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Wednesday, March 6, 2013

American Medical Ethics and "My Aching Aquinas": True, Good, and Conscientious?


 
The American Medical Association
Code of Ethics

The Patient-Physician Relationship

"The practice of medicine, and its embodiment in the clinical encounter between a patient and a physician, is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering.

"The relationship between patient and physician is based on trust and gives rise to physicians’ ethical obligations to place patients’ welfare above their own self-interest and above obligations to other groups, and to advocate for their patients’ welfare.

"Within the patient-physician relationship, a physician is ethically required to use sound medical judgment, holding the best interests of the patient as paramount."

(The American Medical Association)
 
 
The AMA’s Principles of Medical Ethics

Every physician who is a member of the AMA must uphold the AMA’s Principles of Medical Ethics. The Code links theory and practice, ethical principles and real world dilemmas in the care of patients.

The following Principles adopted by the American Medical Association are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.

Principles of Medical Ethics

 
I. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.

II. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.

III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.

IV. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.

V. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.

VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.

VII. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.

VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.

IX. A physician shall support access to medical care for all people.

(Adopted June 1957; revised June 1980; revised June 2001.)


How Does a Person Act According To What He Knows?

Conscience is an external moral facility that traffics in values rather than facts. This raises awareness of its "quiet but important presence" within the daily lives of physicians and medical practitioners.

As it turns out, this more integrated conception of conscience was common in premodern moral philosophy. Theologian Thomas Aquinas (~1225-1274), whose work was important in extending the thought of Aristotle into the medieval era, suggests how Aquinas’ thirteenth-century conception of conscience might apply to modern bioethics and to the modern education of physicians.

In his work on moral philosophy, Aquinas presents a complex and detailed account of human action which, though dated in some ways by Aristotelian assumptions about biology, is still relevant today.

Aquinas stated that human knowing (knowledge) can be directed in two ways:

* Speculatively, (make an inference) with regard to what is true.

* Practically, (qualified by practice or practical training) with regard to what is good, or what should be done.

What is true and what is good are, of course, closely linked to one another, and in fact Aquinas believed...

* Humans are equipped with a disposition (called synderesis) to know certain self-evident abstract practical truths, such as that “the good is to be done, and evil avoided.”


Acting Ethically Involves Tremendous Challenge

The biggest challenge in acting well is not formulating abstract moral principles but, rather, applying those principles to concrete situations in the complex context of everyday life. And this relating of abstract principles to real-life situations.

* Figuring out what “the good” is in any particular setting, is what Aquinas refers to as conscience (conscientia), the application of knowledge to a particular case .
 
(Thomas Aquinas. Summa theologiae. Ia.79.13.)

Conscience, then, is for Aquinas not even a power or a faculty at all—it is simply the act by which the action-guiding practical intellect identifies the good (i.e., that which should be pursued) in a particular situation.

* Conscience in this view turns out to be nothing more, and nothing less, than clinical judgment—identifying what course of action is appropriate in a specific patient case.

Yet, clinical judgment is neither innate nor infallible, but must be formed and refined over months and years in the context of supervised medical training, so also Aquinas knew that conscience was not infallible either.

* The ability to exercise conscience appropriately—to consistently recognize courses of action that are good or fitting in particular situations—is in fact a hard-won achievement which Aquinas describes as the virtue of prudence (prudentia).

The prudent physician, in Aquinas’s sense, is not one who is painstakingly risk-avoidant or conservative in decision-making but, rather, one who consistently knows what to do in complex clinical situations: the prudent physician shows consistent “presence of mind."

(Pieper J. The Four Cardinal Virtues. Notre Dame, IN: University of Notre Dame Press; 1966.)

But this clinical presence of mind (prudence), which names the consistent presence of good clinical judgment (conscience) in the practice of a physician, is not easily achieved. It requires a person to cultivate virtues like courage, self-control, and justice that help orient him or her to things that are truly good, rather than things that only seem so.

