Primum Non Nocere Malevolus

A Reflective Report on Ethical Issues Facing a House Officer

Being a Foundation Doctor often involves following orders and performing seemingly menial tasks; this experience can be dis-empowering, with ethical decisions left to more experienced clinicians. But occasionally, amongst our frantic duties, we can overlook simple ethical issues. This essay will present examples of these, which I will use to present some basic ethical and moral responsibilities of a doctor, which should underpin all our encounters.

Part 1: Limitations of the modern Principles of Biomedical Ethics

“Principlism” is a theory first published in 1979 by Beauchamp and Childress. According to this methodology, any ethical problem is solved by applying the four principles of respect for patient autonomy, non-maleficence, beneficence, and justice(1). I have found Principlism useful as a ‘check-list’ to ensure several angles of ethical reasoning have been considered, and in my experience this is how Principlism is commonly used in the clinical setting. However, it relies heavily on intuitive decisions once the principles are ‘balanced,’ and there are often a variety of solutions which can be arrived at. Senior clinicians will have their own intuitive ways of doing this, informed by experience, but these processes are often inaccessible to a junior.

Part 2: Two Examples of Ethical Problems

Case One: The Tendency To Overtreat In Hospital Palliative Care
Whilst on-call and covering the medical wards at night, I was asked to see a 78 year old man with pneumonia. He was hypovolaemic and in a drowsy condition. I spent considerable time fumbling over collapsed veins inserting cannulas, administering fluid challenges, and taking samples of blood. I then read his notes and found he had been deteriorating over several days. He had not responded to intravenous antibiotics, and his kidneys were failing. He had been assessed by Critical Care the previous day, who concluded that due to several co-morbidities, he was unsuitable for dialysis on the intensive care unit.

My senior then arrived. He sat the patient’s wife down, explained the situation to her, and agreed to cease non-essential therapy. This allowed the patient a peaceful death and was a more holistic approach.

Case Two: Truth-Telling
During my time on a surgical firm, a 70 year old man was admitted, with altered bowel habits and rectal bleeding, for further investigations. A colonoscopy was performed, revealing an extensive tumour of the large bowel. The impression was invasive cancer. However, I was told by my seniors not to discuss this with the patient, but rather to wait until further reports and investigations had been performed.

Later that morning I was confronted by the patient, and later the relatives, and asked directly what the test had shown. On this occasion I described some basic appearances of the tumour within the limits of my expertise, but that I was not experienced enough to report more fully. I also discussed the possible diagnoses and which tests would be required. I was therefore honest without conveying the full impression of my seniors.

Part 3: Applying Ethical Principles

Principlism alone hasn’t helped me in these situations. In the first example I lacked the intuitive ability to engage in the Principlist framework at all. In the second example I feel my actions were appropriate, and could easily use Principlism to justify them. However, Principlism could also be used to argue the converse, depending on the moral agent. I propose a simple but crucial Hippocratic basis for ethical decisions, involving true harm avoidance. I will then elaborate on the Hippocratic principle of helping the patient, using moral rationale of similar antiquity.

The Problem of Harm
The maxim Primum non nocere, meaning “first do no harm” is popularly thought of as an essential Hippocratic approach to medicine. However, such a succinct phrase is not found in Hippocrates’ writings, which were originally written in Greek, casting doubt on whether the Latin phrase can be considered Hippocratic. More likely it is a mid-nineteenth century formulation, departing from true Hippocratic tradition(2).

In the 4th century BC, Hippocrates wrote:

“As to diseases, make a habit of two things - to help, or at least to do no harm.”

[A Latin translation of the above: “si subvenire alicui non vales, saltem noli eum nocere” isn’t nearly as concise as the ancient language usually allows!] This truly Hippocratic phrase implies the first principle of a physician is to do good, rather than avoid harm altogether. In the Hippocratic Oath, this ordering of priorities is maintained:

“to help the sick for the good of my patients according to my ability and my judgement, and never do harm to anyone.”

Beauchamp and Childress seem to follow the opposite order, placing autonomy and non-maleficience before beneficience. It is possible that this departure from tradition has led to a more risk-averse practice of medicine. To prohibit ‘nocere’ is rather wasted if it will shackle the physician from practicing their art. I believe the confusion lies with the definition of “harm.”

