[One way] Americans deal with the different standards dilemma is to confuse data with wisdom. We heap up information. Computers help. Estimates are that there are six million articles annually published in English alone which relate to medicine. We do computer searches. We find out how much it costs. What the risks are. What the various treatments are. These are statements of what is. We will return to them, for they are important in making ethical decisions. However, ethics is about what ought to be, or what ought not to be. Data is about what is, or what is not. Even stacked exceedingly high and heated, a pile of “is” statements will not convert to an “ought” statement. Empirical statements do not transform under pressure and heat to normative statements.
Excerpt from "Counseling Persons with Questions on Medical Ethics"
Monday, March 25, 2013
Monday, March 18, 2013
Narrow-Minded Empiricism
Now, one of my “oughts.” We ought to pay more attention to the empiric data than we do. As I have tried to do this, I have discovered that the empiric data is often thin, subject to various interpretations, and varying. The consensus as to the proper treatment of peptic ulcer disease, of acute myocardial infarction, and many other things have changed drastically since I entered medicine. We call these changes “advances” but sometimes you get to see the indicator needle swing not 180 degrees, but 360 degrees. What is more, our empiric information, even when it is accurate, sometimes expresses a narrow-minded or one-sided view of reality. The way we think of the causes of diseases in medicine betrays that we are very prone to be materialistic reductionists. We seek those causes which are tangible and visible and which are reduced to their smallest elements, such as biochemistry.
As example, what causes gonorrhea? We are taught in medical school that gonorrhea is caused by Neisseria gonorrhea, a gram negative coccus. The answer is only partial and, if allowed to stand in that form, leads into a narrowness. Most commonly, sexual intercourse is also involved. More than that, it is normally required that the sexual intercourse be that in which at least one of the partners has had intercourse with one or more others who had the germ. The coccus is a sine qua non for the disease, but other features are also required: (1) Sexual intercourse. (2) Sexual partners in that intercourse who have had intercourse with others. In fact, though the germ appears to be rather readily infectious, for the disease to continue its propagation among humans requires that sexual intercourse be considerably afield from monogamy.
Without these additional causal features, gonorrhea might actually disappear even without treatment as the infected persons died out without passing it on. Throughout my lifetime – I am about as old as penicillin – there has never been a time when we did not have a chemotherapeutic agent effective against Neisseria gonorrhea. Throughout my lifetime, however, the prevalence of Neisseria gonorrhea has varied and often has been much higher than when I was a child. Thus, the view that Neisseria gonorrhea causes the disease is incomplete. It doesn't work by itself. It is, dare I say it, narrow-minded. In addition to the bacterium is also required that sufficient numbers of the population believe that it is appropriate to engage frequently in non-monogamous sexual intercourse, and who act on that belief.
Medical ethics has been bound down by an inflexible, narrow-minded habit of viewing problems in their most materialistic terms. We feel comfortable dealing with bacteria in our patients' genital tracts, but not with the belief systems in their minds. Excuses are offered, such as, “You don't really think that people are going to suddenly become monogamous, do you? That's impractical.”
Though that is supposed to be an unanswerable rhetorical question, I submit that it is eminently answerable. First of all, it misrepresents the broader viewpoint. No, people won't “suddenly” do much of anything, as a whole. Secondly, if antibiotics have failed to perfectly eradicate gonorrhea, certainly parallel efforts working on the belief system needn't be expected to produce perfect results. Finally, I remember when the belief systems made a difference. In regard, therefore, to causes of disease, consider what causes heart disease, emphysema, AIDS, alcoholism, trauma. Do we think of the causes narrowly? Do we think of fried foods, cigarettes, the HIV particle, ethanol, or motor vehicles and firearms? If so, why? Even if we do not regard ourselves in medicine as capable of making a difference in the larger conceptualizations, do we obstruct others in society who are willing to take that approach?
Excerpt from "Counseling Persons with Questions on Medical Ethics"
As example, what causes gonorrhea? We are taught in medical school that gonorrhea is caused by Neisseria gonorrhea, a gram negative coccus. The answer is only partial and, if allowed to stand in that form, leads into a narrowness. Most commonly, sexual intercourse is also involved. More than that, it is normally required that the sexual intercourse be that in which at least one of the partners has had intercourse with one or more others who had the germ. The coccus is a sine qua non for the disease, but other features are also required: (1) Sexual intercourse. (2) Sexual partners in that intercourse who have had intercourse with others. In fact, though the germ appears to be rather readily infectious, for the disease to continue its propagation among humans requires that sexual intercourse be considerably afield from monogamy.
Without these additional causal features, gonorrhea might actually disappear even without treatment as the infected persons died out without passing it on. Throughout my lifetime – I am about as old as penicillin – there has never been a time when we did not have a chemotherapeutic agent effective against Neisseria gonorrhea. Throughout my lifetime, however, the prevalence of Neisseria gonorrhea has varied and often has been much higher than when I was a child. Thus, the view that Neisseria gonorrhea causes the disease is incomplete. It doesn't work by itself. It is, dare I say it, narrow-minded. In addition to the bacterium is also required that sufficient numbers of the population believe that it is appropriate to engage frequently in non-monogamous sexual intercourse, and who act on that belief.
