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“Battlefield acupuncture”?

THE SCENE: Iraq, Afghanistan, or anywhere where U.S. troops are risking life and limb.

THE TIME: The not-too-distant-future. Maybe even 2009.

Joe is on patrol.

It’s the middle of summer in the desert town. The air hangs heavy, hot, dry and dusty, like a blast furnace firing steel. The heat penetrates Joe’s 80 lb pack in much the same way the heat from boiling water penetrates the shell of an unfortunate lobster. Joe’s heart races. His squad is on edge; their eyes dart furiously to and fro, looking for the deadly threat that might lurk in the shadows. Every shadow is a potential source of death, every alley a refuge from which the enemy can attack and kill him or his buddies, every rooftop a fortress from which the enemy can rain death upon the squad. The area is known to be thick with terrorists and insurgents. Joe pictured them waiting unseen from every nook and cranny for the opportunity to attack. The skin on Joe’s back is all prickly. He distinctly feels as though he has a huge bullseye pointed on his back. He feels a bead of sweat dripping down his forehead and onto his eyelid, all slimy and salty. Joe desperately wants to wipe it away, but that would necessitate removing one of his hands from his weapon. The split second it would take for him to put it back might mean the difference between life and death for him or one of his buddies.

A loud roar fills Joe’s ears, and suddenly he feels as though he has no weight. The scene unfolds in slow motion, just like in the movies. Dazed, Joe hears a tumult as though from a great distance, but can see nothing. Yelling and gunfire all around, he becomes conscious enough to realize that he’s lying flat on his back. He feels searing pain in his legs and a hot liquid oozing around them. It occurs to Joe that it must be his own blood or even perhaps his own urine, but he’s just too dazed to care.

“Medic!” Joe hears someone scream. He feels someone pull his helmet from his head and realizes that the sound of gunfire and yelling is receding. His unit must be driving away the ambushers. Good! He thinks. Give those assholes hell, guys! He opens his eyes, and realizes that his buddy’s got his back, and turns to see another man, a medic, drop to his knees at his side. His uniform is stained a disturbing red. Joe feels the medic wrapping something around his thigh. It’s a tourniquet, and Joe cries out in pain as he feels it constricting around his upper thigh.

“Bleeding’s better!” Joe hears the medic say to his buddy. “I’ll take it from here.” Joe’s buddy runs off to join the rest of his unit, and the medic moves his face close to Joe’s. He feels himself being moved from side to side and then his legs being moved. More pain. Joe cries out.

The medic leans in to talk to Joe, “I think we’ve got the bleeding under control for now. I put a tourniquet on your leg. Let’s get you out of here. The docs’ll patch you up in no time.” Joe is vaguely aware of another corpsmen with a stretcher nearby. The medic leans in again, “Are you in pain, soldier?”

“What do you think? My leg hurts like a sonofabitch! I could really use something for the pain,” Joe hears himself yelling, again as if from a distance. Pain is shooting through his leg, setting every nerve on fire, and the tourniquet is biting into raw muscle through the edge of a wound that comes all the way up to his groin. The flayed edges of his skin shoot fire to his brain, and he can feel his broken bones grinding against each other every time he moves in spite of the splint.

“I’ve got something better that’ll help,” the medic screams over the din.

Better? Joe thinks. I’m in agony here. I need something! Anything!

The medic pulls a small box out of his pack. Joe sees that it’s a small case. He opens it. Its contents look something like this:

acupuncturekit

Joe is puzzled. Where’s the morphine? He wonders. “What are those needles?” Joe asks. “What are you doing? I’ve never seen syringes that look like that before!”

“Acupuncture,” replies the medic. “I’ll take care of you.”

“What are you going to do with them?” Joe replies.

“Stick them into your earlobe. It’ll take the pain away really fast.”

“Are you shittin’ me?” Joe screeches, trying to get up to grab the medic by the front of his uniform. “My leg’s a bloody mess, I’m in agony, and you’re tellin’ me you’re gonna stick little needles in my ear and make it all better? Like that‘s going to do anything! I need real pain medicine! Give me morphine! NOW!
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Posted in: Acupuncture, Medical Ethics, Politics and Regulation

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How SHOULD We Discuss Quackery with Innocents and the Not-so-Innocent?

Recents posts by Drs. Albietz and Gorski have highlighted questions that are recurrent on SBM. We are convinced that medicine should be based on real knowledge, to the extent that it exists, and that physicians should be honest; these are matters of science and ethics. How do we reconcile that with heartfelt, if misguided beliefs of patients, their families, and others? When Dr. Albietz wrote that it might have been better for the chiropractor to visit in the same way that “priests, imams, prayer sessions, rabbis, etc visit children within the PICU,” it was reminiscent of Dr. Peter Moran’s hypothetical “witch doctor.” When he lamented academic medicine’s current dalliances with quackery, it brought to mind the NCCAM, David Katz, Andrew Weil, Bravewell , and their enablers.

