To do a CPR or not?

You are resident on duty in the ER of a private hospital. Then a frantic mother comes in with her 1 month old baby boy who was found unresponsive. She comes from a poor town at least 20 minutes away from the hospital. The mother said the baby had been sick with cough and fever for more than a week now. You quickly check on the vital signs of the baby boy: CR=0, RR=0 and unresponsive. The mother begs you to “do the best that you can to help my baby live.” You look at the baby and you think it is next to impossible to revive him. If the impossible does happen and you were able to get a heartbeat, there is only a slim chance the baby will live. You look at the mother and see her anguish. If you do the CPR, you know it will cost her a lot of money. Money she does not have, causing her to delay medical consult for her baby. Yet, you also want to give mother and baby a fighting chance.  It is also a bonus as you know it will help you gain valuable clinical skills intubating the patient, doing CPR and providing correct emergency drugs.

Is it OK to perform an expensive procedure to a dead or dying patient when there are no clear medical benefits? Is it justifiable to do a procedure out of compassion even if it may lead to more suffering for the family? Is it OK to do it because there are benefits the doctor can gain?

In this scenario, I suggest we consider 5 Ethical Principles. There are other more principles but let me focus on these five. It is important we consider the ethical principles of 1.)“beneficence” and 2.)“non-maleficence”  to the patient. Remember that the CPR is a medical procedure designed to reverse clinical death. Would the procedure benefit the patient? Would it not cause undue harm or suffering to him? How about to the family? However, we must not forget the 3.)"Principle of Futility." This principle looks into the length of life and quality of life. If there is low chance of survival and low quality of life after the procedure then it is futile. Of course, we need to consider the consequence of our decision to the family involved.  The issue of 4.) surrogate decision making and 5.) justice must also be considered. Since the baby cannot decide for himself, who decides best for the baby? Also, more than our own gain as doctors, we must prioritize the patient and the family’s welfare. What will happen to the family emotionally, psychologically, financially and socially after the procedure? Is it justifiable to decide clinically based on the financial capacity of the family? Communication with the family is also important. Being honest to the patient and the family will help us better decide on our actions.

So, what would you do?

3 Common Unethical Scenarios on Doctor - Doctor Relationship

A friend posted in Facebook how one doctor did not show good ethical practice when he was receiving a referral from a fellow doctor. I remembered writing a brief essay about the doctor-doctor relationship years ago in my personal blog theomed.blogspot.com. I'm sharing an edited version below:

Human pride is one of the pitfalls of human nature. But this is not an excuse to disrespect others. That is why a physician is virtuous enough to know what to do and how to foster good relationship with ones colleagues. Yet, young doctors and even their mentors get drunk of their title as doctors that they forget their ethics.

 

Here are 3 common scenarios of unethical doctor-doctor relationship:

 

1. Maligning a colleague

 

A patient comes in with a referral letter from a family physician for the pediatric patient to be admitted because of Dengue. The pediatrician refuses the patient to be admitted because she did not see any indication for the patient to be admitted. The pediatrician may be right and she has all the right reasons for refusing the request for admission. What went out of bounds is her remark against the referring doctor. She comments that the referring doctor is ONLY a family physician and his decisions should not be accepted. Here, the pediatrician is obviously insinuating that the other doctor is inferior to her. More than that, she shows disrespect by maligning the knowledge and the decision of her colleague. Hers is one example of utter DISRESPECT that have plagued the medical practice in hospitals. We, as doctors, have forgotten the basic principle in our code of conduct - that we should work together in harmony and mutual respect.

 

2. Delaying or refusing referral

 

Another example of disharmony in the workplace of doctors is the referral system in government hospitals. I will emphasize the government hospitals, because these things rarely happen in the private setting. A surgeon refers his diabetic patient to the internist for control of the blood sugar and clearance for surgical procedure. The internist delays seeing the patient, as a retaliatory act to what he claims the surgeon is doing whenever he refers also for surgical clearance of his patients suspected of having surgical abdomen. The patient is the one suffering from such behavior of doctors. The patient, of course, complains his surgeon to the hospital authorities for not being able to refer and resolve his case quickly.