Medical ethics has been bound down by an inflexible, narrow-minded habit of viewing problems in their most materialistic terms. We feel comfortable dealing with bacteria in our patients' genital tracts, but not with the belief systems in their minds. Excuses are offered, such as, “You don't really think that people are going to suddenly become monogamous, do you? That's impractical.”
Though that is supposed to be an unanswerable rhetorical question, I submit that it is eminently answerable. First of all, it misrepresents the broader viewpoint. No, people won't “suddenly” do much of anything, as a whole. Secondly, if antibiotics have failed to perfectly eradicate gonorrhea, certainly parallel efforts working on the belief system needn't be expected to produce perfect results. Finally, I remember when the belief systems made a difference. In regard, therefore, to causes of disease, consider what causes heart disease, emphysema, AIDS, alcoholism, trauma. Do we think of the causes narrowly? Do we think of fried foods, cigarettes, the HIV particle, ethanol, or motor vehicles and firearms? If so, why? Even if we do not regard ourselves in medicine as capable of making a difference in the larger conceptualizations, do we obstruct others in society who are willing to take that approach?
Excerpt from "Counseling Persons with Questions on Medical Ethics"
Monday, March 11, 2013
Teasing Out Relevant Medical Information
One of the matters we need to know in counseling persons with medical ethical questions is the relevant medical information. This information is our unique contribution in helping people make ethical decisions. At some risk to being caught up in the example, I will proceed to illustrate this with an example. The example I chose is screening for prostate cancer, a hot topic in medicine now. I mentioned earlier as an ethical matter what to do when a 75 year old man without urinary symptoms asks about screening for prostate disease as he heard on the radio. I chose the example because I have faced the question often enough. This is not a baboon liver sort of issue. Further, it is one in which the relevant medical information is key.
I happen to be convinced that screening for prostate cancer in asymptomatic 75 year old men with current tools of PSA, digital rectal exam, ultrasound, and biopsy, or any combination thereof, ought not to be done. There are perhaps urologists or others who want to argue. I love to argue, but I do not wish to let one example capture the whole. I grant that there is another view of the data. The point is that this is an ethical question because it seeks an “ought” answer. The patient asks, “Ought I to have the screening?” And the doctor asks, “Ought I to recommend and do the screening?” Of course, there are additional implied “oughts” in the question: “I ought to seek to extend my life and my health if I can” is one of these. If the doctor and the patient are agreed on this implied “ought” about life and health, then the ethical matter hinges on the empiric information. Does screening of asymptomatic American men aged 75 years improve their health or longevity?
I suggest to you that a number of the conundrums of medical ethics, particularly those that are grouped under “distributive justice” – who gets what when resources are limited – can be reduced in size by attention to the empirical information – physicians, doctors, insurance, hospitals, drugs, nursing, and so forth. Many articles and talks today agonize over how to distribute “scarce medical resources.” I am repeatedly drawn to inquire as to the actual effectiveness of the resources. Medicine is not as solidly based in unequivocal scientific empiricism as we like to think. Much is done by consensus – we think so, we hope so, it seems so, we've usually done it this way, it is considered good practice to...
Excerpt from "Counseling Persons with Questions on Medical Ethics"
I happen to be convinced that screening for prostate cancer in asymptomatic 75 year old men with current tools of PSA, digital rectal exam, ultrasound, and biopsy, or any combination thereof, ought not to be done. There are perhaps urologists or others who want to argue. I love to argue, but I do not wish to let one example capture the whole. I grant that there is another view of the data. The point is that this is an ethical question because it seeks an “ought” answer. The patient asks, “Ought I to have the screening?” And the doctor asks, “Ought I to recommend and do the screening?” Of course, there are additional implied “oughts” in the question: “I ought to seek to extend my life and my health if I can” is one of these. If the doctor and the patient are agreed on this implied “ought” about life and health, then the ethical matter hinges on the empiric information. Does screening of asymptomatic American men aged 75 years improve their health or longevity?
I suggest to you that a number of the conundrums of medical ethics, particularly those that are grouped under “distributive justice” – who gets what when resources are limited – can be reduced in size by attention to the empirical information – physicians, doctors, insurance, hospitals, drugs, nursing, and so forth. Many articles and talks today agonize over how to distribute “scarce medical resources.” I am repeatedly drawn to inquire as to the actual effectiveness of the resources. Medicine is not as solidly based in unequivocal scientific empiricism as we like to think. Much is done by consensus – we think so, we hope so, it seems so, we've usually done it this way, it is considered good practice to...
Excerpt from "Counseling Persons with Questions on Medical Ethics"
Monday, March 4, 2013
Prioritizing Risks and Benefits
As finite beings who do not know everything, we need to help our patients know relative risks. Life is risk. Health care decisions are often decisions of prioritization. No path is risk-free. We should not so focus upon the most fearful risk and back away from it without looking behind us to see what risks we are backing into. For a Christian, good stewardship means making the most of the resources we have to further the kingdom of God. That means making risk/benefit estimates.
Excerpt from "Counseling Persons with Questions on Medical Ethics"
Excerpt from "Counseling Persons with Questions on Medical Ethics"
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