The Ethics of Death and Dying

(Sidenote: This is the final essay for the requirements in our Medical Ethics class. I've somehow missed the way Ethics was taught to me during my undergraduate years. Yes, I'd had to read through Kant, Confucius, Foucault and Aristotle. Well, a little of each; I didn't exactly finish all of the required readings for the course but I got the main gist of their ideas. And indirectly, being forced to read so many readings that have no connection whatsoever to my course did benefit me during Medicine. At least now, I can honestly say, although the readings are long at least they're straight to the point. Unlike those philosophers, with Ricoeur as an exception

Anyway, what are your thoughts about Death, Life and Dying? Please leave a comment and again, I apologize if I'm not able to reply instantaneously. Oh, this was written in reaction to the film, "Wit", more specifically the scene where Dr. Vivian Bearing was given the option of being resuscitated or not by the nurse.)

There is always something unknown about death. However, this is in direct contradiction to health professionals who require certainty. A health professional performs a very detailed history and a thorough physical examination. And then orders all sorts of diagnostic imaging to arrive at a certain diagnosis. All of this certainty is built on avoiding the greatest uncertainty of them all: death.

            What happens after we die? Nobody knows and no one can really say for sure. Some say there is an afterlife, some say there isn't  One thing is for sure, a human person ceases to be when he dies and this is what is at the root of death. A human being cease. No one can really say if he went to heaven or became one with the Force or any other primordial energy. What is left is the pain of loss among the dead person’s loved ones and those who knew the person during his life.

            No one can really explain death. Sure, we health professionals can explain the pathophysiology of a patient’s cancer and we can explain how the glutamate cascade is responsible for the death of neurons in a stroke patient but we really can’t say why that particular person. No amount of explanation can wash away a person’s cessation of existence so it is but natural we stave away death. We invent all sorts of contraptions and interventions to avoid death and prolong life just so we can avoid the biggest uncertainty of all.

            Yet there are times when patients opt for a DNR, Do Not Resuscitate. For a physician it may seem like a slap in the cheek. Here you are trying to save this patient’s life yet this patient has given up hope and prepares for the inevitable. Is the DNR patient less than human for giving up? And conversely, is it always the default position to fight for life at all costs? 

            The resounding answer is a big no. A DNR can be seen as an acceptance rather than giving up. Sometimes life at all costs can be too high a price. Can we say that a person is truly alive if he or she is hooked to a machine? Far from being seen as a sign of weakness, a DNR simply means another option. It is but another choice for which nobody can be condemned for. Just as long as the circumstances were made clear to the patient and he’s been given all the time.

            How we treat the dying says about how we think of Death in general. Treating them with scorn and prolonging Life at all costs shows how we secretly fear death. Does a person cease to be a human being if he accepts he’s going to die? Of course not for Death is but a part of being human. There can be no Life if there is no Death.

            Far from thinking Death as a big uncertainty, it can be thought of as another journey that all of us have to take. We can try to delay it as much as possible by living a healthy lifestyle or by heroic measures but inevitably we die. On a personal level, we can never be sure of what is going to happen but for those left behind, we leave a legacy. So really, a DNR is but another option. What is more pathetic are people who can’t come to terms with the inevitable and prolong life at all costs.

            There are a lot more things worse than dying. What we can do is treat Death with humanity instead of fear and scorn. 

Revelation

(Side note: This essay was written in response to a lecturer asking all of us why we chose to be in medical school. I have written about it in great detail here:  http://thelukanmd.blogspot.com/2012/11/start-of-lukan-medical-journey.html. As I was writing this particular essay, I focused on the particular event that started it all. And as the title suggests, it really did come to me like a revelation, a sudden jolt or realization. It's somehow of a refresher essay for me of why. I've changed since I've written the very detailed reason but somehow the reason is still there although somewhat modified.)

