In Howard Brody and Eric Avery’s Medicine’s Duty to Treat Pandemic Illness: Solidarity and Vulnerability, they conclude physicians have a duty to treat pandemic illness because there is “no single ethical foundation for a duty to treat that would be commensurate with the needs posed by an emerging infectious disease pandemic” (Brody, 42). While I respect and understand the reasons behind their conclusion and appreciate their consideration to individual commitments and social values, I do think they fail to speak to some other ideas in question such as, what does it mean to be a physician?

The authors claim “by announcing to the community they are practitioners of medicine, physicians implicitly accept and undertake these duties,” (Brody, 40) but this raises the fundamental question of what it means to be a physician. As mentioned in the article, some physicians reacted to the assumption of their duty to treat with thoughts such as “Wait a minute—I never signed up for this” (Brody, 42). This got me wondering, why do people become physicians? Is it for the “awe of discovering the human body, the honor of being trusted to give advice, the gratitude for helping someone through a difficult illness”, for the prestige of the “Dr.” title, for the financial means it provides, or for another reason (Ofri)? Whatever the reason may be, these few listed options make me question whether all physicians go into medicine so that they may “help people” as many of my pre-med colleagues would say. There are many different professions and roles people can take on to help people, and perhaps, people take on the role of physician for the science rather than the people-aspect. If that is the case, we could argue that they indeed did not “sign up for this (referring to endangering oneself for the sake of the patient).” That being said, “the tradition of the American Medical Association, since its organization in 1847, is that: ‘what an epidemic prevails, a physician must continue his labors without regard to the risk to his own health” (Daniels, 37). So, in a way, physicians should know what is expected from them. However, I acknowledge reality is not so black and white. Some physician specialties to consider are: anesthesiologist, cardiologist, dermatologist, endocrinologist, family medicine, forensic pathologist, hematologist, infectious disease specialist, neurologist, oncologist, psychiatrist, radiologist, sleep disorder specialist, sports medicine specialist and more. There are so many different types of physicians and each specialty has different degrees of exposure to hazard. I wonder if the strict adherence to the duty to treat would deter people from entering certain specialties innately more prone to hazards involved with pandemics (ie. infectious diseases, etc). There are many frustrations that come with the role of a physician including the short amount of time allotted to visiting patients and the documentation and technical duties that come with patient visits.

To read more on the debate over duty to treat, I recommend the book, which comes to mind called Five Days at Memorial by Sheri Fink. It is a book about Hurricane Katrina wreaking havoc and sending hospitals such as Memorial into a state of crisis. While some healthcare professionals flee the storm and leave behind patients, others stay at the hospital and continue giving care, working till exhausting and continuing despite being understaffed and having limited resources. This parallels the treatment of pandemics in that health care professionals put themselves in harms way.

I also recommend checking out this article, “Duty to Treat and Right to Refuse”, by Normal Daniels: https://www.jstor.org/stable/3562338?seq=1#page_scan_tab_contents

While I hope physicians take on the duty to treat no matter what, I ultimately still see the role of treating during pandemic as supererogatory. I see these healthcare workers as humans first, then physicians. If they want to prioritize their own health, family, or something else, they should be able to do that.

Citations

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York, NY: Oxford UP, 2001. Print.

Brody, Howard, and Eric N. Avery. “Medicine’s Duty to Treat Pandemic Illness: Solidarity and Vulnerability.” Hastings Center Report. The Hastings Center, 15 Jan. 2009. Web. 16 Apr. 2017.

Fink, Sheri. Five Days at Memorial: Life and Death in a Storm-ravaged Hospital. New York: Broadway, 2016. Print.

“Medical Specialists – Types of Specialists.” WebMD. WebMD, n.d. Web.

Ofri, M.D. Danielle. “Why Would Anyone Choose to Become a Doctor?” The New York Times. The New York Times, 21 July 2011. Web. 17 Apr. 2017.

Thomas, John E., and Wilfrid J. Waluchow. Well and Good: Case Studies in Biomedical Ethics. Peterborough: Broadview, 1987. Print.

