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10/04/2018

Veterans Take State to Court over California Aid-In-Dying Law

The 2016 California End of Life Options Act allows dying patients who are of sound mind, and can request and administer medication independently, to acquire a lethal drug prescription. But the California Department of Veterans Affairs announced tha...

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10/03/2018

Gattaca Continues to Spark Pertinent Bioethics Discussions




It’s October and the Center for Practical Bioethics is about to kickoff our fall film series: Science, Medicine &Unintended Consequences. Our first entry in the three-film series is Gattaca (1997), staring Ethan Hawke, Uma Thurman, and Jude Law. Directed by Andrew Niccol, Gattaca is set in a near-future where reproductive eugenics is available to would-be parents. There we find a stratified society, in which opportunity is reserved for those with tailored genes (and presumably parents rich enough to pay for them), even while genetic discrimination is technically illegal.

The movie gives shape to the various anxieties that accompany discussion of genetic engineering in humans. Given the ability to identify appealing genetic traits, what would happen if we designed our offspring? Given the knowledge of how our genes will affect our future health, what would happen if that information were available to potential employers. We see both the effects it could have on our society; regular genetic screening, structural discrimination, but also the effects it could have on individuals; parents alienated from their children, crises of identity and inadequacy.


Overall, the world of Gattaca is depicted as clearly dystopic, but twenty years after the film’s production consumer genetic screening products are finding their way into the markets, and powerful genetic editing technologies are being used on human cells for the first time. I don’t believe that these technologies will necessarily lead us to a dystopian future, but movies like Gattaca remind us that they can cast long shadows. Careful consideration, a robust ethical framework, and broad-based discussion are essential to successfully identifying and avoiding the risks associated with emerging technologies.


On that note, I hope that everyone enjoys our screening of Gattaca and the discussion that will follow!


Matthew Pjecha is a Program Associate at the Center for Practical Bioethics.


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10/03/2018

Revising the Uniform Determination of Death Act

I was impressed by this editorial in the October 2009 issue of Nature: "Delimiting death: Procuring organs for transplant demands a realistic definition of life’s end."

The article notes: "In practice, unfortunately, physicians know that when they declare that someone on life support is dead, they are usually obeying the spirit, but not the letter, of [the UDDA]. And many are feeling increasingly uncomfortable about it."

"The kind of clear, unambiguous boundary assumed in the 1981 law simply does not exist. Ideally, the law should be changed to describe more accurately and honestly the way that death is determined in clinical practice. . . .  The time has come for a serious discussion on redrafting laws that push doctors towards a form of deceit."

These sorts of calls for revising the UDDA have only become louder and more frequent over the past nine years.




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10/02/2018

Is More “Ruining” of Medicine on the Way?

By Mark McQuain Ask older medical doctors their opinion on the current state of the practice of medicine and I suspect the majority will give you an earful, generally along the lines of “How [blank] has ruined the practice of medicine”, filing in [blank] with any number of things, including the government, insurance companies, pharmaceutical …

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10/02/2018

Texas Court Orders Hospital to "Treat" Dead Girl Payton Summons

Last Tuesday, 9-year-old Payton Summons suffered a cardiac arrest and was unconscious when she arrived at Cook Children's Medical Center in Forth Worth, Texas. Sadly, clinicians soon determined that Payton was dead. Nevertheless, Payton's parents woul...

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10/01/2018

The Sad Case of Daniel Te’o-Nesheim

BY NEIL SKJOLDAL The New York Times  recently published a lengthy article on Daniel Te’o-Nesheim, a former NFL player who died at age 30 after playing football for half his life. With all the recent information about the dangers of football-related head trauma, it is not surprising to learn that upon his death, Te’o-Nesheim’s family donated …

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10/01/2018

Nonbeneficial Treatment: Across State Lines

Join me at 8:00 on Saturday, October 20, in the Magic Kingdom Ballroom 3 at ASBH 2018 for "Nonbeneficial Treatment: Across State Lines."

This panel presentation will explore various approaches to management of requests for Non-Beneficial Treatment from three different health systems in California, Michigan, and Nevada. 

The presentation will focus on a) legislation impacting health care decision-making in these states, b) policies adopted by institutions to address this challenging clinical situation, and c) a discussion of the financial impact of requests for Non-Beneficial Treatment on an organization. 

