Can Congress Make You Buy Broccoli?

There's a fascinating editorial in the New England Journal of Medicine titled, "Can Congress Make You Buy Broccoli? And Why That’s a Hard Question." The authors are from the Department of Health Law, Bioethics, and Human Rights, Boston University School of Public Health, Boston. It was an interesting article, given that people are now debating the constitutionality of the Affordable Care Act (ACA). The authors point out four major reasons why the broccoli question is so difficult to answer. You can read the NEJM article here.

'Father of test tube baby' wins Nobel Prize for medicine

We all probably know someone who was conceived by in vitro fertilization (IVF). The "father of the test tube baby," Robert G. Edwards, won the Nobel Prize for medicine. On 25 July, 1978, the first "test tube baby" was born. You can read about Louise Brown on Wikipedia.

It's quite amazing to see that advances in medical technology have contributed to over 4 million births through in vitro fertilization. What will be next? There's no doubt that we'll eventually face some deep ethical and moral issues as we try to control human reproduction.

Should CME be mandatory for physicians?

In the world of rapidly changing medicine, how often should physicians participate in continuing medical education (CME)? Did you know that some states actually don't require physicians to complete any CME activities? Most states require a certain number of CME credits for relicensure, but most state medical boards are not actually checking to ensure that physicians are up-to-date on their CME requirements. They simply have a box that you check that indicates that you have met the CME requirements for relicensure. In the event that you were audited, you would need to show proof of your CME participation.

What's especially interesting is that certain states require CME in specific topic areas such as:

• medical ethics
• HIV/AIDS
• risk management
• pain management
• cultural competency
• domestic violence
• end-of-life care
• medical error prevention
• bioterrorism
• geriatrics
  
• prescribing controlled substances
• and more

You'll notice that the only topic that relates to a specific diseases is HIV/AIDS. Does it really make sense for every physician to take CME courses in these specific areas? For instance, if I'm a pathologist, do I really need to learn about domestic violence? What if I'm a radiologist?

Well, in my opinion, these CME requirements are reasonable, so as long as physicians don't complain too much, I don't think that state medical boards will be making any significant revisions in the near future. 

When herbal treatments "cause harm"

The phrase "Above all, do no harm" is usually attributed to the Hippocratic Oath. Many patients often think that herbal treatments can't possibly cause harm because they're "all natural." The reality is that some herbal therapies have very active ingredients that can have significant pharmacological effects. (remember that opium and marijuana are both "natural" plants)

CNN has a story about this topic titled, "Herbs, vitamins that can hurt you." In that story, you'll read about an individual who ended up taking an overdose of vitamin B6. Dr. Roberta Lee, vice chairwoman of the Department of Integrative Medicine at the Beth Israel Medical Center in Manhattan, comments: "A lot of people think herbs are safe because they come from nature, and they are safe if used properly," Lee said. "But you can still get into trouble with them."

According to the CNN story, here's a list of herbs and supplements that can be dangerous if taken the wrong way: either in high doses, in combination with certain drugs or before surgery.

1. St. John's wort
2. Kava
3. Fish oil
4. Artemisinin
5. Various herbs when taken before surgery

Herbs and vitamins are not harmless substances. Make sure to always tell your healthcare provider about any herbs, vitamins, or supplements you may be taking.

Quadriplegic man receives the right to refuse food and die

Here's a medical ethics case: An Australian high court ruled that a quadriplegic man has the right to refuse food and water and can be allowed to die. The ruling means that the nursing facility in which Christian Rossiter has lived since November 2008 cannot be held criminally liable for allowing the patient to die, the Supreme Court of Western Australia said. Watch this video clip (if you can't view the video, click here to view the video on MedicineandTechnology.com)

Click here to read this story on CNN.

Should "older" women get pregnant? Fertility and ethics

I don't plan to define "older." However, we know that older women can conceive (especially if they go through in vitro fertilization or IVF), but should they? What are the ethical issues involved? Modern medical technology has advanced infertility treatment, but when do we start crossing ethical boundaries? CNN's Diana Magnay explores some of these issues in this little video.

DNA testing in children, talents, and privacy in China

In China, scientists (probably along with some government officials) are performing genetic tests in young kids to identify skills and talents by analyzing their DNA. That's right, no personal privacy issues here. Submit a DNA sample to see what talents your parents should cultivate. Is this ethical? This is a fascinating video.

Medical treatment based on the color of your skin

Racism may not be obvious, but it can present itself in very subtle ways. CNN has a story titled, "Does your doctor judge you based on your color?"