I disagree with the conclusion “routine childhood immunization should not be compulsory if adequate levels of immunization can be achieved by other means,” by Isaacs, Kilham, and Marshall [will be referred to as “Authors”] in “Should routine childhood immunizations be compulsory?”

If I’m being honest, I feel troubled by my own opinion because it contrasts with that of published scholars affiliated with the Departments of Immunology and Infectious Diseases, the Children’s Hospital at Westmead, the Paediatric Trials Unit and the Department of Paediatrics, the Women’s and Children’s Hospital. Nonetheless, in this blog post, I will outline the reasons for my disagreement.

The Authors base their conclusion on “ethical and practical reasons” (Issacs). Ethical concerns they mention include: autonomy, parental rights, coercion, trust, and weight of risks-benefits. And, the only practical reason they mention is difficulty enforcing.

“Practical” Reason: Enforcement

Because the Authors only present one practical reason, I choose to address this point first. The authors frame the physical restrainment of a child for immunization as an aggressive act comparable to assault. This comparison, in my opinion, is exaggerated and dramatic as no threat is posed and there is no intent of physical harm or injury. This opinion is made considering assault as “an act that threatens physical harm to a person, whether or not actual harm is done” (Oxford Dictionary). The Authors say restrainment for immunization is only “justifiable in a situation of extreme risk,” but they fail to provide criteria of what is considered ‘extreme’ and ‘risky’ (Issasc). Infectious diseases can definitely be considered a potential risk, and in the way I see it, immunization is actually preventing extreme risk.

Ethical Reasons

Parental Rights and Autonomy. The arguments for parental rights and autonomy are weak. Immunizing one’s child does not make or break a parental style of child rearing. Receiving an immunization(s) does not directly shape a child’s habits, values, morals, or beliefs. The Authors, themselves, even mention the ethical consideration that “ people who are afraid of harming their child by immunization …[generally tend] to be more worried about causing damage to one’s child by doing something to them rather than by not doing it” (Issacs).

The Authors counter their very own argument the “protection of the community only applies for transmittable disease” with the concepts of herd community and free riders. They say “an important implication of herd community is that failure to immunize a child against a transmissible infection may not only render that child susceptible to infection, but may imperil other children” (Issacs). Perhaps it is okay (not terribly harmful and dangerous for the community) if a small handful of people are not immunized. Even then, we cannot all be the exception to the rule; we cannot all be free riders because as “the number of free riders increases, the population becomes more susceptible, and disease will start to circulate” (Issacs).

Risk-Benefits and Trust. The Authors do not specify which routine childhood immunizations should not be compulsory. So, assuming their argument encompasses all routine childhood immunizations, their argument for risk-benefit is ineffective. Although the “risk benefit equation varies from disease to disease,” the overall benefits of immunizations outweigh the risks for the diseases. Vaccines are scientifically proven to be effective. It is the very reason why immunizations are worthwhile. In fact, “most childhood vaccines produce immunity about 90 – 100% of the time” (U.S. Department of Health and Human Services).

The Authors claim “making immunizations compulsory renders trust redundant,” which implicitly claims there is a problem with redundancy (Isaacs). To that end, I ask, is there a problem with redundancy? Is it hurtful or inappropriate for health care professional to repetitively give reassurance? I do not think so. Also, does the enforcement of immunization invalidate physician-patient trust? Nope.            The Authors associate enforcement with coercion, which is paradoxical to their saying if “high levels [of immunization] can be maintained through encouragement and incentives, this effectively achieves the aims of the moderate communitarian, without the need for legislation” because incentivizing can be considered a form of coercion as well. In fact, when talking about inducement, the Authors pose the question: “Could this be seen as a form of coercion, particularly to poorer families who are far more dependent on such welfare payments”(Issacs)? I think, yes. Enforcement of immunizations, I think, would be an act of paternalism by the government.