            It starts with a crazy idea as these things go. As I was nearing the end of my college stay; I absolutely had no idea what I was going to do after I graduate. Initially, I started like those traditional medical students who right after high school wanted to go to Medicine. I even chose the quintessential pre-medical course. And yes, these decisions solely came from me; my parents never forced me into anything. The only thing they chose was what university I’d be entering. However, when I entered into college; I never imagined it would be that hard. I breezed through high school getting high grades without breaking a sweat.

It got me thinking that if I went to Medicine; it would be harder and there would be a lot more reading to be done. I didn't exert much effort back then. And before I knew it, I was graduating and with no clear direction. So yes, I was an underachiever back then. I didn't study throughout the night. And I even slept early.

            I remember it was a morning during my free time. I was sitting at a computer terminal in Rizal Library. I suddenly had a revelation that I didn't like animals or plants or even microbes. What I really liked was studying humans. I've been denying to myself that I was born to be studying and learning. So without any prior notice to my parents; on that same morning I registered myself to take the NMAT and enrolled myself in review classes. All that was left to do was choose what medical schools to apply to.

            As I was late in planning for medical school; I didn't know the choices. I couldn't apply to the medical school of the university because I lacked units so I had to search for other options. So I searched through the Facebook profiles of my batch mates and through that search I made 3 choices. Initially it was only 2 but I added a 3^rd option because of my unspectacular undergraduate GWA. And to cut the story short, I was accepted to only 2.

            So far, I can say I made the right choice. Although, sometimes it depresses me because I’m 24 yet I’m still in school and still dependent on my parents. However, it brings me unspeakable joy when I get asked by people about medical knowledge. Heck, every parental visit sometimes becomes a medical consultation. And I haven’t even obtained the mystical “M.D.” added to my surname. It comes with a pressure to be updated but I've learned it only drives me to learn and read further.   

The Ethics of the Patient-Doctor Confidentiality

(Side note: This essay was written in reaction to this: http://www.youtube.com/watch?v=MoP7xgW1A9U. To summarize, the doctor in question posted on Facebook some sensitive patient details. The doctor didn't post the patient's name. However some people want the doctor to be fired because she violated patient confidentiality. How about you, what are your thoughts about patient confidentiality? Please leave a comment below )

            At Mercy Hospital, there was an obstretrician/gynecologist who upon posting on her Facebook wall patient details; she was fired. She was merely venting her frustrations because said patient was late for her appointments. She did not post said patient’s name or photo and only included some medical data that is not specific for any patient. Her post ended with “May I show up late for her delivery?”

            In the USA, there is no law prescribing the exact specifications of the patient-doctor relationship. Instead it was based on the Hippocratic Oath with this passage: "Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret." And information divulged by the patient can only be said to fellow medical professionals as evidenced from this passage, again from the Hippocratic Oath: "Those things which are sacred, are to be imparted only to sacred persons; and it is not lawful to impart them to the profane until they have been initiated into the mysteries of the science."²

            And instead, doctor-patient confidentiality is centered on ethics and there has to be a doctor-patient relationship to warrant secrecy for effective healthcare. Laws only specify up to what extent such information can be made available. Such cases include notifiable diseases and medical databases although patient identifiers are not included. Finally, only the patient can void the doctor-patient relationship and in medico-jurisprudence cases where medical information is necessary.²

            First and foremost, there was no patient-identifier present in the doctor’s Facebook post. The patient’s photo was not even present on the doctor’s wall making it difficult to say that the doctor was pertaining to a specific patient. The obstetrician/gynecologist was merely expressing her right to free speech and venting because of her time wasted due to the patient’s lateness. It can be argued that her post was demeaning to the patient but only up to a certain extent. It can be likened to an employee in a company venting about her customers but we seldom hear complaints about these people. However, it seems that the doctor is subject to higher standards than most employees.

