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Blog Posts (3276)

July 28, 2016

Marking the 40th Anniversary of In re Quinlan’s Landmark Contribution to Death & Dying Jurisprudence

Norm Cantor reflects, this week, on the 40th Anniversary of In re Quinlan’s landmark contribution to death and dying jurisprudence.

His conclusion is sobering:  "Unfortunately, 40 years have not sufficed to fully and uniformly integrate the lessons of Quinlan into American medical practice."

"Just as Brown v. Board of Education, for all its wisdom, could not judicially create integrated schools, Quinlan has not universally relieved moribund patients from being mired in an unwanted, cognitively unaware limbo."

July 27, 2016

New WHO diagnostic labels perpetuate transgender stigma

The movement of the World Health Organization (WHO) to declassify transgender identity as a mental disorder is simultaneously a step forward in affirming the personhood of gender minority individuals, and a step backward in diagnoses that adequately reflect their health … Continue reading
July 27, 2016

Unilateral Do Not Resuscitate Orders

Meredith Miceli, an Associate General Counsel for the Ochsner Health System in New Orleans, published an article in the summer 2016 Ochsner Journal: "Unilateral Do Not Resuscitate Orders."

Ms. Miceli observes that Louisiana has no legal process like the 1999 Texas Advance Directives Act that offers safe harbor legal immunity.  Indeed, she notes there is "no legal guidance" in Louisiana.  (But the 1998 Causey case might suggest some  caution.)

"So, what  should an attending physician do when, in his or her professional judgment, any clinical treatment other than comfort care will be ineffective or harmful to a patient, but the family’s wishes . . . are in support of doing everything?"

Ms. Miceli advises that "a physician can act to validate his or her opinion on the appropriateness of the DNR order by obtaining the opinion of another physician, and . . . the latter’s signature on the DNR order as well as on an explanatory progress note . . . ."

"This 2-physician signoff process will serve to confirm the medical decision-making . . . and help protect the attending physician from claims of unsoundness or arbitrariness of decision. This 2-physician signature . . . is a prudent layer of protection . . . ."

This process does not provide what many providers crave in these situations: the elimination of uncertainty and risk.  But Miceli is right.  The fairer the internal process, the more likely it will receive deference and respect by external reviewers like a judge or jury.  

July 26, 2016

Election 2016: Where do the parties stand on health

by Craig M. Klugman, Ph.D.

These recent weeks have been historical firsts in the U.S. The first time a billionaire with no political experience became a major party Presidential candidate and the first time a female became a Presidential candidate.…

July 26, 2016

Self-Reflection Through a Glass, Darkly

By Josh Hopps It is the end of the USMLE Step 1 exam season in undergraduate medical education.  If UME is a solar system, Step 1 is the sun, irradiating and superheating some, leaving others cold and frozen out, and supporting life for those who thrive in intense and constrained circumstances.  Its enormous gravity pulls […]
July 26, 2016

Law, Perception, and Cultural Cognition Near the End of Life

My colleague Kathy Cerminara has published the following article in the Washburn Law Review: "Law, Perception, and Cultural Cognition Near the End of Life."  From the introduction:

In the decade since Schiavo, neuroscience has developed in leaps and bounds, paving the way to further questions about the “fact” of a VS diagnosis. Neuroscientists have begun reporting success in using brain imagery to capture the structure and function of the brains of patients with disorders of consciousness, such as VS. 

Tools such as functional magnetic resonance imaging (“fMRI”) and electroencephalograms (“EEGs”) suggest that the clinical diagnostic criteria used to determine whether a patient is in a VS may be flawed. Such flaws may result in some diagnoses that are arrived at correctly yet are factually inaccurate, indicating that a patient is in a VS when he or she is actually in a minimally conscious state (“MCS”).

Neurologist Dr. James Bernat has noted, “[t]he public has become both fascinated by states of unconsciousness and skeptical of the ability of clinicians to diagnose them correctly, treat them properly, and issue prognoses accurately.”

This skepticism opens up space for discussion into which we must proceed cautiously because of the potential to read these studies as support for opinion in the guise of fact. Ms. Schiavo’s brother, Bobby Schindler, for example, has described fMRI techniques as demonstrating that “an ‘unscientific, inaccurate’ diagnosis of unresponsive patients [in VS] is being used as a ‘criterion to kill.'” 

Yet, neuroscientists themselves caution that their research is not advanced enough to accurately describe such diagnoses as unscientific or inaccurate, even if public opinion or social consensus favored the use of them “to kill.” Because of the emotional nature of the life-or-death issues involved, future disputes over VS are inevitable, and they easily could become as hotly contested as those that erupted during the final years of Ms. Schiavo’s life.

