16th Annual Rosemary Flanigan Lecture

The Politics of Palliative Care
Kathleen M. Foley, MD

Tuesday, August 3, 2010
6 pm Reception
7 pm Lecture

St. Joseph Medical Center
Alex George Auditorium, Building D
1000 Carondelet
Kansas City, MO 64114

The lecture is free but registration is requested by clicking here.

The Intersection of Neuroscience and National Security

Jonathan Marks
The Bioethics Channel
12 minutes 12 seconds

The intersection of neuroscience and national security is an intriguing place, fraught with excitement but also a need for caution.

Jonathan Marks explains in an article in the June 2010 edition of the American Journal of Bioethics.

Links:

Podcast
Allegations about CIA interrogations raise medical-ethics questions, Minnesota Post, June 24

Center in the News

A couple of media hits over the weekend about Elena Kagan for US Supreme Court and the conviction of a physician in Kansas.

Elena Kagan 'as liberal as they come' on 'life' issues: Bioethicist
USA Today
June 27, 2010

At bioethics.net, Summer Johnson blogs, “All things considered, Kagan is about as liberal as they come” when it comes to bioethics.

Link: Kagan on Bioethics, Bioethics.net, Summer Johnson, PhD

Guilty Verdict Bad News For Chronic Pain Patients?
Kansas Public Radio
June 25, 2010

A federal court jury found Stephen Schneider and his wife, Linda, guilty of prescription practices that led to the deaths of ten patients. In this report Myra Christopher of the Center for Practical Bioethics explains how even legitimate prosecutions may diminish the level of pain relief for patients who need it.

Link: Couple found guilty in Kansas ‘pill mill’ case, The Wichita Eagle, June 25

Not Enough to Exercise Conscience

Rosemary Flanigan

June 25, 2010

Just as I was reading a short squib on conscience by one of my favorite philosophers, John Kavanaugh from St. Louis University, my colleague John Carney sent out a comment he found on the net that troubled me.

First, Kavanaugh on conscience—“a particular kind of judgment—a moral judgment—by which we apply our knowledge of good and evil to practical action.”

Of course. It’s what we can’t help doing thousands of times a day: making moral judgments about what we read, hear, see. Without those judgments, of course, there could be no ethical reflection because they serve as the “meat” for analysis.

But it’s not enough that we exercise our conscience; we also have to be sure it’s “informed” properly. And that means evidence, information and data. (Just because your conscience is certain doesn’t mean it’s correct!)

Now, jump with me to John’s reading this remark on the net this morning from another online ethics discussion group. A Yale emergency medicine chief said, “Ethics consults are exceedingly rare as the consultation process is typically deemed to be too burdensome and bureaucratic in order to be functional—hell, we can’t even get a plastic surgeon to come in a timely fashion, let alone an ethics consultation.”

See where I’m going? Of late, whenever I use a case in ethics brown bag sessions, I start out asking people to tell the group their initial moral judgment—and we go on from there. How many times we have changed our own minds as we gather evidence, information and data.

So must it be for an ethics committee. Sorry, Yale ER medicine man, we ethics committee members ought to respond fast, get to where you want us to be, but then we can’t proceed at the breakneck speed that medical trauma decisions must be made.

It’s just a different kettle of fish. ANYONE DISAGREE???

Ethics Consults Part Deaux: Peer Review Instead?

Rosemary Flanigan

June 24, 2010

Thanks to all of you who have been thinking with me about that ethics committees ought NOT consult on. I think ethics committees are so uniquely related to their institutions—and different institutions (and different histories of the committee) permit and even encourage different types of participation.

One physician blogger responded that we ought “not engage in investigating and deciding on the ethical behavior of physicians as demonstrated in the context of the physicians’ medical or surgical hospital practice. The ethics can be too closely related also to standards of medical or surgical practice. . .these matters belong in peer review.”

That may be so, but the beginning of such cases could arise from an ethics consult with its eventual resolution coming out of peer review. DOES ANYONE AGREE?

I have been reading the articles in Cambridge Quarterly about bioethics in Scotland, Japan, Croatia, Iceland, Pakistan, Italy and Israel. Guess what? Lots of the same problems as we have.

In a survey with over 500 internal practice, oncology, and intensive care specialists and associated nurses in Croatia, the following were “the most frequently faced dilemmas: uncertain or impaired decisionmaking capacity, limitation of treatment at the end of life, and disagreements among family members.”

Doesn’t that sound familiar?

So, upward and onward!!

Palliative Care: A Case-Based Guide

Happy to pass this along from our good friend Christian Sinclair, who has co-edited Palliative Care: A Case-based Guide.

Click here for listing on Amazon. Review states in part:

Palliative Care: a Case-based Guide provides the clinician with a crucial set of skills to address the challenging issues related to communication and symptom management. Care-oriented and practical, this book is ideal for all health care professionals committed to providing quality, compassionate care to end-of-life patients.

