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Topic: Doctor-Patient Relationships
June 10, 2012 | Posted By Posted By David Lemberg, M.S., D.C.

Medicine as treatment or medicine as healing? Despite facile responses, these two constructions are distinct. It is possible that the failure to distinguish between the the modalities of treatment and healing is responsible for much of the current health care mess. Such failure may also account in large part for the abject failure of medicine to provide meaningful solutions to the epidemics of type II diabetes and overweight/obesity. Similarly, when a person ill with cancer or a person ill with a cardiovascular disorder encounters the health care system, the orientation of his physicians to treatment or healing will have a significant impact on the person’s long-term health and well-being.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

May 19, 2012 | Posted By Posted By David Lemberg, M.S., D.C.

We (in America) live in a capitalist society. That is a given. We also live in a democratic society. The Declaration of Independence states that all men [humans] are endowed by their Creator with certain inalienable rights including life, liberty, and the pursuit of happiness. It is not clear that any of these specific rights can be fulfilled when access to a minimum standard of health care is denied, obstructed, or otherwise not available. In the case when health care is available, that care needs to be delivered stripped of any considerations other than those related to providing assistance for that patient.

But in America many ancillary considerations intervene. Care of a patient is confounded by care for special interests, often involving kickbacks (whether in the form of travel expenses, gifts, complimentary lunches and dinners, or even cash payments) rendered by obsequious agents of big pharma or medical device corporations. Worse, on a broader scale, the recent phenomenon of the Patent and Trademark Office (PTO) blithely granting biomedical patents to any and all comers has seriously harmed medical practice and the health of Americans in need.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

May 14, 2012 | Posted By Posted By David Lemberg, M.S., D.C.

Do we really need more drugs? We can gain some insight into this question by posing a qualifying question: “How’s it working out so far?” The answer is rather obvious: “Not all that well.” Despite spending $2.5 trillion in 2009 on health care, representing almost 18% of our gross domestic product, the life expectancy of Americans ranks #36 worldwide. Numerous developing nations enjoy longer lifespans than we do. (Costa Rica, for example, ranks #30.) On the other end of the spectrum, the New York Times recently reported that the U.S. rate of premature births is comparable to that of developing nations. Regarding this impactful public health issue with long-term consequences for society, the U.S. does worse than any Western European country. The U.S. premature birth rate of 12% is comparable with that in Kenya, and Honduras. In other words, on this measure the overweening technological superiority of our notoriously costly health care system fares no better than that of countries with per capita incomes of $2 a day.

With respect to chronic disease, it is not unreasonable to assert that medical treatment has obtained equivocal results in the population. Statins are a drug class that has demonstrated proven benefit. For persons who have risk factors for atherosclerotic coronary artery disease, statin use effectively reduces the risk of death due to cardiovascular disease, including stroke. Benefits of statin use increases over time. But drug companies want to extend the statin hegemony to include persons at low cardiovascular risk. In other words, global pharmaceutical corporations want physicians to prescribe statins for prevention in otherwise healthy persons.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

May 2, 2012 | Posted By Michael Brannigan, PhD

The year is 2029. After discussing schedules, I've picked early afternoon April 28 as my day. That works for most of us. My wife will have returned from her conference. My sisters can fly in after their dance recital. My brother rescheduled his interviews.

Cousins can drive in from the coast. Some nieces and nephews can't make it, but that's all right. They're busy. Dr. Landis assured us it would be brief. I'll just take the pill the good doc gives me and fall quickly asleep, peacefully, forever. No pain. I'm doing what's right. It is better for all of us.

As we face dying's three dreads — pain, abandonment, helplessness — what is the practical allure of physician-assisted suicide?

April 19, 2012 | Posted By Posted By David Lemberg, M.S., D.C.

Something remarkable is happening in the world of medicine (the field is often considered a monolithic special interest group). On April 4, 2012, nine medical specialty societies released lists of the "Top Five" services that are the most expensive and "have been shown not to provide any meaningful benefit to at least some major categories of patients". These nine lists are the first results of the "Choosing Wisely" campaign, launched by the American Board of Internal Medicine in response to a 2010 article in the New England Journal of Medicine.

That article challenged physicians to take the lead in health care reform. Rather than waiting for the government to impose new standards and regulations, the article encouraged physicians and professional medical societies to identify wasteful services and procedures that could be readily eliminated.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

April 5, 2012 | Posted By Posted By David Lemberg, M.S., D.C.

Last week's historic three days of arguments before the Supreme Court on the merits of the Affordable Care Act provided many head-scratching moments. Those naive enough to believe that the case was actually going to be considered on constitutional grounds (this being the Supreme Court, after all) were rudely awakened to an apparent actual agenda of partisan politics and corporate interests.

Broccoli was a key theme, startling the 50 million Americans who may be able to purchase green vegetables at the local market but are unable to purchase badly needed health insurance. The welfare of health insurers was a second prominent theme, providing concrete evidence to those who posit that our nation is no longer a government of the people, but rather a "government of the corporation".

