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Topic: Doctor-Patient Relationships
May 11, 2015 | Posted By Jane Jankowski, DPS, LMSW

In the most recent issue of The Journal of Clinical Ethics, authors Genes and Appel explore the ethical considerations at play when physicians might use the internet to gather patient information. They conclude, correctly I believe, that there are circumstances in which accessing information about a patient supports beneficent efforts to provide quality care, even in non-emergent circumstances. Rather than damaging the doctor patient relationship, an informed provider is better equipped to support the patient’s best interests if loved ones can be located, presentation of information can be confirmed as factual or not, and the context of this patient’s needs can be more fully understood by the care team.

Social media, such as the now ubiquitous Facebook, is often considered a forum where people may express thoughts and feelings they fail to articulate in person. Consider the posts of an angry or despondent partner after the end of a relationship. Should commentary become threatening – to self or others – this is considered cause for concern and these comments are taken as valid expressions that warrant immediate emergency intervention. Text messages carry the same weight as spoken words, and are preserved in electronic format to be shared by the recipient at will. Failing to consider such communications as part of the purview of healthcare providers could lead to harm for the patient or others. While these expressions might not be quickly discoverable by physicians, they can, in some instances, be lifesaving components adding to the overall clinical picture. 

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.  

April 10, 2015 | Posted By Wayne Shelton, PhD

The history of America from the beginning was a struggle of opposing ideological perspectives over the role of the state’s power vis-à-vis the consciences of individual citizens. The 17th century Puritans in the Massachusetts Bay Colony basically transported to America the same kind of religious, state intrusion into the lives of individuals they were trying to escape in England by requiring citizens to subscribe to the official state religion. Fortunately, there were courageous individuals there at the time, like Roger Williams (1603-1683), who strongly resisted such requirements. Williams, prior to coming to America, had been educated at Cambridge and worked for Lord Chief Justice Edward Coke. (1552-1634)  Coke was the famous English jurist whose work provided much of the foundations of the Anglo-American legal system, and who famously “declared the king to be subject to the law, and the laws of Parliament to be void if in violation of "common right and reason”.  No doubt Williams’ prior education and influences from Coke, and from others like Francis Bacon (1561-1626) who taught him the way of learning through experiment and observation, helped temper his strong theological commitments in relation to his views about the proper relationship between the authority of the state and religion, and the extent to which the state could have control over the consciences of free individuals, what Williams called “soul liberty”. Williams himself did not have theological quarrels with the Puritans; however, he did not believe religious conviction could be coerced. It was on this moral and political basis, that Williams founded Rhode Island, the first state ever to have a constitution guaranteeing expansive freedom of conscience to individual citizens. Fortunately, the thinking of Williams became the mindset of the key founders, particularly Jefferson (1743-1826) and Madison (1751-1836), of the American constitutional system. (For a full account of Roger Williams’ life and influence, see the wonderful book, Roger Williams and the Creation of the American Soul: Church, State, and the Birth of Liberty by John M. Barry)

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. 

January 8, 2015 | Posted By Bruce White, DO, JD

On December 22, 2014, JAMA Internal Medicine published an article online titled “Mortality and Treatment Patterns Among Patients Hospitalized With Acute Cardiovascular Conditions During Dates of National Cardiology Meetings.” A note by the journal’s editor Rita F. Redberg, MD, MSc, a cardiologist, titled “Cardiac Patient Outcomes During National Cardiology Meetings” appeared the same day. [JAMA Intern Med. Published online December 22, 2014. doi:10.1001/jamainternmed.2014.6801] Also, the same day press reports appeared – among other news outlets – in The New York TimesLos Angeles Times, and on the Web pages of the Harvard Medical School commenting on these articles. The newspaper articles and press release titles are more tantalizing: “Do Heart Patients Fare Better When Doctors Away?”; “Some Heart Patients Do Better When the Cardiologist Is Away”; and “Startling Benefit of Cardiology Meetings.”

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. 


July 1, 2014 | Posted By Marleen Eijkholt, PhD

Crowdsourcing seems this month’s health care buzzword. It is everywhere. I’ve seen it used in three different health care contexts over the last months: 1) as a means to raise money for treatment, 2) as a means to gain access to treatments, and 3) as a means to help medical diagnoses.  In thinking about these contexts I found myself asking: Would I use it, or would I not? I am curious to hear if you would use the tool of crowdsourcing, after I give my ideas. Please feel free to comment at the end of my post.

What is crowdsourcing?

The dictionary defines crowdsourcing as: “the practice of obtaining needed services, ideas, or content by soliciting contributions from a large group of people and especially from the online community rather than from traditional employees or suppliers”In my own terms, crowdsourcing is an appeal to the online crowd/public to assist in a specific endeavor, like the above. Crowdsourcing is about ‘power in numbers’.  It could be an appeal to the public to raise money, signatures, or to gather information/expertise. 

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.

December 9, 2013 | Posted By Jane Jankowski, LMSW, MS

A recent article published in ACPInternist (www.acpinternist.org) estimates that 35% of adults have looked online to try to diagnose a medical condition for themselves or for someone else, based on a 2013 survey.  While many providers dread having to explain that minor ailments are indeed minor because the patient fears something more dire based on website material, it seems that other providers are learning to accommodate and embrace the possibilities the internet holds for both patients and physicians. Like it or not, it seems clear that the online medical tools have become a part of many doctor patient relationships.

Given that you are reading this on a website, it seems reasonable to presume that my audience here is internet savvy and likely to be aware of the many types of websites and services available to healthcare consumers. There and numerous informational sites, symptom Mayo Clinic symptom checker, medical detective services where (for a fee) a large group weighs in with opinions on what an elusive diagnosis might be www.CrowdMed.com . Just to see what these tools offer, I decided to play ‘patient’ with Isabel, a relatively advanced symptom checker.

