cannot be undone. But, perhaps most importantly, never giving up on the inherent ability of people to come together to get the right things done…to watching out for the lion together. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

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01/11/2017

Flatulence and Elections

Approximately once a month I open my schedule and see that my first task of the day is to write a post for the Alden March Bioethics Blog, Bioethics Today. The first part of this task is to determine what to write about. Sometimes that is the most difficult part of the job. I try to give myself fairly wide discretion in choice of topics but this is a bioethics blog so I do try to be conscientious about finding some relationship between the topic of the blog and bioethics. Sometimes that is hard. Recently while perusing the venerable Washington Post I came upon an article that I felt I had to write a blog about.

It also happened that today was the day that my calendar told me it was time to write a blog. So here goes.

It was reported today that there was a fire in the operating room April 15 during a surgical procedure. An unidentified woman was undergoing a surgical procedure on the cervix with a laser. To make a long story short, the woman passed gas, the laser ignited the flatulence and the surgical draping caught fire.

I was attracted to this article because I used to be a young boy (this was a very long time ago) and all young boys believe that everything about farts is funny and entertaining. It was even more entertaining when the flatulence was ignited. Alas when I first saw the article I thought it would be funny but it was not. The woman was seriously burned.  This no longer seemed like a good topic for a blog and I left it incompletely written and unpublished.

While this happened months ago it is current again. At least in my thinking it has become current. The reason for this is that sometimes things that start out seeming funny or absurd become serious issues. I admit that only months ago I thought that the fact that a certain individual was running for president was both funny and absurd. Now he has been elected and it seems neither funny nor absurd. It seems very serious indeed.

So now in my mind the presidential election process evokes thoughts of a woman who was seriously burned in a fire ignited by her own flatulence. I hope the nation and the world are not seriously burned by this election but I fear they will be.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

 

 

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01/06/2017

Exercise is good for you and High Heels are not: Health Reports on the Obvious

In a quest for health news which might spark some meaningful topic worth sharing with the Bioethics community, I was repeatedly dismayed at the number of articles offering relatively little useful information at all. In fact, there seemed to be a surprising number of articles that offer scientific support for topics that might be tempting for a superficial glance, but do not add meaningfully to the much broader well-being of individuals and communities. I strongly support using any tools necessary to disseminate health information to persons who may benefit from evidence based health information, but the focus of this effort ought to address more meaningful goals of medicine and human welfare.

An article published in Substance Use and Misuse points out that of the over 15,000 individuals there was no significant relationship between alcohol consumption and physical activity (PA) study link. This article offers common sense health advice for future efforts: “Prevention programs to increase PA levels from low to moderate combined with a reduction of alcohol intake in men who regularly drink alcohol should be considered.” This conclusion is based on the finding that persons who drink heavily also have lower physical activity levels. Hardly seems groundbreaking. Yet, if there had been a correlation suggesting that heavy drinkers are also quite physically active, what would this offer as a useful nugget of health information? Don’t worry about heavy alcohol consumption?

Studying the long term effect of wearing high heel shoes has also gained attention in the media and academic literature. Though, in fairness, I suppose someone has to study it so we can provide evidence based practice considerations to persons who develop foot or ankle problems, or are required to wear high heels as part of a work uniform. “One condition known to compound the difficulty of walking is the use of high heeled shoes.”  study link #2.  I believe all who have worn high heels are likely to agree on this point. The piece does offer some considerations about blood flow to the lower extremities, which could be helpful to physicians treating patients with high heeled related ambulatory difficulties, so a relevant factor in advising patients. Nonetheless, it seems a bit startling that such research is surfacing in the media to answer this question for consumers.  A recent New York Times blog (blogs.nytimes.com/2015/06/17) titled “Reducing the frequency of wearing high-heeled shoes and increasing ankle strength can prevent ankle injury in women” leads off with a critique of having a character run from Jurassic dinosaurs while she is wearing high heels, and offers evidence for negative effects of long term high heeled shoe wearing. Just in case there was any doubt, the article concludes with sound advice for not wearing high heels as the footwear of choice if escaping a fast moving deadly animal.

Media is a powerful too, and so is scientific inquiry. I believe the public can digest more meaningful discussions of health related matters than those which confirm common sense.