I'd hate to think that doctors are racist, but the title implies exactly that point. Are doctors racist? Here's a quote from the story:

Reid, who is African-American (and who also has diabetes), firmly believes that if he'd been a white man, the junior doctor wouldn't have been so quick to order the cheaper and more drastic solution over his objections... Reid says he thinks the young doctor assumed he wasn't smart enough to think through a medical decision.

CNN contacted the hospital but Montefiore Medical Center refused to discuss his case.

"It's absolutely proven through studies that a black man and a white man going to the hospital with the same complaint will be treated differently," Dr. Neil Calman, a family physician and president of the Institute for Family Health in New York, said. Where's the proof, right?

• A 2005 study found African-American cardiac patients were less likely than whites to receive a lifesaving procedure called revascularization, where doctors restore the flow of oxygen to the heart.
• A 2007 study involving clinical case vignettes found that doctors were more likely to recommend lifesaving drugs when they thought the patient was white than when they thought the patient was black.
  

Doctors are humans and they are prone to bias. It's a part of human nature. In some cases, doctors may make an extra effort to treat minorities with extra care. Is that fair for non-minorities? At the end of the day, we all want equal care. We don't want favoritism, but it happens because we're all human. It's not just about race, either. According to CNN, a study from researchers at the New York University School of Medicine found more than 40 percent of the doctors surveyed had a negative reaction to obese people. Here we go again. Some people find the word "obese" to be offensive, and they may sue you if you call them that.

Treating multiple myeloma when the patient is a Jehovah's Witness

During medical school, we're often faced with clinical case vignettes where we get to practice problem solving skills. Such cases also often involve issues surrounding medical ethics. Anytime you get a case where the patient is a Jehovah's Witness, you know you'll be dealing with something ethical (that probably involves blood transfusions).

According to Wikipedia, "Jehovah's Witnesses are not permitted to accept red cells, white cells, platelets or plasma, though they may accept fractions made from these components at their own discretion."

How do you treat a patient who has multiple myeloma if that individual requires blood transfusions but refuses? This is being discussed on Sermo by various oncology physicians. It's a very difficult situation because what is medically necessary isn't an option if the patient competently refuses that treatment. Will a combination of various anti-cancer drugs (such as Thalomid or thalidomide, Velcade or bortezomib, and Revlimid or lenalidomide) and growth factors (such as Procrit or epoetin alfa and Aranesp or darbepoetin alfa) help an individual who has progressed so far in this illness? Or, are such strategies medically futile?

I think one of the most difficult things to face is a dying patient who refuses medical care. It's more than a mental exercise. When you know that you can do something to help that person and that person is willfully refusing (it may be for a variety of reasons), that just becomes a very challenging situation. Alternative medical options may be futile. Do you try them anyways? Sometimes there are no practical options that won't endanger the patient further. You can't just walk out or abandon that type of patient. Do you suggest hospice? At what point do you discontinue futile efforts?

Ethics of concierge medicine

Concierge medicine is often referred to as boutique or retainer-based medical practices. We have seen a surge of physicians and medical groups converting to this type of model over the last several years. Why? Because you can get paid more for seeing fewer patients. Sounds almost ironic, doesn't it? In a typical concierge practice model, patients pay an annual retainer fee outside of insurance to gain greater access to their physician. What does this mean? It means that you may be able to call your doctor directly. Forget about answering services. Also, it may mean that you doctor will see you in the middle of the night if you develop chest pain. Forget waiting in the ER if you need to get admitted by your physician.

If political leaders like presidents can have concierge-type medical care, then is it unethical to offer it to other rich and powerful people? If a billionaire hires you to live and work as a personal doctor for his/her family, would it be unethical to do that? I think the bigger issue revolves around the accessibility to care. If you're the only doctor in a 50 mile radius and you decide to convert your practice, then there may be some ethical issues concerning the accessibility to care and medical need. A related topic deals with the acceptance of Medicaid insurance. Many physicians are choosing not to accept Medicaid because the reimbursement is so low. Eventually, a cash-only model may become the prominent model (especially if the government steps in and offers some level of universal health coverage).

Let's evaluate the ethics behind concierge medicine:

• Autonomy: Probably not an issue.
  
• Beneficence: "the act of doing good things." Well, as long as you offer good care to those who are paying you, you're fine there.
• Non-Maleficence: "do no harm." Well, this is where concierge medicine may have a problem. If you move to a brand new area to set up your concierge medical care, then you may be fine. However, as I mentioned above, if you're the only doctor in a remote area and you decide to convert your practice, then there may be some ethical issues concerning the accessibility to care and medical need. You may be "harming" those who are unable to afford your prices.
  
• Informed consent: Don't see any issues here as long as your contract is well-written.
• Confidentiality: Probably not an issue.