Alternatives to compulsion

Education. While I disagree with the Authors overall conclusion, I do agree with their idea we should increase education re: benefit of immunizations. However, dispersion of information and health care education can be a difficult and challenging process. For example, there may be “unreliable funding and resources,” and we need to consider “long duration [is] needed to create lasting change” (World Health Organization). Perhaps eventually we will reach a point where everyone is educated, but in the meantime, I believe it better to implement compulsory immunization.

Outbreak Legislation. While it is possible to “enact emergency legislation to compel immunization,” in the event of an outbreak, pandemic, or bioterrorist attack, it would be a race against the clock or a matter of luck for those who are not immunized. Would it not be better to have received the immunization ahead of time? We should not view this only as a matter of planning for what might or could happen, but also for the sake of matters such as communitarianism, consequentialism and community rights. It’s true; “a circumstance of risk involves a possible occurrence of something that has been valuated as harmful along with an uncertainty about its actual occurrence” (Beauchamp, 230). But we ought to wonder: is it worth the risk?

No-fault and compensation schemes. While I do acknowledge vaccines sometimes harm people, I still believe the benefits of immunization outweigh the slim risks. I do not find it necessary for me expand on the effectiveness of vaccines which counters the few cases. That being said, monetary compensation is viable as the amount spent on treating vaccine preventable diseases is incredible. I defer to the following to prove my point: https://www.cdc.gov/vaccines/programs/vfc/pubs/methods/

Closing-thoughts

The Authors have made several strong and valid points in favor of compulsory immunization. They have even made arguments for compulsory immunization, which counter the very arguments they make against compulsory immunization. Now that I have expressed my opinion and provided the facts and personal sentiments to why I disagree with the Authors, I’d love to hear what you guys think. Do you agree with the arguments against compulsory immunizations the Authors make?

Citations

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York, NY: Oxford UP, 2001. Print.

Isaacs, D., HA Kilham, and H. Marshall. “Should Routine Childhood Immunizations Be Compulsory?” Journal of Paediatrics and Child Health. Blackwell Science Pty, 22 June 2004. Web. 26 Mar. 2017.

“Types of Healthy Settings.” WHO. World Health Organization, n.d. Web. 26 Mar. 2017.

U.S. Department of Health and Human Services. “Vaccines.gov.” Vaccines Are Effective. U.S. Department of Health and Human Services, 11 Oct. 2006. Web. 26 Mar. 2017.

“VFC Publications: Supplement.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 23 Apr. 2014. Web. 26 Mar. 2017.

The underlying question of Case 6.2 Sue Rodriguez: “Please Help Me to Die” seems to be: should physician-assisted suicide be permitted?

Facts to consider include the condition of the disease, laws and policies. In this case Amyotrophic lateral sclerosis aka. Lou Gehrig’s Disease gives the patient 2-14 months to live with the eventual loss of motor functions. Polices and laws to consider determined by the patient’s citizenship is the Canada Charter of Rights and Freedoms; we specifically observe the policies S.1, S.7, S.12, and S.15(I). While these are important, I focus this blog post more on the values in question.

Consider: rights

In class we discussed rights, which makes the claim people should do something for you. The two rights in consideration are negative rights and positive rights. Negative right is the right to live or not be interfered with. Positive right is the right to health care. We could argue health care professional are obligated to “harm” the patient and not interfere with the “life/living” of the patient. However, I suggest we consider in health care, “the right to life has traditionally been taken as a negative right… however, [it] seems to be moving towards a positive right, not just to remain alive, but to be enabled in doing what we want to with our lives, and thus disposing of them if we so choose” (Philos).