The panelists are professionally trained clinical ethicists from interdisciplinary backgrounds. First panelist will reflect on California Probate Code and the experience of a health care institution through policy development and ethics consultations around Non-Beneficial Treatments. The presenter will also discuss a case that was challenged in court. 

Second panelist will present the current Non-Beneficial Treatment policy at a large health system in Michigan. The presenter will discuss applicable state law, and current proposed legislation from partisan organizations that would affect institutions’ and healthcare providers’ abilities to refuse to provide non-beneficial life-sustaining treatments. 

Third panelist will review current approach to Non-Beneficial Treatment requests at a Nevada health care institution. The panelist will discuss current efforts by the health system to positively impact Nevada legislation on Non-Beneficial Treatment. These efforts are focused on clarifying health care provider obligations within legislation regarding health care decision-making. 

Last panelist will focus on a study performed to assess the cost of Non-Beneficial Treatment cases for an organization. The presenter will also address the context for the study and the ethical challenges these conflict situations pose for the organization.

Shilpa Shashidhara, PhD
Ana Tyler, JD, MA
Robert Fulbright, JD, MA
Ruchika Mishra


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10/01/2018

Sloan Kettering Controversies: Trust is the Public Foundation of Medical Research

by Ann Mongoven, PhD, MPH

Recent controversies at Memorial Sloan Kettering Cancer Center raise ethical questions about medical research that deserve public attention. Jose Baselga, M.D., Ph.D., a famed cancer physician and researcher, resigned as chief medical officer following reports that he failed to disclose millions of dollars received from drug companies. Baselga claimed the lack of disclosure was unintentional. Then the New York Times and Pro Publica published reports raising questions about whether data-sharing between Sloan and biotechnology start-up Paige.AI constitutes a conflict of interest. Paige seeks to develop artificial intelligence programs that will improve pathology diagnostics.  Prominent board members and physicians within Sloan, a non-profit hospital and research center, invested in Paige.…

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09/30/2018

Inappropriate Treatment Policies: Central Issues and a Working Example

At 10:30 on Saturday, October 20, 2018, at ASBH 2018, check out "Inappropriate Treatment Policies: Central Issues and a Working Example."

When a patient or surrogate asks for a treatment or other intervention that the attending physician believes is medically unnecessary or inappropriate, the differences that arise are frequently difficult to resolve. In addition, in such situations, physicians and other caregivers often feel isolated and without institutional support. Yet only a few dozen hospitals/systems have developed institutional policies – sometimes called “futility” or “inappropriate care” policies – aimed at supporting physicians and other caregivers in these ethically and practically difficult situations while assuring that the patient receives treatments that meet the current standard of care. 

XYZ Health System first developed its Medically Unnecessary or Inappropriate Treatment Policy in 2005 and has reviewed and amended the policy twice since then. In this session, three members of XYZ Health System’s Institutional Ethics Committee – a physician/ethicist, a philosopher/ethicist, and a lawyer/ethicist – will begin by describing a typical case in which such a policy might be implemented and explain how XYZ’s policy works. They will then describe the ethical, practical, and institutional challenges that the policy was designed to meet, discuss its relative success so far in meeting them, and describe the changes and adjustments that subsequent review of XYZ’s policy has produced. By comparing a number of institutions’ policies they will identify the key questions that an institution aiming to create such a policy needs to address and explain the conceptual issues involved in properly articulating a policy of this sort. The session will conclude with open discussion of these topics with the audience.

David T. Ozar, Ph.D.
Joseph Gibes, M.D,M.A.
Cavan K. Doyle, J.D., LL.M.


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09/29/2018

Clinical Ethics and Inappropriate Care at ASBH 2018

Join me at 11:30, on Sunday, October 18, 2018, at ASBH 2018 in Castle B-C for this session on Clinical Ethics and Inappropriate Care.