            The doctor-patient relationship is a relationship that is based on trust. This means that the patient can trust the doctor to always do what is in his/her own best interest. The doctor is tasked to always be professional towards patients and is trusted that he/she will prescribe the necessary medical interventions. This element of trust is crucial because without it; healthcare cannot be effective. ¹

            What people are reacting in this doctor’s case would be the issue of trust. Even though there were no patient-identifiers present in the Facebook wall; they feel that the trust people put in doctors has been violated because details that can only be obtained from a real-live patient has been announced in public. There is an implied understanding that parts of the medical interview is confidential; there are exceptions but even then, these are rare.          

            And when doctors reveal intimate details, it was as if the doctor was undressing a patient in public and exposing the patient’s body. It is this act of nakedness that is inherent in the doctor’s seemingly harmless Facebook post. The doctor may not have posted the name or photo but she has still exposed part of the patient to the public.

            Which brings us to the final point: should the doctor have been fired for exercising her right to free speech? And the resounding answer is no. Instead she should have been given a reprimand. Medical professionals are subject to a higher standard because there is an element of trust in order to deliver effective health care. The difficulty lies in determining where does this trust end and where does it begin. With the advent of new technologies such as social media; information is easily spread. For instance, post an embarrassing photo and it will spread like wildfire.  

            As such, all medical professionals must always be cautious in posting details about patients even if they are unremarkable and innocent. It also helps if the tone is in a neutral manner. It is not that medical professionals are to be silent but they should be highly aware that whatever they say is subject to higher scrutiny because they deal directly with people’s lives and can affect them. Whether we like it or not, we will always be under intense scrutiny and as such we will have to deal with job pressures in a professional manner.

References:

1. “The Doctor–Patient Relationship Challenges, Opportunities, and Strategies”. Susan Dorr Goold,  Mack Lipkin, Jr. 25. Jul, 2013. J Gen Intern Med: 1999 January; 14 (Suppl 1): S26-S33.

2. "Healthcare - Doctor-Patient Confidentiality." Encyclopedia of Everyday Law. Ed. Shirelle Phelps. Gale Cengage, 2003. eNotes.com. 25 Jul, 2013. <http://www.enotes. com/healthcare-reference/>. 

Integrity

(Side note: This essay was written in response to a lecture about integrity. The funny thing was, I had to cut that class because I wasn't feeling that well so I had to rely on 2nd hand accounts of the lecture so that I know what the lecturer was talking about. Anyway, what I've written is not just for the sake of passing the class but it comes from the heart. Who knows, maybe someday I'll come back to this post if ever I feel like giving up or taking shortcuts detrimental to a patient's health and life.) 

            Integrity is something that is important in all aspects of life. It is not the sole monopoly of medical doctors yet due to the high expectations placed upon medical doctors; it is highly stressed upon us. For instance, a doctor without integrity will easily prescribe drugs just because the drug company gave him a huge financial incentive without even thinking of the possible side effects that the patient can experience due to the drug. Worse, it might not even be indicated for the patient’s condition.

               However, integrity is not something that is easily passed on or easily taught. It is not something that can be learned through a class. It is something experienced and observed. Also, it is something that is imbibed meaning that a person must choose to embody integrity. And in choosing to do so, that person must have a very deep reason for embodying an abstract yet important idea.

                Practically, a medical doctor with integrity will be visited by more patients because he can be trusted to give cost-effective medical interventions without being swayed by the pharmaceutical companies. On a much deeper level, said medical doctor can sleep better at night because he did not place any human being in harm’s way. Either way, a medical doctor with integrity is a full-fledged medical doctor.

                But then what does it mean to embody integrity? The most important thing is that this is an ongoing question that the medical doctor must answer everyday of his life. This question is re-asked and re-answered whenever new situations arise to combat the medical doctor’s values or outlooks on medical practice. That is not to say that integrity is limited to the medical practice. It is not. The question of integrity permeates even outside of the medical doctor’s practice. It permeates the life and relations of the medical doctor. Even the simple act of being on time for every appointment, however small a gesture, is already an act of integrity. And yet integrity is a question. It is something that is redefined and cannot be sequestered into a well-defined box.