Consider: language

Case 6.2 Sue Rodriguez: “Please Help Me to Die” —I question why Beauchamp and Childress decided to title the case “please help me to die” and frame it with a negative connotation right off the bat. I wonder if this negative connotation influences the readers’ (our) opinions of whether assisted suicide is be “right” or “wrong” and should or should not be permitted. Would rephrasing make a difference? Perhaps we should consider some of the following titles:

• “Please help stop my suffering”
• “Please help me stop the continuation of my disease”
• “Please help me maintain my autonomy”
• “Please help me keep my dignity”
• “Please respect my decision”

Additional Considerations

Idea: Physician-assisted suicide is unnecessary because the suffering of dying patient can always be relieved through proper pain-management and palliative care (*Palliative: relieving pain without dealing with the cause of the condition)

My response: Perhaps physical pain can be alleviated, but does this take into account mental and spiritual pain and/or suffering? How can this type of pain be managed

“Mental pain is less dramatic than physical pain, but it is more common and also more hard to bear. The frequent attempt to conceal mental pain increases the burden: it is easier to say “My tooth is aching” than to say “My heart is broken.” —C.S. Lewis, The Problem of Pain

Idea: Physician-assisted suicide is unnecessary because individuals can always find the means to kill themselves without a doctor’s assistance.

*Trigger warning for suicide content*

My response: Is it ethical to deny patients physician-assisted suicide and force them to turn to other means of suicide that are potentially more dangerous, harmful, or painful? Some means of suicide include: inhalation of fumes, use of gun, knives, hanging, jumping from fatal heights, ingesting dangerous combinations of drugs, etc. Couldn’t providing physician-assisted suicide as a viable option help filter and catch individuals considering suicide? This gives healthcare professionals to opportunity to consult patients on the matter instead of them “impulsively” or “unreasonably” attempting suicide. The “most dangerous form of suicidal desire is caused by the simultaneous presence of two interpersonal constructs—thwarted belongingness and perceived burdensomeness (and hopelessness about these states,” (Orden) but with the opportunity to speak to patients considering suicide, physicians could make sure patients are thinking in a logical, reasonable manner and understand their options (future) and have all the facts. Wouldn’t this be a more responsible methodology? Through this filtering system, health care professionals could ensure the patients themselves, if they are the one making the decision, meet the qualifications for decision makers listed by Beauchamp and Childress:

1. “Ability to make reason judgments (competence)
2. Adequate knowledge and information
3. Emotional stability
4. A commitment to the incompetent patients’ interests, free of conflicts of interest and free of controlling influence by those who might not act in the patient’s best interests” (Beauchamp, 190). (In the filtration perspective, the patient remains free of controlling influence of others.)

Idea: physician-assisted suicide is a form of killing, which is inconsistent with a physician’s duty never to harm a patient

My response: Isn’t physician-assisted suicide a form of keeping patients from more harm? A way of preventing more pain? I personally agree with Angell, “The greatest harm we can do is to consign a desperate patient to unbearable suffering.” Beauchamp and Childress’s conditions justifying physician-assisted suicide include:

1. A voluntary request by a competent patient
2. An ongoing patient-physician relationship
3. Mutual and informed decision making by patient and physician
4. A supportive yet critical and probing environment of decision making
5. A considered rejection of alternatives
6. Structured consultation with other parties in medicine
7. A patient’s expression of a durable preference for death
8. Unacceptable suffering by the patient
9. Use of a means that is as painless ad comfortable as possible (Beauchamp, 184).

This list of conditions, in my opinion, is a more complete or holistic approach and exists as a “continuum of medical care” (Beauchamp, 188). This protects patients, especially patients deemed incompetent, by considering perspectives of “families, courts, guardians, conservators, hospital committees, and health professionals, which all merit consideration.” (Beauchamp, 188). I believe this is a good step towards combatting dehumanization of patients or reduction of patients to their disease or condition. This balances the non-human aspect of the science and medicine while still considering the emotion and reality of the human beings involved.

Citations:

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York, NY: Oxford UP, 2001. Print.

Lewis, Clive S. The Problem of Pain. New York, NY: HarperCollins, 2014. Print.

Orden, Kimberly A. Van, Tracy K. Witte, Kelly C. Cukrowicz, Scott Braithwaite, Edward A. Selby, and Thomas E. Joiner. “The Interpersonal Theory of Suicide.” Psychological Review. U.S. National Library of Medicine, Apr. 2010. Web. 27 Feb. 2017.