Not only are such disputes emotional and potentially violent, but they also are all too common. Everyone will encounter death at some point in his or her life. Everyone will watch friends and family members die; some rapidly, under emergency circumstances, and some after long, drawn-out dying processes. Tens of thousands of patients lie in VS in facilities across America at this very moment, and emotions easily flare when medical decisions are required in such contexts. Each of those patients’ long, drawn-out dying processes, like Ms. Schiavo’s, has the potential to involve a struggle between autonomy, liberty, and the awesome capability of medicine--a struggle to respect innovation in the medical sciences without sacrificing important freedoms.

This Article will assist in navigating such struggles. First, Part II will briefly recount Ms. Schiavo’s case as a vivid example, before delving into the relevant advances in neuroscience that have occurred since its resolution. Part II will analyze why those advances do not warrant questioning the validity of the current view of VS and MCS. Part III will explain the current sharp demarcation between these two conditions in the law of end-of-life decisionmaking. Finally, in Part IV, this Article will develop a typology of skeptics who question established, long-standing scientific conclusions such as the VS diagnosis. Use of this typology in conjunction with cultural cognition theory will aid in debates over the law relating to end-of-life decisionmaking on behalf of patients in VS.

In short, this Article will demonstrate that knee-jerk, emotional protests against statements like Bobby Schindler’s will not be as effective as other approaches to preserving hard-won medical decisionmaking liberties. The line between fact and opinion is still too blurry to accept those protests and change the law regarding refusal of treatment on behalf of those in VS. Nevertheless, we should recognize and engage with those who distrust the received wisdom in this area rather than reject their positions outright.

July 25, 2016

Euthanasia: Pro and Con Podcast

A new Podcast series objectively examines pro and con perspectives on euthanasia. Recent guests have included Margaret Somerville and Derek Humphry.
July 22, 2016

Out of Control Physicians: Too Many Doctors Doing Too Many Things to Too Many Patients

My father is 92 years old, and I am beginning to wonder whether the best thing for his health would be to stay away from doctors. That’s because well intentioned physicians often expose their elderly patients to harmful and unnecessary … Continue reading

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July 22, 2016

One Hundred Washington State Hospital Policies on End-of-Life Treatment

Two years ago, Washington state passed a rule requiring hospitals to post their policies on end-of-life care.  I blogged about the policies here.

Unfortunately, the state website was not a model of clarity.  Consequently, the ACLU, End-of-Life Washington, and others launched a new website, ClearHealth Washington, to decode the often murky policies.

“Providing this information at the service level, we think this is a clear and more useful way for information to be used by consumers, so that they know where they can access the services that they need,” said Margaret Chen, staff attorney at the ACLU of Washington.  (HT KPLU)

Unfortunately, since the underlying policies are vague and unclear, the ClearHealth website is not yet able to answer basic access questions for consumers.  Only one hospital seems to have completed a checklist designed by the ClearHealth project.

July 21, 2016

Lighting Up New Interest in Teen Smoking Behavior: E-Cigarette Use

Adolescence is known to be a time of experimentation and pushing towards the independence of adulthood. Risk taking, heightened need for social validation, and evolving independent self-hood are hallmarks of this important stage of life. Smoking is often viewed as a behavior that marks adulthood, and is sometimes seen as rebellious against norms (and laws) restricting purchase and use until age 18. Research in discreet regions of the US shows that e-cigarettes are more likely to be the source of nicotine exposure students in 11th and 12 grades, rather than ignited products. This same article elucidates the psychosocial factors linked to e-cigarette use, and finds that some of the determinants correlated with use in teens are prior cigarette use, having a household member using e-cigarettes, and peer endorsement of using e-cigarettes. The study found that current users did not feel there were health risks related to using e-cigarettes.

The question asked in this NY Times blog is what the correlation might be between e-cigarette use and combustible tobacco use. Are e-cigarettes a new pathway to tobacco use, and therefore dangerous by association? Just how dangerous are the vapors inhaled from e-cigarettes themselves? The concern is that there are now simply more teens using smoking products overall, thanks to the e-cigarette. “The numbers suggest that rather than prompting teenagers to replace cigarette smoking with vaping, e-cigarettes instead have enticed an entirely new group of teenagers to use nicotine” according to the NY Times piece, and based on the most recent work by Barrington-Trimis. 

As noted in the various articles linked here, it is unclear what long term health effects will impact e-cigarette users and how use of these products will correlate to combustible tobacco products, though the early data suggests there is a connection. Addressing e-cigarette use may require special, creative initiatives to reach the youths who would not otherwise have exposed themselves to a nicotine smoking product. Healthcare providers caring for adolescents will need to join in the effort to understand the factors influencing the decision to use e-cigarettes in order to address the uncertain health effects and serve as a resource for teens who believe that e-cigarettes pose a lower risk avenue to participate in smoking activities.