To clarify the situation, I propose that two types of harm are considered, following these two Hippocratic quotations. The first I will term “Collateral Harm.” By this I refer to physical damage. For instance, almost every intervention has side-effects, which are a necessary but inadvertent harm to the patient, and always to be balanced against the benefits of an intervention.

The second type I will term “Malicious Harm.” This is an injustice, a wrong or evil inflicted intentionally upon the patient. This type of harm is absolutely prohibited. An example of this is given in the Hippocratic Oath immediately after mentioning avoiding harm; the prohibition of giving a deadly poison, even when requested. Malicious Harm is at odds with the aims of medicine. Therefore Primum non Nocere Malevolus would be a better clarification on the maxim for harm avoidance.

One way to distinguish between these types of harm is by looking at the disposition of the physician, and the intention of his actions. For example, a dying person can be given morphine as pain relief, which may hasten death in large doses. But unless a drug has been given to intentionally injure the patient, then the physician has done no Malicious Harm in prescribing it.

In Case One, the harm of over-treating was not Malicious, because I had good intentions. What I had not taken into account was minimising Collateral Harm, which is essential in Palliative Care; to quote Hippocrates “... at least to do no harm.”

In Case Two, I had caused worry to the patient (Collateral Harm) by discussing the provisional diagnosis. However, to withhold this would be Malicious Harm, by neglecting my duty of care (E.g. GMC good practice of respecting the patient’s right to information).

Now that I have applied a correct understanding of harm avoidance, how can I enhance the true Hippocratic principle of ‘doing good’? To do this I will look at the disposition of the physician and the intention of his actions, in a similar way to how Malicious Harm can be differentiated:

Doing Good
Virtue Ethics is an excellent way of preserving and fostering the intention of helping patients. It is an ancient ethical system first developed by Greek philosophers Socrates, Plato and Aristotle(3). They proposed that the moral character of the agent is important in finding the right solution to a problem. Put simply, good people are more likely to do good things. By exploring how a virtuous character can be developed by habitual practice, one can find the qualities which will lead to being a good doctor. The classically defined virtues are courage, prudence, temperance and justice. These are termed ‘cardinal’ virtues, after the Latin cardo or hinge, since they are the hinges upon which the door of the moral life swings.

Virtue Ethics considers the motivation behind the action to be of crucial importance. To have dealt best with Case One, the way my senior did, requires a virtuous character with elements of compassion, prudence and temperance. In Case Two, withholding truth would be excluded, since a virtuous doctor has qualities of trustworthiness and integrity. Good virtues guide a doctor in discerning the best way to give information to the patient. Ultimately, a virtuous doctor will put their patients first, thus avoiding Malicious Harm.

Part 4: Conclusion

Medical ethics is not merely a checklist produced when common ‘ethical issues’ arise; it is a necessary daily tool to inform practice. My clarified maxim Primum non Nocere Malevolus provides a better foundation of the most basic aims of medicine, and Virtue Ethics helps avoid this malicious intent by exhorting virtue. I have begun to appreciate that there is a need to develop an informed conscience, and for a desire to do the best for one’s patients. I encourage a more holistic implementation of medical ethics, guided by the great moral philosophers of the past.


REFERENCES

1. Beauchamp T, Childress J. Principles of Biomedical Ethics [5th ed]. Oxford: Oxford University Press, 2001
2. Jones DA. The Hippocratic Oath III: Do no harm, withdrawal of treatment, and the mental capacity act. CMQ 2007;57(2):15-23
3. Gardiner P. A Virtue Ethics Approach to Moral Dilemmas in Medicine. J Med Ethics 2003;29:297-302

Welcome

Richard A. Watson, M.D. is our newest member. Although Richard did not indicate a website or blog ulr, I'll list it if he sends it along.

He did send a tag to an interesting article linked here. Another "bioethicist" of the Peter Singer model. Wonderful.

If you thought Peter Singer, now a professor at Princeton University, was Australia’s gift to world bioethics, then I have news for you. One of his PhD students, now a professor at Oxford, Julian Savulescu, is leaving him in the dust.

