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The Point - January 2015

In this issue:

Article #1

Excerpted from "Life-and-Death Decisions That Keep Doctors Up at Night," Medscape. December 15, 2014 — Few professions invoke such a sweeping array of ethical questions as medicine. Although ethics may factor into life-and-death decisions, they can also play a role in everyday decision-making, such as whether or not to accept a lunch invitation from a pharmaceutical representative or ask a former patient on a date. On many of these issues, physicians are sharply divided.

Although six U.S. states have laws permitting physician-assisted suicide, doctors—like much of the general public—are deeply divided over the issue. A slim majority of doctors (54%) say they favor allowing physician-assisted suicide. Still, a passionate minority (31%) protest that assisted suicide violates the Hippocratic Oath.

When it comes to owning a harmful error that would affect a patient, 9 out of 10 (91%) of doctors say honesty is the only policy. Despite this near unanimous consensus, 6% of respondents say there are or could be situations in which it would be acceptable to cover up or fail to disclose a mistake. Others acknowledge that in a perfect world, they would step forward, but are less inclined to do so in light of the danger of malpractice suits.

When it comes to accepting perks, most doctors are adamant that they cannot be "bought." Nearly 6 out of 10 (59%) say that perks, such as meals and speaking fees, won't sway their decisions. Many regard restrictions on interactions with pharmaceutical representatives as "puritanical." Still others (30%) say that although they like to believe they couldn't be swayed, they recognize that data indicate otherwise and therefore oppose such interaction.

Commentary #1

Dr. Robert OrrClinical Ethicist and CMDA Trustee Robert D. Orr, MD, CM: Medscape recently distributed a survey to more than 21,500 physicians from the U.S. and Europe asking their opinions or practices on several dilemmas in clinical and professional ethics. The results are interesting and varied, but we must be cautious in interpreting these results. Decisions about right and wrong are not a matter of a majority vote. Perhaps your mother, like mine, taught me that, ‘Just because everybody is doing it doesn’t make it right.’

“There have been numerous reports of physician surveys on the legalization of physician-assisted suicide (PAS), and we know results vary depending on the wording of the question. Recent surveys in the U.S. show that 35 to 55 percent of physicians support legalization of PAS; physician support has consistently been higher in Europe. The most recent comparable international survey found 65 percent opposed legalization. Importantly, when some surveys asked about personal beliefs rather than public policy, a large majority (about 75 percent) of physicians have said that they would be unwilling to participate even if it were legal. In addition, in at least one survey a large majority said they believed it would be impossible to ensure protection from abuse.

“Physician opinions about honesty in reporting harmful errors not surprisingly show the great divide between the moral ideal versus the reality of human psychology. It reminds me of the ongoing struggle Paul describes in Romans 7. The survey results suggest that the moral ideal persists in regard to conflicts of interest (i.e., most physicians believe their practices cannot be altered by accepting ‘perks’ from vendors). However, empiric research consistently shows the opposite. One fascinating study showed that only 2 percent of respondents felt gifts from pharmaceutical reps influenced their prescribing practice, though 30 percent of the same sample believed those same gifts influenced their colleagues. It’s the Pharisee (‘God, I thank you that I am not like other people…’) versus the tax collector (‘God, have mercy on me, a sinner’) (Luke 18:9-13, NIV 2011).

“Whether you rely on Paul, Luke or my mother, don’t take the Medscape survey results too seriously.”


Physician-Assisted Suicide Fact Sheet
CDD STAT Interview with Kara Tippetts
CMDA Ethics Statement on Industry Relationships

Article #2

Excerpted from Republicans Introduce Five Anti-Abortion Bills In First Days Of New Congress,” Huffington Post. January 8, 2015 — Emboldened by a new Senate majority, Republicans in Congress introduced five abortion restrictions in the first three days of the new legislative session that would severely limit women's access to the procedure.

Reps. Trent Franks (R-Ariz.) and Marsha Blackburn (R-Tenn.) on Monday reintroduced a ban on abortions after 20 weeks of pregnancy, which the GOP-controlled House already passed once in 2013. And Sen. David Vitter (R-La.) introduced four bills on Wednesday that would bar Planned Parenthood from receiving federal family planning funds, require all abortion providers to have admitting privileges at a local hospital, ban abortions performed on the basis of gender, and allow hospitals, doctors and nurses to refuse to provide or participate in abortion care for women, even in cases of emergency.

Planned Parenthood Action Fund President Cecile Richards condemned the onslaught of anti-abortion bills on Thursday and the attack on her own organization. “The public wants Congress to protect women’s health, not interfere in women’s personal medical decisions," she said in a statement, "which means making sure all forms of birth control are affordable, women can get preventive care at Planned Parenthood and other trusted providers, and abortion remains safe and legal."

Abortion rights advocates expressed frustration that Republicans are launching new attacks on abortion at a federal level after running as moderates on the issue in the 2014 midterm elections. "The Republican Congress is like Groundhog's Day," said Ilyse Hogue, president of NARAL Pro-Choice America. "Just as they did in 2010, anti-choice Republicans hid their agenda on the campaign trail by promising to work to address the economy or the numerous other issues.”

Commentary #2

Dr. Gene RuddCMDA Senior Vice President Gene Rudd, MD: “Reporters need things to say and write about, so they ask lots of questions. Just today a reporter asked if I thought there would be a wave of abortion legislation in 2015. My response, ‘Of course; and in 2016 and onward.’ Sadly, I do not see this critical social issue resolved in 2015.

