Update
Ethics Grand Rounds: The Year in Review
For the past eleven years, Loma Linda University Center for Christian
Bioethics has sponsored stimulating monthly discussions called "Ethics
Grand Rounds." The 1995-1996 year proved to be no exception. The
discussion topics covered a wide range of issues and the speakers represented
a diverse array of values and opinions. The first Grand Rounds of the year took place on September 27, 1995, and focused on the particularly controversial subject, "Practicing on Newly Dead Bodies." The speakers were Kenneth Iserson, MD, director of the Arizona Bioethics Program, and Ann Dudley Goldblatt, JD, LLM, of the MacLean Center for Medical Ethics at the University of Chicago.
Dr. Iserson expressed and defended his opinion that it is ethical for doctors to develop and practice skills using dead bodies. He contended that a person who asks for treatment by a physician has implicitly agreed to contribute to the growth of the medical profession, which could be accomplished by letting physicians practice on his or her body after death. After all, Dr. Iserson concluded, why should a person receive medical benefits if they won't contribute to future benefits for others?
Ms. Goldblatt focused on the legality of practicing on newly dead bodies. She contended that it is not ethical to use the dead without their or their family's consent. She agreed with Dr. Iserson that a body isn't a person, however, the body is personal property and cannot be used without knowing and voluntary consent. She advised that the best way to obtain consent would be to get a presumed consent law or a required response law passed.
The October 11 Grand Rounds was entitled, "Medical Futility: The Debate Continues." The speakers were Debra Craig, MD, MA, specialist in geriatrics and clinical ethics and assistant professor of medicine at LLU, and Gerald R. Winslow, PhD, chair of the Center for Christian Bioethics at LLU.
Dr. Craig believes that with rigid definitions and application, "futility" is a term physicians can and should use. Deciding when a case is futile must be a joint decision of the physician and medical community, the patient or family, and society as a whole. Only a consensus of all these will ensure that the concept of futility is applied morally.
Dr. Winslow believes that "futility" is a power tool. He agreed that under Dr. Craig's rigid standards futility could have practical applications, but ultimately, these rigid standards would not be followed and futility would have too broad a definition to be uniformly applied. He cited as an example a study in which physicians were polled as to what probability of success they viewed as being futile. Their responses ranged from zero to 60 percent!
"Treating Prostate Cancer: Ethical Options Today" was the subject of Grand Rounds on November 8, 1995. Ed Blight, MD, professor of urology at LLU, and Dennis deLeon, MD, assistant professor of family medicine at LLU, spoke on this subject.
Dr. Blight opened by explaining the options facing prostate cancer patients. These patients can elect for surgery or monthly injections of a hormone for treatment of the cancer. They can also choose whether to begin treatment as soon as the cancer has been detected or after they become symptomatic. In either case neither option is more beneficial than the other in terms of longevity or quality of life. The uncertainty surrounding how and when to treat makes these decisions confusing for both patients and physicians.
Dr. deLeon thinks that the medical community is guilty of inflating its ability to cure prostate cancer. He believes that in cases of diseases with no definitive treatment, like prostate cancer, the goal should be for patient/physician values sharing. Patients should be told the truth about realistic treatment goals and should become more involved in how their medical dollars are spent.
The topic of Grand Rounds on December 6, 1995 was "ICU Nurses, Babies and Children: Ethical Challenges." Ronald Perkin, MD, associate chair of pediatrics at LLU, and Lois Van Cleve, RN, PhD, associate dean of graduate nursing at LLU addressed this topic.
Dr. Perkin began by stating that thirty percent of pediatric nurses exhibit a state of physical and emotional depletion resulting from conditions of work. As a solution to this "burnout," he recommended involving nurses in decision making, providing them with values education, and establishing nursing ethics committees. Medicine must become a team decision in order to give the best possible care to patients.
Dr. Van Cleve focused on a study of nurses in a California hospital whose job was to provide care to anencephalic babies being kept alive in order to donate their organs. Ninety-one percent of the nurses believed that their opinions should be equally as important as physician opinions since they are the ones caring for the infants on a daily basis. Dr. Van Cleve concluded by stating that nurses' opinions do matter and will have increasing impact on decisions made by physicians.
The first Grand Rounds of 1996 took place on January 10. The subject was "Reanimation and Organ Transplan-tation," and the speakers were Steven Gundry, MD, chief of cardiothoracic surgery at LLU, and Robert Orr, MD, director of clinical ethics at LLU.
