Categories

Tag: Medical Ethics

As Balwani and Holmes Head To Jail…Will Others in Health Tech Follow?

by MIKE MAGEE

This week’s headlines seemingly closed a chapter on the story of medical research criminality in America. Ramesh “Sunny” Balwani, former president and COO of Theranos was sentenced to 13 years in prison for fraud. That’s 2 years more than his former business and romantic partner, Elizabeth Holmes.

White crime criminal defense attorney for all things science tech, Michael Weinstein, took the opportunity to trumpet out a confident message that crime doesn’t pay in Medicine with these words, “It clearly sends a signal to Silicon Valley that puffery and fraud and misrepresentation will be prosecuted, there will be consequences and the end result is potentially decades in prison.”

The smooth talking fraudsters played a good hand for years, buoyed by a Board, asleep at the $9 billion valuation wheel, with the likes of George Shultz, Henry Kissinger, Rupert Murdoch and Larry Ellison. But attorney Weinstein and all associated with Health Tech entrepreneurship would do well to read again a classic piece of health journalism from fifty-six years ago.

On June 16, 1966, the New England Journal of Medicine published an article titled “Ethics and Clinical Research.” Written by a highly respected Harvard physician, Henry K. Beecher, the head of anesthesiology at Massachusetts General Hospital, the article referred to “troubling charges” that had grown out of “troubling practices” at “leading medical schools, university hospitals, private hospitals, governmental military departments (the Army, the Navy and the Air Force), governmental institutes (the National Institutes of Health), Veterans Administration hospitals and industry.”

Beecher then reviewed 50 distinct contemporary American clinical studies with ethical violations judged by standards at Beecher’s own Massachusetts General Hospital.

Continue reading…

We Use Too Many Medications: Be Very Afraid of Interactions

By HANS DUVEFELT

I happened to read about the pharmacodynamics of parenteral versus oral furosemide when I came across a unique interaction between this commonest of diuretics and risperidone: Elderly dementia patients on risperidone have twice their expected mortality if also given furosemide. I knew that all atypical antipsychotics can double mortality in elderly dementia patients, but was unaware of the additional risperidone-furosemide risk. Epocrates only has a nonspecific warning to monitor blood pressure when prescribing both drugs.

This is only today’s example of an interaction I didn’t have at my fingertips. I very often check Epocrates on my iPhone for interactions before prescribing, because – quite frankly – my EMR always gives me an entire screen of fine print idiotic kindergarten warnings nobody ever has time to read in a real clinical situation. (In my case provided by the otherwise decent makers of UpToDate.)

I keep coming back in my thoughts and blogging about drug interactions. And every time I run into one that surprised me or caused harm, I think of the inherent, exponential risks of polypharmacy and the virtues of oligopharmacy.

Continue reading…

Health Professionals Are Tomorrow’s Health Journalists. Here is a Code of Ethics to Guide Us and Trump’s White House Doctor.

By MIKE MAGEE

The patient/health-professional relationship is fundamentally grounded in science and trust, and involves the exchange of compassion, understanding and partnership. The Covid-19 pandemic has challenged this relationship by acutely increasing the nation’s burden of disease, creating new barriers to face-to-face contact, and injecting high levels of fear and misinformation.

Dr. Sean Conley, Trump’s White House physician, in his dodgy and evasive management of legitimate questions from the White House press corps regarding the President’s health, has made matters worse.

As this week’s report on an analysis of 38 million articles on the pandemic revealed, much of the misinformation our citizens have experienced can be traced to a single individual who lacks any health credentials – our own President Trump. Sarah Evanega, the director of the Cornell Alliance for Science and lead author of the report stated, “The biggest surprise was that the president of the United States was the single largest driver of misinformation around Covid. That’s concerning in that there are real-world dire health implications.”

The solution to that specific problem is only one month away – vote him out. But if Trump can be successfully sent packing, how prepared are our health professionals, in the face of these new and complex challenges? A President Biden health reform package will likely include expansion of health care teams, exponential growth of telemedicine, and increasing dependence on reliable information to advance personal health planning.