 

 

3. Side comments

 

The most common problem perhaps, leading to the numerous malpractice suits, is the side comments doctors make to their colleagues. An example is the Internist who saw a Pulmonary TB patient who sought second opinion after being seen by a private doctor. The Internist comments to the patient, "do not seek consult to this doctor again. Did you know that it took him several years to finish medicine because he flunked his subjects. Look, he did not even recognize that you have tuberculosis. And why did he give you pulmonary medicines that can compromise your liver. That doctor will just make you more sick." That may be exaggerated but even simple side comments like, "hindi ka niya chineck-up ng mabuti (he did not give a complete physical exam)" undermines your colleagues skill and practice. Such comments are unwarranted, but in reality, such comments exist. What virtuous doctor in their right mind, would comment such derogatory remark about their colleague?  

 

In the quest to advance the practice of medicine, doctors have forgotten about their virtues and ethics. Ethics has been neglected for a long time. It is now the time to check the virtues of our doctors. A virtuous doctor can never and will never intentionally hurt his/her fellow human being, regardless if he/she is a patient or a colleague. We can never go wrong with a virtuous doctor. I encourage you to push and demand for our doctors to check their ethics, and be virtuous!

3 Reasons Doctors Do Not Join Medical Missions

I often get invites to join medical missions. But as a public health practitioner we know that short term "Band-Aid" solutions are not enough to improve the community's health. I can not just give anti-hypertensive drugs to a person, I must ensure that the diet of the whole family is modified, the physical activities are changed and the wider community advocates for changes in government policy, regulate sugar and salt content in foods, set up parks for exercises, put bike lanes in city streets among others. The entire health system must be involved and all other sectors must participate. I am sharing a blog-post from theomed.blogspot.com on the 3 reasons doctors who believe in community-oriented primary care do not join medical missions.

 

It is becoming difficult for organizers to get doctors to join them in their medical missions. I am not an advocate of medical missions. Before I give you the reasons why, let me clarify that what we mean of medical missions are the trend today of one-time events of medicals consults and surgeries with giving of medicines to patients as a tool for achieving something else. Med missions are sometimes beneficial especially during emergencies but other than that, it is an ineffective practice.


Here are three reasons why:

1. Medical missions do not address the health problem.

The medical management does not address the cause of the problem. A patient may come in with Tuberculosis due to the poor sanitation of the area, or poor nutrition, or poor hygiene habits. The current trend in medical management today is holistic approach wherein the doctor not only intervenes at the medical condition of the patient but also considers the other factors surrounding the patient. These factors include the mental, social and spiritual factors. Medical management also includes patient education on how the patient can improve her living condition, environment, lifestyle and other things more than just taking the prescribed medicines. This may not be possible as time is not a luxury during med missions. Also, some cases like TB needs further patient care which leads us to the second reason.

When Jesus healed the lepers, he restored their relationship with society. Remember, patient care is more than just treating the disease.


2. Medical missions do not provide continuing patient care.

Proper medical care is continuous and personalized. When medical missions are one time event, it does not allow for patient to follow-up with their health care provider for continuing care. Imagine the popular summer medical mission providing free circumcision to young boys. If complications happen to the wound, how will the boy get follow-up care from the healthcare giver? Even if complications do not happen, the healthcare worker are ethically bound to continue care to the patient until they are well. This will not happen in one-time medical missions. Because of time constraints, personalized care are seldom given to patients.

When Jesus touched the sick, he touched their lives and they became his friends. Remember, the doctor-patient relationship is a contract of trust for care not for a one time meeting.


3. The ultimate goal is not patient well-being.

While medical missions looks into the health condition of the patients, the intent of the mission is not always the person's health. It is an open secret that politicians sponsor medical missions with the real intent of campaigning for people support. Churches sponsor medical missions as an evangelistic tool to persuade people to become Christians. Organizations sponsor medical missions as an outreach activity to gain prestige and recognition. There are other reasons individuals and groups sponsor medical mission but few are intent in addressing the health needs of the people. If the intent is to help people achieve good health, then they know that a one-time medical mission is not enough.

When Jesus came to heal the sick, his purpose was to heal the sick. Remember, health is an end not a means. Lest I be misunderstood, when I say health, I mean the life promised by Jesus in John 10:10.

It is unethical for doctors to violate the principles of medicine. So, like most of my colleagues, I may decline invites in your one-time big time medical missions.

There maybe some benefits to the med missions but we can do better. I can name 5 health ministries churches can do. It is high time we level-up what we can do to improve the health of the community.

Three Reasons Why Doctors are Poorly Compensated

One of the many complains I hear from young doctors is that they are receiving low compensation as APE doctors, reliever doctors and ROD in private hospitals. This is actually not a new issue and not exclusive to a developing country like the Philippines. Doctors oftentimes receive compensation lower than what society expects them to receive. This becomes an ethical issue on justice. I am sharing below the post from theomed.blogspot.com on reasons why physicians are unjustly compensated.