His postal address may be an ivory tower but he gets down and dirty with “practical ethics”. He argues trenchantly for performance enhancing drugs in sport, genetic screening, early abortion, late-term abortion, sex-selective abortion, embryonic stem cell research, hybrid embryos, saviour siblings, therapeutic cloning, reproductive cloning, genetic engineering of children for higher IQs, eugenics, and organ markets. For starters.

Welcome, Richard. Your invitation to post to this blog is in the (e-)mail.

The Cost of Eliminating Down's Syndrome

Aborting children with Down's Syndrome will not raise an eyebrow in some crowds.  Hell, some might condemn anyone who would choose to bring these little monsters into the world.  But the cost of perfecting humanity may cost a few "normal" children.  Eugenics is a messy affair and always has been.   According to The Telegraph:

Two healthy babies are miscarried for every three Down's Syndrome babies that are detected and prevented from being born, research has suggested.

The losses are down to the invasive methods used to test for the condition, which affects approximately one in every 1,000 babies conceived, the researchers claim.

They also cast doubt on the advice and risk assessment given to the 6,000 women each year who are offered screening and subsequent testing to assess the health of their unborn baby.

If an expectant mother is deemed to be at risk of carrying a Down's baby following a blood test, she will then go on to undergo an amniocentesis and chorionic villus sampling (CVS) test, which involves inserting a fine needle through the abdomen to either withdraw amniotic fluid or take a tissue sample.

The NHS cites a miscarriage rate of between one and two per cent following the tests, but the researchers, from the charity Down's Syndrome Education International, point out that only the number of Down's babies terminated, miscarried or born are recorded, not the number of healthy babies lost.

Creating liberal utopias will always cost innocent lives.  It's hard work and occasionally someone will get in the way.

Technorati Tags: Down's Syndrome,abortion,chorionic villus sampling,CVS,amniocentesis,eugenics,utopia

Disability on Display

If nothing else, Sara Palin's nomination as Republican VP candidate has brought matters of disabled children to the forefront in this political season. Palin and her husband have welcomed a child with Down's Syndrome into their family.

Unfortunately not all are willing to accept children as they are rather than as they might be. Wesley Smith at SHS blog has a disturbing post about a mother who murdered her disabled child.

Joanne Hill, 32, planned the murder after her husband refused to allow their daughter, Naomi, to be adopted, it was alleged.

A jury heard how Mrs Hill struggled to cope caring for the youngster, who suffered with cerebral palsy. She wore callipers to help her walk and had poor hearing.

Opening the case for the prosecution Michael Chambers QC told Chester Crown Court that Mrs Hill was "ashamed and embarrassed" of her daughter's condition and murdered her in a "determined and planned act".

"Joanne Hill could not come to terms with the fact that her daughter Naomi was disabled," he said.

"Instead of seeking help from the social services, she quite deliberately and consciously acted to kill Naomi."

Mrs Hill allegedly planned the murder for the afternoon of November 26 last year knowing her husband Simon would not be home until 5.30pm.

After picking up Naomi from the childminder she drove them to the family home in Deeside, Flintshire, north Wales, poured herself a glass of wine then ran a bath.

Mr Chambers said: "When the bath was full she told Naomi she was having a bath, but Naomi didn't want one. The defendant carried her upstairs and undressed her.

"The defendant put her in the bath and drowned her by holding her head under the water for a long time until she was dead."

Smith writes:

Princeton University's Peter Singer and some other bioethicists argue that killing unwanted babies is perfectly fine since babies aren't persons. Babies born with disabilities and terminal illnesses are already being subjected to infanticide in the Netherlands--acts of murder under Dutch law that go unpunished, and which have been supported by prestigious medical and bioethics journals such as in an article published in the prestigious Hastings Center Report. Here in America, 90% of fetuses testing with genetic anomalies such as Down or dwarfism are not allowed to be born--a eugenics action sometimes encouraged by doctors and genetic counselors. In Canada, Robert Latimer murders his daughter Tracy because she had cerebral palsy and is embraced by many there as a loving and compassionate father. Meanwhile, some people savage the Palins because they are affronted by Trig's presence in the world and a Canadian medical official worries that it could mean more parents deciding not to abort their disabled babies.