The AMA Principles of Medical Ethics ends with this statement: "A physician shall support access to medical care for all people." Hmm, not sure how this relates to concierge medicine.

However, the AMA Principles of Medical Ethics also has this statement: "A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care."

Alternative Cancer Care in Mexico

According to CNN, there are many cancer patients escaping to oasis-type of cancer centers in Mexico to receive alternative care for their illness. To many, the idea of receiving alternative medicine for cancer may sound absurd. It may be OK to take some herbs and vitamins for benign conditions such as headaches and arthritis. But for cancer? Can alternative therapies like herbs, vitamins, meditation, and relaxation cure malignant tumors? If they do, are we simply seeing cases of spontaneous regression where the body destroys cancer by sensing that something is wrong?

The idea of complementary medicine for cancer has been a really controversial topic lately because of the story of Danny Hauser, a 13-yr-old cancer patient who is receiving chemotherapy because of a court order. He's also receiving alternative medicine, including acupuncture, vitamins, and minerals (among others). Does he have the right to choose what type of cancer care he wants? This gets into the ethics of autonomy, but it gets complicated because Danny is not an adult. Hence, in the world of medical ethics, he doesn't have the same type of autonomy as an adult. It may not sound fair, but the world of ethics doesn't always revolve around fairness (depending on your point of view).

So, if an adult chooses to forego Western medicine for cancer and decides to receive alternative care in Mexico, that's OK (from an ethics standpoint). However, if a child chooses to forego Western medicine for life-threatening cancer, that's when we have some serious ethical issues. That's where the ethics committees get involved and pulls in the judicial system when needed. How do we really know what the child wants? What if the child is only 2 or 3 years old? Do parents have the right to determine what is best for the child? At what age should a child have autonomy over medical treatment decisions?

Maybe you don't like to think about any of these complex ethical issues. If you're an oncologist looking for some lucrative opportunities in a resort-like (think all-year vacation) setting, then take a look at the Oasis of Hope Hospital in Tijuana.

To read the CNN piece about alternative cancer care in Mexico, click here. Image source: CNN

AMA on Ethics and CME

The CME (Continuing Medical Education) industry has gone through some significant changes over the last several years. Have you been keeping up with all the changes?

The American Medical Association (AMA) Council on Ethical and Judicial Affairs (CEJA) recently released a report titled, "Financial Relationships with Industry in Continuing Medical Education." This report outlines the ethics of industry supported education - according to the Council on Ethical and Judicial Affairs (CEJA).

Please note that advisory report will be up for consideration at the AMA's upcoming annual House of Delegates meeting. This report is not necessarily the AMA's take/perspective/position on ethics and CME.

Here's the bottom line from the CEJA report:

• It is ethically preferable to accept funding only from non-commercial supporters (this would probably mean that doctors would have to pay for their CME credits).
• It is ethically permissible to accept funding from commercial supporters (such as pharmaceutical companies, biotech, medical device, etc.). This generally leads to free CME.
  

The world of medicine is constantly changing and physicians need every opportunity to keep up with the latest clinical development. If they have to pay for CME, will they be less inclined to learn? Does the abundant supply of free CME cause physicians to practice evidence-based medicine? How does free CME impact patient outcomes?

What Happens if We Eradicate Malaria?

So what happens if we eradicate malaria? What will medical students learn about the banana-shaped falciparum? CNN has an interesting perspective about this issue. As World Malaria Day approaches, I often wonder what could happen if we develop a successful vaccine against malaria by bioengineering mosquitoes. Would the world population get out of control at that point? Public health professionals will have a major ethical dilemma on their hands. Thanks to Michigan.gov for the photo.

NY Times: Harvard Medical School and Ethics

There's a very interesting story on the NY Times about Harvard medical school and ethics as it relates to relationships with industry. We're primarily talking about the pharmaceutical and biotechnology industries, but we must also remember medical device and diagnostic equipment companies. In any case, Harvard professors are deeply involved in industry-funded research and many of them are also paid speakers and consultants for several of these companies. Conflict of interest is the key buzzword (or in this case, buzzphrase). How do you resolve any potential conflicts of interest in such situations? It can get quite complicated, especially if you have significant ties to industry. However, I believe that it can be done, but that's not to say that everyone out there is doing it correctly.

There have been many stories of highly-ranked academic professors quitting their academic careers to work for industry. I think people need to find what's right for them, and for some, a career in non-clinical medicine is the right fit. I personally know several people who have transitioned from academia to pharma and most of them seem to enjoy the different challenges and rewards faced in a corporate environment. Of course, there are pros and cons to every decision, including the decision about leaving academia. The bottom line is that it's a very personal decision.