The Ethical and Legal Framework for the Decision Not to Resuscitate

Practicing physicians are frequently faced with the question of whether or not to institute cardiopulmonary resuscitation in case of cardiac or respiratory arrest in a patient in hospital. Medical training has usually not included any systematic analysis of this issue from either an ethical or a legal standpoint. Many physicians may be unaware that ethical and legal principles, as well as professional guidelines, exist to guide such decision making. In practice, physicians make this decision without the benefit of training in ethical analysis. The problem is especially acute in teaching hospitals when young physicians unacquainted with formal ethics or the law must often make decisions emergently. Studies show some discrepancy between ethical and legal principles and the actual decision making by physicians. For this reason, we recommend an approach that will enable physicians to make and implement decisions not to resuscitate that are consistent with current ethical and legal standards.     

Ethical aspects of limiting residents' work hours

DEFINITION OF THE PROBLEM: The regulation of residents' work hours involves several ethical conflicts which need to be systematically analysed and evaluated. ARGUMENTS AND CONCLUSION: The most important ethical principle when regulating work hours is to avoid the harm resulting from the over-work of physicians and from an excessive division of labour. Additionally, other ethical principles have to be taken into account, in particular the principles of nonmaleficence and beneficence for future patients and for physicians. The article presents arguments for balancing the relevant ethical principles and analyses the structural difficulties that occur unavoidably in any regulation of the complex activities of physicians.     

Genetic screening and genetic counseling: knowledge, attitudes, and practices in two groups of family planning professionals.

67 obstetrical and gynecological physicians and 102 professional staff members of family planning clinics (FPCs) in the Pittsburgh, Pennsylvania, area returned questionnaires relating to knowledge of basic genetic principles and attitudes towards genetic screening and genetic counseling. The best understood genetic risk was Down's syndrome in children born to mothers over 40 years of age. Nearly 90% of physicians and 85% of FPC staff knew this but only 12% of physicians and 30% of FPC staff knew it is caused by chromosomal aberration. Next best understood defect is sickle cell anemia. In overall knowledge the physicians had a mean score of 4.45 of 7 genetic questions, FPC staff, 3.32. However, FPC workers who had received in-service genetic training scored 4.42 (p less than .001). Knowledge of the 2 genetic clinics in the area and acceptance of the principles of genetic screening were associated with the individual's acceptance of sterilization as a method of birth control and acceptance of abortion if the fetus had significant risk of being born deformed. Both of these associations were at the significant level for both physicians and FPC workers. Both physicians and FPC workers who have themselves had genetic counseling or who have family members who have had such counseling show higher acceptance levels. An association was also found between acceptance and genetic educational background. About 92% of respondents who had read articles or textbooks pertaining to genetics during the preceding year approved of including genetic information as part of maternal and child health projects compared with 82% of those who had not (p less than .02). Among the physicians 36% felt it should be required, 34% voluntary, and 30% did not know; for FPC workers, 59, 27, and 14%, respectively. Protestants and Jews tended to favor required premarital screening while Catholics tended to oppose it (p less than .007). It is disconcerting that over 50% of the physicians did not know the recurrence risk of PKU and over 20% did not know the gene is the basic unit of inheritance. While it is true that over 1/2 completed basic professional education more than 20 years ago when genetics was not part of the medical school curriculums this basic knowledge needs to have been acquired during continuing medical education. In this study more than 1/3 of the FPC staff indicated they had been asked to provide genetic counseling or had referred clients. This points up the importance of such workers in a comprehensive genetic counseling service.     

Medical direction and control of emergency medical services in Canada.

