Sunday, January 15, 2017

PHYSICIAN-ASSISTED SUICIDE what do I think and feel. SANTARA

PHYSICIAN-ASSISTED SUICIDE

"Many physicians have known an old, wise, and respected clinical faculty member who told of helping terminal cancer patients with intractable pain "go to sleep with a bit of extra morphine sulfate; in the days before you could get sent to jail for helping these poor folks." Of course, this action was performed quietly, with permission from the patient and/or his or her family (not written) and the tacit understanding of the nursing staff. "

Distilled water injections  and  pancreatic  cancer 
The physician-assisted suicide debate, like the abortion issue, is many sided

 there is a constitutionally protected liberty interest in determining the time and manner of one's own death.

the court found no reason to prohibit those in the final stages of their illnesses who are not on life support from making the same choice by requesting lethal medication from their physicians [

permits the debate [about assisted suicide] to continue, as it should in a democratic society"

In January 2006, the Supreme Court upheld Oregon's 1997 Death with Dignity Act, a unique initiative that allows physicians to prescribe lethal doses of prescription medicines to patients diagnosed with a terminal illness that will lead to death within six months 

There must be two witnesses to attest that the patient is competent, one of which shall not be a family member; the attending physician also may not be a witness. No criminal, civil, or disciplinary action may be brought against any person involved in implementing or witnessing the act.
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Theories of Ethics

DEONTOLOGICAL ETHICAL THEORIES

  • People should always be treated as ends and never as means.
  • Human life has value.
  • One is always to tell the truth.
  • Above all in health care, do no harm.
  • All people are of equal value

  • Theological Ethics

  • Categorical Imperative

  • individuals possessed a special sense that would reveal ethical truth to them. That ethical truth is thought to be inborn and causes humans to act in the proper manner.

  • TELEOLOGICAL ETHICAL THEORIES

  • Utilitarianism
  •  consequential ethics
  •  situational ethics
Who decides what is good or best for the greatest number?
Is it society, the government, or the individual? 
For the rest of the people, are they to receive some of the benefits, or is it an all or nothing concept? 
How does "good" become quantified in healthcare in such concepts as good, harm, benefits, and greatest? Where does this leave the individual trying to make healthcare decisions?

Existentialism


One modern teleological ethical theory is existentialism. In its pure form, no one is bound by external standards, codes of ethics, laws, or traditions.

Pragmatism

To the pragmatist, whatever is practical and useful is considered best for both the people who are problem solving and those who are being assisted.
This ethical model is mainly concerned with outcomes, and what is considered practical for one situation may not be for another. Pragmatists reject the idea that there can be a universal ethical theory; therefore, their decision-making process may seem inconsistent to those who follow traditional ethical models.

 It is not the action, but the intent or motive of the individual that is of importance. 
The motivist would say that there are no theoretical principles that can stand alone as a basis for ethical living

The nontheistic believer, on the other hand, develops understanding from within, through intuition and reason with no belief rooted in God. In either case natural law is said to hold precedence over man-made law.

To some, it is also a rather cold-hearted approach-not making decisions with an individual, but for the individual based upon what others believe to be good for that person. The principle of paternalism would fit within this context.

The concept of transcultural nursing was penned by M. Leninger and focuses on a comparative analysis of differing cultures, health-illness values, patterns, caring behavior, and nursing care. Decisions are made on the basis of the value or worth of someone by the quality of interrelationships.
Western society largely operates on a basis of facts, conclusions, and predetermined, agreed-upon solutions based upon male Anglo-American ideals.

Ethical Relativism/Multiculturalism

The ethical theory of relativism/multiculturalism falls under the postmodernist philosophical perspective and may be referred to as moral relativism [5]. Multiculturalism promotes the idea that all cultural groups be treated with respect and equality [7]. According to ethical relativists, ethical principles are culturally bound and one must examine ethical principles within each culture or society [5]. The question then becomes how ethical principles that are primarily deontological and rooted in Western values are applicable in other societies. The challenge of ethical relativism is how to determine which values take precedent 

Though not an inherent gift, moral reasoning is required to reach ethically sound decisions. This is a skill, and moral reasoning must be practiced so it becomes a part of any healthcare professional's life.

 For example, a healthcare professional assigned to care for a patient in the terminal stages of acquired immune deficiency syndrome (AIDS) might have strong fears about contracting the disease and transmitting it to his or her family. Is it ethical for him or her to refuse this assignment?
 on the basis of utilitarianism would weigh the good of their family members against the good of the patient. Based on the greatest good principle, it would be ethical for the healthcare provider to refuse to care for the patient. 