Medical ethics tells us that "(T)he primary objective of the practice of medicine is service to mankind..." This principle has been abused to justify poor compensation for doctors with their work. There is injustice. This is specially true for young doctors who receives retainer fees or compensated for the number of hours rendered. But what is the doctor's service worth? If its value is measured monetarily, how much would it cost?

The first and most common argument thrown is that, "medicine is a service and should not be profit-oriented."

It seems to me that the assumption here is that only those that are cheap and free are considered a service. If you receive good money for a service rendered, that becomes profit-oriented. So doctors are made to believe that it is okay for them to receive little to no compensation for their service rendered. If doctors earn good money for their practice, they are not serving humanity.

This is where the professional fee for the professional service given becomes important. Of course, doctors are either compensated with either retainer fees or fee-for-service. But in general, what is a fair fee for the service rendered by the doctor? What will be a "just compensation" for doctors?
The PMA says the "(P)rofessional fees should be commensurate to the services rendered with due consideration to the patient’s financial status, nature of the case, time consumed and the professional standing and skill of the physician in the community."  They also explained that for self-employed professionals, there is no universal fee. It depends on the prevailing and acceptable fee among the practitioners in the community.

If there is an acceptable fee, why are doctors poorly compensated for their service? Again, this may not be true for fee-for-service doctors with good practice. But this is especially true for many young doctors on retainer fees/per-duty fee or resident physicians.

 

The second reason, doctors are told that the hospital can only afford to compensate them with a small amount for their service. It's either the doctor take it or leave it. Let me illustrate further:

I am looking to hire a helper in our house (pun intended.) She will help cook the food, wash the dishes, clean the house and wash the clothes. I will need her services to have a decent and clean place. For such services, the acceptable rate in our area for helpers is P3000 a month. (Don't ask me where I live.) I can only offer P2000. Although the acceptable rate is P3000, the prevailing rate and the most common rate offered is P2500. Well, times are tough. It's difficult to get a job. I know people need the money. If they don't want P2000 a month, then they don't have to accept it. I am not pressuring them. I am just offering it to whoever is willing to offer their service for that fee. Is it just for me to offer compensation for the service I know is worth more than that? Is it my fault if there are people willing to receive such compensation for their service?

The third and most important reason why doctors are poorly compensated is because NO ONE CARES. Not even the doctors.

 

Maybe because of reason 1 and 2. But this injustice perpetuates because no one is standing against it. A learned prophet once taught, "Learn to do good; seek justice, correct oppression... " (Isaiah 1:17).

 

The injustice must stop. People must do something against the unjust practices. Desmond Tutu famously said, "If you are neutral in situations of injustice, you have chosen the side of the oppressor." We must take sides now. No, one or two person cannot do it.  There needs to be a collective effort to stand against it. The government, the health industry, hospitals, doctors and even patients must do their share. Together, change can happen.

Doctors still do service to humanity. But what is its value to you?

Three Ethical Dilemmas on Ebola Virus Medicine

(This is a re-post from the blog theomed.blogspot.com. This post raises the question on justice and human dignity in relation to the experimental drug on Ebola.)

 

The Ebola Virus outbreak in West Africa has put the spotlight on ethicists. As the health world scrambles to address the problem, bioethicists are also facing ethical dilemma related to Ebola. It is a well known fact that the Ebola virus has not treatment and no vaccine available in the market today. But there are several pharmaceuticals racing against each other to develop a medicine against it. Last week, the US government tested the new drug ZMapp on two Americans infected with the virus. There was a public protest on why the medicines were given to the Americans and not made available to the general public. This raised several ethical issues.

 

Here are three of the biggest ethical issues that we all need to consider.

1. Is it ethical for us to use vaccines and drugs against Ebola that has not been adequately tested on humans?

So, here is the dilemma. The drug, as reported, is still on trial stage. There has only been the animal test phase. No human trial for its safety and efficacy has been done. The ZMapp given to the infected Americans, at its best, is a human research to its efficacy. Although, early reports showed positive response to the drug, there is no conclusive evidence to show it is effective. Would it be proper then to subject thousands of people to this medicine without knowing its effect to humans?

