17 posts tagged “ethics”
Day by day, I think my enthusiasm for this profession is fading away little by little. I think it's because of the way our health system has turned out. Not only in M'sia I guess but around the world too. Darn...I could have taken any course...I mean any course in university.
You can't blame some doctors for a little nonchalant about their patients, a little cold hearted at seeing death or a little non-committal to treatment decisions. Today there is a paradigm shift in patients' thinking. Today's patients do not put priority on "tender, loving, care". They want guarantees they get their diagnosis STAT, they want to be cured STAT and they expect state of the art treatment FOC if possible. As soon as something adverse happens, they are quick to point fingers. Somebody must be responsible for that. After all the government keeps on harping that we have "World class infrastructure, world class facilities and world class expertise" so nothing should go wrong. (Btw, I thought it is mainly medical personnel that is migrating south in droves but a recent article in the newspapers, lawyers, architects etc etc are also leaving M'sia in droves)
Well, so today's doctors also have a paradigm shift. Avoid being blamed at all costs. Despite knowing the futility of treating an extremely poor prognosis patient who will obviously die (some people may argue that a miracle can happen), doctors offer all kinds of "possible" investigations and treatments. Never mind that we do not have access to the treatment, never mind that we do not have enough beds for treatment, never mind that patient obviously cannot afford it and never mind that it is unlikely to be of any benefit (but still "possible", yeah anything is possible). But if the patient gets worse or dies, the doctor is absolved of any "negligence". "Hey, I told you so you need this and that but you couldn't get it/it's not available so it's not my fault"
I just wonder if it is ethical to offer a treatment which we obviously have no access to. Patients will feel shortchanged and distressed that he is not getting that "elusive state of the art treatment" and lose hope. But hey, that's not the doctors' problem. Doctors are just adapting to the demands of todays' healthcare and society's expectations. Defensive medicine. Avoid being blamed at all costs. Perhaps later must refer the patient to psychiatry for depression as well...how ironic!
Patients also are are quick to demand anything in the public sector, but if it is the private sector I guess you'll have to talk till your jaw ache to justify a RM100K medication which is no miracle cure either - but patients expect a miracle cure because they are paying so much !! On the other hand, once you mention the costs of treatment to the public patients, they shut up very quickly, just for a brief moment...before they open up again and say why can't they get it free from the government !!! Dang...can never win one.
Anyway defensive medicine is here to stay whether anyone likes it or not.
Sometimes patients (and relatives ) do not like me very much as I'm frequently the harbinger of doom. Well, I have the unenviable task of breaking bad news to the patient (and frequently the relatives too). And of course as ridiculously as it sounds I do ask if they want to know the diagnosis.
I feel to give inappropriate hope or unreasonably high hopes to a patient is not right. Preparing a patient for death is just as important as giving hope to life. It's a tough balance. But when there is an 95% chance of a patient dying...would you prepare him for death or lift his hopes up for the 5% chance? Colleagues may disagree with me, but I'm being pragmatic and sometimes patient's relatives do not like to talk to me because of this.
I think preparing a person for death is extremely important. A person may have personal stuffs to settle, dark closets to open, people to forgive, ask for forgiveness etc etc. Giving inappropriate hope may deter the patient from doing things dear to him before he leaves this world. Patient or their relatives may start to look for futile treatments to improve the 5% chance. They may spend lots of money for dubious treatments (futile treatments are never a justification for desperation), numerous 2nd, 3rd and 4th opinions, makes excessive demands to their loved ones, ultimately leaving everything in a mess when they pass away. Not to mention the relatives later blaming the nurses and doctors and trying their best to find any minor fault which they think may have contributed to his (hastened) death.
The common reaction given by the patient (and more frequently their relatives ), especially Christians I must admit, is that perhaps a miracle will happen. Yes, a miracle can happen I agree. But we cannot make decisions based on the hope that a miracle will happen. Yes, you might survive a 10 storey fall by miracle, but would you bet on surviving the fall?
Preparing someone for death is difficult. It's unpopular, nobody likes to hear it, nobody likes to do it. And nobody will thank you for telling them chances are they are dying. Not in our Asian culture anyway. We avoid it, we give inappropriate hope, we pass the buck, we refuse to address it. But I think it's absolutely necessary at the risk of looking as if we are "taking the easy way out", for not trying hard enough.