Congratulations Christian!

Boundaries for Ethics Consults

George Flanagan, D.Min, M.A.

June 22, 2010

In my itinerant visits to ethics committees far and near, I have discovered not just a few who will take on any request that comes to it, and they find themselves then doing the follow-up work rightly falling in the domain of other professions—nursing, social work, e.g.

Even if we are unclear philosophically about the appropriate cause for ethics committee consultation, we must have some sort of boundary that prevents the EC from becoming the common recourse for staff dealing with any kind of problem.

Allowing ourselves to be ombudsman for all will lead to our fatigue and, possibly, our ineffectiveness in our appropriate work. There is not question that we find ourselves responding to consults about “difficult decisions” that may not yield an authentic ethical question; however, the ASBH competencies indicate that we are equipped to provide facilitation skills that can be very useful in helping others work through difficult decisions.

Nevertheless, as a career chaplain prior to my work at the Center, my encouragement in those cases is “Call the Chaplain!” It’s not a dump—they are particularly trained and tasked with this type of work. And, of course, the fact that the chaplain may be on the EC doesn’t necessarily make it an ethics question.

Organ Donations and Presumed Consent

Tarris Rosell, PhD
June 21, 2010

Organ donations are in the news as state legislatures consider presumed consent as a way to increase the number of available organs. Physicians are also considering whether organ donations should be part of advance care planning.

Tarris Rosell, PhD, the Rosemary Flanigan Chair at the Center for Practical Bioethics, provides some insight in this edition of The Bioethics Channel.

Links:

Podcast, Organ Donations and Presumed Consent, 14 minutes 39 seconds

'Presumed consent' legislative proposal for organ donations sparks debate, Binghamton Press, June 19 2010

Ashley X: Where Ethics Committee Should Not Go?

Rosemary Flanigan, PhD

June 18, 2010

The new issue of Cambridge Quarterly of Healthcare Ethics arrived and I read the “Ethics Committees at Work” section first—as I always do. (Oftentimes I use the issues there and in the Hastings Center Report for my brown bag sessions.)

This time it was a request for the “Ashley Treatment” (remember the 2006 case of the profoundly developmentally compromised six-year-old in Seattle for whom the Children’s Hospital had attenuated growth, removed breast buds and performed a hysterectomy for the best interests of her parents to care for her).

This case concerned a nine-year-old on the East coast but a similar request.

And the commentaries were excellent: the pediatrician, while admitting initial lack of a moral compass, thought he could attenuate growth but no more; the philosopher and senior medical ethicist from Stanford argued that the surgery should be performed; the ethicist from the U.K. said, “Leave this case to the courts,” and John Paris and a law instructor showed why this case goes beyond the scope of an ethics committee, viz., that there are societal issues that demand a closer look at broader implications than could be expected of an ethics committee.

There are some places we should not go.

I need to refresh my memory if our ethics committee has refused case consults and on what grounds. Do you faithful readers have some examples—and not just of cases that clearly lacked ethical relevance. HELP!!!

Link: Podcast, Ashley X Revisited, Norman Fost, MD; John Lantos, MD; 8 minutes 20 seconds

Balancing Outcomes and Moral Values

Rosemary Flanigan

June 17, 2010

John Lantos reviewed a book for the latest Hastings Center Report (Vicki Forman. This Lovely Life. Mariner Books 2009) and I thought of our case consults.

The author delivered twins after just twenty-three weeks of gestation. One twin dies. Eight years later, after years of challenges, the other severely disabled twin also dies of acute intestinal blockage.

She tells of the refusal of the neonatologists to write a DNR order (John gnashes his teeth!), of the ongoing daily decisions, of her eventual embrace of the remaining child and his multiple anomalies. So when she is asked, “Knowing what you know now, would you still demand that the twins not be resuscitated?” she answers, “I don’t know.”

We ask questions like that in our consults—and how can we expect others to respond as if the there were no intervening mass of fear, grief, compassion and love?

I shall die urging people to be reflective and to do ethical analyses but we must also admit (as in the Truog case) that it is not an exercise of balancing outcomes or justifying placing one moral value above another. Though these steps are important, sometimes they are not sufficient.

ANY COMMENTS???

Questions about Cardiac Death and Organ Donation

Rosemary Flanigan

June 16, 2010

The May/June issue of the Hastings Center Report—and Don Marquis’ article, “Are DCD Donors Dead?" Don is a long-time friend of the Center and we have had many exchanges over the years.

Donation after cardiac death is the issue: removing organs as soon as possible is desirable, yet the donor must be dead. He knows that DCD protocols are widely accepted indicating that they are persuasive—but are they sound?

In a carefully worded argument involving irreversibility and permanence, Don argues that if a heart can be re-started, then how can the donor have been “dead”?

Maybe it is easier for me to see the donor as dead because of all those years I taught the philosophy of the human person. We are a coordinated whole; if a part of me can’t do its function because all the other parts can’t support it, then that part dies in me.