 The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

 

 

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12/28/2016

Albany Medical College May be the Best Medical School in the Country

I realize that this is not the assessment of the US News and World Report, or other major organizations that rank US medical schools, but I believe it quite possibly is true.  Organizations that rank medical schools look at dollars of research grant funding, or the test scores of the students, but what is really important is the quality of the physician they graduate.  But what do we mean by quality?  And who should be the judge of this?

A survey of patients in a primary care setting revealed that the most important quality that they sought in their physicians was empathy.  More important than even clinical skill or knowledge, they wanted a physician who listened and cared.  This response cut across demographics—the old, young, rich, poor, all ranked empathy as the most important quality of a physician. And shouldn’t patients be the ones to tell us what is most valuable in a physician, and by extension what the most important mission of medical schools must be?

The curriculum of medical schools across the country differs little in terms of the basic sciences taught and clinical rotations of the last two years.  Students from Harvard and Albany need to pass the same standardized tests to graduate, but that doesn’t mean there aren’t differences.  Students at Albany Medical College spend more time learning ethics, and discussing the humanistic aspects of clinical care during their last two years of medical school than any other medical school I have yet discovered.  When Dr Shelton and I discussed our curriculum at a national bioethics conference two years ago, educators from other schools were shocked at how much curriculum time we had with students during their clinical years, and none had anything close to comparable.

I just finished six one-and-a-half hour sessions with third-year students on their internal medical clerkship.  At the end I asked them whether it had helped them.  The fact that I do not grade them at all made their answers less suspect, and to a person they praised the time we had spent together. 

            “A chance to reflect.”

            “Helping me stay human.”

            “I want to keep feeling.”

At that same bioethics conference I listened to a talk on teaching empathy during medical school, and I kept thinking that the speaker had it all wrong.  Our job is to preserve empathy, not teach it, and we preserve it by allowing students the opportunity to share the good, the bad, and the ugly with each other in a safe environment.  We do that. Others should follow our example.  A third-year student told me that the best examples of compassionate patient care came from the residents who had trained at Albany Medical College as medical students, and that she believed it was the ethics curriculum that was making the difference.

NIH grants, and licensing exam scores are not unimportant, and Albany Medical College is a good medical school by any marker chosen.  But by the marker chosen by patients, we may, in fact, be the best.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

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12/21/2016

In Memoriam: John A. Balint, MD

After over three decades of dedicated service to Albany Medical College as a researcher, practicing physician, administrator, and mentor, when some people might consider retirement, John Balint in the early 1990’s was just beginning to redefine his career. It was during this time that I first met John at the University of Chicago, Center for Clinical Medical Ethics, when we were both members of the 1993-1994 Fellowship class. I was privileged to learn about his amazing life up to that point, but what seemed more important at that time, were his high hopes for the future.

John sought out this fellowship opportunity to prepare himself to lead the new Center for Medical Ethics which would be charged with teaching a new course that was being created in the curriculum reform process called Health, Care, and Society (HCS). To say John was excited about the new direction of his life was an understatement. As one of the leaders of this four-year longitudinal course, John was now able to focus on his deepest passion in medicine: the physician-patient relationship and the elements of good doctoring.

Of course I know now that John had been preparing for his new role from the beginning of his life. He often said his interest in the physician-patient relationship was passed along to him from his father, Michael Balint, the prominent physician-psychoanalyst and early thought leader on this topic. As a small boy growing up in Budapest, Hungary, John told me the story of joining his dad on a trip to Vienna to visit Sigmund Freud, where John played under Freud’s desk while the two men talked about their patients. Though John went on to study medicine at Cambridge University in England, and then received advanced training in gastroenterology both in England and the United States, he maintained an interest in his father’s work, which included The Doctor, The Patient, and His Illness originally published in 1957.

John came to Albany Medical College in 1963 to head the new division of gastroenterology and to put an indelible mark on the institution to which he dedicated most of his life. From having leading roles in NIH research grants, to serving as chair of the Department of Medicine and being an invaluable mentor and teacher to many students, residents, and fellows, John was a remarkably well-rounded physician-scientist. But most of all, as those who were around him in the clinical setting know, he was the consummate clinician—a good doctor in the mold of great doctors since Osler. One can hardly imagine better preparation, along with a fellowship in medical ethics, for leading the new program in ethics in Albany.