We as physicians have wonderful opportunity to affirm life from conception until natural death. Our patients respect us and we can influence the debate. Our actions and words are noted. Set the example and frame the debate in a life affirming way.

Technorati Tags: Down's Syndrome,disability,ethanasia,suffering,Catholic,physician,cerebral palsy,infanticide

Welcome to a New Member

Catholic Physicians Blog is pleased to welcome a new member. Richard Kim blogs at http://catholicpsychiatrist.blogspot.com/. Great to have you onboard!

Psychiatry

I have recently finished a four-month rotation in Psychiatry. I wanted to impart some of the things I learned from this, which have inspired me towards a career in this noble art. The specific area of work was a community based outreach service called 'Early Intervention'. This service is basically aimed at young people (16-35) who are experiencing psychotic symptoms for the first time. These kind of symptoms are common features of Schizophrenia, which is a syndrome prominent in the public conscious. However, not everyone understands this devastating illness, or how it can be managed, so I was privileged to be able to gain an insight.

Schizophrenia was a term first coined by Eugen Bleuler (1857-1939) in 1908. Prior to this, the condition was called 'Dementia Praecox', as assigned by the German Psychiatrist Emil Kraepelin (1856-1926) who introduced a distinctly clinical outlook to Psychiatry. Bleuler correctly realised that it was not a dementia, and also not exclusively confined to young people. His new term, 'Schizophrenia', was derived from the Greek term meaning 'Split mind'. There is a common misconception, perhaps stemming from this etymology, that it is a syndrome of split personality. This is false, and not to be confused with Dissociative Identity Disorder.

The sort of symptoms which Schizophrenia involves are hallucinations and delusions. Typically an individual will hear voices, talking in a derogatory manner about or to the subject. Sometimes the voices will give a running commentary on what the person is doing. Less commonly hallucinations can be visual, or in other modalities.

An individual with Schizophrenia will often feel that their thoughts are not their own. They may believe that thoughts are being physically inserted into their head, or taken away, or that their thoughts are being broadcast for all to hear. Delusions often develop from these symptoms and can be quite complex, and reflect a fragmentation of their experience of reality. To be a delusion it has to be a false, unshakable belief which is out of keeping with their cultural context. Often these seem to be related to popular constructs around them. Sometimes they may have a religious content, other times about aliens, and quite commonly at the moment about government conspiracies. Particular to Schizophrenia, these delusions often contain contradictions, with a lack of logical consistency, and have an unpredictable series of actions which may flow from it. The Oxford textbook of Psychiatry(1), in relation to this, quotes Eugen Bleuler thus

"Kings, Emperors, Popes, and Redeemers engage for the most part, in quite banal work, provided they still have any energy at all for activity".

The result of these is that affected individuals display bizarre, erratic behaviour. Their speech often becomes rambling and incoherent, as they exhibit a 'loosening of associations' in their thought processes. Negative symptoms, like depression, withdrawal and a lack of motivation often predominate. People around them become increasingly baffled and worried. Fortunately current anti-psychotic medication, and services to improve social functioning, can return people to a normal and fulfilling life. The diagnosis 'Schizophrenia' is less commonly used, especially early on, since it is difficult to predict the course of the illness, and patients do not necessarily benefit from having a stigmatising label applied to them.

This can all obviously be incredibly distressing. I write the above because I find it all very fascinating, and because it is so poorly understood, even within the medical profession. My work with Early Intervention has brought me in touch with all kinds of people from a wide range of demographics, but in this case all young, often around the age of 17 and going through stressful life adjustments.

Perhaps another similarity with these young people is that many of them have smoked Cannabis heavily. It is difficult for people to understand what a serious problem this is, especially since it is a drug so commonly consumed at schools, colleges and universities. An initial study(2) suggested that those with a strong history of Cannabis use, especially in early adolescence, are up to 6 times more likely to develop the illness. Since about 1% of the population will suffer from psychosis at some point in their life, this is not a negligible risk. More importantly, those with the illness can relapse suddenly upon exposure to Cannabis, and it is often a factor in delayed recovery. This should come as no surprise, since Cannabis increases levels of Dopamine in the brain, which is the biochemical process believed to be most associated with Schizophrenia, and the target of most therapeutic drugs (which incidentally have much fewer side-effects than was previously the case).