 (Thomas Aquinas. Summa theologiae. Ia-IIae. 57.4)

It requires years of iterative practice and openness to correction by more experienced teachers. And it requires that medical decision making not be reduced to algorithm.

(Thomas Aquinas. Summa theologiae. Ia-IIae. 52.3; IIaIIae.47.15.)
 
 Extending Aquinas’s thinking equating conscience with clinical judgment and vice-versa would have several important implications for medical education and for modern debates about “conscientious objection” within medicine.

First, “conscience” would no longer be understood as a separate decision-making faculty that comes into play only with regard to morally or socially controversial situations: it simply is clinical judgment.

Second, equating conscience with clinical judgment would challenge the way that ethics is marginalized (and marginalizes itself) within contemporary medical educational institutions and their teaching curricula.

“Ethics” is not a specialized and esoteric discipline to be invoked only in moments of crisis or “dilemma”; it is, rather, simply an account of what good medical practice looks like in particular situations, even when these situations are pedestrian and uncontroversial.

Third, equating clinical judgment with conscience makes clear that medical education is at root a process of moral formation, in which promising but naive clinicians who lack the ability to discern the good in particular clinical situations (that is, whose acts of conscience are unreliable) are formed, through hard study and iterative practice under the guidance of competent teachers, to become clinicians capable of consistently knowing and doing the good.

Medical education, in other words, is essentially a training of conscience. The consistent and reliable display of rightly-formed conscience over the course a medical career, furthermore, is prudence—arguably the most important characteristic that any physician can ever display.

(Warren Kinghorn, MD, ThD. "Conscience as Clinical Judgment: Medical Education
and the Virtue of Prudence." Virtual Mentor. American Medical Association Journal of Ethics.
March 2013, Volume 15, Number 3: 202-205)

 
What Would You Do If You Knew The Following?
 
A report released in 2012 titled, “County Health Rankings & Roadmaps, A Healthier Nation, County by County,” showed Scioto County as one of Ohio’s unhealthiest counties. The annual report, released by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, examines every county in the United States and ranks them on a state level based on health outcomes and factors.

The report ranked Scioto County as the 8th unhealthiest county in the U.S. Here are the numbers for Scioto County:

> Premature deaths (years of life lost per 100,000): 11,262 (44th highest)
> Percent reporting fair or poor health: 26% (27th highest)
> Unemployment: 12.8%
> Children in poverty: 32% (84th highest)
> Largest municipality: Portsmouth

On average, residents of Scioto, Ohio, report being physically unhealthy 7.1 days out of each month — the second-highest rate in the country. They also report being mentally unhealthy 6.2 days each month, which is the fifth-highest rate in the country. As is the case with many other counties on this list, Scioto has a number of particularly unhealthy behavioral traits. For example, 36% of residents are smokers — the country’s highest rate. The county also has among the highest rates of preventable hospital stays among medicare enrollees.

The same report ranked Scioto County 87th out of 88 Ohio Counties for health outcomes and 88th for health factors.

According to a study on life expectancy of U.S. counties by the University of Washington’s Institute for Health Metrics and Evaluations (IMHE), Scioto County men had the lowest expectancy of anyone in Ohio at the conclusion of the study in 2009.

The average life expectancy of Scioto County men has increased from 69.7 in 1989 to 71.2 in 2009, but was still the lowest in the state. Scioto County women fared much better than men, with an average life expectancy of 78.1.

A few years ago, studies show thirty five million pills a year had been prescribed in Scioto County, a county with a population of 79,499 (Source: U.S. Census Bureau). That’s 440 pills per person (including babies, children, people who’ve never taken a prescription drug in their lives).

In 2010 , Scioto County recently ranked number 10 in the top 100 oxycodone dispenser counties in the United States.

In 2010, nearly 1 in 10 babies was born addicted to drugs last year in Scioto County. Admissions for prescription painkiller overdoses were five times the national average.

In 2010, nearly 1 in 10 babies was born addicted to drugs last year in Scioto County.

In 2010, admissions for prescription painkiller overdoses were five times the national average.

At least 117 people died of overdoses in the county between 2000 and 2008.