  • Collection of a database
  • Case presentation
  • Identification of medical problems
  • Identification of psychological problems
  • Identification of an ethical dilemma
  • Identification of legal or policy issues
  • Discussion of ethical issues
  • Suggestions for approaches to problems
  • Discussion with initiator, patient, if possible, and other individuals directly involved with specific patient or problem
  • Documentation of issues discussed and suggested approaches to be placed in the patient's chart

A person who becomes a healthcare worker accepts the obligations and duties of the role. Caring for patients with infectious diseases is one of those obligations; therefore, refusal would be a violation of this duty. 

Medical Facts

  • What is the patient's current medical status?
  • Are there other contributing medical conditions?
  • What is the diagnosis? The prognosis? How reliable are these?
  • Has a second opinion been obtained? Would it be helpful?
  • Are there other tests that could clarify the situation?
  • What treatments are possible?
  • What is the probable life expectancy and what will be the general condition if treatment is given?
  • What are the risks and side effects of treatment?
  • What is the probability that treatment will benefit the patient?
  • What benefits will treatment provide?

Patient Preferences

  • Is the patient competent? Does he or she understand the need for medical care, the options that are available, and the probable results of choosing each of the various available courses of action?
  • Has the patient been informed about his or her condition?
  • How was the patient informed?
  • Have all the treatment alternatives and their possible consequences been discussed with the patient?
  • Has the patient had time to reflect upon the situation and upon the possible options?
  • Has the patient made a clear statement about his or her wishes? If so, what are they?
  • Has the patient discussed the situation thoroughly with someone other than the members of the immediate healthcare team?
  • If the patient is not currently competent, is he or she expected to regain competence?
  • If the patient is incompetent, did he or she ever make a clear statement that would indicate his or her wishes in these circumstances?
  • Is there an advance directive for this patient, and is it available to the healthcare team?
  • If the patient has not made any clear statement and does not have an advance directive, is there information from anyone regarding what the patient might have wanted or might reasonably be assumed to have wanted?

Views of Family

  • Are there family members and who are they? Are they available to the healthcare team?
  • Do they fully understand the patient's condition?
  • What are their positions?
  • Do they agree with one another?
  • Are there any reasons to question their motives?
  • Has one person been identified as having the primary responsibility for communication and decision making?
  • Does anyone have legal custody of the patient (guardianship)?
  • If the patient is a minor, are the legal guardian(s) choosing a course of action that is clearly in the child's best interests?
  • If there are problems in communicating with the family, can someone be found (e.g., translator, minister) who could be helpful as a liaison between the family and the healthcare team?

Views of the Caregivers

  • Are the caregivers fully apprised of the facts?
  • What are their views?
  • If the caregivers disagree, what accounts for the disagreements? Can they be resolved?

Legal, Administrative, and External Factors

  • Are there state statutes or case law that apply to this situation?
  • What potential liability might be present with respect to the hospital, to the providers, and to the parent or guardian?
  • Are there hospital policies or guidelines that apply and would they be helpful in this situation?
  • Are there other persons (in or outside the institution) who should be given information or asked for an opinion?
  • Would it help to consult the literature for any aspect of this case?
  • Is expense to the patient and/or family a factor?
Initiate and act because ethics without action is just talk

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healthcare decision :economic factors that affect the individual family, must also be evaluated.

Economic factors that affect the individual family, must also be evaluated. this is an accepted ethical principle even in  USA

 Allocation can easily become an ethical dilemma when those resources are scarce.
What happens  when  3 persons  from  a single family are comotose and  on ventilators

 All people are of equal value
Are they really ?

 Would you treat the pope the same way as a serial criminal ?or a mentally retarded child ?
enforcement of the rights and duties in the legal system that do not exist in the ethical system
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kickback cut prctice a rose .or a garbage dump is the same called by any name

http://indianexpress.com/article/cities/pune/book-by-city-based-doctors-unwraps-unethical-practices/

Book by city-based doctors unwraps unethical practices

78 doctors from across the country wrote testimonies for the book which will be released on February 26 at AIIMS in New Delhi


