Meeting Sept 24, 2015 GreaterLAVAMedicalCenterWadsworthBldg.500,11301WilshireBlvd.LA9007364006thFL)Operator:310-478-3711SWcornerSanDiegoFrway(405)/WilshireBlvd.ExitWilshireBlvd,Westfrom405,rightontocampuswestoffreeway,freeparkinginvisitorlots5:30PMfreedinner(noRSVPneeded)6:00meeting1.CasePresentation:JosephRaho,PhD,UCLA

ClinicalEthicsFellow2.ShouldEthicsConsultationbeAvailableto

NursingFacilities?ChristineWilson,JD3.RolesandResponsibilitiesinEthics

Consultation–StuartFinder,PhD,CedarsSinai **** Upcoming Conferences**** --Oct20-25ASBHAmericanSocietyforBioethicsandHumanitiesAnnualconference,Houston--Nov5-6KPNationalBioethicsSymposiumProfessionalismandSharedDecisionMaking:BacktotheFutureHiltonUniversalCityJohnLantosMD,CyndaRushtonPhDRNaskeynoteshttps://www.signup4.net/public/ap.aspx?EID=PHYE495E&OID=50toregister--FriNov.13noonto2pmCaliforniaHospital,1440SoGrand,BioethicsSeminarAnInsider’sViewfromtheMentalHealthPerspectiveElynKatz,attorneyandauthorofTheCenterWillNotHold,MyJourneyThroughMadnessCMEandlunchprovidedCall(310)9180321fordetails

***************************************** Weigh in with the Editor Editor-inchief:KendraFleagleGorlitsky,M.D. grngasalud@aol.com Contributors: Ken Murray, M.D. Richard Boudreau, MD J.D.PhD Michael Silva, MS3, KSOM USC ******************************* MEDICALHUBRISANDITSEFFECTSONPATIENTOUTCOMESANDEND-OF-LIFECAREhttp://well.blogs.nytimes.com/2015/08/20/wondering-if-i-hastened-a-patients-death/?partner=rss&emc=rss&_r=1Dr.MikkaelSekeres,directoroftheleukemiaprogramattheClevelandClinic,inthisself-scrutinizingarticleexaminestheappropriatenessofhisguidanceregardingtreatmentofapatientinhismid-60’sconfrontingleukemiawithaverypoorprognosis.Thepatientdiedafteraverybriefcourseofharrowingchemotherapyanditscomplications.

“Iwasleftwondering,notforthefirsttimeinmycareer,ifIhadlaunchedsomeoneonapathtowardprematuredeath.Attheveryleast,Iwasguiltyofthatactofhubrisofwhichoncologistsareoftenaccused:givingchemotherapytoapersononlydaysbeforehisdeath.”

AstudypublishedinthejournalCancerrevealed,“Among330olderadultswithleukemia,approximately60percentreceivedchemotherapy...Withamedianfollow-upoftwoyears,88percentofpeoplehaddied.” Fifty–onepercentoftheremainingdaysofthosewhoreceivedchemotherapywerespenteitherhospitalizedorinclinicand“within30daysofdeath,almost85percentofpatientswerehospitalized,and45percenthadreceivedchemotherapy.”Thosetreatedwithchemotherapywerehalfaslikelyasthosenotreceivingtreatmentfortheirleukemiatoenterhospice,whichincludedonly22percentofthetotal.“Perhapsinfocusingonthe10percentorsoofpeoplewhoenjoyalongsurvivalfollowingtheirleukemiadiagnosis,whomwecan’troutinelyidentifywhenwediscussthepotentialbenefitsofchemotherapy,weneglecttoemphasizeequally

the90percentwhodon’t,theamountoftheirlivestheywillspendinhealthcaresettings,andalternativewaysoflivingoutthetimetheyhaveleft…

“Butifwedocallattentiontothemajority,willwebepreparingthemappropriatelyfortheremainingtimetheyhaveonthisearth?”wondersDr.Sekeres,“Ordashingwhathopetheyhaveofdefeatingtheircancer?” Hot Topics: Vaccines “SB277HASPASSEDBUTWHATHAPPENSNEXT?”-http://www.nejm.org/doi/full/10.1056/NEJMp1508701?query=featured_home&ImpetusforpassingSB277:

Ratesofpersonal-beliefexemptionsdoubledsince2007,(CaliforniaDept.ofPublichealthdata)andvaccinationcoveragethoughttobelowenoughtojeopardizeherdimmunity.Therecent2015measlesoutbreakwasattributedtoaresultofinsufficientvaccinationcompliance.Evidenceshowsstrictvaccinationlawsreduceriskofvaccine-preventableillness.DoesSB277violate1stAmendmentrighttofreedomofreligion?