Of these overdose deaths between 2000 and 2008, health officials say 9 in every 10 fatal drug overdoses in Scioto County are caused by prescription drugs. Of those drug deaths, nearly two-thirds of the individuals did not have prescriptions, meaning they bought the drugs illegally or got them from friends or family.

Thanks to a thriving drug culture that breeds crime and intravenous use, Scioto County's per-capita rates of murder, fatal overdoses and hepatitis C infections have been outranked in recent years only by Ohio's biggest urban areas.

The DEA considers the county one of the worst places in the country for prescription painkiller abuse, with more people abusing per capita than almost anywhere else.

In a rare step, the Scioto County health commissioner declared a public-health emergency, something usually reserved for disease outbreaks

A few years ago, ten pill mills blanketed Scioto County handing our illegal prescriptions of deadly opioids. Today, thanks to the efforts of the Scioto Drug Action Team, none survive.

Like a rain of deadly cluster bombs, drugs blanketed Appalachia, killing and disabling family members and friends in record numbers. No doubt, greed and all-consuming addiction pushed many once-resourceful citizens toward the killing grounds that permeated all neighborhoods and social strata. But, what ethical person puts more value on blood money than the value and dignity of life?

No one deserved to suffer the consequences of the crimes committed by those who willfully distributed the means to acquiring illegal prescription drugs. The pain clinic owners, doctors, and pharmacists who contributed to the carnage are most certainly unethical and deserve harsh punishment for their criminal activities.

Damn the entire process of pill mill operation, which was legal before passage of Ohio House Bill 93 in 2011 and which allowed profitable bloodletting to flourish. Before HB 93, no rule, regulation or ordinance stood to oppose the gruesome human consumption of each passing day -- 4 died each day in Ohio of drug overdose. That's 1,460 deaths a year. Imagine one state losing that many loyal service members in a sanctioned foreign war.

How do I see the ethics involved in the health epidemic in Scioto County?

For a single person to profit from intentional poisoning with prescription substances exhibits pure evil. If a community condones everyday operations of careless operations, its citizens turn their backs to State-sanctioned murder.

Now, we must ask if our own FDA and Big Pharma continue to perpetuate the epidemic of prescription drug abuse. The FDA continues to approve opioids for the relief of moderate pain. And, drug company revenues climbed more than $200 billion in the years between 1995 and 2010.

But with high profits came significant indications of criminality. The global pharmaceutical industry has racked up fines of more than $11 billion in the past three years for criminal wrongdoing, including withholding safety data and promoting drugs for use beyond their licensed conditions.

In all, 26 companies, including eight of the 10 top players in the global industry, have been found to be acting dishonestly. The scale of the wrongdoing, revealed for the first time, has undermined public and professional trust in the industry and is holding back clinical progress, according to two papers published in the New England Journal of Medicine.

So, new, voluntary (not mandatory) opioid prescriber training is in effect in 2013. Of all groups, Big Pharma is in charge of the funds and the curriculum for the training. The goal is that 60% of prescribers (docs, dentists, etc.) will complete the training in 3 years. Nowhere in the training does it say that prescribers should tell patients these drugs are addictive. And these programs give the implied message that there's evidence for using opioids in long-term, noncancer chronic pain.


Let's Decide If Voluntary, Bias Compliance Is Ethical

* Does it address the need for what is true?
* Does it adequately respect what is good?
* Does it show good conscience and a disposition to avoid what is evil?
* Does it show proper prudence that is fitting in this particular situation?

I, personally believe voluntary training required to prescribe opioids such as OxyContin and Vicodin is not sufficient and certainly not ethical. It fails the test for what is speculative and practical.  I support mandatory, unbiased training based on the latest clinical research and true statistics. Please sign a petition that will be presented to the FDA to encourage CHANGE TODAY. Thank you.

Here is the petition address: http://www.change.org/petitions/f-d-a-commissioner-margaret-a-hamburg-require-doctors-to-have-mandatory-training-to-prescribe-painkillers

 
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