Ethical Dilemmas

Ted Rosen, MD Professor of Dermatology

Baylor College of Medicine Houston, Texas

1. Euthanasia/Assisted suicide

2. Stem cell acquisition from embryos

3. Abortion

4. Allocation of scarce resources

5. All of the above

Which of these is a major

modern ethical problem?

1. Do what is in the best interest of the patient

2. First thing: Do no harm

3. The patient has the right to refuse or choose

4. The patient and the doctor both have the right to dignity

5. A fair compensation for services should be given

Which of these is NOT one of the

six principles of medical ethics?

Medical ethics does not originate in/from…..?

1. Religion

2. Tradition

3. Authority

4. Reason

5. Family

Having physical intimacy with a patient is….

1. Acceptable

2. Acceptable, but only if the person agrees to stop being a patient

3. Acceptable, but only if the person stopped being a patient 6 or more months before

4. Never acceptable

5. Only acceptable if the patient is Brad Pitt or Eva Longoria

Definition of Medical Ethics

1. System of values in the medical profession

2. Systematic application of those values to

the daily practice of medicine, leading to….

3. “Standards” of behavior concerning

relationships with: patients, colleagues, society

1. Beneficence: Best interest of pt.

2. Non-Malfeasance: Do no harm

3. Autonomy: Right to refuse or choose (consent)

4. Justice: Treatment on the merit of illness

5. Dignity: Patient and doctor both have the right to dignity

6. Honesty: Deserve to know the whole truth

Six Principles of Medical Ethics

Where Does Medical Ethics Originate?

Tradition: “That’s the way it’s always been.”

Authority 1: “That’s the way I was taught to do it.”

Authority 2: “That’s the law.”

Reason: “It makes sense to behave that way.”

Religion: “That’s the moral way to act.”

Are any of these absolute?

Potential for Inherent Conflict

Medicine: “Can we?”

Ethics: “Should we?”

(50) Shades of Gray

Nationwide survey of 24,000 physicians across 26 specialties. Done by Medscape in August-September, 2012. Here are responding physicians, grouped by specialty.

Nationwide survey of 24,000 physicians across 26 specialties. Done by Medscape in August-September, 2012. Here are responding physicians, grouped by specialty.

• Euthanasia/Assisted suicide

• Brain death

• Organ transplantation

• Stem cell acquisition from embryos

• Abortion

• Universal genotyping

• Allocation of scarce resources

Major Modern Ethical Problems

Applicability to Dermatology

Pro: You never know what will happen, and the family often needs to see this effort so that they can “let go.”

Con: If the outcome is blatantly obvious, why waste valuable resources?

1. YES2. No

Ethical Responses To Specific Situations May Change

• A few years ago, widely metastatic melanoma was essentially hopeless, and was a sentence to an agonizing death

• Today, we have many individual drugs and drug combinations that may cure or, at least, prolong life and/or improve quality of life

Applicability to Dermatology

• Rare event in Dermatology

• Rural hospital with limited supply of rituximab

• 63 year-old with pemphigus, flaring versus a 16 year-old w/ disseminated B-cell lymphoma

Pros: Longer life expectancy should receive priority, and we already do that nationally with organ transplants.

Cons: There is no guarantee that the young patient will live longer or be more valuable to society. One shouId not deprive seniors of health care JUST because they are old.

1. YES2. No

Applicability to Dermatology

• G6PD before Dapsone. NEVER done in Third World countries and rarely in Europe, because deficiency is rare (<4%) and if patients start to hemolyze, you can stop drug and reverse well before catastrophe arises; in USA we almost always do this….

• Biopsy an obvious seb ker to “prove” its not a melanoma

Pros: Medicine is not an exact science. You only know a test or procedure in “unnecessary” when the results are available.

Cons: “Defensive medicine” is an excuse for ignorance and also an embarrassing alibi. It is wasteful to the medical system.

Applicability to Dermatology• You do a biopsy on a lesion you are pretty

certain is a benign nevus or seb ker. You read your own slides. During processing, the tissue is lost.

• You meant for the patient to get an IM shot of Benadryl due to a mild allergic reaction, but your nurse gave IM Vitamin-B12 instead. You call the patient an hour after the shot, and they say that the reaction is going away.

Pros: With absolutely no harm done, why undermine the patient’s confidence? Innocuous errors are fodder for plaintiff’s attorneys.

Cons: Honesty is the foundation of the doctor-patient relationship. In the end, patients appreciate honesty.

Applicability to Dermatology

So glad I cured

your genital warts!

Pros: If a match made in heaven shows up in the office….and the relationship’s foundation is love….so be it.

Cons: This is so creepy that it is beyond unethical. A patient is vulnerable and easily taken advantage of.

Applicability to Dermatology

• Anyone engaged in the practice of medicine may have to face this choice….

Pros: The practical reality is: running a medical office is a business. If I lose money, I have to drop staff or cut corners. Who do I help doing that?

Cons: It is both a privilege and obligation to care for others. If it meant too many of my patients leaving, I would just cope somehow.

Applicability to Dermatology

• Your patient has PsO of the elbows only, about 2.5% BSA. Nothing conservative has worked, and he is very itchy.

• His insurance plan allows biologics ONLY if the BSA involvement is >5%.

• You think he needs etanercept.

• Do you fill out the pre-auth forms stating BSA >5% ?