Today’s modern health professionals are tomorrow’s health journalists. What principles should guide them in their new and expanded role. As a guide, I offer the following:

Continue reading…

Money, Medicine and Ethics

The American College of Physicians has published their updated manual on ethics for physicians and the following passage is causing quite a stir:

Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.

On the right, American Enterprise Institute scholar Scott Gottlieb writes “Parsimonious, to me, implies an element of stinginess, and stinginess implies an element of subterfuge.” (Quote of the Day in American Health Line.)

On the left, Aaron Carroll writes:

I would fight tooth and nail to get anything — and I mean anything — to save [his own child]. I’d do it even if it cost a fortune and might not work. That’s why I don’t think you should leave these kinds of decisions up to the individual. Every single person feels the way I do about every single person they love, and no one will ever be able to say no. That’s human.

Similarly, I don’t think that it’s necessarily fair to make it a physician’s responsibility. I also want my child’s doctor to fight tooth and nail to get anything that might save my child. Many times, physicians have long-standing relationships with patients. Asking them to divorce themselves from the very human feelings that compel them to do anything that might help their patients is not something that I think will necessarily improve the practice of medicine. They also should be human.

So whose job is it? Well, mine for instance. That’s what I do as a health services researcher. That’s what policy makers should also do….

That’s a roundabout way of saying that only the government can ration care the right way. Here is Don Taylor’s (Incidental Economist) take on the subject.

My view: people in health care have become so completely immersed in the idea of third-party payment that they have completely lost sight of the whole idea of agency.

[youtube]http://www.youtube.com/watch?v=BQMI7TksYo0&feature=player_embedded[/youtube]

This game of life I play
Living and dying with the choices I made

Can you imagine a lawyer discussing the prospects of launching a lawsuit without bringing up the matter of cost? What about an architect submitting plans for a building but completely ignoring what it would cost to build it?  Outside of medicine, can you imagine any professional anywhere discussing any project with a client and pretending that money doesn’t matter? Of course not.

Then what is so special about medicine? Answer: the field has been completely corrupted by the idea that (a) patients should never be in a position to choose between health benefits and monetary cost, (b) doctors shouldn’t have to think about such tradeoffs either, (c) in order to insulate the patient from having to choose between health care and other uses of money, third-party payers should pay all the medical bills and (d) since no one else is going to think about what anything costs, the third-party payer is the only entity left to decide which services are worthwhile and which ones aren’t.

To appreciate how doctors could do the same thing other professionals do in advising patients on how to spend their own money, take a look at the graphic below. These numbers are several years old and there may be more recent studies, but the graphic will serve our heuristic purpose. Armed with this information, what would a responsible doctor tell her patient about Pap smears and how often the patient should get them?

Source: Tammy O. Tengs et al., “Five Hundred Lifesaving Interventions and Their Cost-Effectiveness,” Risk Analysis, June 1995.

 

Note that getting a Pap smear every four years (versus never getting one) costs $12,000 per year of life saved, when averaged over the whole population. What the responsible doctor should say is, “In the risk avoidance business, this is a really good buy. Based on choices people like you make in other walks of life, this is a good decision. This type of risk reduction is well worth what it costs.”

What about getting the test every three years (versus every four) or every two years (versus every three)? Here the doctor should say, “Now we are moving toward the upper boundary of what most other people are willing to spend to avoid various kinds of risks. So at this point, serious thought needs to be given to whether the test is really worth what it cost.”

How about getting the test done every year (versus every two years)? Here the responsible doctor will say, “This is definitely a bad buy (unless there is some specific indication). The cost of an annual Pap smear in relation to the amount of risk reduction achieved is way outside the range of choices most people make with respect to other risks.”

Notice what is going on here. The responsible doctor, functioning as an agent of a patient who is not familiar with the medical literature and who is not skilled at evaluating risks or trading off risk reduction for other uses of money, advises her patient in these matters. She helps her patient manage both her health and her money — because both are important.

