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Thursday, August 25, 2016

When does "practicing medicine" become "playing God"?

Since reading and reviewing Ann Neumann's riveting book "The Good Death," I've reached out, and we have become Facebook friends. Her thoughtful FB posts have led me to numerous related topics. I am about to download and read this book that one of Ann's posts made me aware of.

Sheri Fink is an acclaimed journalist with both a medical degree and a Ph.D. "Five Days at Memorial" recounts the horror in New Orleans at one hospital in the wake of Hurricane Katrina 11 years ago.
Five Days at Memorial is Pulitzer Prize winner Sheri Fink’s landmark investigation of patient deaths at a New Orleans hospital ravaged by Hurricane Katrina – and her suspenseful portrayal of the quest for truth and justice.

After Katrina struck and the floodwaters rose, the power failed, and the heat climbed, exhausted caregivers chose to designate certain patients last for rescue. Months later, several health professionals faced criminal allegations that they deliberately injected numerous patients with drugs to hasten their deaths.

Five Days at Memorial, the culmination of six years of reporting, unspools the mystery of what happened in those days, bringing the reader into a hospital fighting for its life and into a conversation about the most terrifying form of health care rationing.
Sheri recently did an excellent NPR RadioLab segment:
When people are dying and you can only save some, how do you choose? Maybe you save the youngest. Or the sickest. Maybe you even just put all the names in a hat and pick at random. Would your answer change if a sick person was standing right in front of you?

In this episode, we follow New York Times reporter Sheri Fink as she searches for the answer. In a warzone, a hurricane, a church basement, and an earthquake, the question remains the same. What happens, what should happen, when humans are forced to play god?

Highly recommended use of an hour.

Her Pulitzer-winning 2009 ProPublica piece "The Deadly Choices at Memorial," which looks to have laid the groundwork for her 2013 book, left me mentally exhausted. It is one searing read.

The smell of death was overpowering the moment a relief worker cracked open one of the hospital chapel’s wooden doors. Inside, more than a dozen bodies lay motionless on low cots and on the ground, shrouded in white sheets. Here, a wisp of gray hair peeked out. There, a knee was flung akimbo. A pallid hand reached across a blue gown.

Within days, the grisly tableau became the focus of an investigation into what happened when the floodwaters of Hurricane Katrina marooned Memorial Medical Center in Uptown New Orleans. The hurricane knocked out power and running water and sent the temperatures inside above 100 degrees. Still, investigators were surprised at the number of bodies in the makeshift morgue and were stunned when health care workers charged that a well-regarded doctor and two respected nurses had hastened the deaths of some patients by injecting them with lethal doses of drugs. Mortuary workers eventually carried 45 corpses from Memorial, more than from any comparable-size hospital in the drowned city.

Investigators pored over the evidence, and in July 2006, nearly a year after Katrina, Louisiana Department of Justice agents arrested the doctor and the nurses in connection with the deaths of four patients. The physician, Anna Pou, defended herself on national television, saying her role was to ‘‘help’’ patients ‘‘through their pain,’’ a position she maintains today. After a New Orleans grand jury declined to indict her on second-degree murder charges, the case faded from view.

In the four years since Katrina, Pou has helped write and pass three laws in Louisiana that offer immunity to health care professionals from most civil lawsuits — though not in cases of willful misconduct — for their work in future disasters, from hurricanes to terrorist attacks to pandemic influenza. The laws also encourage prosecutors to await the findings of a medical panel before deciding whether to prosecute medical professionals. Pou has also been advising state and national medical organizations on disaster preparedness and legal reform; she has lectured on medicine and ethics at national conferences and addressed military medical trainees. In her advocacy, she argues for changing the standards of medical care in emergencies. She has said that informed consent is impossible during disasters and that doctors need to be able to evacuate the sickest or most severely injured patients last — along with those who have Do Not Resuscitate orders — an approach that she and her colleagues used as conditions worsened after Katrina.

Pou and others cite what happened at Memorial and Pou’s subsequent arrest — which she has referred to as a "personal tragedy" — to justify changing the standards of care during crises. But the story of what happened in the frantic days when Memorial was cut off from the world has not been fully told. Over the past two and a half years, I have obtained previously unavailable records and interviewed dozens of people who were involved in the events at Memorial and the investigation that followed.