I will not even dare elaborate on another ethical if not racist issue behind this. Suffice for me to ask the perennial questions, why are experimental drugs done in third world countries? Why subject Africans to experimental drugs with unknown risks or benefits?

The WHO ethics panel agreed that it is ethical to use experimental, non-approved drugs to fight the Ebola outbreak. They reasoned that this outbreak is a special circumstance that needs special consideration. A research protocol needs to be followed in doing human research. Are we following the proper protocol in using these experimental drugs? Human research requires that the risks and benefits to the person should be weighed. Without knowing the gravity of the risk nor any benefits it can provide to the patients, would it still be ethical to provide these medicines to humans?

2. Who would receive the limited number of this new Ebola medicine?

The second, and perhaps the most difficult, ethical dilemma is sorting out questions on the principle of justice - specifically distributive justice. Who should receive the new Ebola medicine? Pharmaceuticals have reported that they have only more than a dozen of medicines available ready. Regardless of problem #1 being resolved, the medicines are now sent to West African countries. It's now time to give them to the people affected by Ebola. As of this writing, WHO has reported that more than 1 million people are now affected by Ebola. Who among them would receive the 12 or 15 or 20 medicines?

There are 4 countries severely affected by the Ebola virus - Guinea, Liberia, Nigeria and Sierra Leone. Who among these countries should receive the most of the available medicine? Should it be the closest ally of the western world? Should it be the country with the highest death toll? Where should the pharmaceuticals developing the medicine send their products? When they have settled that issue, more ethical questions needs to be raised. Who would be the blessed people to get treated first? Two Liberian doctors are going to receive the experimental drugs. Why the doctors? Why not the mother of 8 children whose husband recently died also of Ebola?

3. Why raise the ethical dilemma for the Ebola stricken West Africa?

The third maybe a little difficult for me to explain. This was raised by my Nigerian friend which I am now only beginning to understand. I will try my best to make it simple. When the ZMapp medicines were given to the infected Americans, there was no ethical question about it. It did not bother WHO to convene a panel of ethicists. In reality, experimental medicine are given almost anywhere. Here in the Philippines, stem cell therapy is on top of them. When a patient willingly consents to receive an experimental drug, no one bothers to stop them because it is still experimental. Yet, in the case of the Ebola virus outbreak, the world has to pause and reconsider giving the drugs. At a time where the affected people are crying out to give them anything - even experimental drugs - to stop Ebola, the world has to bring up ethical questions.

Yes, for some people - especially those who desperately need them - to second guess giving a "potentially" helpful drug is tantamount to withholding any hope of cure. Are there underlying reasons behind the hesitancy? Is money an issue? Does the financial gains and costs holding the world back? Are we really concerned about the efficacy of the drug and the safety of the sick people? Are we really being ethical about this?

Welcome to Ethics for the Young Doctor

Why this blog?

As I begin to teach bioethics to medical students, I realized there is not too much online material that helps young doctors understand in a simple way complicated matters in bioethics. Not all doctors are bioethicist. But all doctors face ethical issues in their daily practice.

This blog hopes to offer practical insights and opinions on common ethical dilemmas that young doctors encounter in their practice.


To whom is this blog dedicated to?

As I have my students in mind, this blog hopes to be able to communicate to aspiring doctors ethical principles that they need to consider when faced an ethical problem. Medical clerks and interns will be guided on ethical reasoning as they start to be in the clinics. The young doctor will receive insights and opinions as they begin their practice of medicine.


How to read this blog?

The format of this blog is easy and simple. An ethical dilemma will be presented. An ethical question will then be asked. Reflections, insights and tips related to the ethical issue will then be offered. A summary or conclusion will close the post.


What will be the Topics Covered?

This blog will cover a wide range of bioethical issues. Primarily it will discuss:
- Doctor-Patient relationship
- Ethical way to break the diagnosis
- Dealing with sidewalk consults (including consults in SMS, FB, email and phone consults by your relatives and friends)
- Doctor-Pharmaceutical Relationships
- Dealing with RTD and Conference sponsorship from Pharmaceuticals
- Receiving gifts from Medreps
- Doctor-Doctor relationships
- Referring patients to a colleague
- Referral Fees
- Group practice
- Doctor-Society Issues
- Advertising your practice
- Unjust doctor compensation
- Others

What's Next?

The blog offers reflections and insights from the author to help young doctors decide for themselves. It is not an instruction on what they will do. It is, therefore, helpful if readers offer their insights as well to provide alternative views to other readers too. Happy reading and hope to learn from you.