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.

September 26, 2013 | Posted By Paul Burcher, MD, PhD

Many of my obstetrical colleagues groan when a patient presents a birth plan during prenatal care, but I do not.  I see it as an opportunity to do what Frank Chervenak and Laurence McCullough have called “preventive ethics”—avoiding conflict later by addressing issues before problems arise.  Prenatal care is unique in medicine in that we spend so much time with generally healthy patients seeking to prevent medical complications that, if they arise at all, are likely to arise much later during labor.  The same mindset that propels and justifies prenatal care should direct our response to birth plans:  this is an opportunity to prevent problems, and misunderstandings during labor, and the fact that the patient has well-formed opinions about what kind of care she wishes to receive during labor means she is engaged and seeking to educate herself.  In short, women presenting with birth plans are generally our most conscientious and informed 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.

July 8, 2013 | Posted By Jane Jankowski, LMSW, MS

The long awaited DSM-V was finally released for clinical use in May 2013, and was welcomed with a storm of debate. The task force charged with the revising the manual note that the manual had not been updated for 20 years and required revision to reflect changes in scientific knowledge and clinical experience in an ever shifting social context. Whether or not the DSM-V will alter clinical practice may depend on how the manual is viewed by practitioners. 

One possible benefit of expanding the list of diagnoses in a psychiatric manual includes improving recognition of problematic behavior health issues by insurance companies who fund treatment for diagnosable problems. Expanding the diagnostic options may enhance access to beneficial services for many, and this could prove helpful to those who might not otherwise receive treatment. Practitioners in the US know all too well that a diagnosis is needed if the provider is going to be paid by an insurance company. It remains to be seen if the changes in the DSM-V affect payment to providers.

One point to consider in the reimbursement argument is that a diagnosis is not necessary for treatment because those in desperate need are not turned away, though ongoing therapy may be hard to find with or without a diagnosis. The downside of expanding the various diagnostic categories is that people may be less likely to be held accountable for behavior negative or even legal consequences, notably changes in the paraphilia categories. We must be vigilant that mental health does not become misused as an excuse for antisocial, illegal, or dangerous behaviors where it is inappropriate to do so. 

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.

June 24, 2013 | Posted By Wayne Shelton, PhD

The moral basis for competent, clinical ethics consultation, I would like to argue, is largely derived from the moral premises of our normative understanding of what it means to be a “good doctor” as reflected in a self-conscious commitment of a good physician to treat patients as best as one can according to prevailing standards of professionalism and medical ethical principles. The good doctor stands in relationship to a patient, within a well-defined framework of moral rights and professional obligations. This linkage between the activity of clinical ethics consultation and our understanding of a good physician further defines the work of the ethics consultant squarely in framework of clinical, medical competencies.  

To further see this linkage, it is useful to consider how and when value conflicts arise in the physician-patient relationship. For the vast majority of physician-patient encounters, there is agreement and absence of conflict. But in the less frequent cases of moral conflict, there are competing visions of what should happen—regarding the goals of care and who has the moral authority to define those goals. In short, how are competing rights and obligations to be balanced between the patient and physician, but also the surrogate, the hospital and potentially many other interests, especially in the midst of the emotion and stress that illness and impending death can induce both to patients and their families? It is the latter contextual aspect of grounding value conflicts within a patient’s and family’s illness experience, and the necessary ability to function effectively in clinical encounters, that requires the competent ethics consultant to also possess the general qualities of a caregiver, and to understand the moral perspective of a good physician.

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.

May 9, 2013 | Posted By Wayne Shelton, PhD

In the fall of 1970 Philip Tumulty, a Johns Hopkins’ internist, gave a lecture to the 3rd year medical school class at Johns Hopkins. His lecture was published in the same year in the New England Journal of Medicine under the title of “What is a clinician, and what does he do?” (Tumulty PA. What is a clinician and what does he do? N Engl J Med. 1970 Jul 2;283(1):20-4.) In this classic piece, this eminent physician of his era claimed that the primary role of the clinician is to “manage a sick person with the purpose of alleviating the total effect of his illness”. 

This paper, probably better than any other paper I have ever read gets to the essence of what a patient needs from an expert clinical caregiver; it lays out eloquently and robustly the characteristics of a good clinician and what is involved in excellent clinical care of patients. As Tumulty says, it is not a diseased body organ that shows up for physical diagnosis and treatment; rather, it is an anxious, fearful, wondering person concerned about her personal life, including her family, work, friends as well as her hopes and dreams. This means the clinician must be a thoughtful and systematic fact finder, a careful listener, a keen analyst of the facts and a prudent planner regarding which tests and treatment options make the most sense for this particular patient. Moreover, Tumulty rightly assumes that these skills should be embodied in the clinician as natural traits that the clinician genuinely enjoys performing. 

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.

February 12, 2013 | Posted By Jane Jankowski, LMSW, MS

With the explosion of health information available online and in print media it can be difficult for consumers to determine which sources to trust and which ones to toss.  As with all of the material available on the World Wide Web, consumers must exercise caution and diligence when evaluating the veracity of internet information. While we may be pretty good at knowing how to determine which sites look trustworthy enough to safely manage credit card information or other private data, it may be more difficult for consumers to assess the reliability of health information on the internet. Given the sometimes high stakes involved in making healthcare decisions perhaps such sites should be required to include links which will connect consumers to tools which will train them to better evaluate health information in the media. Though this will not guarantee any given web surfer will take advantage of these links, but it could be a start to improving health information literacy.

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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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
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