“The main thrust of the interview (and I assume the article being written) was to challenge the right of Congress to interfere with the patient-doctor relationship. Here are some of the thoughts I shared:

  • Patients and doctors already have a myriad of laws and regulations governing the relationship.
  • We might argue there are too many and some are not needed or inappropriate.
  • But we cannot rationally argue that the patient-doctor relationship is outside the law.
  • When a patient has an inflamed appendix, we have laws and regulations that say who may perform surgery and what standards must be met.
  • Laws and regulations are even more important when a third life is involved.
  • We don’t allow mothers to abuse or kill their born children, even if she and her doctor thought that would be best for her mental health.
  • Laws that restrict abortion are simply society’s effort to decide how early in life we will bestow protection.
  • While I favor protection from life’s beginning, for 2015, I will be pleased to see our society begin protecting life from 20 weeks gestation.

“Just as I was writing these comments, the American Congress of Obstetricians and Gynecologists (formally American College) announced they would hold a press conference to decry Congress’ intrusion into the patient-doctor relationship. The battle continues.”


CMDA’s Abortion Ethics Statement
The Modern Implications of Abortion by John Patrick, MD
Visit our Freedom2Care legislative action website for easy-to-use forms to voice your values to your legislators.

URGENT ACTION: The US House of Representatives will vote on the Pain-Capable Unborn Child Protection Act during the March for Life this Thursday, Jan. 22. This bill will ban abortions after 20 weeks, when our own members and others have testified that developing babies have all the architecture needed to feel pain at intense levels. Click here to use our Freedom2Care pre-written, customizable form to urge your Representative to support this important bill.

To attend the March for Life, click here. Our VP for Govt. Relations will represent CMA on stage at this annual event that marks the Supreme Court’s 1973 Roe v. Wade abortion decision.

Article #3

Excerpted from Girl says she knows she'll die without chemo,” The Associated Press. January 8, 2015 — A 17-year-old girl being forced by state officials to undergo chemotherapy for her cancer said Thursday she understands she'll die if she stops treatment but it should be her decision. The state Supreme Court ruled earlier in the day state officials aren’t violating the rights of the girl, Cassandra C., who has Hodgkin lymphoma.

Cassandra told The Associated Press in an exclusive interview from her hospital it disgusts her to have "such toxic harmful drugs" in her body and she'd like to explore alternative treatments. She said by text she understands "death is the outcome of refusing chemo" but believes in "the quality of my life, not the quantity." Cassandra will be free to make her own medical decisions when she turns 18 in September. She, with her mother, had fought against the six-month course of chemotherapy. The case centered on whether the girl is mature enough to determine how to treat her Hodgkin lymphoma, with which she was diagnosed in September. Several other states recognize the mature minor doctrine.

Cassandra is confined in a room at Connecticut Children's Medical Center in Hartford, where she's being forced to undergo chemotherapy, which doctors said would give her an 85 percent chance of survival. Without it, they said, there was a near certainty of death within two years.

The teen's mother, Jackie Fortin, of Windsor Locks, said after the arguments Thursday that as a single mom for the last 15 years she wouldn't allow her daughter to die. She said they just want to seek alternative treatments that don't include putting the "poison" of chemotherapy into her body. After Cassandra was diagnosed with high-risk Hodgkin lymphoma, she and her mother missed several appointments, prompting doctors to notify the state Department of Children and Families, court documents say. Child welfare agency officials defended their treatment of Cassandra, saying they have a responsibility to protect her.

Commentary #3

Dr. Nick YatesCMDA Member and former member and chair of the CMDA Ethics Committee Nick Yates, MD, MA (Bioethics): “Adolescent decision-making has troubled parents for eons, and there is – likely – no relief in sight. The American Academy of Pediatrics has much to say on this topic. Many experts in adolescents feel that teenage decision-making is informed by 1) a teen’s feeling that ‘rules’ don’t directly apply; 2) that peer relationships guide decision-making; and 3) that a teen’s reasoning often disregards germane information.

“Recognizing these potential limitations in forethought, a teenager attempting to engage in life or death decision-making must demonstrate decision-making capacity. Typically this is acknowledged through ‘informed consent’ – which is acknowledged when an individual has full medical information and decision-making capacity and can make a decision that is free from coercion. Decision-making capacity, while being more complicated (to acknowledge), does not necessarily require a legal determination, but it does require demonstration that the teen knows and understands the medical information, is able to weigh the ‘pros and cons’ and is willing to make a decision between medical options. Decision-making capacity is demonstrated when one is complicit with routine medical evaluations and demonstrates mature behavior. ‘Standard and routine’ life-saving medical therapies may be declined under the proper setting if informed consent is recognized.

“When attempting to obtain court approval for end-of-life decision making, the teen must demonstrate maturity, dignity and decorum. Age is not necessarily a disqualifying factor, but immature or improper behavior certainly might be. Decision-making capacity may not be granted if medical appointments are missed and if a patient is missing for a week.

“End-of-life decision making is difficult under the best of circumstances, and it certainly must not be a platform for pontification.”


CMDA’s Patient Refusal of Therapy Ethics Statement
American Academy of Pediatrics Statement on Informed Consent
Bioethics Series: Informed Consent

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