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Published Articles (27)

AJOB Primary Research: Volume 7 Issue 3 - Jul 2016

Religious identity and workplace discrimination: A national survey of American Muslim physicians Aasim I. Padela, Huda Adam, Maha Ahmad, Zahra Hosseinian & Farr Curlin

AJOB Primary Research: Volume 7 Issue 3 - Jul 2016

Improving third-year medical students' competency in clinical moral reasoning: Two interventions Paul J. Cummins, Katherine J. Mendis, Robert Fallar, Amanda Favia, Lily Frank, Carolyn Plunkett, Nada Gligorov & Rosamond Rhodes

AJOB Primary Research: Volume 7 Issue 3 - Jul 2016

Experimental evidence showing that physician guidance promotes perceptions of physician empathy Daniel Russell Hans, Priyanka Dubé & Jason Adam Wasserman

American Journal of Bioethics: Volume 16 Issue 8 - Aug 2016

The Curious Case of the De-ICD: Negotiating the Dynamics of Autonomy and Paternalism in Complex Clinical Relationships Daryl Pullman & Kathleen Hodgkinson

American Journal of Bioethics: Volume 16 Issue 8 - Aug 2016

Reason, Emotion, and Implanted Devices John D. Lantos

American Journal of Bioethics: Volume 16 Issue 1 - Jan 2016

Professional Judgment and Justice: Equal Respect for the Professional Judgment of Critical-Care Physicians David Magnus & Norm Rizk

American Journal of Bioethics: Volume 15 Issue 10 - Oct 2015

Do Patients Want to Participate in Decisions About Their Own Medical Care? John D. Lantos

American Journal of Bioethics: Volume 15 Issue 4 - Apr 2015

Ideology and Microbiology: Ebola, Science, and Deliberative Democracy Joseph J. Fins

American Journal of Bioethics: Volume 15 Issue 2 - Feb 2015

Collectivizing Rescue Obligations in Bioethics Jeremy R. Garrett

American Journal of Bioethics: Volume 15 Issue 2 - Feb 2015

Rethinking the Rescue Paradigm Kayhan Parsi

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News (2025)

July 26, 2016 8:33 am

A New Depression Treatment Shows Promise (Time)

A new method known as behavioral activation (BA) is effective and can be cheaper than cognitive behavioral therapy.

July 19, 2016 8:26 am

Medicine is failing obese people (Vox)

Watching a person die from cardiac arrest in an intensive care unit is devastating. It’s especially so when the person is a woman in her 40s who has been smothered to death by her own weight — and we doctors can do nothing to save her.

July 15, 2016 8:46 am

Opioid Bill Reframes Addiction As A Health Problem, Not A Crime (NPR)

The Senate is set to approve a bill intended to change the way police and health care workers treat people struggling with opioid addictions.

July 12, 2016 8:36 am

Women Doctors Are Paid $20,000 Less Than Male Doctors (Time)

In academic medicine, female full professors earn the same amount as male associate professors.

July 7, 2016 8:02 am

Seniors with access to medical marijuana use fewer prescription drugs (Reuters)

Physicians wrote significantly fewer prescriptions for painkillers and other medications for elderly and disabled patients who had legal access to medical marijuana, a new study finds.

July 6, 2016 8:05 am

Few Young Doctors Are Training To Care For U.S. Elderly (NPR)

At Edgewood Summit retirement community in Charleston, W.Va., 93-year-old Mary Mullens is waxing eloquent about her geriatrician, Dr. Todd Goldberg. “He’s sure got a lot to do,” she says, “and does it so well.” West Virginia has the third oldest population in the nation, right behind Maine and Florida. But Goldberg is one of only 36 geriatricians in the state.

June 30, 2016 8:40 am

Doctors less satisfied, more burned out with electronic records (Reuters)

Most doctors who use electronic health records and order entry software tend to be less satisfied with how much time they spend on clerical tasks and are at higher risk of burnout than others, according to a new study.

June 29, 2016 8:36 am

FDA approves first pill to treat all forms of hepatitis C (CBS News)

Federal health officials on Tuesday approved the first pill to treat all major forms of hepatitis C, the latest in a series of drug approvals that have reshaped treatment of the liver-destroying virus.

June 28, 2016 8:31 am

End-Of-Life Care Better For Patients With Cancer, Dementia: Study Finds (Kaiser Health News)

A new study offers surprising findings about end-of-life care — specifically, physicians tend to be more likely to accommodate the advanced-care wishes of patients with cancer or dementia than renal disease, congestive heart failure, pulmonary disease or frailty.

June 9, 2016 7:59 am

White Male Doctors Are Paid Way More Than Blacks and Women (Time)

Far too often, a person’s sex or skin color is connected to how much he or she earns—even in the reputationally well-paying field of medicine, finds a new study published in The BMJ. Men make more than women, and white male doctors typically earn about $60,000 more than black male doctors.

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