It always astonishes me the sort of social pressures which impede the practice of Psychiatry. Rather than a noble and respected profession, it is often seen by outsiders as a threatening and arrogant speciality. In my experience Psychiatrists are the most thoughtful, friendly, and intuitive doctors around. Their communication skills are superb, and indeed have to be, since they are the only real diagnostic tools available. I see two social pressures to predominate: anti-Paternalism (and accompanying medical consumerism) and so-called human rights arguments. Perhaps I will expand upon these observations another time, but for now I just wanted to focus on the experience of mental illness, in particular one as devastating as psychosis. There is a tendency for people to view these patients with suspicion and apprehension, and to alienate them further. However, what they really need is to be valued and loved in the way Jesus instructed us. A great saint summed it up thus:

When her mother reproached her for caring for the poor and sick at home, Saint Rose of Lima said to her: "When we serve the poor and the sick, we serve Jesus. We must not fail to help our neighbours, because in them we serve Jesus."

Catechism of the Catholic Church 2449

We can therefore see in our brethren Christ himself, and be moved to compassion by hearing Christ say: "As long as you did it to one of these my least brethren, you did it to me." (St Matthew's Gospel 25:40)

Mental illnesses are like any other disease in that they have physical and psychological aetiology; we must not think they are due purely to social or spiritual factors, as important these are in any illness. We must certainly not think that something like psychosis is a manifestation of demonic activity; I hope very much that this sort of opinion is cast firmly aside. Yes, demonic possession does exist - but mental illness is something discrete and always to be excluded by a diocesan investigation. Ultimately though, amongst the indispensable drug treatment and psychological interventions, spiritual remedies will always be welcome. In a sense, Psychiatry is the one area of medicine where all components of the human being meet, and the scope is thus endless.

References:
1. Gelder M et al. Oxford Textbook of Psychiatry. Oxford University Press: 2000
2. Zammit S, Allebeck P et al. Self reported cannabis use as a risk factor for schizophrenia in Swedish conscripts of 1969: historical cohort study. BMJ 2002;325:1199

HHS Proposed Regulations to Protect the Conscience Rights of Health Care Providers

This is from the Priest for Life website.

The United States Department of Health and Human Services has publicized new proposed regulations to protect the conscience rights of health care providers. They are inviting comments from the public from now through September 19, and we ask you to do so today!

The HHS press release announcing this is at http://www.hhs.gov/news/press/2008pres/08/20080821a.html

Comments can be submitted at http://www.Regulations.gov or via e-mail to consciencecomment@hhs.gov.

“Many health care providers routinely face pressure to change their medical practice – often in direct opposition to their personal convictions,” said HHS Assistant Secretary of Health, Admiral Joxel Garcia, M.D. “During my practice as an OB-GYN, I witnessed this first-hand. But health care providers shouldn’t have to check their conscience at the hospital door. This proposed rule will help ensure that doesn’t happen.”

Be sure to register your comments with HHS.

Welcome!

Catholic Physicians' Blog welcomes Matthew Doyle who blogs at http://www.lacrimarum-valle.blogspot.com/. Welcome Matthew. Love your blog!

The Saint Song

As a child of the 60's, 70's, and beyond, I remember hearing Tom Lehrer belt out tunes on albums from "Wehrner von Braun" to "The Vatican Rag" to "National Brotherhood Week."  One of those memorable ditties was "The Elements Song," in which Tom went through all of the known elements up to that time sung to the tune of Gilbert & Sullivan's, "I am the very model of a Modern Major General."

The trials and tribulations of the Saints and how they sought and achieved holiness has been an interest of mine for quite some time, especially those Saints that we as physicians look to for patronage - Luke, Cosmas and Damien, Pantaleone, etc.  I thought of a way recently to introduce others to the Saints, in a "Lehrer-esque" manner.  This is the result.  Hope you like it.