The interviews and documents cast the story of Pou and her colleagues in a new light. It is now evident that more medical professionals were involved in the decision to inject patients — and far more patients were injected — than was previously understood. When the names on toxicology reports and autopsies are matched with recollections and documentation from the days after Katrina, it appears that at least 17 patients were injected with morphine or the sedative midazolam, or both, after a long-awaited rescue effort was at last emptying the hospital. A number of these patients were extremely ill and might not have survived the evacuation. Several were almost certainly not near death when they were injected, according to medical professionals who treated them at Memorial and an internist’s review of their charts and autopsies that was commissioned by investigators but never made public.

In the course of my reporting, I went to several events involving Pou, including two fund-raisers on her behalf, a conference and several of her appearances before the Louisiana Legislature. Pou also sat down with me for a long interview last year, but she has repeatedly declined to discuss any details related to patient deaths, citing three ongoing wrongful-death suits and the need for sensitivity in the cases of those who have not sued. She has prevented journalists from attending her lectures about Katrina and filed a brief with the Louisiana Supreme Court opposing the release of a 50,000-page file assembled by investigators on deaths at Memorial.

The full details of what Pou did, and why, may never be known. But the arguments she is making about disaster preparedness — that medical workers should be virtually immune from prosecution for good-faith work during devastating events and that lifesaving interventions, including evacuation, shouldn’t necessarily go to the sickest first — deserve closer attention. This is particularly important as health officials are now weighing, with little public discussion and insufficient scientific evidence, protocols for making the kind of agonizing decisions that will, no doubt, arise again...
 A long read. A tough read. One that will bring no "closure." Worth it nonetheless.

When Katrina hit, my wife was Environmental Division Director of Quality for Baton Rouge-based Shaw Group. They were quickly awarded a number of (somewhat controversial) remediation contracts (they were the company that pumped NOLA "dry," ran the blue tarp roofing program, and administered the FEMA trailer complexes).

Cheryl subsequently spent the rest of the fall down in Baton Rouge and NOLA (we were living in Vegas at the time), where her crews worked 16-20 hours a day, 6-7 days a week. IIRC, I saw her for all of 11 days between Katrina and Christmas.

Mardis Gras 2006 was canceled in NOLA, but the party went on in Baton Rouge, and we went.


Sheri wrote in the NY Times the other day.
Whose Lives Should Be Saved?
Researchers Ask the Public

By SHERI FINK AUG. 21, 2016

BALTIMORE — In a church basement in a poor East Baltimore neighborhood, a
Johns Hopkins doctor enlisted residents to help answer one of the most fraught
questions in public health: When a surge of patients — from a disaster, disease
outbreak or terrorist attack — overwhelms hospitals, how should you ration care? Whose lives should be saved first?

For the past several years, Dr. Lee Daugherty Biddison, a critical care
physician at Johns Hopkins, and colleagues have led an unusual public debate
around Maryland, from Zion Baptist Church in East Baltimore to a wellness center in wealthy Howard County to a hospital on the rural Eastern Shore. Preparing to make recommendations for state officials that could serve as a national model, the researchers heard hundreds of citizens discuss whether a doctor could remove one patient from lifesaving equipment, like a ventilator, to make way for another who might have a better chance of recovering, or take age into consideration in setting priorities.

At that first public forum in 2012 in East Baltimore, Cierra Brown, a former
Johns Hopkins Hospital custodian, said she favored a random approach like a
lottery. “I don’t think any of us should choose whether a person should live or die,” she said...
Morally fraught, all of it. We remain pretty much unprepared to deal with the kind of post-major disaster large-scale triaging that will have to be done yet again -- with the inevitable ensuing angry non-participant 20-20 hindsight armchair accusations of "playing God."