Many doctors have clearly decided that there is no choice but to practice medicine as if one is running a business. They were involved in ‘cut practice’ right from the beginning. After the advent of large and corporate hospitals, these practices have increased further,’’ says Dr Vinay Kulkarni, a skin specialist from Pune.
Dr H V Sardesai, a city-based senior physician, says that there is a cut practice where pharmaceutical companies take doctors on foreign tours. They make all the arrangements and the doctors pretend to be on a study trip. “Unfortunatelym, there are many doctors who enjoy all this. Why is there such a large difference between prices of the same medicine sold by different pharmaceutical companies when the chemical used is the same?” he said.
Dr Rajendra Malose, a general practitioner from Nashik, however, is blunt when he points out that doctors get Rs 30-40,000 just for referring a patient for angioplasty. Dead patients continue to be kept on ventilators, until the anger of their relatives cool off, he says. As soon as an accident takes place on the highway, seven or eight persons go running to the site and take charge. “Is it a good or a bad thing that they promptly take such patients to orthopaedic wards of corporate hospitals?” he asks.
These revealing testimonies of 78 doctors from various parts of the country about the reality of private medical practice in India has been compiled in a book authored by Pune-based Dr Abhay Shukla and Dr Arun Gadre. It will be released on February 26 at AIIMS in New Delhi. The book is an English translation of the Marathi one — Kaifiyat pramanik doctoranchi (reflections by sincere doctors).
It contains interviews of 78 practicing doctors from Mumbai, Pune, Delhi, Kolkata, Bangalore and Chennai. “These whistleblower doctors have mustered the ethical courage to expose facts for the first time on such a scale,” Dr Arun Gadre says.
Several doctors spoke up including Dr Vijay Ajgaonkar, senior diabetologist from Mumbai, who says, “Now our greed has increased to the extent that when a patient of one consultant goes to another consultant, the second one prescribes the same medicine, but merely changes the brand to show that he is doing something different. And it is true that this profession has now become completely commercial.”
Huge corporate hospitals and multi-speciality hospitals are growing in number. These organisations put pressure on all the doctors linked to the hospital and on their full-time doctor employees.
“Unnecessary investigations are then forced upon the patients,” says Ajgaonkar. Dr Shyam Kagal, a city-based physician, says that in the past he was attached to a certain hospital where the management told him plainly that to continue work he would have to admit a certain minimum number of patients every month.
Dr Sanjay Gupte, a city-based gynaecologist and ex-national president of FOGSI, hit the nail on the head saying corporate hospitals want only those doctors who can help them to earn more money. “As a result, doctors who practise ethically cannot last there. I know of a hospital where if the patient is charged Rs 1,50,000, the doctor gets a mere Rs 15,000. Ninety percent of the income goes into the corporate coffers,” he adds.


http://www.dnaindia.com/mumbai/report-mard-seeks-action-against-thyrocare-for-cut-practice-lab-refutes-charge-2219996



MARD seeks action against Thyrocare for cut practice; lab refutes charge

DNA CORRESPONDENT | Sun, 5 Jun 2016-07:20am , DNA
The Maharashtra Association of Resident Doctors (MARD) has alleged that Thyrocare, which is one of the leading diagsnostic centres in Mumbai, is involved in encouraging cut practice among doctors. The association has written a letter to the Maharashtra Medical Council (MMC) asking it to look into the matter and take action.
"There is a gross violation of ethics by the laboratory to get more doctors to refer more patients to them for blood samples. We sent the letter to MMC on Friday and asked them to investigate," said Dr Sagar Mundada, president, MARD.
The association has come in possession of a leaflet that, it says, proves its charge true.
Thyrocare, however, has denied the allegation that it pays doctors commission for getting them to send patients to the lab. "We never believed in the cut system and have always advocated against it to everyone involved in the chain. The letter circulated clearly states that this is an offer for the laboratories and not doctors. Coupons are printed with special rates for various tests. These are less than the online rates as they are referred by doctors and much lesser than industry rates. Coupons are sent to laboratories. Laboratories in turn distribute handbills to the doctors in their area," said Santhosh M, general manager, business development, Thyrocare.
He added that Thyrocare also sends the details to doctors so that they understand that the laboratory cannot charge more.



Medical Council shoots off notice to hospital over ‘cut practice’

| TNN | May 12, 2014, 11.23 PM IST


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Ethics



 Much of the material is excerpts from 

 http://www.netce.com/coursecontent.php?courseid=1014&scrollTo=BEGIN#chap.4

 what a patient wants for himself may not be in unison with what his family or physician believes should be done. Even between seemingly alike individuals, with similar education and background, value systems may prove to be radically different. What if a patient refuses life support, but the family insists they want every lifesaving measure taken? Conversely, what if a comatose patient's family members want life support and other interventions stopped and a physician refuses to discontinue therapy?