Dr. Albietz argued that when talking to credulous patients or their families, taking a hard line against quackery is likely to be counter-productive. Most of us would agree with that. Dr. Gorski described a different scenario: after calling a quack “a quack” when talking to a friend of a friend who is a scientist, he concluded that he had been too “blunt.” Several commenters disagreed, but all would probably agree with Dr. Gorski that “you have to know when to pick one way over another; i.e., diplomacy over all out war or vice versa.”

Another Case of Foot-In-Mouth Disease

I recently had an experience strikingly similar to Dr. Gorski’s, during which I castigated myself for my rancor even as I was incapable of moderating it. Fellow blogger Dr. Val Jones was a witness!

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Posted in: Medical Academia, Medical Ethics, Science and Medicine

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Between a Rock and a Hard Place: A Case Study Exploring the Battle Lines of Science Based Medicine

Editor’s Note: This is a guest post solicited by Dr. Hall, who describes Dr. Albietz thusly: He’s a skeptical young pediatrician who works in a PICU and recently had a chiropractor come into the PICU to consult on a child with intractable seizures. He was sort of coerced to allow this at the parents’ request and against his better judgment. His hospital had set a precedent of letting alternative practitioners have temporary privileges in cases like this. He was torn between his academic integrity and doing the most humane thing for the patient and family.

Primum non nocere.” First, do no harm. It is a guiding principle of medicine, and one which is next to impossible to achieve in practice. It is difficult for the general public to hear, but any intervention a physician makes, and indeed the decision to make no intervention, carries a risk of harm with it. Given enough time, every physician will make a decision which results in unintended harm to a patient, even death, and it haunts us every day of our careers. Faced with this horrible certainty, what is one to do? The only responsible, ethical position to take is to ensure that each patient receives the care most likely to generate a positive outcome, in other words, to stack the deck as steeply in favor of the patient as is possible. Diligent application of the scientific method to every therapy, novel and new, old and venerated, is the only way we as physicians can be certain we are doing the greatest good and the least harm to those who seek our help; it is the only way to assuage our conscience if things end badly.

Our professional organizations and academic institutions have been vital in formulating, propagating, and enforcing the practice of evidence based medicine (EBM). They have stood, to borrow the phrase from Carl Sagan, as “a candle in the dark,” promoting the best practices and protecting patients from those that are ineffective, fraudulent, harmful, or even simply sub-standard. It is a heartening environment in which to work.

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Posted in: Chiropractic, Medical Ethics

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The “Gonzalez Trial” for Pancreatic Cancer: Outcome Revealed

A Review

Dr. Lipson’s “detoxification” post on Thanksgiving Day and Dr. Gorski’s recent post about “Gerson Therapy” were timely, because last weekend I noticed something that I should have noticed months ago. Before delivering the punch line, let me remind you, Dear Reader, of the nature of the topic. The regimen advocated by Nicholas Gonzalez is a variation of a “detoxification” treatment for cancer that has been around, in one form or another, for more than 50 years (“Gerson Therapy” is another example).† Here is the National Cancer Institute’s (NCI) description:

Patients receive pancreatic enzymes orally every 4 hours and at meals daily on days 1-16, followed by 5 days of rest. Patients receive magnesium citrate and Papaya Plus with the pancreatic enzymes. Additionally, patients receive nutritional supplementation with vitamins, minerals, trace elements, and animal glandular products 4 times per day on days 1-16, followed by 5 days of rest. Courses repeat every 21 days until death despite relapse. Patients consume a moderate vegetarian metabolizer diet during the course of therapy, which excludes red meat, poultry, and white sugar. Coffee enemas are performed twice a day, along with skin brushing daily, skin cleansing once a week with castor oil during the first 6 months of therapy, and a salt and soda bath each week. Patients also undergo a complete liver flush and a clean sweep and purge on a rotating basis each month during the 5 days of rest.

As unlikely as it may seem, in 1999 American taxpayers began paying for people with cancer of the pancreas to be subjected to that regimen, in a trial sponsored by the National Center for Complementary and Alternative Medicine (NCCAM) and the NCI, conducted under the auspices of Columbia University. Gonzalez provided the treatments. A few months ago I presented a multi-part treatise on the “Gonzalez regimen” and the trial. It demonstrated that all evidence, from basic science to clinical, including the case series that supposedly provided the justification for the trial, had failed to support any real promise (the case series had previously been considered by reader Dr. Peter Moran, who also found them wanting).