I had a 90 year old rather frail patient with end stage kidney disease who needs dialysis. Everybody knows dialysis slots are extremely limited (we are not in USA or Europe) and nobody wants to "give a death sentence" to this patient. She may get a couple of "urgent" dialysis but long term slots are not available. So the decision was left hanging. And unfairly I feel, doctors pushed the decision to the patient's children! Hey dialysis is not risk free, the patient may well collapse during dialysis. What the patient's children said? They said " Doc, you do what you think is best. DO NOT ask us again for our decision (to dialyse or not). Several doctors have asked us the same thing many many times ". My colleague and I made the final decision - rightly or wrongly. I would have done the same for myself.
On the other extreme there are relatives of dying patients who wants "Everything to be done to ensure the patient lives for as long as possible", whatever living means to them, perhaps to avoid their own conscience of "killing" the patient. Prolonging death is unethical. Not to mention the extremely limited resources which perhaps could be used to save someone else.
Recently was on call, saw the numerous patients who are/were being artificially ventilated for various reasons. Among the reasons were inoperable metastatic lung cancer, liver failure with cirrhosis, progressive/untreatable lung disease and hypoxic brain damage.Their prognosis is worst than dismal at best. I really don't know if the patients really want to go like this. Is this really how they want to be "treated" or to leave this world? In any case they have no choice - not over here. Are we "treating" their family members rather than the patients? The world is a stage...
What would the patients say if they can or are allowed to make their own decisions? In any case, it would be over-ruled by the family members on the premise that the patient is not mentally alert or in right frame of mind to make that decision. Who wants to have a heated argument with the family members of a DYING patient? And with the sequelae that follows...
The best way is to have a living will - a legally binding document which cannot be over-ruled by the family members. To state how they want to be treated if they have a terminal/life threatening condition. Alas this is a very alien concept here. In any case, any living will has to be voluntarily produced by the family member or a legal officer - which may be with-held or destroyed too.
It is very disconcerting to see terminal dying patients having tubes shoved into their lungs, their stomach and urinary tract. And members of the public/relatives ( who can tell who is who? ) going in and out of the ward, peaking here and there - like watching a bloody blockbuster movie. And they love seeing CPR being done - like it's an entertainment show. The healthcare personnel will appear "uncompassionate" if they ask the "relatives/visitors" to leave to attend to/ resuscitate the patient. Some of the healthcare personnel are harassed and scolded by these relatives too. And like Murphy's law, these patients WILL deteriorate during visiting hours when the ward is like a fish market. Some visitors will just REFUSE to leave because they say IT'S THEIR RIGHT TO BE THERE DURING VISITING HOURS. And they will just stand around looking at the "drama" involving other patients. Bloody B***tards !!
So are you going to stand there arguing with the visitors or resuscitate the patient? Your choice.
Ventilated patients gasping for their breath, sedated or even already unconscious are being poked daily for bloods, their every bodily functions being "taken care of" artificially. Swollen limbs, bed sores, bruises, haematomas everywhere. Faecal smell permeates the whole ward every time a pampers is changed. Until the patient's heart finally stop, inevitably.
Is this how you want to die?
If I have no realistic chance of a meaningful life,
Please spare me the indignity of a prolonged painful death,
Kindly do not shove tubes down my every orifice,
Please do not inflict more pain by poking me daily for bloods,
And above all, do not hook me up to a machine while I die.
In my practising experience, this term is a rather foreign term here.
Example 1:
An extremely ill elderly lady has end-stage kidney disease. She will succumb in days, weeks or maybe months if renal replacement treatment is not instituted. She is old and frail. Dialysis carries a significant mortality risk for her. She declined any dialysis despite proper explanation ( to reasons only known to her ). She was ready to leave this world. BUT...her relatives (including children) somehow insisted she must get dialysis and managed to "persuade" her to have the dialysis against her wishes. So she underwent a risky procedure and was dialysed. She developed multiple complications and was artificially ventilated. She is now on tracheostomy (a tube into the windpipe) for breathing. She developed severe pneumonia and will probably succumb to it soon. Now she is just lying there, apathetic to her surroundings and would allow anybody to poke her, prick her, dialyse her, feed her etc. She just lies there gasping...doesn't speak nor move, staring at the ceiling, oblivious to her surrondings. Only god knows what is running through her mind.
But probably her relatives will be satisfied with the "heroic effort". After all we've done "everything possible" to "save" her. Patient's rights? What's that? After all, as I've said before a dead patient cannot speak for you but a living relative can certainly create hell for you.