OBJECTIVE: To determine the level of physician involvement in prehospital emergency medical services (EMS) in Canada, as compared with published principles of medical control and direction. DESIGN: Mail and telephone survey by means of a questionnaire from March to November 1991. SETTING: All Canadian provinces and territories. PARTICIPANTS: Fifty-six key prehospital EMS physicians, senior government administrators and senior representatives of the agencies responsible for licensing physicians in each province or territory. MAIN OUTCOME MEASURES: Responses to questions regarding the legislation, organization, administration, practice and regulation of medical direction and control by physicians in each province or territory. RESULTS: EMS legislation describing medical direction and control was completely lacking in five provinces and both territories and was incomplete in the remainder. Provincial guidelines written by physicians for prehospital patient care were present in only four provinces. Formal organization of medical directors varied from none to partially remunerated networks. Regional medical-director systems were present in three provinces, and local medical directors were required for all communities in three. Most rural ambulance services were found to engage physicians only when there was local interest. CONCLUSIONS: The level of physician involvement in the medical direction and control of EMS appears to be inconsistent across Canada and insufficient in most jurisdictions, as compared with accepted principles.     

The Clinician and Forensic Medicine

Although it is an intrinsic part of all medical practice forensic medicine often is either unrecognized as such or is consciously or subconsciously evaded. The failure to apply some rather basic and simple forensic principles that only the physician is capable of doing may result in problems to the patient ranging from frustration to near catastrophe. For physicians who are reasonably well equipped to understand the legal system, the successful conclusion of a legal case, including, sometimes, an appearance in court, can be stimulating and interesting.     

Mycobacterium avium complex and Mycobacterium tuberculosis in patients infected with the human immunodeficiency virus.

Primary care physicians play an important role in identifying and treating bacterial infections in adults infected with the human immunodeficiency virus (HIV). Mycobacterium avium complex and Mycobacterium tuberculosis are pathogens that can cause systemic or local infection in these patients. We review the epidemiology, pathogenesis, clinical presentation, and principles of treatment for these two mycobacterial pathogens. Because M tuberculosis disease is preventable and curable and yet communicable, physicians should maintain a high degree of suspicion for tuberculosis in HIV-infected adults. In comparison, the goal of treating M avium complex in patients with advanced HIV disease is to reduce constitutional symptoms and improve survival.     

Observations on the Classification and Distribution of Pulmonary Emphysema in Canada

General principles of epidemiology are reviewed, using as an example the chronic non-specific respiratory diseases in Canada. Lack of agreement in definition and classification seriously hampers the use of governmental statistics to study the epidemiology of these diseases. Though Canada is experiencing a mid-century epidemic of deaths from emphysema, evidence is presented which suggests that provincial variation in this death rate is artificial and is likely apparent because physicians do not categorize deaths from this and related diseases in any similar fashion. Three-year-average age-standardized death rates by provincial areas for emphysema with or without bronchitis, asthma, chronic bronchitis and bronchiectasis are presented in evidence that provincial variation is largely obliterated when all chronic non-specific respiratory diseases are considered as a single nosological unit. Advantages and disadvantages of a recent clinical classification of these diseases are reviewed, and it is concluded that such a classification has a great deal to offer epidemiologists or clinicians studying the cause and natural history of these diseases.     

Sepsis after autologous fat grafting

Autologous fat grafting is an increasingly popular technique, with numerous examples of excellent results. Adherence to key principles, including sterile technique and low-volume injection throughout layers of tissue, appears to be critical to obtaining good results. Reports of adverse outcomes are infrequent, but several case reports document both infectious and aesthetic complications. This case report represents an extreme complication, including abscess formation, life-threatening sepsis, and residual deformity. It serves as yet another reminder that early adoption of surgical procedures by those without a sound understanding of the underlying principles and techniques can have disastrous consequences. Furthermore, physicians operating on any patient must understand the potential for complications and be able to manage these appropriately when they occur.     