But it may be able to live in another functioning whole. What do you think?

Prosecutors, some doctors clash over painkillers

Myra Christopher, president of the Center for Practical Bioethics in Kansas City, Mo., said most government prosecutions appear to be well-founded but that the enforcement is having a "chilling effect" in the legitimate prescribing of painkillers.

"Physicians are very sensitive about these cases and when these cases get a lot of media attention ... it compels them to believe their fears are right," said Christopher

Link to article here.

The DNA Debate at UC Berkeley

Glenn McGee, PhD

June 15, 2010

So what’s the problem?

You’re an incoming first year student at a major university, and they send you a cotton swab for a DNA sample. It’s voluntary, anonymous and presented as a way to tell if you are vulnerable to certain health problems.

Simple, right? Not according to Glenn McGee, PhD, the John B. Francis Chair at the Center for Practical Bioethics.

In this edition of The Bioethics Channel Dr. McGee explores the ethical issues around the University of California-Berkeley program asking for DNA samples from incoming freshmen.

Links:

Podcast, 14 minutes 29 seconds

UC Berkeley offer to test DNA of incoming students sparks debate, Los Angeles Times, June 1

Organ Donation and Advance Care Planning: The Right Mix?

Tarris Rosell, PhD
June 4, 2010

What is interesting to me about what Mark Fox writes is his apparent recommendation of primary care physicians serving as advocates for potential living donor patients.

Currently, that prospective patient-donor enters the transplant program for evaluation as a living donor and becomes a patient there. And as good as most of those clinicians are (in my limited experience anyway), with attentiveness to the principles of respect for person’s autonomy and nonmaleficence, there is nonetheless an inevitable and inherent bias built into the evaluation process.

The bias, of course, is toward donation.

Donation is seen as “the right thing to do.” It is viewed by transplanters as a societal good—good for the organ recipient, and good for the transplant program. With recognition of that conflict of interest, Vanderbilt’s transplant center built in to their process years ago the option, not requisite usually, of an ethics consult interview with the prospective donor and the recipient. (I was one of the ethics consultants during a two year fellowship in the late 1990s. Mark Fox did his clinical ethics training there, as well.)

I believe the transplant ethics consultation service and fellowship has gone away now at Vanderbilt, and is surely not the norm most other places. So prospective living donors probably could benefit from someone outside the evaluating transplant program, perhaps their primary care physician, who helps them assess the risks and harms while balancing those against the potential for benefiting another.

If so, primary care docs will need to be educated on what living donor transplantation entails, since they may have biases, also, and those might not be well grounded in facts.

Link: Organ donation should be part of health discussions, Ethics Forum, American Medical News, May 31, 2010

Top 10 Podcasts May 2010: The Bioethics Channel

Pain Contracts: Great Good or Great Harm?, Scott Fishman, MD, 7 minutes 10 seconds

Ethics and Public Health, Summer Johnson, PhD, 13 minutes 49 seconds

Pain Contracts: Unintended Consequences, Richard Payne, MD, 6 minutes 24 seconds

Stem Cell Tourism and the Power of Hope, Christopher Thomas Scott, 13 minutes 29 seconds

Pain Contracts: Balance at the Bedside, Will Rowe, 5 minutes 4 seconds

Pain Contracts: A Patient Perspective, Carlton Haywood, PhD, 9 minutes 42 seconds

The Ethics of Synthetic Cells, Glenn McGee, PhD, 16 minutes 35 seconds

Pain Contracts: Too Many Variables, Aaron Gilson, 10 minutes 18 seconds

Pain Contracts: Trust but Verify?, Ben Rich, 7 minutes 33 seconds

Pain Contracts: Social Determinants, Carmen Green, MD, 10 minutes 11 seconds

Top 10 Practical Bioethics Blog: May 2010

Ethics Committees as Decision Makers?

Feeding Tube Futile?

Performing Futile CPR Revisited

Pain Contracts as Policy: A Good Idea?

Couldn't attend Annual Dinner? No problem.

24 Hour Genetic Testing at Your Local Walgreens

What ethics committees AREN'T

Presumed Consent for Organ Donation? An Unlikely Fix

"Purposeful" vs "Desired” Medicine

Teaching Bioethics from Virtue to Kant

The Ethics of Synthetic Cells

Glenn McGee, PhD

May 28, 2010

What have we done? And what does it mean?

Those are the questions after headlines exploded with news of a synthetic cell created from a made-from-scratch genome.

Lorell LaBoube, host of The Bioethics Channel, discusses the ethical implications of this emerging story with Glenn McGee, PhD, the John B. Francis Chair at the Center for Practical Bioethics.

Links:

Podcast, 16 minutes 35 seconds

How We Created the First Synthetic Cell, J. Craig Venter and Daniel Gibson, Wall Street Journal, May 26, 2010

Church warns cell scientists not to play God, Associated Press, May 21