“Right to Life, Right to Die and Assisted Suicide.” Journal of Applied Philosophy. U.S. National Library of Medicine, 2004. Web. 27 Feb. 2017.

The question presented by Case 10.3 “should patients be informed of remote risks of procedures” seems to appeal to the “obvious” answer: yes, patients should be informed. The elements of the situation, however, are not so simple. I would like to consider the points: (1) risk of death and (2) full disclosure and trust.

What poses risks of death?

Many daily activities and interactions are likely to have some “remote risk of death” (Thomas, 300). There are common medical procedures that can cause death, things in your household that can kill you and your daily choices such as diet and exercise can lead to fatal chronic diseases. To name a few: walking, drinking alcohol, smoking cigarettes, taking the stairs, choking, getting bit by a dog, vehicular accidents, and exposure to forces of nature. According to Medical News Today, the top 10 reasons for death in America are heart disease, cancer, chronic respiratory diseases, unintentional injuries/accidents, stroke, Alzheimers, diabetes, influenza and pneumonia, kidney disease and suicide. There is even a show called 1000 Way to Die, which narrates silly, yet real, causes of death. So, what poses risks of death? Pretty much anything and everything.

Is there such thing as full disclosure?

What is the practicality of full disclosure? Realistically, is it feasible to truly explain to patient(s) a procedure or treatment to a level of comprehension comparable to the comprehension of a medical professional, who has dedicated years to studying and understanding these procedures/treatments? The complexity of health and medicine is so immense and great; this is a reason why within medical professions there are many different specializations. It is not feasible to expect one person to know everything. The act of going to professionals and seeking health care requires an automatic certain level of trust. We trust healthcare workers to act in the patient’s best interest, take care of our loved ones, fight infectious diseases, and “save” patients. We rely on these people with specialized profession because they know and understand their role better than those with less knowledge in their field of study.

In the case of Joe and the anesthesiologist, I believe the anesthesiologist did give full disclosure. Precondition threshold elements of competence and voluntariness are fulfilled, and consent elements of decision and authorization are also fulfilled. The only division under debate would be information elements including elements of disclosure and understanding. Yes, “patients have a right to be given full information about any procedure to which they are subjected,” (Thomas, 301) and yes, healthcare workers are “obligated to disclose a core set of information” (Beauchamp 125). But, the key word is CORE. In the case of Joe, death was not a CORE part of information. I disagree with Joe’s son that the anesthesiologist “show[ed] lack of respect for patients as persons” (Thomas, 301). Healthcare workers such as the anesthesiologist do their best to inform patients while “consider[ing] the burden of fear and distress placed on patients” (Thomas, 310). Restaurants do not warn customers the risk of choking and dying before they order. Car dealerships do not give statistics of vehicular death before selling you a car. The anesthesiologist does not overwhelm patients by listing every bullet point of information about a procedure. Plans, unfortunately, do not always proceed as planned, and unexpected events cannot always be anticipated.

So the big question: who is right—Joe’s son or the anesthesiologist? I wouldn’t go so far as to say one party or the other is “right”, but rather, the anesthesiologist is not in the wrong.

Questions (for us) to consider: would you rather be imposed with burden of fear or remain blissfully ignorant? Have you ever withheld information from someone else? Is Joe’s son merely looking for someone to blame in his mourning and sadness? How can healthcare professionals, patients, and their families better communicate with more compassion?

Citations:

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York, NY: Oxford UP, 2001. Print.

“Danger of Death!” The Economist. The Economist Newspaper, 01 Sept. 2014. Web. 29 Jan. 2017.

Nichols, Hannah. “The Top 10 Leading Causes of Death in the US.” Medical News Today. MediLexicon International, 21 Sept. 2015. Web. 29 Jan. 2017.

Thomas, John E., and Wilfrid J. Waluchow. Well and Good: Case Studies in Biomedical Ethics. Peterborough: Broadview, 1987. Print.