Questions like "Why the doctors didn't do anything to "save" her?" or "I will lodge a complain/sue you if you don't dialyse her and she dies" can be expected from relatives.
Example 2 :
Again an elderly bed bound frail lady with multiple co-morbidities including previous stroke has chronic lung disease with failing lungs due to disease progression which is basically untreatable. She is unable to breathe properly to keep herself well oxygenated. She was previously artificially ventilated before and was not fully conscious any longer. Her VIP politician son THROUGH THE PHONE insisted everything must be done to "prolong her life" despite explanation of her condition. Politics came into the picture also. Veiled threats were made. So finally she was put on an artificial ventilator again. She developed cardiac arrest, was resuscitated and is still unconscious. (probably due to stroke/brain damage). So there she is, lying unconscious, the ventilator breathing for her while she is waiting to die from an inevitable hospital acquired infection/cardiac arrest again. BUT son is probably satisfied. "Everything" has been done to "prolong her life" - more like prolonging her death. And the hospital is probably saved from a potential lawsuit or a complicated sequelae with politics in tow.
WHAT ABOUT A PATIENT'S RIGHT TO DIE IN A DIGNIFIED MANNER?
I pity the many junior doctors who are bullied by the relatives in this manner. Even myself have succumbed to these pressures at times. After all you have 30 other ill patients to take care of with 40 others waiting in the clinic downstairs. You can fight, you can try to protect the patients' rights. But when relatives keep barging in your clinic every 5 minutes "to discuss with you" and takes your precious time away from other ill patients, you ask yourself "Is this a battle worth fighting at the expense of other patients?" Are you prepared to get physical (trust me, this is a real possibility) if necessary? Are you prepared to go to court? Are you prepared to go through months of attending a complaints committee meeting? Are you prepared to write tons of rubbish reports? After all with or without intervention the patient WILL eventually die. After all who cares about the lack of beds for other more deserving patients?- not my problem. Who cares about wasting resources in a public hospital? - not my money. Just do whatever the relatives want and save yourself from A LOT of problems. Trust me, these thoughts run through EVERY DOCTOR in public service. The poor junior doctors most often are the ones getting bullied - they have their career to think of too. Sad scenario.
WHAT ABOUT PATIENT'S RIGHTS, I ASK?
Welcome to the real world!
While waiting for my Maggi mee to boil, I thought I would pen down something my colleague and I were debating earlier. My colleague from another unit is an enthusiastic photographer. He likes taking portraits during his free time. In fact he often takes photos of his wife ( or other gals ) and proudly show me his photographic skills.
The debate was this. He had asked one of my female Medical Officer (who is married - and with her husband's blessing, also a colleague) to pose for a photo shoot during the weekend. She agreed. He asked me to join him for the photoshoot. I gave it a thought but declined. It didn't feel right to photo shoot a subordinate even if it's outside work. I believe in separating social friends from subordinates. How to be impartial and uphold discipline if certain subordinates become social friends? What if I am accused of favouritism or even sexual harassment in the future if we fall out of friendship later? It doesn't feel ethical to me. But my colleague says, nothing wrong wat...friend friend only wat, she also never mind. Being a subordinate is not an issue.
Hmm...what do you think?
Furthermore this boy-girl stuff is always tricky. My spouse's classmate once told my spouse, boy and girl cannot be true platonic friends wan. Either become boyfriend and girlfriend or fight and stop being friends. Haiya....the male-female dynamics are so complicated.
Ok my Maggi mee is boiling.
I had a patient recently who was admitted with lethargy and some non-specific complaints. She seemed a little hostile. During my first encounter with the patient, she wasn't forthcoming and not very cooperative. I quickly did a quick examination because my house officer says she has an enlarged liver. To my surprise she was pale and had a large lymph node in the armpit and several at the neck. Liver was enlarged and hard.
She didn't allow further examination. After some suggestive questioning, I gather she already knew her diagnosis. She refused to tell us. She doesn't want to know anything else, refused further investigations and refused any treatment. I asked her how she wants to be treated- she said wait first. The only thing she wants to know is if she has dengue. She persistently asked me if she has dengue because the last night a house officer told her it could be dengue because the platelets were a little low!! ( which irritated me a little coz I had to repeatedly say many times I guarantee you 100 percent you don't have dengue )
After further suggestive questioning we knew she had the big C for some time. She had refused surgery and chemotherapy. She didn't want to tell the reason. The surgeons had tried to persuade her for treatment many times when she was at a curable stage but failed. She had gone to seek traditional treatment instead. She even claimed she got better after the traditional treatment.