It showed that the impetus for the trial, as has been true for other regrettable trials of implausible health claims, can be traced not to science but to the reactionary politics of anti-intellectual populism: initially to Laetrile and to the “Harkinites,” and more recently to the Honorable Dan Burton (R-IN). It reported that there were major problems with the Gonzalez trial from the outset, and that for at least one subject the regimen was more torture than therapy. It reported that for unclear reasons the trial had come to a halt a couple of years ago, and that it appeared that there would never be a report of its findings.

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Posted in: Cancer, Clinical Trials, Medical Academia, Medical Ethics, Politics and Regulation

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Canadian Justice: Breast-Fondling Chiropractor Faces “Interpersonal Skills Training”

There is something unexpectedly sinister about this news report from my former home town in Canada. Apparently, a local chiropractor has been using his “medical training” to excuse his sexual misconduct. Here’s the story from the Halifax Chronicle Herald:

During a hearing in July, the woman said the chiropractor would frequently grip her around the ribs and hold tight, sometimes cupping her breasts, while speaking softly over her shoulder.

On other visits, she said, he would have her lie on a table and would undo one side of her johnny shirt, exposing her breast, place a thumb between her breasts and roll her onto her side by pressing the weight of his own body on her.

Dr. LaPierre testified he performed a technique called the Zindler manoeuvre. It involves applying precise, quick pressure to a restricted joint to restore movement. He said he would have explained the procedure to her the first time but not on subsequent treatments…

The second incident involved a woman who complained that in 2006 the chiropractor “massaged” her breast while trying to find the source of her back pain.

Dr. LaPierre said he was using a technique called “matrix repatterning” that required contact with the woman’s sternum. He said he didn’t recall where the rest of his hand was at the time. He determined the woman had a rib out of alignment.

What was the punishment for his behavior?

Dr. Phillip LaPierre must have a female observer present when he examines women for the next five years, must take training on interpersonal skills and must pay a fine and costs totaling $26,000 now that a panel of the Nova Scotia College of Chiropractors has found him guilty of sexual misconduct based on the two complaints.

It’s hard to imagine such a small fee in an American court of law. If a US physician were molesting his patients, I’m willing to bet that the fine would have an additional zero or two at the end.
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Posted in: Chiropractic, Medical Ethics

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“Integrative Medicine Experts”: Another Barrier to Effective Discipline

This is the final entry in the current series having to do with state regulation of physicians.† It is the final one merely because I’m tired of the topic, for now. There is plenty more to write about, including an event that occurred only yesterday right here at my own hospital. I’ll give a preview of that at the end of this post, but first we’ll look at another recent event.

Dazing Arizona  

Arizona’s citizens, more than most, can expect to be bamboozled by pseudomedicine. We’ve seen that the Arizona Board of Homeopathic Medical Examiners has, for years, provided a regulatory safe haven for quacks with MD and DO degrees. Although I haven’t previously mentioned it in this series, which is about quack medical doctors, Arizona is also a haven for another group of quacks: “naturopathic doctors.” Like its homeopathy board, Arizona’s Naturopathic Physicians Board of Medical Examiners has been less than committed to protecting the public from its licensees. In each board’s case, the state Office of the Auditor General has suggested numerous fixes, but there has been little indication of improvements.

Nor would improvements be expected: in the words of Edzard Ernst,

Those who believe that regulation is a substitute for evidence will find that even the most meticulous regulation of nonsense must still result in nonsense.

Arizona is also the home of one of the first academic “integrative medicine” programs, begun by Andrew Weil at the University of Arizona. We have previously seen examples of misleading language emanating from that program. We’ve also seen the program’s inordinate effect on the Federation of State Medical Boards (FSMB). We’ve seen examples of the writings of Kenneth Pelletier, one of the U of Arizona program’s consultants to the FSMB. A recent disciplinary case in Arizona illustrates the potential danger of a state medical board seeking consultation from another “integrative medicine expert” from that program.

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Posted in: Health Fraud, Medical Academia, Medical Ethics, Politics and Regulation, Science and Medicine

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Does alternative medicine have alternative ethics?

Kimball Atwood has an interesting series of posts on the ethics of alternative medicine which I strongly encourage you to read.  He does a great job examining the ethical implications of certain alternative medicine practices, and has a terrific dialog with Peter Moran, a frequent commenter here.   At my other online locale, I make frequent forays into the morass of medical ethics, with an emphasis on specific clinical scenarios.  Today, though, I’d like to take a step back and examine the nature of medical ethics as they apply to so-called alternative medicine.

