Sunday, April 1, 2012

Controversies in Bioethics

1) It is now possible to keep people alive who are in coma for years.  When should we pull the plug?  This was a question that I faced as a first year surgical resident in the Intensive Care Unit. The questions which had to be considered were a) What was the chance of survival.   b) if a person survived and came out of coma what would the quality of life be expected at c) who was going to pay for the equipment for the length of time it would need to be in use.
At the time we only had a half dozen respirators. I worked with Dr. Jack Hildes in Community Medicine and we discussed his experience with  iron lungs in the polio epidemic.  Dr. Hildes developed a volunteer bagging brigade which would bag people with respiratory failure and then have them on the more poweful iron long respirator for a period of time each day.  The government committee decision making was so slow that hundreds more people would have died but Dr. Jack Hildes personally  mortgaged his home to buy more iron lungs which coupled with the volunteer bagging brigades kept dozens of people alive through their acute episode. Subsequently there were people who lived out their lives in iron lungs.
So I made decisions on who lived and who died often in the intensive care unit. Family were involved but I was careful to ensure them that I was responsible for the decision not them, saving them from potential guilt.  I pulled the plug. I didn't like it.  Naturally.  I had senior colleagues who I was discussing this with too though some of the decisions were made more swiftly with limitted input because the damage was catastrophic.
I routinely called off resuscitations and was involved in the decision to end resuscitations up until a decade back.  I believe I may have been involved in dozens of such decisions.  It was something I did as a country gp, an emergency doctor, as a surgical resident in intensive care.  I have been involved in the decision as a psychiatrist later in my career and doing a locum covering emergency in my years as a psychiatrist I was involved in these decisions. Once a nurse wanted to continue after I wanted to quit so I went with her call and the girl revived. That was one of the last cases I was involved in like this.  I felt peculiar that I'd not 'believed' really.
I've sat in committees and talked about this subject with a variety of people. When I was younger I enjoyed the discussions more than when I got older. Older I found that I really only wanted to hear from people who'd been directly involved in pulling plugs themselves. One of my native friends made the decision to end a family members life. She told me that all the academic considerations were irrelevant in the moment of decision making.  My minister friend asked to end treatment on her family member said much the same.  I found myself that my own 'ideas' changed a 'quantum' level after my first plug pulling.  Today I know when I will pull the plug and yet administration and bean counters have wanted me the doctor to pull the plug sooner. Theres' always pressure to get rid of the sick and move the dead. It's like a factory out there and the boss man wants things moving and there's all manner of subtle pressure placed on the doctor to 'perform'.  I think I was jaded by the time I wanted to call the resuscitation before the nurse. I wanted to go back to bed.  She was young, a Christian, a believer and were it not for her, the girl would have died.  We went the extra mile like I and countless other doctors had done time and time again.  When we stopped we usual felt comfortable.
The last 99 emergency I was involved in was in the US about 5 years ago. . I was the third responder and another doctor, an internist, I admired had arrived with the nurse before me.  Guy collapsed in a hospital.  We did everything with the crash cart and a half dozen doctors and a full range of medicine over the next half hour or so. Then I admired this fellow because he said, "Is there anyone who thinks we should continue?" At that time there was about 20 people there. Family and hospital staff, administration and clergy had all arrived in the middle of this day.   No one said we should.  We stopped. The man had never resumed breathing and his heart beat had never returned. It was a 'witnessed' arrest but the doctor knew that he had an underlying terminal illness already. The nurse and I in the example before where she kept going was an 'unwitnessed arrest'.  There's far less hope with unwitnessed arrests.

