Chapter 36: Participatory Ethics

Medical Ethics for Challenging Times

[Finding Your Moorings in an Era of Dramatic Change]

By Render S. Davis

When I do good, I feel good; when I do bad, I feel bad. That’s my religion – Abraham Lincoln

Introduction

There are few who would doubt that the practice of medicine today is dramatically changing.  The standards that were predominant a generation ago appear to no longer drive the rapidly evolving relationship between physicians, patients, and health care organizations. Other entities, most notably payers and regulators, have interposed themselves into the relationship and the result is a rapidly evolving approach to health care.

Today, questions of cost, access, patient empowerment and quality drive a continuing and – at times – contentious debate.

Yet, the ethical principles of beneficence, respect for autonomy, and justice that served as a foundation for the healing professions since the age of Hippocrates, remain as important today as two millennia ago. 

Ethical dilemmas arise, not from clear choices between good and evil, but when there are no clear choices between competing goods. Often these issues surface when ethical principles themselves are weighed in relationship to each other. When a physician’s obligation to treat conflicts with a patient’s right to self determination; or when an individual’s demand for autonomous choice offends our society’s sense of justice and fairness, are but a few examples of ethical principles in conflict. 

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24 thoughts on “Chapter 36: Participatory Ethics

  1. One and the Same Physician?

    Is this the same doctor that the author of this chapter quotes in the second edition of this book?

    John La Puma, MD, FACP
    URL: http://drjohnlapuma.com
    FB: http://facebook.com/johnlapuma
    Twitter: @johnlapuma
    Blog: http://drjohnlapuma.com/blogs
    YouTube: http://youtube.com/drlapuma
    Lifetime TV videos: http://ChefMD.com

    Chef Clinic and
    The Santa Barbara Institute for Medical Nutrition & Healthy Weight
    PO Box 24039
    Santa Barbara, CA USA 93121
    Info: 805.284.2238

    Conflict notice: Dr. La Puma hosts “What’s Cooking with ChefMD?” airing on Lifetime TV’s “Health Corner” every Sunday at 930 a.m. EST/PST, 830 a.m. CST, since 2006. He wrote and earns royalties from the New York Times bestseller “ChefMD’s Big Book of Culinary Medicine” (http://tinyurl.com/34h8pm). He co-authored and earns royalties from the Times Bestseller “RealAge Diet” and “Cooking the RealAge Way” with Dr. Michael Roizen, and contributed recipes to Dr Oz and Roizen’s #1 “You the Owner’s Manual.” He has an equity interest in the URLs above.

    Please advise.
    I thought he was an ethicist; not a nutritionist.
    Joyce

  2. Insecure Physicians,

    As consumer-oriented websites arise, some insecure doctors are telling their patients to censor comments, or find another physician.

    This, of course, is anathema to collaborative websites like http://www.RateMDs.com and http://www.Vitals.com.

    These sites give internet users the chance to recommend physicians and review hospitals nationwide. Yet, some ethicists believe that such self-interested behavior is not professional and when a doctor acts primarily out of self-interest it is ethically suspect.

    Moussa Chapter

  3. Blogging [Blabbing] Doctors,

    Julie Chicoine, compliance director at The Ohio State University Medical Center, offers the following pointers for blogging physicians:

    * Be careful. “You should … write as if your patients, co-workers, colleagues, etc. are going to read your posting every day, and know that it came from you.

    * Focus on education and general medical principles. Avoid information that is too specific and situations that are likely to be identified by others in your local community.

    * Ask your malpractice carrier if they have issues with this topic.

    * Never post in the heat of passion. No matter what the circumstances, allow yourself a cooling-off period before logging on and sharing your concerns.

    * Blogs are not the appropriate forum for medical mistakes or hospital errors. Pursue those concerns through the appropriate administrative channels within the hospital.

    And, always include a disclaimer that written blog posts, or video blogs [vlogs], are not medical advice.

    Debra

  4. Telling a patient story and the issues facing physician writers
    By Danielle Ofri, MD, PhD

    http://www.kevinmd.com/blog/2010/02/telling-patient-story-issues-facing-physician-writers.html#more-42354

    Danielle Ofri is writer and practicing internist at New York City’s Bellevue Hospital who blogs at Medicine In Translation. She is the editor-in-chief of the Bellevue Literary Review. Her newest book is Medicine in Translation: Journeys with my Patients.