First, and perhaps most important, I am not an ethicist.  I do not have the depth of reading, the knowledge of terminology, or the specific education to lead a formal discussion on ethics.  What I am is a practicing internist, who must make ethical decisions on a daily basis. Most of these decisions are of necessity made “from the heart”, but it is not infrequent that I must evaluate a situation more formally and fall back on some of the ethical principles of my profession.

Ethics are not static.  They are not a divine gift bestowed on each of us as we don our white coats.  They are a living part of our specific cultures, and of the profession we serve.  Some of the modern principles of medical ethics are newer than others.  Beneficence, non-maleficence, and confidentiality are ancient principles of medical ethics, which continue to be relevant today.  Patient autonomy is a more recent value, reflecting a shift in how society views the relationship between patient and physician.  These ethics must be mutable, as the profession itself is ever-changing.  Despite this fluidity, there is an identifiable line of “doctor-hood” that has existed for at least the last century, and the members of this guild have always tried to adhere to some type of code of behavior.

Alternative medicine poses real challenges to the principle of medical ethics.  First, we’ll discuss who, in fact, is bound by these principles, then the way in which alternative medicine is or is not compatible with medical ethics. (more…)

Posted in: Medical Ethics, Science and Medicine

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Circumcision: What Does Science Say?

Some people think circumcision is mutilation; others want one even if they don’t know what it is. When I was working in an Air Force hospital emergency room one night, a young airman came in requesting a circumcision. I asked him why he wanted one. He said a couple of his friends had had it done, and he’d heard it was a good idea, and he was going to be getting out of the Air Force pretty soon and wanted to have it done while Uncle Sam would still foot the bill. I examined him: he had a neatly circumcised penis without so much as a hint of any foreskin remnant. I’ve always wondered what he thought we were going to cut off.

The subject of circumcision evokes strong emotions. Some people think of neonatal circumcision as a religious duty or a valuable preventive health measure; others think it is the epitome of child abuse. I have no strong feelings either way. I’m not sure what I would have decided if I’d had sons; fortunately my children were both daughters so I didn’t have to decide. I’m going to try to stand back and look at the scientific evidence objectively. What are the medical benefits and risks of circumcision? (more…)

Posted in: Medical Ethics, Surgical Procedures

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How State Medical Boards Shoot Themselves (and You) in the Foot

This is almost the final entry (for now) in a series of posts about the pitfalls of regulating physicians who peddle quackery.† In previous entries we’ve seen how quacks have portrayed an illegal and pseudoscientific treatment, intravenous hydrogen peroxide, as legitimate; how a physician who practiced that and other dubious methods eluded definitive regulatory sanctions for years; examples of quacks banding together to form pseudomedical pseudoprofessional organizations (PPOs) and bogus board-certification schemes to establish the appearance of professional legitimacy, for protection from regulatory scrutiny, to garner political clout, to attract funds from interested businesses, to dupe the Accreditation Council for Continuing Medical Education into granting continuing medical education credits (CMEs) for pseudoscientific conferences, and more.

Now we’ll look at several examples of how state medical boards in the U.S. have abdicated their responsibility to protect the public from such practitioners. A few caveats: first, in most cases I can only guess why that has happened. Some of it has probably been due to naiveté, or to political or legal pressures. To some extent it has probably been due to faddism and its close relative, misleading language. Next, the examples given here are by no means exhaustive. Next, a state medical board can only be as effective as the language in the state’s medical practice act allows it to be, and that is determined by legislators (politics), not board members. Finally, state medical boards have not uniformly made the wrong choices regarding quack practices and practitioners.

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Posted in: Health Fraud, Homeopathy, Medical Ethics, Politics and Regulation, Science and Medicine

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Massage for AIDS

ResearchBlogging.orgI recently learned of a study entitled “Dominican Children with HIV not Receiving Antiretrovirals: Massage Therapy Influences their Behavior and Development.” It disturbed me, and I couldn’t get it out of my head. They’re massaging these kids but letting them die of AIDS? I went back and read the complete article, and it left me even more disturbed.

They studied 48 Dominican children ages 2-8 with untreated HIV/AIDS, randomizing them to receive twice weekly sessions of either massage or play therapy for 12 weeks. The abstract said that those in the massage group improved in self-help abilities and communication, and that children over the age of 6 showed a decrease in depressive/anxious behaviors and negative thoughts. That’s what the abstract said. The text revealed a more complex story. (more…)

Posted in: Clinical Trials, Medical Ethics

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