Notwithstanding my grad degree in "Ethics and Policy Studies" and its deep study in and application of the concepts and mechanics of getting from "is" to "ought," I can't call myself an "ethicist," a title conventionally reserved for "moral philosophers" (typically at the doctoral level) who work in the field ongoing.
My EPS work was relatively pedestrian, addressing the question "should you have to take a non-cause drug test as a condition of employment, etc." About 3/4ths of my 1998 pre-thesis defense draft remains posted here.
My core takeaway from my studies is that "ethics" is not some about some authoritative "good/bad cookbook" lookup reference text. Derivation of "right/just/moral" conduct comes from deep, honest (if difficult) rational deductive and inductive deliberation that takes into account the breadth of applicable traditional and evolving foundational moral sentiment (even at the risk of some potential circularity with respect to those latter elements).
The word "philosophy" derives fundamentally from "philo" ("love of") "sophia" ("knowledge"). That it wanders off in the byzantine halls of academia into inscrutable snooty 50-dollar word-laden tedium in no way negates that.
"Ethics" as defined in the Wiki:
Ethics or moral philosophy is the branch of philosophy that involves systematizing, defending, and recommending concepts of right and wrong conduct. The term ethics derives from the Ancient Greek word ἠθικός ethikos, which is derived from the word ἦθος ethos (habit, "custom"). The branch of philosophy axiology comprises the sub-branches of ethics and aesthetics, each concerned with values.
As a branch of philosophy, ethics investigates the questions "What is the best way for people to live?" and "What actions are right or wrong in particular circumstances?" In practice, ethics seeks to resolve questions of human morality, by defining concepts such as good and evil, right and wrong, virtue and vice, justice and crime. As a field of intellectual enquiry, moral philosophy also is related to the fields of moral psychology, descriptive ethics, and value theory.
Three major areas of study within ethics recognised today are:
  1. Meta-ethics, concerning the theoretical meaning and reference of moral propositions, and how their truth values (if any) can be determined
  2. Normative ethics, concerning the practical means of determining a moral course of action
  3. Applied ethics, concerning what a person is obligated (or permitted) to do in a specific situation or a particular domain of action...
"Ethicist," specifically:
An ethicist is one whose judgment on ethics and ethical codes has come to be trusted by a specific community, and (importantly) is expressed in some way that makes it possible for others to mimic or approximate that judgment. Following the advice of ethicists is one means of acquiring knowledge (see argument, argument from authority).

The term jurist describes an ethicist whose judgment on law becomes part of a legal code, or otherwise has force of law. This may be due to formal (de jure) state sanction.

Some jurists have less formal (de facto) backing by an ethical community, e.g. a religious community. In Islamic Law, for instance, such a community following (taqlid) a specific jurisprudence (fiqh) of shariah mimics judgment of a prior jurist. Catholic Canon Law has a similar structure. Such a jurist may be a theologian or simply a prominent teacher. To those outside this tradition, the jurist is simply an ethicist who they may more freely disagree with, and whose input on any issue is advisory. However, they may find it hard to avoid a fatwa or excommunication or other such shunning by the religious community, so it may be hard advice to ignore.

Outside the legal professions and spiritual traditions, ethicists are usually considered to be either philosophers or mediators of disputes...
How about "medical ethics"?
The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct that define the essentials of honorable behavior for the physician.

Principles of Medical Ethics 

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

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

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

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

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

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

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

VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
IX. A physician shall support access to medical care for all people.
All dutifully noble and necessary. The difficulties invariably ensue in the specific applications under exigent circumstances. While deductive and inductive methods of "argument analysis" and "critical thinking" are fairly clear (i.e., premises to conclusions), once we get to the consideration of contending "moral values" (few of which can claim any scientific grounding) we are frequently stymied, stalemated.

My first grad school semester paper comprised a deconstructive argument analysis and evaluation of the 1994 JAMA "Single Paper" proposal (pdf).

A generation later we're still arguing over the same asserted (and contentious) relative merits.


We get a lot of our "moral sensibilities" via our myriad religious traditions. apropos, a favorite old book of mine is this one.

It is hard to say exactly when modern science began. Many scholars would date it at roughly 1600, when both Kepler and Galileo started using precision measurement to map the universe. But one thing is certain: starting from whatever date we choose, modern science was, in many important ways and right from the start, deeply antagonistic to established religion.