Dr. Gundry explained that part of the problem with the lack of donated organs in this country stems from which definition of death is applied when deciding if a patient's organs can be used for someone in need. LLU has developed a system called reanimation, which can restart a heart from a person meeting all the definitions of death, thereby eliminating any controversy as to whether the person is really dead.
Dr. Orr began by explaining the benefits of reanimation. Reanimation allows for consent to be obtained before the procedure, both cardiac and brain death criteria to be met, and for thirty minutes to elapse before the heart is procured, which allows the family to be present at their loved one's death. Dr. Orr recommended being sure that the decision to withdraw life support comes before the decision to donate the heart, and that separate physicians handle the cases of the donor and recipient to avoid conflicts of interest.
"Ethical Issues in Using Placebos" was the topic of the February Grand Rounds. G.W. Saukel, MD, chief of surgical pathology at LLU, and Dan Zimbroff, MD, medical director of psychopharmacology research at LLU served as speakers.
Dr. Saukel explained that placebo studies are beneficial because they are randomized, sensitive, and efficient. Many people oppose placebo studies, claiming that to not give patients a possible treatment is to do them harm. However, the FDA has to date never approved a new drug whose efficacy was not proven by a placebo arm. Dr. Saukel believes that it is acceptable to use placebo arms for diseases that have no accepted therapy.
Dr. Zimbroff concentrated on the ways in which placebo studies affect psychopharmacology research on schizophrenia. He contended that it is ethical to use a placebo arm in schizophrenic studies even when a current treatment is available. Dr. Zimbroff believes that placebo arms are especially ethical in mental health studies because many mental patients have spontaneous remissions, and the rate of spontaneous remission must be tested against the effects of the new treatment.
On March 6, 1996, "'Personhood' and the Meaning of Death" was the topic of the Ethics Grand Rounds. The speakers were James Walters, PhD, professor of Christian ethics at LLU, and Debra Craig, MA, MD, assistant professor of medicine at LLU.
Dr. Walters believes that personalism is an appealing concept because people who have a rich, complex experience of life should define what a person is. His criteria for defining personhood includes potentiality for gaining mental richness, development toward a personal being, and bonding of the individual with others.
Dr. Craig questioned why society feels a need to define personhood and if the definition matters. She is most comfortable with grouping into general categories of personhood rather than giving individuals specific personhood ratings. She reminded the audience that even individuals without personhood have interests and legal rights.
In April the Grand Rounds topic was "MISTAKES! Noting Them, Stopping Them, Coping With Them." The speakers were Steven Hardin, MD, professor of internal medicine, and E. Nathan Schilt, a malpractice defense attorney in San Bernardino, California.
Dr. Hardin began by giving the startling fact that twenty percent of patients are victims of mistakes. A recent study he did indicates that the more severe the mistake the more likely patients are to require acknowledgment, referral, and compensation. Also, if patients are not informed of the mistake they are more likely to change to another physician, report the physician that made the mistake, and file for litigation. His report concludes that patients demand honesty and forthrightness.
Mr. Schilt's talk centered on how to view mistakes from a legal perspective. The law requires a physician to give care and treatment and to do no harm but does not require disclosure. He recommended that physicians only tell patients what is important and necessary for their care and safety. Mr. Schilt believes that the decreasing strength of the physician/patient relationship is one reason why medical litigation is increasing at such a rapid rate.
"Ethics in a Short White Coat: Moral Dilemma of Medical Students" was the Grand Rounds topic in May. Instead of having two speakers, many different people presented facts and experiences.
Dr. Kelly Morton began the discussion by stating that 62% of medical students feel their ethical values were eroded during medical school. She believes that some of this results from peer pressure on students' medical teams. Several graduating medical students gave examples of situations they had encountered when they questioned the ethics of decisions made by physicians. These situations included miscoding a diagnosis to deceive an insurance company, documenting a procedure that wasn't performed, and practicing on patients who had not and could not give their consent to the practice.
Dr. John Testerman pointed out that ethical decisions made by medical students are different from those made by physicians because students are powerless to protest. They need good grades and evaluations from the physicians making the decisions and therefore are wary of contradicting those decisions.
Another year of Grand Rounds discussions at Loma Linda University has ended. The School of Medicine and Faculty of Religion would like to thank all speakers and coordinators for their time and effort. Plans are underway for the 1996-97 grand rounds, which we expect to be as intriguing as in years past.
Audio and video tapes can be ordered by sending a check or money order to:
PO Box 51
Loma Linda, California 92354
Video Tapes - $15.00 + $2.00 S/H
Audio Tapes - $7.50 + $1.00 S/H
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