The outrage has been profound, including Op-Ed pieces in The New York Times, featured articles in The New Yorker, and commentary in the New England Journal of Medicine.

First, the produce. During the second day of arguments, Justice Scalia attempted to define the market for health care. He said ". . . you define the market as food, therefore everybody is in the market; therefore, you can make people buy broccoli." Chief Justice Roberts picked up the theme as easily as if he were choosing a ripe cantaloupe at his local farm stand. Roberts informed us that "a car or broccoli aren't purchased for their own sake, either." Broccoli is purchased to cover the need for food, we were sagely advised.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

March 25, 2012 | Posted By Posted By David Lemberg, M.S., D.C.

On Monday, March 26th, 2012, the Supreme Court will begin hearing arguments on National Federation of Independent Business v. Sebelius and two linked cases, the lawsuits against the Patient Protection and Affordable Care Act (ACA; signed into law by President Obama on 3/23/2010). The court announced on February 21st that it would hear 6 hours of arguments over 3 days, an historic and unprecedented amount of time. The last time the Supreme Court heard more than 2 hours of arguments was when it considered the McCain-Feingold campaign finance law in 2003.

At issue in the cases before the Supreme Court is the constitutionality of federal involvement, interference, or interposition (depending on who's doing the interpreting) regarding activities of private citizens and activities of the states. The question of constitutionality of the ACA relates specifically to the Commerce Clause (U.S. Constitution Article 1, Section 8, Clause 3). The Commerce Clause states "Congress shall have power to regulate commerce with foreign nations, and among the several states, and with the Indian tribes". As with all clauses of the Constitution, the Commerce Clause must be interpreted and applied. The Supreme Court is the final arbiter and interpreter of all such applications, declaring the constitutionality (or lack thereof) of congressional and state legislation.

The challenges to the ACA state that the federal government has exceeded its constitutionally enumerated powers. The Tenth Amendment states "The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people." The challenges suggest that the ACA attempts to wield a federal power that does not exist under the Constitution and attempts to interfere with powers appropriately "reserved" to the states and to "the people". The challenges assert that it is the right of a citizen, rather than a prerogative of the federal government, to determine whether she will purchase health insurance. The challenges also assert that the federal government cannot dictate how a state conducts its Medicaid program.

 

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

March 17, 2012 | Posted By Posted By David Lemberg, M.S., D.C.

We need less medical care, not more. We need more preventive services and more patient education, not more high-technology crisis care. Specifically, we need more primary care physicians.

Most informed citizens are aware that in the U.S., per capita expenditures on health care are the highest in the world. Each American spends an average of $8100 per year, representing a substantial proportion of annual income. The total U.S. health care burden of $2.5 trillion (in 2009) is 17.6% of our gross domestic product.

These numbers need to come down, but costs continue to rise. A long-term solution is available, one that doesn't involve structural changes in how health care services are bought and paid for. [Such structural change is critically important, but vested interests continue to severely dominate the U.S. political landscape.] The specific long-term solution involves focusing on primary care.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

March 14, 2012 | Posted By Posted By David Lemberg, M.S., D.C.

"Do no harm." This is the foundation of medical ethics. When interacting with a physician, the patient expects that the treatment she receives will not unknowingly cause more harm than the disease or disorder which brought her to the doctor's office. Presumably, the process of informed consent prepares the patient for untoward outcomes.

But the complexity of medical practice increases ongoingly and time spent with individual patients continues to diminish. To any reasonable observer these trends make no sense and are, intuitively, contradictory. Obviously, as a decision-making process becomes more complex, more time would necessarily be required to arrive at a meaningful solution. A highly correlated, direct relationship should obtain. In stark contrast to what would reasonably be expected, overall medical complexity and overall time spent in direct patient contact now have an inverse relationship.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

January 27, 2012 | Posted By Wayne Shelton, PhD

For most of the past 20 years I have had the privilege of talking with and learning from medical students in small group discussions. As medical students leave the classrooms of the first and second year and transition into the third year, they confront a new reality: they are now actually encountering patients directly for the first time and are working with physicians in the daily care of patients. The more encounters they have with patients and their families and with their clinical mentors, the more stories they have to tell, which often lead to vexing questions that shed light on many of the problems of our health care system in the United States. 

One of the common themes throughout each year is the growing disenchantment with primary care, for a variety of reasons. Most of the students are assigned at some point to a clinical mentor who is a practicing internist seeing many patients each day in a primary care setting. Students often present cases of patients with complex medical and psychosocial issues that require interaction with and support from the physician. Not infrequently do we hear accounts of how patient non-compliance is a barrier to a constructive outcome. The idea of seeing patients over time with the same medical problems, while not heeding medical advice, strikes many students as a frustrating aspect of primary care. Also the students talk of these same physicians continuing to work into the evening, doing mountains of administrative work because of multiple insurance forms to complete. 

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

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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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