    Ann MIller; RN, MHA

  5. Dr. Marcinko and readers

    Wouldn’t it be wonderful to test someone’s DNA and know the right drug to prescribe at the right dose the first time without the worry of adverse side effects?

    Pharmacogenetics—the manner in which a person’s genes affect their response to drugs, has the potential to do just that.

    Genetic and genomic tests hold enormous promise for revolutionizing our medical understanding of a disease. However, it is irresponsible to suggest that a simple genetic test, at this point in time, can appropriately dictate prescribing practices for certain drugs.

    Dr. Diane J. Allingham-Hawkins would be available to give you, and your readers, a perspective on this ongoing genetics testing dialogue. Dr. Allingham-Hawkins is Director of the Genetics Test Evaluation Program at Hayes, Inc., an unbiased, healthcare research and consulting firm that is helping hospitals and insurers cope with the cost and ethical issues related to genetic testing. She is an outspoken interviewee with deep knowledge of the subject matter and very pointed opinions regarding genetic testing.

    A great interview for your consideration.

    More: http://medicalexecutivepost.com/?p=21641&preview=true

    Karen D. Matthias RN, MBA – Vice President
    Hayes, Inc – 157 S. Broad Street
    Lansdale, PA 19446
    P: 215-855-0615 x7918
    E-mail: kmatthias@hayesinc.com

  6. The incredible power of the internet is illustrated in the phenomenon of crowd sourcing. In this context, the term means to harvest the reach and scope of social and professional networking on the Internet to solve a complex problem.

    IOW: A knowledge seeker asks a question and participants respond.

    It demonstrates how the asynchronous participation of many participants inevitably converges on the right answer in less than 24 hours. You just have to be patient and let the truth emerge.

    Ethical doctors embrace the participation, while healthcare merchants loathe it.

    Grayson

    1. I actually thuhogt “okay, maybe she’s right, maybe she’s just a health practitioner writing about what interests her” so I looked at a bunch of the others before voting. I have to say that the ones I looked at were awful. Smart-assy, self-congratulatory, “in” groupy. You, on the other hand, are straightforward and clear. You write your thuhogts and opinions clearly. You totally deserve my (and others’) votes!

  7. About the Journal of Medical Ethics
    [Aims and Scope]

    The Journal of Medical Ethics [JME] is a leading international journal that reflects the whole field of medical ethics. The journal seeks to promote ethical reflection and conduct in scientific research and medical practice. It features original articles on ethical aspects of health care, as well as case conferences, book reviews, editorials, correspondence, news and notes. To ensure international relevance JME has Editorial Board members from all around the world including the US, Europe, Australasia and Far East.

    Subscribers to the Journal of Medical Ethics also receive Medical Humanities journal at no extra cost. JME is the official journal of the Institute of Medical Ethics.

    http://jme.bmj.com/site/about/index.xhtml

    Jerome

  8. Patient’s Bill of Rights

    The White House just released this “Fact Sheet: The Affordable Care Act’s New Patient’s Bill of Rights,” the Obama administration’s summary of new regulations issued by the Department of Health and Human Services.

    The formatting is from the original version of the Patient’s Bill of Rights, as released by the administration.

    http://www.physiciansnews.com/2010/06/23/patients-bill-of-rights/

    Hope Hetico RN, MHA

  9. Revamped Informed Consent Puts the Patient at the Center

    With the call for more patient-centered, transparent health care, a number of outdated hospital processes are getting a facelift. Informed consent, in particular, has come under scrutiny, as shared decision-making between provider and patient gains greater importance.

    “It is time for a fundamental rethinking around informed consent, but there are few incentives to improve it,” contends Harlan Krumholz, M.D., professor of medicine, epidemiology and public health at Yale University and author of “Informed Consent to Promote Patient-Centered Care,” which appeared in the March 2010 issue of the Journal of the American Medical Association.

    “Patients are signing documents on a gurney, or minutes away from sedation, and are hardly in the frame of mind to sign. Often, they’re choosing procedures they would not if they truly understood what they were getting into.”

    http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/07JUL2010/1007HHN_Inbox_patientcare&domain=HHNMAG

    Source: Tracy Granzyk Wetzel

    I could not agree more.