I was honored and excited when John asked me to join him as his new associate in the Center For Medical Ethics, Education and Research. When I joined him in 1994 our primary mission was to develop HCS throughout the 4 years of undergraduate training ,(the first year had begun in 1993-94), start a new clinical ethics consultation service for the physicians and nurses at Albany Medical Center, and become part of the lifeblood of the institution. John was never interested in purely theoretical pursuits in ethics—he wanted the new focus on ethics to make a positive difference in the lives of the students, patients and staff we served. Within a few years Liva Jacoby and Sheila Otto joined John and me, and together we were making our mission a reality. During our first decade working together I was honored to coauthor a number of papers with John including our 1996 article, Regaining the Initiative: Forging a New Model of the Patient-Physician Relation, which was published in JAMA.

John was a visionary who never stopped dreaming about new possibilities with a great deal of energy and enthusiasm. He was excited to support the joint Albany Medical College/Union Graduate College Master’s of Science in Bioethics as well as the new Distinction in Bioethics for our medical students, both of which began in 2001. By the time John stepped down from the directorship, the Center for Medical Ethics had become the Alden March Bioethics Institute, which has continued to grow and flourish. But it began with John’s passion to make ethics relevant in medical education and in clinical practice, and to train a new generation of young learners to become good doctors.

Though we mourn his loss, we also celebrate his remarkable life and work. He will be greatly missed, but the mission he dedicated himself to and our memory of him will continue.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

 

 

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12/13/2016

Imminent Threats To Healthcare and Medical Professionalism: We Must Remain Vigilant

In a previous blog I expressed concerns about the possible direction of politics in our country and the risks it poses to the larger procedural, democratic framework, which I take to be essential to the work of contemporary bioethics. Now that the election is over and a new administration is taking shape, I have many grave concerns about the fundamentally new policy directions our nation will be taking. None concern me more than how the planned changes in our healthcare system in the United States and, if they happen, how our most vulnerable patients will be affected. This is because a top agenda for them on day one will be to repeal the Affordable Care Act (ACA), which has provided healthcare coverage for about 21 million more people since its inception in 2009.

The ACA was an imperfect healthcare plan from the start. But after decades of false starts to reform a system that does not have a close second in terms of excessive costs and inefficiencies among industrialized nations, especially in relation to outcomes, in 2009 it was the best option our country had at that time. In spite of some problems in its implementation, due largely to lack of cooperation and critics setting up obstacles, the ACA has become entrenched into our healthcare system. If it is repealed, there will be widespread suffering and chaos. Just recently the nations’ hospital industry “…warned President-elect Donald Trump and congressional leaders on Tuesday that repealing the Affordable Care Act could cost hospitals $165 billion by the middle of the next decade and trigger “an unprecedented public health crisis.”

 The eagerness of the new administration to gut the ACA was affirmed by the appointment of Tom Price, Representative from Georgia who has been a ferocious and over the top critic of this law from its inception. A prominent orthopedic surgeon prior to running for Congress, Dr. Price seems to advocate for a system that is extricated from government as much as possible and placed in the hands of the private insurance companies. His plan, which provides for individual fixed tax credits and health savings accounts and allows insurance companies to cross state lines, may be helpful for many Americans who are relatively well off and have healthcare to start with. But for most of the sickest patient in lower income brackets, these market-based ideas will do nothing to help them and in fact make them worse off. But real world, harmful consequences are the concerns of an ideologue: All that matters is having in place a policy that accords with an ideal vision of how the world should work.

There is no practical way that a purely market based approached to providing access to healthcare to Americans will accomplish the goals of healthcare that the majority of Americans have, which is to provide some type of basic, quality healthcare to all citizens, at an affordable cost. Price’s approach will leave millions of American citizens, many already with serious health problems without access to health except via the emergency rooms. The predictable consequences will be astronomically increasing costs because healthcare will retreat to its pre-ACA days of inefficiency by focusing more on rescuing patients from acute conditions than preventing them from occurring in the first place; and physicians caring for patients with insurance will be doing more and more procedures for which they will be handsomely paid, without improving quality for patients. Which makes it all the sadder to see the American Medical Association (AMA), as it has done at prior critical historical junctures as it did in standing against the passage of Medicare and Medicaid in 1965, endorsing Price’s nomination.