2) When does life begin?  When I did my abortions I was told that I was killing the equivalent of a tumor. It was early days.  6 weeks . A couple of d&cs'. But I 'm a hunter and a fisherman and I felt "life" switch off like I do every time I shoot or catch my food.  I never did another abortion after that.  All the evidence confirms that life begins early. I switched from pro abortion to pro life years later.  I don't think we accept murdering children so we have to be clear about when we as a society accept anyone taking a life. Long ago we decided children had rights and stopped parents from killing their own. The idea 'its' my body' is a bit outdated when a child occurs. This all may be resolved soon with extrauterine birth vats.  Scientists usually have solutions that philosophers would still be discussing millenia hence. The philosophers would have nice hair doos though.
Sure, you keep your body, but the state will not let you kill a 'viable child' as we can save the life of that child.  This debate has gone on a long time and I've been on both sides of it. The venomous things said to me by the pro abortion group and the threats have been difficult.. All the pro life doctors I know, like me, have had their lives threatened. I just don't do abortions and don't recommend them routinely. Yet I have had tremendous pressure on me to do so. I have paid hundreds of thousands of dollars for my political incorrectness in this matter too.   Increasingly we are told that we have to make referrals to doctors who do. Why should I support a colleagues business plan. I can recommend that people contact the authorities and they the authorities would recommend whatever. I don't think I would ever have felt clean recommending a patient see Dr. Mortgentaller.
I certainly don't judge a woman who has an abortion today either. I certainly would rather abort than pass a basketball out my ass.  Yet I don't think society is really discussing the matter appropriately when so many women are going overseas to pay women to use their wombs whereas here a pregnant woman can't do such an obvious thing. Abortion clinics are just the end of a long line of abuses of pregnant women.  I loved when conservatives argued that women should be paid $50,000 a child to stay home and raise them rather than being told to have an abortion or be a single mother who can't afford even the cost of day care and certainly won't be encouraged to get a law degree or medical degree if you have a child to care for .
I can see the same thing said to me as a doctor about euthanasia. " You must refer your patient to  Dr. Kevorkian."  I don't think I'd feel good recommending Dr. Kevorkian, either. I met a woman doctor who fleed from Russia after she couldn't sleep for nightmares after hundreds of abortions .She just wanted to practice medicine without having to do abortions and the state woudln't allow her. Now in China they've solved the feminist problem by aborting generations of women.
This discussion needs to go on at a state level reviewing the new input from technology. I personally have no concern about birth control or morning after pills and believe that these preventions should be readily available. I am not sure though that I should be required to pay for your condoms. I don't even know I want to pay for you to have children.
So this is an area that is ripe for further bioethics discussion.  Right now abortion is a high paid low risk extremely lucrative business which attracts the most mercantile doctors. I don't think I should question my colleagues industry in a free market society. We aren't yet lining up tobacco company CEO's against the wall and shooting them so until we are willing to do that I don't think we can stop business men and women doctors from making a killing.
3) Who gets the first brain transplant?  There is a whole lot of discussion in bioethics about organ transplants. I'm in favour of politicians being first when it comes to brain transplants but I'm not sure that those who are selling their brains would offer superior brain material to what's already in office.
4) All longevity enhancing technologies are an area of controvery in regards to how they are distributed. For years I've read hundreds of scientific and futuristic novels discussing some aspect of bioethics and longevity. My favourite was the fellow who had organ transplants to stay alive and then decided that he'd have multiple vaginas and penile attachments after winning a galactic lottery. He slimed when he walked and was a very suspicious character. The book itself was highlu humorous but if you really are interested in bioethics you'd better start taking an interest in science fiction. Gattaca remains my favourite movie about genetics and bioethics.
5) Plastic surgery - we seem to accept that rich get new faces and the poor don't. I didn't question this until I got old. Now I'm a little miffed that I can't get my botox for free like I can fungal cream.
6) I work in addiction and there's no end of discussion about bioethics in the Canadian Society of Addiction Medicine, International Society of Addiction Medicine and the American Society of Addiction Medicine. Right now all the rage is the availability of marijuana and heroin to the public. At another level the questions is who should get it at what price. People who are willing to pay $300 a day for heroin are having it provided by the state for free.  That's the research package but should heroin addiction be allowed for the poor?  Interesting question.  Diversion with drug courts could be decided in a variety of different ways than it is now.