Medical Ghostwriting and Informed Consent

Ghostwriting in its various forms has received critical scrutiny from medical ethicists, journal editors, and science studies scholars trying to explain where ghostwriting goes wrong and ascertain how to counter it. Recent analyses have characterized ghostwriting as plagiarism or fraud, and have urged that it be deterred through stricter compliance with journal submission requirements, conflict of interest disclosures, author‐institutional censure, legal remedies, and journals' refusal to publish commercially sponsored articles. As a supplement to such efforts, this paper offers a critical assessment of medical ghostwriting as contrary to good patient care, on the grounds that it contradicts established general principles guiding clinical ethics. Specifically, I argue that ghostwriting undermines trust relationships between authors and their readers, and between these readers and their trusting patients, and in so doing contradicts the duty of respect for patient autonomy by obstructing informed consent. For this reason, complicity in ghostwriting practices should be understood as a violation of the professional ethical duties of physicians and other healthcare workers.     

Global physician budgets as common-property resources: some implications for physicians and medical associations.

Since 1990 payment for physician services in the fee-for-service sector has shifted from an open-ended system to fixed global budgets. This shift has created a new economic context for practising medicine in Canada. A global cap creates a conflict between physicians'' individual economic self-interest and their collective interest in constraining total billings within the capped budget. These types of incentive problems occur in managing what are known in economics as "common-property resources." Analysts studying common-property resources have documented several management principles associated with successful, long-run use of such resources in the face of these conflicting incentives. These management principles include early defining the boundaries of the common-property resource, explicitly specifying rules for using the resource, developing collective decision-making arrangements and monitoring mechanisms, and creating low-cost conflict-resolution mechanisms. The authors argue that global physician budgets can usefully be viewed as common-property-resources. They describe some of the key management principles and note some implications for physicians and the provincial and territorial medical associations as they adapt to global budgets.     

Diagnostic testing revisited: pathways through uncertainty

To aid physicians who may be having difficulty applying the principles of decision analysis to diagnostic data according to the methods published in the past several years, the authors of this paper set out a few principles and schemes for using and interpreting diagnostic data obtained from dichotomous tests. They also present a simple BASIC program for calculating post-test probabilities from likelihood ratios and pretest probabilities that a particular disease is present in a particular patient; the program can be adapted for use on microcomputers.     

In the patient's best interest--a call to action,a call to balance

Nurses, physicians, and other healthcare professionals often complain that a loss of freedom or other obstacles hinder their ability to act in the best interest of the patient. These barriers cause professional burnout and moral outrage, and may contribute to a migration away from medicine or, more broadly, healthcare. Understanding the historical underpinnings of the phrase "in the patient's best interest," and realizing that healthcare, which is fundamentally a moral enterprise must be built on sound business principles can help healthcare professionals reframe the issue, and reclaim their original commitment to a difficult path.     

Differential diagnosis and treatment of the "housebound syndrome".

Not all people who become housebound suffer from agoraphobia. Other emotional illnesses can underlie this behaviour. Early diagnosis is important. Some conditions can be treated by family physicians without special training, and some are appropriately treated only in special settings. This paper describes psychiatric disorders that may present as a "housebound syndrome" and outlines the principles of treatment for each.     

Physicians and the pharmaceutical industry (update 1994). Canadian Medical Association.

The history of health care delivery in Canada has been marked by close collaboration between physicians and the pharmaceutical and health supply industries, this collaboration extending to research as well as to education. Since medicine is a self-governing profession physicians have a responsibility to ensure that their participation in such collaborative efforts is in keeping with their duties toward their patients and society. The following guidelines have been developed by the CMA to assist physicians in determining when a relationship with industry is appropriate. Although directed primarily to individual physicians, including residents and interns as well as medical students, the guidelines also govern the relationships between industry and medical associations. These guidelines focus on the pharmaceutical companies; however, the CMA considers that the same principles apply to the relationship between its members and manufacturers of medical devices, infant formulas and similar products, and health care products and service suppliers in general. These guidelines reflect a national consensus and are meant to serve as an educational resource for physicians throughout Canada.     

The alluring myth of private medicine.