                Finally, integrity can be likened to an ongoing re-evaluation in the sense that it requires re-updating of one’s outlook and values. To put it more concretely, what may seem an act of integrity then can be an act without integrity today. No act can really be defined as full of integrity for definitions will invariably exclude the person who will execute said act. One can only be guided by his own values and other human being’s own values. It is important that a medical doctor always strives to better himself. In the fullest sense of this phrase: a medical doctor is not just a medical doctor. 

Apologies (or Excuses)

I apologize to my regular readers (if I have any) for the lack of blog posts these months. 2nd year Medicine in the Philippine setting is a bit more challenging. Many more subjects hence more books to read. Thick and heavy books.

Anyway, I'll be posting a few essays I've written for my Medical Ethics class. Not just because they got high grades but well, someone might benefit from them.

Finally, to describe 2nd year Medicine in a few words: exhausting, endless readings but fun. Here is where what I learned in 1st year (Human Anatomy, Human Physiology, Medical Biochemistry, Foundations of Medicine and Preventive and Community Medicine) blends into these subjects: Pathology, Microbiology and Parasitology, Pharmacology, Clinical Evaluation, Medicine I, Neurology I, Preventive and Community Medicine II, Medical Ethics, Pediatrics I, Basic Science Research. 2nd year is where diseases, drugs and how to conduct a physical examination and medical history are taught.

How Medical Missions Actually Make People Poorer

You're all familiar with this: health professionals wanting to help their fellow countrymen/women. And since they are trained for giving services to others, what better way to help then to give a free medical check-up and free drugs a.k.a. a medical mission. I am not against people helping other people out that is a very noble gesture. However, we have to look at the unintended consequences and the long-term effects of these missions.

Sure, you may have helped people by giving free diagnoses and free medicines. But without looking at the systemic cause of their ailments; the people you've treated will just get the same disease. Also, with the current set-up of medical missions, you've removed their agency and made them into mendicants dependent on health professionals for good health. 

Any medical mission will thus have to be based on this premise: would you give people fish or teach people to fish?

In any case, my specific recommendations would be the following:

1. Remove food supplements from the roster of drugs you'll be giving to people. You're really not helping them. In the medical mission I participated in, the people almost always requested for food supplements for themselves and their own children thinking it was the norm. Sure, you may keep people in good nutrition for a short period of time but that doesn't attack the root cause of their malnutrition in the first place which is poor eating habits.

Think about it, where do you get vitamins and minerals from nutritious food like fruits and vegetables right? So people should eat more of fruits and vegetables rather than junk foods. Of course, the usual counter of the people being helped would be a) because their children doesn't want to eat fruits and vegetables and b)the parents are busy working so they cannot guide their children into eating proper food. Impress upon them that is it their own responsibility to maintain their own health and of their children. It is their job to teach their children and caretakers proper eating habits not the responsibility of health professionals.

2. Only take drugs for diseases present in the community you intend to help. This I admit entails a lot of homework because before the medical mission proper some people will have to go into the community and ask around. This saves time and effort. Why would you stock up on drugs that have no recipients in the first place? And this is connected to point 1. It also removes the temptation of people stocking up on unnecessary drugs. Remember that all drugs have side-effects and should not be taken unless directed by a medical doctor.

3. Eliminate "tuli" missions for they are really not that medically necessary. Honestly, there are minimal benefits to be gained by circumcision. Sure, it decreases the chance of acquiring sexually-transmitted diseases; however, the better approach would be to educate the people on sexuality and how to prevent transmissions of STDs. You may ask why I include sexuality. Well, any talk on STD prevention will always need a talk on human sexuality. People will have to be aware that their own sexuality is something beautiful not abominable. Also, educating males about proper cleaning of their penises is much better than mandatory circumcision. Anyhow, I digress.

There is a strong stigma against uncircumcised men in the Philippines but ask yourself, are you health professional or a "datu"? You are there to help with medical emergencies and cultural passages of manhood need not concern you. Does it really make sense that a 10 - 12 y/o boy is forced to undergo mutilation of his foreskin just for the sake of being called a "man"? The better option is to let the boy decide for himself.