Inappropriate ICU Admissions: One Step Closer to Addressing Inappropriate ICU Care for Patients
Katherine E. Kruse, MD; Ruth Marks, MS3; Stephanie M. Harman, MD; David Magnus, PhD

Major medical societies have developed comprehensive guidelines to identify non-beneficial treatment within the Intensive Care Unit (ICU). Recently, the Society of Critical Care Medicine’s Ethics Committee published a policy statement to more clearly define inappropriate treatments as those provided without reasonable expectation that the patient will survive outside the acute care setting or when the patient is unable to perceive the benefits of treatment. Closely related to providing inappropriate ICU treatments is inappropriately admitting a patient to the ICU, for which these societies have yet to reach consensus. Qualitative research methods were used to explore the causes of inappropriate ICU admissions. Acute and intensive care physicians from a quaternary care hospital participated in semi-structured interviews exploring the physician's role in ICU admissions and considerations surrounding inappropriate ICU admissions. Major themes included the following: 1) challenge of gauging clinical trajectories in pressured, time-sensitive situations and those with limited information during inter-facility transfers; 2) inexperience of trainees leads to increased ICU triage; and 3) lack of upstream advanced care discussions early in a patient’s life-limiting disease decreases the patient’s quality of life and death and makes the ICU a repository for goals of care discussions. There are significant challenges in preventing inappropriate admissions to the ICU due to prognostic uncertainty and the perceived lack of advance care conversations regarding the ICU in the context of overall goals of care. Augmenting ICU admission policies to include relative contraindications would improve guidance and trigger discussions surrounding the appropriateness of admitting a patient to the ICU.

Who Are Patients Perceived to Receive Inappropriate Critical Care and What Happens to Them?
Neil Wenger, MD, MPH; Thanh Neville, MD, MSHS

Medical interventions that prolong life without achieving an effect that the patient can meaningfully appreciate are often considered “inappropriate” by clinicians. The characteristics of these patients and the treatments they receive have not been described. For patients assessed as receiving inappropriate treatment, we described the patients’ clinical details, pain, level of consciousness (LOC), and resource utilization during hospitalization. For 3 months, we surveyed critical care physicians daily in five intensive care units to identify patients that clinicians perceived as receiving inappropriate critical care. Detailed chart abstraction was performed on the 123 patients assessed as having received inappropriate treatment to capture characteristics, testing, life-sustaining treatments, and nursing assessments of daily pain and LOC.
The 123 patients had a mean age of 67 and on admission 41% had cancer and 25% had advanced pulmonary disease. Fifty-seven percent of patients had severe neurological injury, overwhelming sepsis or irreversible respiratory failure. Patients were less likely to be alert (OR 0.39, CI 0.16-0.91, p=0.03) on days they were assessed as receiving inappropriate critical care. After they were assessed as receiving inappropriate critical care, patients received 172 imaging studies, 151 procedures, 546 units of infused blood products, 1542 days of mechanical ventilation, 254 days of vasopressors, 226 days of hemodialysis and 10 attempts at cardiopulmonary resuscitation. In conclusion. patients assessed as receiving inappropriate critical care receive much burdensome and resource-intensive medical care, largely while non-alert, demonstrating the effects of mismatch between treatment and prognosis.

Creeping Noninterference-Focused Autonomy in Modern Medicine: How We Created and Continue to Feed the Problem of Futility
Catherine S. Heith, MD

The intersection of autonomy with modern-technologized and patient-satisfaction-driven medicine has had unexpected consequences. Although autonomy sprung from informed consent and the "right to die" movement, modern medicine, when paired with “orthodox autonomy,” has produced "the right to live" phenomenon. Alistair Wardrope’s "orthodox autonomy"—“⋯ autonomy interpreted in terms of the Doctrine of Informed Consent”—focuses on the "non-interference" component of autonomy. This emphasis on non-interference has consequences that have bound both physicians and patients/families in a pattern of inappropriate treatment that diminishes quality of life. It has transferred responsibility to patients/families for decisions that Deber designates "problem solving tasks," or tasks that are medical, creating an increased decision-making burden and sense of responsibility for outcomes on families. This has also given them an increased sense of control that may be inappropriate, such as in chronic or terminal cases when neither medicine nor the family dictate the outcome. This sense of responsibility increases guilt associated with poor outcomes, often unrelated to any decision making but a result of the natural progression of disease. This false sense of control can also delay grieving and acceptance and result in excessive or futile treatment as the family/patient now feels responsible for the outcome, including death. The importance and scope of non-interference in autonomy has been over-interpreted and is feeding the problem of futility. It is important to reinforce that the disease, not the family or their decisions, determine the outcome.


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