Canada''s medicare system has provided Canadians with high-quality health care for almost three decades. Now Canadian health care appears to be at risk of losing the single-payer system, which is the premise on which medicare is built. As medicare comes under increasing financial pressure, many are calling for the introduction of private care as a means of bolstering our health care system and maintaining its quality. Although it appears alluring to some politicians, physicians and commentators, privatization could very well lead to the demise of the principles and practices of the Canadian health care system as we know it, with little clear benefit to the public or physicians.     

Continuous deep sedation and the doctrine of double effect: Do physicians not intend to make the patient unconscious until death if they gradually increase the sedatives?

Continuous deep sedation (CDS) has the effect of making the patient unconscious until death, and that it has this effect is clearly an undesirable aspect of CDS. However, some authors have recently maintained that many physicians do not intend this effect when practicing CDS. According to these authors, CDS is differentiated into two types; in what is called “gradual” CDS (or CDS as a result of proportionate palliative sedation), physicians start with low doses of sedatives and increase them only gradually, whereas in “rapid” CDS (or palliative sedation to unconsciousness), physicians rapidly administer a heavy dose that clearly induces unconsciousness from the beginning. The claim is that the physicians intend permanent unconsciousness only if they rapidly administer a heavy dose, but they do not intend it when the unconsciousness is the result of a gradual increase of sedatives. This paper attempts to refute these claims based on a close examination of the protocol of gradual CDS. If my argument is valid, the doctrine of double effect would not be useful in justifying most, if not all, cases of CDS.     

Bioethics for clinicians: 11. Euthanasia and assisted suicide

Euthanasia and assisted suicide involve taking deliberate action to end or assist in ending the life of another person on compassionate grounds. There is considerable disagreement about the acceptability of these acts and about whether they are ethically distinct from decisions to forgo life-sustaining treatment. Euthanasia and assisted suicide are punishable offences under Canadian criminal law, despite increasing public pressure for a more permissive policy. Some Canadian physicians would be willing to practise euthanasia and assisted suicide if these acts were legal. In practice, physicians must differentiate between respecting competent decisions to forgo treatment, providing appropriate palliative care, and acceeding to a request for euthanasia or assisted suicide. Physicians who believe that euthanasia and assisted suicide should be legally accepted in Canada should pursue their convictions only through legal and democratic means.     

Medical professionalism: one size fits all?

A number of medical specialties have recently developed their own specialty-specific charters. This proliferation of charters is representative of an unease about medical professionalism that has arisen not just from increasing medical specialization, but also from evolving needs as physicians progress through their careers. The development of such specialty-specific definitions of professionalism is undesirable: all specialties should adhere to the same basic principles. These charters and "definitions" should be incorporated into a formal developmental model, derived from needs assessments from the level of medical school through the level of specialization. Such a model would provide physicians with more concrete guidance regarding professional behavior at each stage of their careers, address unmet needs in neglected areas such as mid- and late career, and help alleviate the tension associated with expressing these ideas. Incorporating concepts derived from more classic models of development may create opportunities to address the teaching of values and identify barriers to success.     

Beyond the physician charter: reflections on medical professionalism

The numerous challenges now facing the profession of medicine have led to an intense focus on professionalism by individual physicians and by their professional and academic organizations. In 2002, a distinguished group of leaders in internal medicine created the Physician Charter, which calls on physicians to reaffirm medical professionalism through commitment to three principles and 10 responsibilities. The Charter reflects a duty-based ethic that is chiefly concerned with physician competence. This article offers a critical analysis of the Physician Charter from the perspective of the traditional values of medicine as articulated in medical oaths and championed by leaders of past generations, exemplified by William Osler. The authors argue that medical professionalism should reflect the values of a virtue-based ethic that stresses compassion and beneficence, rather than the values of a duty-based ethic. The challenges that now confront the practice of medicine can be addressed successfully only to the extent that physicians promote virtue-ethics, act collectively in the public interest, and render service that clearly transcends their own self-interests.