We referred her to the palliative and psychiatry team but they didn' t make any headway with her also.
End result ? She died 2 days later. What baffles me is that she is not an uneducated illegal immigrant. She is a government officer! Some illegal immigrants are even more keen for proper treatment instead!
I wonder how much $$ she parted with for her traditional treatment. If traditional & complementary treatments are endorsed by the Ministry in their hospitals, who will be responsible if such patients sought treatment with these traditional practitioners IN THE HOSPITAL ? After all it will appear to be "endorsed" by the Ministry. Is this ethical?
In today's The Star here
This issue will not have come up if MAS was not so stingy. If the 1st class seats were empty, upgrading a passenger will not cost MAS an extra cent. Now instead, MAS is being sent a bill for services rendered. Not to say MAS will pay though.
Anyway the issue is, do doctors have a duty of care to anyone, anytime, anywhere? In the airplane, in a train, in a bus, in a cinema, in a concert, in a meeting etc etc.
Well, in my opinion, in this case, the duty of care primarily lies with the airline. I'm concerned that just because a fellow passenger who happens to be a doctor is available on board, the airline staff would conveniently "wash" their hands off the passengers who needs some "medical" attention. Would the doctor be required to "escort" the passenger throughout the flight? Furthermore if any adverse outcome resulted from the treatment rendered to the passenger, is the doctor liable? Will the airline be liable too?
Another rather more detailed report here at daily telegraph. Apparently the passengers who required assistance were a couple believed to be on hallucinogenic drugs, a man who was hospitalised ( in Australia I presume ) with bowel obstruction for days but didn't get any treatment because he is a non-Australian without travel insurance and a young vomiting woman. Apparently there was only a poor quality medical kit with one pair of gloves and some drugs which wasn't in English and in the units not familiar to her.
Now, what would you expect a doctor to do to the couple who is under drug influence? Jab them with sedatives? Tie them up to their seats? Even if such drugs were available (which is highly highly unlikely as they are controlled drugs), on what authority the doctor have to take such an action?(against the will of the said passengers). This is the police's job. Furthermore I would NEVER jab anyone with any such drugs outside a controlled environment as they have potentially lethal side effects. Who will be responsible if serious side effects occurred and there is no medical support available? The couple shouldn't have been allowed on board at all!
To the man with bowel obstruction who was not treated, why was he allowed on board without a medical personnel/doctor escort? Why didn't MAS provide a doctor for him throughout the flight considering bowel obstruction is a very serious disorder and is potentially fatal especially after being untreated for days. It is a norm for ill patients to be escorted by a medical personnel should he need to be transported elsewhere. Furthermore what do you expect a doctor to do for bowel obstruction in a plane? Open an operating theatre and perform bowel surgery on board?
Btw she had to leave her family and her two crying children, and had to attend to the passengers throughout till landing plus cancelling her tour later. Why is MAS so stingy?
I wouldn't mind rendering some emergency assistance during flight and while not expecting any rewards, I would certainly like to have some medical indemnity for my "goodwill". And on condition the passenger agrees to be treated by me. Can't be too careful these days. Duty of care still lies with the airline.
Patient is sick. Goes to see doctor. Doctor treats. Patient is better, thanks doctor. Doctor gets remuneration. Everybody happy. Wake up! wake up! This is medical practise made in heaven not on earth.
On earth it's vastly different. Like heaven and earth...
More and more people are trying to use doctors these days to their advantage. It's a game of cat and mouse, to see who is caught first. It's a game I'm getting familiar with.
A company sents an ill employee to see their panel doctor. They don't like the suspected diagnosis, wants to fire him. Panel doctor sends to government doctor. Company asks for a medical report ( and thus the diagnosis ) from the doctor regarding the employee. But employee doesn't want to tell. Thus doctor cannot disclose. Company asks the employee to get MC (indefinitely) and stops his salary. Employee is already certified fit to work, company still doesn't want him back. Cannot fire him without reason (medically unfit to work). Company wants "indefinite MC" for employee. Employee wants doctor to convince the company to let him work but diagnosis cannot tell. Both parties chasing after the doctor. Each expect the doctor to side with them.