Applicability to Dermatology• Your long-standing, loyal

patient, Susan, is very concerned about the fine lines that appear at the corner of and under her eyes when she smiles.

• Her insurance plan WILL pay Retin-A prescriptions for “adult acne” but not for cosmetic uses.

• How do you complete the pre-authorization form?

Pros: If the purpose is to facilitate obtaining needed services/meds, we have to remember that the rules of payers are NOT set up for the patients’ welfare. The rules are designed to insure a profit for the company.

Cons: This constitutes both lying and stealing. You should lose your license if you EVER do this.

1. YES*2. No

?

Applicability to Dermatology• Everyone has difficult patients who clearly do

not and will not follow the treatment plans as outlined!

?

Pros: Non-compliance means that you are not providing a service. Why waste the time and effort on a chronically non-compliant (AKA non-adherent) person?

Cons: Non-compliance means that the provider did not explain the plan in a convincing or coherent manner. The fault lies with the doctor, not the patient.

?

1. YES2. No

?

Applicability to Dermatology• Your patient had bad herpes zoster, now resolved

with scarring. Gabapentin and pregabalin, steroids and a TENS unit use fail to provide relief. He calls for his fifth refill of oxycodone. The “Pain Service” at the nearby hospital refuses to see him, insisting that herpes zoster is solely a dermatology issue.

Pros: Becoming an addict is easy and worse than some pain. There’s also the question of the patient selling the narcotics!

Cons: A patient with pain severe enough to require narcotic analegsia, should be provided with sufficient relief in order to maintain quality of life. Not to do so would be unethical.

Applicability to Dermatology

• Any of your colleagues could end up like this…even a partner in the same practice or someone you trained or trained with…

Damn good chardonnay. Who’s the next patient?

Pros: On the basis of patient safety, it is your absolute duty to report an impaired physician.

Cons: Only if I could remain completely anonymous. Otherwise, I could be sued for defamation of character or worse….

1. YES2. No

Applicability to Dermatology• You are recently divorced, and between child support

and alimony, strapped for cash. Your patient, Sarah, is considering Fraxel to correct the features of an aging face. But, she is really concerned about the potential for infection and scar formation.

• You know her procedure will net you a quick $2000…

• She wants it, right?

• Why scare her away…..?

Pros: Too much information doesn’t really help insure an informed decision. Patients don’t all have the education or intellectual capacity to understand the details or nuances.

Cons: People should always be trusted with the full truth: risk versus benefit.

1. YES2. No

Applicability to Dermatology• “Doc, you gotta help me! I am suicidal because

these insects are crawling on and in my skin. Doc, look….here they ARE! All kinds of species. Look. You can see them. Help me!!! Can I get ivermectin? I heard that it kills all kinds of bugs…”

Pros: Placebo treatments can be very powerful and can make the patient feel better, or even lead to a “cure.”

Cons: Don’t let the tail wag the dog. Let the patient go elsewhere before prescribing something you know deep down inside is not needed.

1. YES2. No

Applicability to Dermatology• In every state in the US, syphilis and gonorrhea

are reportable. But herpes is not a reportable disease. You see Joe, with active genital herpes, who boasts about having unprotected sex with many women for the express purpose of “giving it to them.” You find out he is going to start dating Jill, your next door neighbor’s daughter….

Pros: I would seek legal advice first, but eventually inform whomever I needed to in order to protect others.

Cons: If the law doesn’t require disclosure, then it is none of my business and illegal to do so.

1. YES2. No

Applicability to Dermatology

• Your office lunch provided by Valeant!

• Those cookies the Retin-A Micro rep dropped by yesterday….

• Yada, yada, yada

Pros: I am outraged and insulted at the notion that a pen or tuna sandwich actually changes my prescribing habits!

Cons: The evidence clearly does demonstrate that we are kidding ourselves if we believe that prescribing bias can’t be induced even by small gifts.

1. YES2. No

Pros: Patients with a terminal illness, lying in abject misery, should be allowed to control their own fate.

Cons: This is physician-assisted homicide. We swore an oath to do no harm. We should not be judge, jury and executioner.

1. YES2. No

A similar survey done 10 years

ago had a “favorable” outlook

toward this action of about

20%....half of 2012 survey

findings….

A Good Guide….Still

"Medicine is, of all the arts, the most noble....I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous."

- Hippocrates

A Good Guide….Still

"Medicine is, of all the arts, the most noble....I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous."

- Hippocrates

A Good Guide….Still

"Medicine is, of all the arts, the most noble....I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous."

- Hippocrates

Thank You

For thinking about these difficult issues…

1. Euthanasia/Assisted suicide

2. Stem cell acquisition from embryos

3. Abortion

4. Allocation of scarce resources

5. All of the above

Which of these is a major

modern ethical problem?

1. Do what is in the best interest of the patient

2. First thing: Do no harm

3. The patient has the right to refuse or choose

4. The patient and the doctor both have the right to dignity

5. A fair compensation for services should be given

Which of these is NOT one of the

six principles of medical ethics?

Medical ethics does not originate in/from…..?

1. Religion

2. Tradition

3. Authority

4. Reason

5. Family

Having physical intimacy with a patient is….

1. Acceptable

2. Acceptable, but only if the person agrees to stop being a patient

3. Acceptable, but only if the person stopped being a patient 6 or more months before

4. Never acceptable

5. Only acceptable if the patient is Brad Pitt or Eva Longoria