Though Price’s nomination may be bad for patients, it likely represents good news for physicians in terms of their incomes from reimbursement rates. Which is the reason why the AMA supports him and why, in my judgment, it is an abdication of professional, ethical good judgment and responsibility. Their support violates the basic tenant of professionalism as stated in the American College of Physicians (ACP) Ethics Manual that require its members “…to teach and expand, by a code of ethics and a duty of service that put patient care above self-interest, and by the privilege of self-regulation granted by society. Physicians must individually and collectively fulfill the duties of the profession.”

I am heartened by practicing physicians and physicians-in-training who speak out and refuse to be a part of the AMA and its support of Price’s appointment to be Secretary of HHS.  Most notably a petition has gained over 5,000 physicians’ signatures that make it clear “The AMA Does Not Speak For Us”.  As they state in the petition:

 

“We are practicing physicians who deliver healthcare in hospitals and clinics, in cities and rural towns; we are specialists and generalists, and we care for the poor and the rich, the young and the elderly. We see firsthand the difficulties that Americans face daily in accessing affordable, quality healthcare. We believe that in issuing this statement of support for Dr. Price, the AMA has reneged on a fundamental pledge that we as physicians have taken?—?to protect and advance care for our patients.”

 

Medical professionalism always exists in relationship to the prevailing economic and political order in society. Because economic and political winds can shift, so can medical professionalism that at times can put it at risk of losing its moral compass. We do not know yet just how strong the head winds will be. But medical professionals and all citizens who care about the future of just and quality healthcare should be especially vigilant in the coming days and remain prepared to show resistance when necessary.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

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12/09/2016

Don’t feel comfortable asking others if they are having regularly scheduled unprotected vaginal penile penetrative intercourse? Then don’t ask


One of the first questions a newly married straight couple often gets from well-meaning friends and family is “when are you going to start trying?” For those of you who are wondering what this question is getting at, it is asking them if they are going to start to try to get pregnant. It is interesting to analyze the language used here. People typically talk about “trying” without ever specifying what they are in fact trying to do. Part of the reason for this may be because people assume the meaning is obvious from the context, such as “they’ve been trying for six months but haven’t gotten pregnant yet.” Another reason probably has to do with our societal discomfort talking about sex.

We use general and vague terms to imply that we are talking about sex, but often don’t feel comfortable out right discussing it. For example, the birth control pill is generally just referred to as “the pill.” There is still shame and stigma surrounding sex, particularly for women and sexual minorities, so it may be easier and safer for a woman to talk about being on “the pill,” even though everyone knows what she is referring to, than to overtly announce that she is using contraception.

Even though we as a society may not feel comfortable explicitly discussing sex, we still feel that it is our business. From a legal perspective, look at how carefully reproductive medicine is regulated. For instance, certain reproductive procedures (e.g. abortion and sterilization) can require waiting mandatory periods – something that is not common in other areas of nonelective medicine. In the social realm, family, friends, and even strangers feel they have the right to comment on a pregnant woman’s behavior, such as by telling her what she should and should not eat or drink.

Returning to the topic of “trying,” family, friends, and again even strangers often have no qualms about asking women about whether they are trying to conceive. This is especially the case for straight women who are recently married and women who are perceived as being near or at the end of their “biological clock.”

Asking women whether they are “trying” is problematic on many levels. First, it assumes that all women want to become pregnant with genetically related children. While this may be true for many women, it is not true for all women. There is already enough social pressure on women in our pronatalist society to have biological children so people should avoid adding to this pressure. Second, asking people if they are “trying” is just a euphemism for asking them if they are having regularly scheduled unprotected vaginal penile penetrative intercourse, which is usually not considered an appropriate topic, especially among strangers. It is typically seen as impolite to discuss sex under certain circumstances or with certain people and discussing reproductive sex (that is, sex for which one of the purposes is reproduction) should not be treated differently.

To summarize, if you don’t feel comfortable asking others if they are having regularly scheduled unprotected vaginal penile penetrative intercourse, then don’t ask them if they are “trying” to conceive.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

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