 physicians acting in a paternalistic manner toward their patients. Questions regarding many issues, such as organ transplantation, assisted life support, patient self-determination, appropriation of dialysis, in-vitro fertilization, cloning, and even the use of generic drugs, did not arise. The reason is simple: these techniques and procedures were not available.
Prior to the 1960s, medical care decisions were part of the paternalistic role of physicians in our society. Patients readily acquiesced care decisions to their physicians because they were regarded almost as family. What drove this resolve of patients to acquiesce their medical care and treatment decisions to their physicians? David Rothman, as discussed in his book, Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making, believes physicians were given such latitude by their patients because they were well-known and trusted by their patients and the community in which they practiced [3]. There were essentially no specialists. One physician took care of a patient and family for a lifetime. The frontier physician often knew the patient from birth to adulthood, made house calls, and was a family friend who knew best what the patient should do with a healthcare concern. Since the 1960s, physicians have generally become strangers to their patients.
Extensive publicity about three research projects resulted in the establishment of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The first project involved elderly patients with chronic illness who were injected with live cancer cells in an effort to discover whether the cells would survive in a person who was ill but did not previously have cancer. No consent was obtained from patients or family members before proceeding.
The second project began in 1932, when the Public Health Service initiated a syphilis study on 399 black males from Tuskegee, Alabama. The goal of the study was to observe the men over a period of time to examine how the disease progressed in individuals of African descent. When the study began, there was no cure for the disease; however, fifteen years into the study, penicillin was discovered to be a cure for syphilis. The research participants were never informed, and treatment was withheld in spite of the fact that by the end of the experiment in 1972, 128 men had died either from the disease or related complications [21].

Finally in 1967, children with mental retardation at the Willowbrook State School, New York, were given hepatitis by injection in a study that hoped to find a way to reduce the damage done by this disease. Although consent was obtained in this study, the consent sometimes had an element of coercion. Gaining admission to the school was difficult and parents were given a guarantee their child would be admitted if they consented to the participation of their child in the study.
 National Commission for the Protection of Human Subjects was created in 1974 by public law. Finally, in 1979, the commission published The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research




  • Ethical Principles and Guidelines for Research Involving Human Subjects
  • A. Boundaries Between Practice and Research
  • B. Basic Ethical Principles
    1. Respect for Persons
    2. Beneficence
    3. Justice
  • C. Applications

    1. Informed Consent
    2. Assessment of Risk and Benefits
    3. Selection of Subjects
    4.  1973, the first edition of the Hastings Center Studies




  • Remarkable advances were projected in the areas of organ transplantation, human experimentation, prenatal diagnosis of genetic disease, the prolongation of life, and control of human behavior.
  • In November 1978, The President's Commission for the Study of Ethical Problems in Medicine and Medical and Biobehavioral Research was created. Its members began work in January 1980. The United States Congress charged them with conducting studies and reporting on a number of topics, including the definition of death, informed consent, and access to healthcare. By spring 1984, the commission had published nine reports addressing many of the problems facing the healthcare system.


  • more attention began to be paid to the allocation of resources and the effectiveness of complex treatments, especially in terms of the quality of life associated with the prolonging of lives.

  • It was the New Jersey Supreme Court Decision in the Karen Ann Quinlan case that brought bioethics to the level of the individual through the media and transformed physician paternalistic authority into patient-physician shared decision making.

  • the U.S. Supreme Court Decision in the Matter of Nancy Cruzan (1990)

  • the court did decree that if an ethics committee agreed with Quinlan's physicians that there was "no reasonable possibility of Karen's ever emerging from her present comatose condition," and if the family and Ms. Quinlan's guardian agreed, the ventilator could be withdrawn [10]. The expectation was that Karen would die following the weaning off the ventilator. In fact, Ms. Quinlan was successfully weaned off the ventilator and lived until June 1985. However, she never regained consciousness in that time.

  • neither individual could speak for herself once the actual situation requiring a decision presented itself.

  • As long as the now incompetent individual had provided evidence at an earlier time of her life, while competent, of what healthcare decisions she would make under specific conditions, her voice could be heard as if she was competent and making the decision during the present time.

  • "That the intent of our ward, if mentally able, would be to terminate her nutrition and hydration."
  • "That there was no evidence of substance to cause belief that our ward would continue her present existence, hopeless as it is, and slowly progressively worsening."
  • "That the co-guardians, Lester L. and Joyce Cruzan, are authorized to cause the removal of nutrition and hydration from our ward, Nancy Beth Cruzan."

  • Terri Schiavo case was a right-to-die legal case in the United States from 1990 to 2005, involving Theresa Marie "Terri" Schiavo, a woman in an irreversible persistent vegetative state. Schiavo's husband and legal guardian argued that Schiavo would not have wanted prolonged artificial life support without the prospect of recovery, and elected to remove her feeding tube. Schiavo's parents argued in favor of continuing artificial nutrition and hydration and challenged Schiavo's medical diagnosis.[1][2] The highly publicized and prolonged series of legal challenges presented by her parents, which ultimately involved state and federal politicians up to the level of President George W. Bush, caused a seven-year delay before Schiavo's feeding tube was ultimately removed.