When Dr. Carroll says “I’d do it even if it cost a fortune and might not work,” I am sure he is being sincere. But I am equally sure that is not how he normally makes decisions. It is in fact easy to spend a fortune to avoid small-probability events. The EPA makes the private sector do it every day. But if an ordinary family tried that, they would end up spending their entire income avoiding trivial risks. And that is not what normal people do.

Here is another example of a money-is-no-object-no-matter-how-improbable-the-prospects-if-life-and-death-are-at-sake choice. This is Zeke Emanuel, writing in The New York Times the other day:

Proton beam therapy is a kind of radiation used to treat cancers. The particles are made of atomic nuclei rather than the usual X-rays, and theoretically can be focused more precisely on cancerous tissue, minimizing the danger to healthy tissue surrounding it. But the machines are tremendously expensive, requiring a particle accelerator encased in a football-field-size building with concrete walls. As a result, Medicare will pay around $50,000 for proton beam therapy for a patient with prostate cancer, roughly twice as much as it would if the patient received another type of radiation.

Emanuel claims there is no evidence the treatment works for prostate cancer — so the therapy is a waste of $25,000. Is he right? I don’t know. If you’re paying the extra $25,000 out of your own pocket, listen to what the doctors at Mayo have to say (in favor of its use) and then listen to what Emanuel has to say and make up your own mind.

Bottom line: helping patients manage their health dollars as well as their health care should be what doctoring is all about.

John C. Goodman, PhD, is president and CEO of the National Center for Policy Analysis. He is also the Kellye Wright Fellow in health care. His Health Policy Blog is considered among the top conservative health care blogs where health care problems are discussed by top health policy experts from all sides of the political spectrum.

Death of a Porn Star

 

Porn stars all across San Fernando were told to put their clothes back on and go home a couple of weeks ago on the news that a 29 year-old adult actress named Cameron Bay tested positive for HIV.

Shortly thereafter, the Internet lit up. News, judgments, and jokes shot left and right in newsrooms as freely as bodily fluids fly on set. Countless reporters and pundits surely worked overtime to do the deep background: who were Ms. Bay’s co-actors, who did what to whom, and inquiring minds want to know: were condoms used? Imagine the frenzied speculation, all those sticky keystrokes.

Don’t get me wrong: the details of the whodunit have medical import. Public health workers need to find who is at risk. Those who are at risk need testing and education including reminders that early tests can be falsely negative and must be repeated. Since this isn’t the first case of HIV among the scantily clad actors of San Fernando, CA, Ms. Bay’s diagnosis demands we try again to get porn stars to practice safer sex. My guess is legal maneuvers will never do much to affect the sex lives of the nude and infamous, but if porn viewers could learn to have fun even with a condom on set there might be a hope.

Twitter captured all this and more. It showed the diversity of our reactions to Ms. Bay and people like her. Some tweets expressed a sense of inevitability:

Some were judgmental:


Continue reading…

The Ethics of Stupidity: Should a Good Doctor Refuse to Treat an Obese Patient?

Several folks have been kind enough to point out this story, and suggest that I may have an opinion on it:

[A woman from] Shrewsbury, Mass., claims that Dr. Helen Carter, a primary care physician at the UMass Memorial Medical Center in Worchester, refused to treat her because she is clinically obese…

It seems the good doctor has decided not to care for anyone (it is unclear if the prohibition applied to all patients or just to females) weighing over 200 lbs. Apparently there was a nearby specialty facility capable of caring for obese patients, so no one was being sent away with no resource to medical care.

There is nothing either illegal or unethical about this policy, according to the AMA and others. Much hullabaloo has ensued in the various comment trails, with many people stating that it should be (illegal. unethical, or both.) They are wrong. The only thing this physician has done is set her weight limit unreasonably low.

Here are the magic words: Scope of Practice. It means that doctors have not only the right but the ethical and legal responsibility to limit the care they provide based on their capabilities, their training and their experience, which together also translate to “comfort level”.

Continue reading…

assetto corsa mods