And to make this point inclusive of all medical missions: only prepare for medical interventions that are necessary to improve overall health. So giving antibiotics after being examined by a medical doctor, dental work and referring to the nearest hospital is okay. These sorts of interventions.

4. Frame your medical missions in the preventive aspect not on the curative aspect. Curing diseases is good however it makes better sense to prevent these diseases. Take for instance pulmonary tuberculosis and hypertension. These were the common diseases I encountered and in fact common diseases found amongst Filipinos. The Department of Health already has its TB-DOTS program in order to provide early detection and treatment of tuberculosis. Inform the community that tuberculosis is not something to be scared off and there is the TB-DOTS program. I am aware that it is not that simple; however, we have to start from somewhere.

And hypertension is really connected to point 1. If you really think about it, poor eating habits contribute to the high incidence of hypertension found amongst the poor. The cheapest foodstuffs are those with a high salt concentration. So if you don't correct their poor eating habits; you've really not helped them at all. Remember that maintenance drugs of hypertension are expensive and have to be taken everyday.

So in the long-run the economic costs will outweigh whatever curative intervention you hope to accomplish with the current model of medical missions. Not to mention the unnecessary loss of human life.

The list is not exhaustive. There maybe some other aspects that can be improved; however, always remember that it is the people's responsibility to good health not the health professionals.

Now, I anticipate that these recommendations would be met by hostile resistance amongst other health professionals and the people you intend to help. Filipinos are great enablers after all. But it is precisely this behavior of Filipinos that these changes must be implemented. And I also anticipate that the number of people who will attend your medical missions after these changes have been implemented will drastically decrease.

However, at the end of the day; it is their responsibility to maintain their health. But to be realistic, introduce these changes by "breaking it to them gently". For instance, inform the community leader that there will be changes to your medical missions and your intentions behind the changes.

Change is always hard and it's easier to keep to the status quo but really, the status quo just produces mendicants.

A Dichotomy

It's one of those things that you don't intend to do but you are forced out of familial pressure. Me, visiting a shrine in Manaoag, Pangasinan. I've been here before but this time it's different. I no longer belief in anything supernatural for it is an insult to the scientific training I've received and the medical training I'm currently undergoing. Well, I just sucked up my disgust and walked around. It has improved. Before there was no canteen, the rest rooms sucked and the big statue of the Virgin Mary was hidden away. Currently, it's now at the center of a grandiose structure with candles placed around it. I can imagine at night the big statue being illuminated by candlelight.

How I hated it.

Contrast that with the Philippine General Hospital. I can honestly say it has not improved. You have diagnostic laboratories just across PGH and you have the Faculty Medical Arts Building just inside the premises of PGH. For those unaware, FMAB is a private hospital. Anyway, what do these two points imply? Simple, the Philippine General Hospital currently sucks. Well, to put it more substantially: a) why would you have private diagnostic laboratories across a hospital that is mandated to provide the health needs of the the common public and finally, b) why would you have a private hospital, FMAB, inside a public hospital, PGH?

And I hesitate in going to the provincial hospital in Pangasinan. It might even be in worse condition than the Philippine General Hospital.

But somehow, I'm not surprised at this strange dichotomy. The religious when sick ascribe their healing to the intervention of a supernatural deity despite the clear evidence that it was the medical intervention that saved them. And let's not forget the placebo effect.

It is time to move forward. I am not saying that all Filipinos should be atheists/agnostics although it would warm my heart if we were to become a purely atheistic country. Rather, it is time to prioritize rational actions over divine interventions. Gods will not save us from our wretched conditions. Humans are the ones responsible for these conditions and it will be humans who will solve them.

When we were done with the visit; I noticed something else. There were fewer people. I mean during the 1990s, the time when we visited the shrine, there were lines just to get inside the basilica. And the area where you put candles was crowded. Of course, I can't conclusively say the number of visitors to Manaoag decreased. But you can't help but wonder.