Bl**dy hell! This is none of my business. They expect me to fight their battles for them is it? No way man. Employee is fit to work. No MC. You guys go fight it out yourselves.
Practically the employee is already fired. Cannot go to work and got no pay. Just the paperwork formality. Theoretically the employee can file a complain to the tribunal or the courts. We'll see what happens. The game is not over yet. My guess is the company will win by default. They will just have to keep status quo but the employee will have to claw his way through tons of bureaucracy.
We have also seen businessman and companies using doctors to set up laboratories, set up clinics, to sell health products, to promote their health services, to promote their organization ( to give "free" consultation and "checkups" etc ) and so forth. If doctors want to retain some dignity and respect for their own profession, they should not go along. But then again the whole healthcare system now is a business entity. Why blame the doctors later?
Something "unknown" cropped up again. Another ethical issue which I'm waiting for a reply from an "authority" for interest sake.
A young childless couple with limited life expectancy ( both of them, and infertile ) has managed to adopt a baby successfully! Why is this an issue?
Well for starters, if a couple has limited life expectancy ( for example advanced cancers which may not be apparent externally, chronic diseases like chronic renal failure requiring regular dialysis, chronic lung disease, heart failure etc etc etc ), are they the best adopted parents a baby can have? Who benefits more? The baby or the couple? Is it to satisfy the fulfilment of the childless couple to have a "family" before they go to the next world? And is this in the best interest of the child?
One can argue about life expectancy. With modern treatments, prolonged survival is often possible in most diseases. However the physical, mental and monetory strain exerted by regular and long term treatment is very real. Should the baby be subjected to such a family? Even if they are millionaires, this does not negate the physical and mental stress.
My opinion is that this is not in the best interest of the child bordering on pure selfishness. I mean the parents are able to choose their baby with their eyes wide open, but the reverse is not true.
I do not know of any laws with regards to adoption in Malaysia. Do prospective parents have to declare their medical status? Can they invoke their medical confidentiality rights? And of course there are always ways to bypass any laws if they exists anyway. How and who decides the suitability of the prospective parents? ( not everything is about $$ )
Another mystery to solve.
There has been eternal debates between proponents and opponents of abortion.
Today, I attended a conference regarding the problems facing thalassaemia major patients in M'sia. ( Thal major patients are patients who are unable to produce normal red blood cells and thus are dependent on transfusions life long. Without proper chelation therapy to remove the excess iron, their life expectancy will not exceed the 3rd decade). Problems include the lack of blood supply and funds.
Official and legal position is no, abortion of thalassaemia major fetus is not allowed in Malaysia. But we all know abortions is and will be happening with or without sanction.
An interesting point is that if society is not willing to bear the burden of the thalassaemia patients and their carers, then it is certainly hypocritical to prevent the carriers from aborting affected fetus. Support means in terms of donating blood and financial support - chelation therapy is not cheap! The burden on the family/parents is tremendous- financially, physically and emotionally.
People who oppose abortion of affected fetus must then donate $$ and blood regularly to support these patients! You can't just shout by the sideline nor say too bad, it's your fate. You are not bearing the burden, therefore you have no right to make the decision for others. And to prevent carriers from procreating is certainly against every human right! After all there is a 75% chance you will have a healthy offspring. And letting "nature to take its course" for thalassaemia babies is akin to manslaughter. They have no chance of life without blood transfusion.
What then about the right of the unborn child? This is a tricky issue. Abortion if done, should be done before 12 weeks of gestation. Upon conception, it is just a couple of cells dividing. Do they have the same equal right of an independent person ? What about their rights to receive proper medical care later if society cannot or will not provide?
Then again, there will be scenario where the medical practitioner will refuse to address the option of abortion to the affected mother due to their own beliefs. This means one is imposing their values on others and certainly I feel this is not only unethical but bad practice as one should be impartial when addressing any issue and patients should be given ALL options. The choice should then lie with the affected person.
Even when the patient chooses to abort the affected fetus, there will be scenarios where practitioners will refuse to perform the procedure due to their beliefs. However this is clearly within the rights of the practitioner. This is totally different from not informing the option in the first place.
If one cannot be impartial due to one's own beliefs then one should voluntarily withdraw from any participation with the other party. I think this principle should be adhered to in any positions of priviledge for example police, teachers, judges, doctors etc.
What do you think?