Most of the early scientists, of course, remained true believers, genuinely embracing the God of the Church; many of them sincerely believed that they were simply discovering God's archetypal laws as revealed in the book of nature. And yet, with the introduction of the scientific method, a universal acid was released that would slowly, inevitably, painfully eat into and corrode the centuries-old steel of religion, dissolving, often beyond recognition, virtually all of its central tenets and dogmas. Within the span of a mere few centuries, intelligent men and women in all walks of life could deeply and profoundly do something that would have utterly astonished previous epochs: deny the very existence of Spirit.

Despite the entreaties of the tenderhearted in both camps, the relation of science and religion in the modern world— that is, in the last three or four centuries—has changed very little since their introduction to each other in the trial of Galileo, where the scientist agreed to shut his mouth and the Church agreed not to burn him. Many wonderful exceptions aside, the plain historical fact has been that orthodox science and orthodox religion deeply distrust, and often despise, each other.

It has been a tense confrontation, a philosophical cold war of global reach. On the one hand, modern empirical science has made stunning and colossal discoveries: the cure of diseases such as typhoid, smallpox, and malaria, which racked the ancient world with untold anguish; the engineering of marvels from the airplane to the Eiffel Tower to the space shuttle; discoveries in the biological sciences that verge on the secrets of life itself; advances in computer sciences that are literally revolutionizing human existence; not to mention plopping a person on the moon. Science can accomplish such feats, its proponents maintain, because it utilizes a solid method for discovering truth, a method that is empirical and experimental and based on evidence, not one that relies on myths and dogmas and unverifiable proclamations. Thus science, its proponents believe, has made discoveries that have relieved more pain, saved more lives, and advanced knowledge incomparably more than any religion and its pie-in-the-sky God. Humanity's only real salvation is a reliance on scientific truth and its advance, not a projection of human potentials onto an illusory Great Other before whom we grovel and beg in the most childish and undignified of fashions.

There is a strange and curious thing about scientific truth. As its own proponents constantly explain, science is basically value-free. It tells us what is, not what should be or ought to be. An electron isn't good or bad, it just is; the cell's nucleus is not good or bad, it just is; a solar system isn't good or bad, it just is. Consequently science, in elucidating or describing these basic facts about the universe, has virtually nothing to tell us about good and bad, wise and unwise, desirable and undesirable. Science might offer us truth, but how to use that truth wisely: on this science is, and always has been, utterly silent. And rightly so; that is not its job, that is not what it was designed to do, and we certainly should not blame science for this silence. Truth, not wisdom or value or worth, is the province of science.

In the midst of this silence, religion speaks. Humans seem condemned to meaning, condemned to find value, depth, care, concern, worth, significance to their everyday existence. If science will not (and cannot) provide it, most men and women will look elsewhere. For literally billions of people around the world, religion provides the basic meaning of their lives, the glue of their existence, and offers them a set of guidelines about what is good (e.g., love, care, compassion) and what is not (e.g., lying, cheating, stealing, killing). On the deepest level, religion has even claimed to offer a means of contacting or communing with an ultimate Ground of Being. But by any other name, religion offers what it believes is a genuine wisdom.

Fact and meaning, truth and wisdom, science and religion. It is a strange and grotesque coexistence, with value-free science and value-laden religion, deeply distrustful of each other, aggressively attempting to colonize the same small planet. It is a clash of Titans, to be sure, yet neither seems strong enough to prevail decisively nor graceful enough to bow out altogether. The trial of Galileo is repeated countless times, moment to moment, around the world, and it is tearing humanity, more or less, in half...
A good read. Now freely available in pdf format.


Regarding New Orleans, I highly recommend David Simon's HBO series "Treme."

 'Treme' is set in post-Katrina New Orleans. It chronicles the struggles of a diverse group of residents as they rebuild their lives and their city. ‘Treme,' pronounced Truh-may, takes its title from the name of one of the city's oldest neighborhoods, an historically important source of African-American music and culture...

I loves me some NOLA. Always have. Was last there in 2013 to cover HIMSS13.

More to come...

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