7) There's a lot more questions that arise with new advances in science and understanding and they are all controversial.  Who should be involved in the decision making is increasingly a question. In England the committee to discuss these matters were set up in such a way that a doctor participating would not be held accountable for his views. Indeed most of my colleagues who are pro life or anti euthanasia are afraid to speak their mind because they know that promotions in departments depends on whether you are pro or against global warming. As everyone knows euthanasia is good for the planet as it will reduce global warming.   There has been interesting research though that says that 'experts' have no superior advantage over children or janitors in making these kinds of moral and ethical decisions. As a psychiatrist I was subjected to the studies in which people on waitlists got better faster than those who were given treatment. In the fine print it was a selection of patients but I'd be most interested in these kinds of studies being done in these types of questions. Having always enjoyed Plato and Jesus I note that neither needed degrees and their listeners and participants didn't have degrees in the debates that have so profoundly touched history.  Can a dying health care system afford a bioethicist.  Given the choice of a consultation with a bioethetist about my much needed facelift would I want $300 more discussion or $300 more plastic surgery. If you looked in my mirror you'd know my answer to that question.
Bioethics then at it's best should end up in parliament. Unfortunately in Canada due to a serious democratic glitch of the last couple of decades soon to be resolved it is that often the case that  these questions are decided by lawyers and judges, individuals with extreme bias and tendency to the least variety in opinion by selection process and the hierarchal nature. Doctors even are more diverse in their opinion but less diverse than a normal collection of citizens asked to conclude what is best in the matter of ethics.  Juries worked well in this sense until jury selection, psychologists , and the ability to skip jury duty, like skipping the Vietnam War ,disrupted an otherwise good thing.  Today the jury is something out of American Idol mixed with the Survival reality series.
8) My research interest that got me going into community medicine and onto psychiatry was 'non compliance' and 'non adherence to medical regimen'.  I did research on this back in the early 80's  Then as a psychiatrist I was fascinated by 'borderline personality disorders' because they were a next generation of 'antisocial personality disorders' when it came to 'civil disobedience'.  There were alot of other things about this 'class of patients' but I'd heard that in the 20th century, if you want to know all of psychiatry you studied schizophrenia, in the 21st you study 'borderline personality disorder'.  The 'bipolar spectrum disorder' was a classic redefining and overlap that avoided dealing wit h the human by  devolving the question  to the 'my brain is well and your brain is not"and I will drug your brain to make it look like my brain." However we'd all seen that with antisocial personality disorders in contrast to psychopaths they could be turned around and went on to make the finest citizens. The same was true in my practice with borderlines.  I watched dozens of psychiatric patients became famous artists and other citizens when their personality disorder was addressed. Unfortunately there was no magic pill and the treatment required individual, group and medication therapy.  A bit more complex than the 3 minute psychiatric psychopharmacy visit allowed.
Yet what better topic for bioethics than borderline personality disorder as a whole. No group is more disenfranchised and stigmatised in society. Schizophrenics at least have Friends ie Friends of Schizophrenia.  It's not surprising there's no Friends of Borderlines Personality Disorder Society out there holding car washes. .
Eventually I moved into addiction work because this again is an area where all aspects of bioethics come to the fore and this overlaps with borderline personality disorders which I've always contended were untreated ptsd until proven otherwise.
So core to modern medicine is 'change' or 'no change'.  And social darwinism is naturally killing my patients because the successful like to say they were born that way where people like Jared Diamond emphasize the environment to explain even population variance.  Judith Herman has written eloquently why 'trauma' is something that even psychiatrists shy away from.
Whether one believes in fate or free will colours all aspects of the bioethics discussion too.  But most importantly who is paying for the discussion and what the ambition is of the participants will certainly colour the discussion. I've always contended you can't know anything about bioethics decisions if you can't follow the money trails or the egos.
Right now I'm going for the ice cream.

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