The Path to Euthanasia

A recent medical study cast doubt on whether antibiotics should be administered to patients in the advanced stages of dementia. The argument is that it doesn't improve the "quality of life" and that it increases the likelihood of creating super- resistant bacteria which the nursing home resident then brings to the hospital when they get admitted.
As a geriatrician with a practice in skilled nursing facilities, I am concerned about what message this study sends to physicians and the lay community. It is fairly clear to most physicians when a patient is dying and antibiotics are futile. It is not always clear if a patient develops a fever that this will be their terminal event. A dementia patient who spikes a temp is not necessarily moribund and a simple once a day parenteral antibiotic may help them turn the corner, if indeed it is not yet their time to go. By us witholding antibiotics are we "stacking the deck" in a way that will increase the likelihood of their dying? To me this is erring on the side of death and not life! If we are to err, let it be on the side of life, regardless of what someone determines is the "quality of life."
I see this as the tip of the iceberg and we are going to start seeing more "studies" that show the futility of medical treatments for patients with dementia and other "poor quality of life" diseases. We already have a small body of literature that suggests feeding tubes do not prolong the quality of life and as a result, ethics committees in hospitals cite these studies to deny PEG tubes to patients with advanced dementia. Now we will have ethics committees recommending the withdrawl of antibiotics if a patient with urosepsis and dementia presents to the ER with a change in mental status. Perhaps I am being an alarmist, but I don't think so. This is just another brick being layed down on the road to Euthanasia.

Holy Father: "Science Cannot Understand the Mystery of Man."

Pope Benedict XVI addressed academics gathered in Rome to study the human person.  The Holy Father told those in attendance:

"...the exact sciences, both natural and human, have made prodigious advances in their understanding of man and his universe". However at the same time "there is a strong temptation to circumscribe human identity and enclose it with the limits of what is known.”

“In order to avoid going down this path,” the Pontiff said, “it is important not to ignore anthropological, philosophical and theological research, which highlight and maintain the mystery of human beings, because no science can say who they are, where they come from and where they go. The knowledge of human beings is then, the most important of all forms of knowledge".

"Human beings always stand beyond what can be scientifically seen or perceived", the Pope affirmed. This failure manifests itself today in “an incapacity to recognize the foundation upon which human dignity rests, from the embryo until natural death," said the Pope.

"Starting from the question of the new being, who is produced by a fusion of cells and who bears a new and specific genetic heritage", the Holy Father told his audience, "you have highlighted certain essential elements in the mystery of man". Man, said the Pope is "characterized by his otherness. He is a being created by God, a being in the image of God, a being who is loved and is made to love. As a human he is never closed within himself. He is always a bearer of otherness and, from his origins, is in interaction with other human beings".

For those whose of you who read Italian (Paul), find the speech here (and for the rest of us an article about the speech here.)

Technorati Tags: Pope,Benedict,XVI,science,human,man,humanity

The American College of Obstetricians and Gynecologists and Medical "Ethics"

A rather disappointing position from another professional organization. According to Renew America:

The political effort to protect so-called reproductive medicine has led ACOG to the conclusion, according to its Committee on Ethics, that even when healthcare providers have moral concerns about a decision a patient has made, they may not allow those concerns to translate into a refusal to provide a "service" or a prescription to that patient.

If one examines this premise and the committee's language, it becomes painfully clear that the target for the statement is the Christian medical community. For example, in the ACOG statement, we find the following:

When conscientious refusals conflict with moral obligations that are central to the ethical practice of medicine, ethical care requires either that the physician provide care despite reservations or that there be resources in place to allow the patient to gain access to care in the presence of conscientious refusal.

Unfortunately this is yet one more example of a professional organization
which has become so politicized and "PC" that it is but a shadow of its
historical self and mission. I would suggest that one would be hard pressed to
justify membership in the ACOG if one is serious about one's Catholic
faith.

Welcome to Sabin

Welcome to Sabin, our newest member. If you have a blog or web site, Sabin, send me the address and I will blogroll it. We're glad that you are with us and look forward to your posts.

Peace.