    Hope Hetico RN, MHA
    [Managing Editor]

  10. “Great companies have high cultures of accountability, it comes with this culture of criticism I was talking about before, and I think our culture is strong on that.” – Steve Ballmer

  11. HIT and eMR Ethics

    The fields of medicine and information technology (IT) each have separate and related ethical considerations. Ethics may prohibit technology, for example, when using a specific application that would make a security breach likely. However, ethics may also demand technology.

    For example, let us suppose that a new surveillance application would improve public health — is it not ethically imperative to utilize it to save countless lives? But suppose it also almost guarantees a security breach — what does the ethical position on use of the application become then? That is an extreme example, though not completely unrealistic.

    Complicating the picture is the fact that IT in the healthcare arena has so many and varied uses. For instance, office, clinic, and hospital-based medical enterprise resource planning (ERP) is based on the same back-end functions that a company requires, including manufacturing, logistics, distribution, inventory, shipping, invoicing, and accounting. ERP software can also aid in the control of many business activities, like sales, delivery, billing, production, inventory management, quality management, and human resources management.

    However, other applications particular to the medical setting include the following:

    • The EMR, which has the potential to replace medical charts in the future, is feasible.
    • Healthcare application service providers (ASPs) are available via Internet portals.
    • Custom software production may produce more solution-specific applications.
    • Medical speech recognition systems and implementation are replacing dictation systems.
    • Healthcare local area networks (LANs), wide area networks (WANs), voice-over Internet protocol (IP) networks, Web and ATM file servers are ubiquitous.
    • The use of barcodes to monitor pharmaceuticals is decreasing the chance of medication errors and warns providers of potential adverse reactions.
    • Telemedicine and real-time video conferencing are already a reality.
    • Biometrics will be used more often for data access.
    • Personal digital assistants (PDAx) wireless smart-phone connectivity, which relies on digital or broadband technology including satellites, and radio-wave communications are increasingly common.
    • The use of wireless technology in medical devices will be increasing.

    All of these applications offer advantages, but the security of these IT methods and devices is not yet fully standardized or familiar to health professionals. They all involve inherent security and privacy risks, and the prudent healthcare organization will want to ensure that these risks are identified and contained.

    Dr. David Edward Marcinko MBA CMP™
    http://www.CertifiedMedicalPlanner.com
    [Publisher-in-Chief]

  12. More Patient Advocacy Needed

    Few areas of life are as personal as an individual’s health and people have long relied on a caring and competent physician to be their champion in securing the medical resources needed to retain or restore health and function. And, for many physicians, the care of patients was the foundation of their professional calling.

    However, in the hospital setting, and/or contemporary delivery organization, there may be little opportunity for generalist physician “gatekeepers”, resident, interns fellows, or “specialty hospitalists or intensivists” to form a lasting relationship with patients. These institution-based physicians may be called upon to deliver treatments determined by programmatic protocols or algorithm-based practice guidelines that leave little discretion for their professional judgment or personalized “care and concern”.

    Hence DNR order terminology, medical technology, input by relatives and loved-ones, and related confusion often puts modern doctors in a terrific ethical quandary.

    Dr. David Edward Marcinko MBA
    http://www.BusinessofMedicalPractice.com
    [Editor-in-Chief]

    1. It just so happens that many of the topcis that interest you are of a medical nature. This is good for all of us because you bring up points to ponder and get excellent discussions going. Even if I don’t agree (or even vehemently disagree with someone commenting) – it’s a good thing to hear what the contrary views are! So chalk up another vote from me. *** although I must say that Sissy certainly puts it much more elegantly than I do. *grin*

  13. About the Blog:
    http://healthcareorganizationalethics.blogspot.com/

    Medical ethics has traditionally focused on the individual patient, the individual doctor, and the patient-doctor relationship. But today most care occurs in organizational settings – group practices, HMOs, VA and more. Insurers and other third parties have a huge influence on the exam room. Medicare shapes care for the elderly and disabled. Medicaid does the same for the poor. Hospital cultures and policies affect what sick patients experience, for both better and worse.

    All this means that the ethical quality of health care is profoundly influenced by the ethics of organizations. We can’t have ethical health care without ethical organizations.

    Organizational ethics is what this blog is all about. I discuss how organizations engage with the ethical dimensions of their work. I look for approaches we can learn from, not simply to wring my hands and rant. I hope the blog stimulates discussion and debate, and encourage readers to present their own perspectives and suggest topics for postings.

    Visit: http://healthcareorganizationalethics.blogspot.com/

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