    • Competent patients have a constitutional and common-law right to refuse treatment.
    • Incompetent patients have the same rights as competent patients.
    • The interests of the state opposing this right are virtually nonexistent in the case of competent patients and very weak in the case of incompetent patients whose prognosis for recovery is dim.
    • The decision-making process should generally occur in the clinical setting without resort to the courts, which are available to assist in decision making when an impasse is reached.
    • In making decisions for incompetent patients, surrogate decision makers should effectuate the patient's own preferences expressed before the patient lost decision-making capacity (the subjective standard); however, if these references are not known, the surrogate, based on whatever evidence is available, should approximate what the patient would have wanted (the substituted judgment standard). If there is no information about the patient's preferences, the surrogate should make a decision that is in the patient's best interests (the best interests standard).
    • In ascertaining an incompetent patient's preferences, the attending physician and surrogate may rely on the patient's "advance directive," which may be written or oral.
    • Artificial nutrition and hydration are medical treatments and may be withheld or withdrawn under the same conditions as any form of medical treatment.
      • Providers must offer written information and summaries of pertinent institutional policies to all adult patients regarding their rights under state laws to accept or refuse treatment and to make advance directives.
      • The patient's record must be documented to indicate whether the patient has an advance directive.
      • Institutions may not discriminate against or refuse care to a patient based upon whether the patient has executed an advance directive.
      • Institutions have an affirmative obligation to comply with requirements of state law regarding advance directives.
      • Institutions must provide (individually or with others) education to staff and community regarding issues associated with advance directives.
      • State Medicaid laws must be amended to require participating healthcare institutions to furnish the written information mentioned above.
      • With the Department of Health and Human Services' assistance, state Medicaid agencies must develop written descriptions of state laws on advance directives, and these materials are to be distributed by participating healthcare institutions

    • DURABLE POWER OF ATTORNEY FOR HEALTH CARE (DPAHC

    • The purpose of the Act is to communicate and protect patients' rights to self-determination in health care. The underlying assumptions of the PSDA are that:
      • Patients who are informed of their rights are more likely to take advantage of them.
      • If patients are more actively involved in decisions about their medical care, then that care will be more responsive to their needs.
      • Patients may choose care that is less costly
      From 1991, when the PSDA was first implemented, to today, most individuals have not completed advance directives and/or do not have them when they enter healthcare agencies that fall under the umbrella of the PSDA. What does this mean for those working in the healthcare field?
    • Conflict between patient autonomy and physician paternalism, poor communication, institution or physician fear of litigation, and/or family disagreement with the patient or healthcare professionals continues to be an issue. 




  • DEFINITIONS OF ETHICAL PRINCIPLES

    The major ethical principles of significance to physicians and other healthcare personnel are respect for persons, autonomy, veracity, beneficence, non-maleficence, justice, fidelity, and right-to-know [1]. These terms are used widely in bioethics and should be briefly defined:
    • Respect for persons requires that each individual be treated as unique and be entitled to treatment that is respectful of their human dignity.
    • Autonomy refers to the right of the patient to determine what will be done with his or her own person. It also involves the patient's right to have confidentiality of their own medical history and records, and for the medical personnel to safeguard that right.
    • Veracity involves truthfulness. Physicians are obligated to be truthful with patients and/or their families and should avoid withholding information. This allows them to make informed choices.
    • Beneficence refers to the ethical principle of doing or promoting good.
    • Non-maleficence correlates to Hippocrates' principle of doing no harm.
    • Justice is broadly understood as fairness; however, it pertains to what someone or a group is owed. It also relates to the distribution or allocation of a scarce resource or treatment. The principle of justice can also be applied in decisions about end-of-life care, such as the right of the patient to receive adequate palliative treatment.
    • Fidelity means remaining faithful to promises made.
    • Right-to-know is the principle of informed consent.

  • The process starts with the broad and general, often abstract, global ideas of how people should act properly within society. Then, the process narrows in focus to a smaller group or individual situation in which the ethical principles act as a guide for daily living. 

  • Principles of Medical Ethics


    1. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.
    2. 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.
    3. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements that are contrary to the best interests of the patient.
    4. 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.
    5. 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.
    6. 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.
    7. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.
    8. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
    9. A physician shall support access to medical care for all people.

  • Journal of Bioethics
    http://bioethics.net
    AMA Physician Resources: Medical Ethics
    http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics.page
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