Adultsareallowedtorejectmedicaltreatmentonthebasisofreligiousbeliefs.However,the1stAmendmentdoesnotprovideforreligiousexemptionsto“generallyapplicable”lawsthataimtoprotectthegeneralpublichealth.NolegalprecedentinU.S.SupremeCourtexistswithregardstotheapplicabilityofthe1stAmendmentrightstovaccinationpolicies.Twoappellatecourtsrecentlyruledthat1stAmendmentrightsdonotentitlereligiousexemptionstovaccinations.Ifallchildrenhavearighttoreceiveaneducation,couldSB277violate?

Inmanystates(includingCalifornia),receivinganeducationislegallyrecognizedasa“fundamentalright.”However,theU.S.SupremeCourtandConstitutionhaveneverrecognizedarighttoeducation.ThestateofNewYork’sSupremeCourtruledin1904thatthe“state'sconstitutionalrighttoattendpublicschoolsmaybesubordinatedto‘restrictionsandlimitationsintheinterestofthepublichealth.’”Viemeistervs.White,

becametheleadingright-to-educationcasethatalsodiscussesvaccinationpolicy.HowwillSB277beenforced?

CurrentlyinCalifornia(asinmanystates),theschoolsandday-carecentersareresponsibleforensuringthattheirenteringstudentshavereceivedallrequiredvaccinations.Whenastudentisnotcompliant,theyoftenallowthatstudenttobeginclassesanyway--asaneducationalinstitutionlookingoutforchildren’sacademicwelfare--onconditionthatthestudent’sparentspromisetogettheirchildhisorhermissingvaccinations.Whensuchpromisesarenotkept,theschoolsdonotfacepenaltiesforfailingtofollow-upwiththeseparents,evenunderSB277.

But“forcingschooladministrators…toactagainsttheeducationalinterestoftheircharges”turns“trustingrelationshipswithparentsintoadversarialones…”

Asmallgroupofdoctorsfromwithinthetightly-knitanti-vaccinationcommunitycouldbegintobroadlyinterpret“medical”exemptionsandthuslooselygrantthem,whichcouldundercuttheintentofSB277.IsthereanywaytolimittheissuesofenforcementofSB277? Somehaveproposedthat“statelawsshouldinsteadtaskhealthdepartmentswithenforcementresponsibilityforvaccinationmandates.Whenchildrenarepermittedtoenrollwithincompletevaccinations,schoolsandday-carecenterscouldnotifythehealthdepartment,whichcouldconductthenecessaryfollow-up.”Arewereallygoingtostrengthenourherdimmunity?

Bybarringstudentswhoarenon-compliantonvaccinesfromschoolsandday-carecenters,SB277indeedwillachievethegoalofmakingthesevenuessafeforotherchildrenwhoareeithertooyoungtobevaccinatedorwhohaveanillnessthatpreventsthemfromreceivingnecessaryvaccinations.Therealityofunvaccinatedhomeschooledchildrenstilljeopardizespublicherdimmunity.2.IsSB277coercive?Arewerenderinginformedconsentmeaninglessforsome?

Aportionofthepopulationwillbethosewhoareagainstvaccinations,butstillconsentingto

thembecausehome-schooling,providingananny,and/ormovingoutofthestatearenotoptionsforthem.Somemayarguethatinformedconsentwillbeessentiallypointlessforthispopulation,astheywouldvirtuallyNOTbeconsentingtothevaccination,butacceptingitsimplybecausetheyarebeingcoercedtodoso. Concerns about “Physic ian Aid in Dying“ bi l l http://mobile.nytimes.com/2015/09/12/us/california-legislature-approves-assisted-suicide.html?referrer&_r=0 Despiteeffortstosafeguardagainstthis,Dr.AaronKheriaty,directorofthemedicalethicsprogramatUCIrvine,SchoolofMedicine,saidthatlow-incomeandunderinsuredpatientswouldinevitablyfeelpressuretoendtheirownlivesinsomecases,whenthecostofcontinuedtreatmentwouldbeastronomicalcomparedwiththecostofafewlethalpills.

BarbaraWagner,acancerpatientinOregonsaidthatherinsuranceplanhadrefusedtocoveranexpensivetreatmentbutdidoffertopayfor“physicianaidindying.”

“Assoonasthisisintroduced,itimmediatelybecomesthecheapestandmostexpedientwaytodealwithcomplicatedend-of-lifesituations,”Dr.Kheriatysaid.“You’reseeingthepushforassistedsuicidefromgenerallywhite,upper-middle-classpeople,whoareleastlikelytobepressured.You’renotseeingsupportfromtheunderinsuredandeconomicallymarginalized.Thosepeoplewantaccesstobetterhealthcare.”ReflectionsontheWeb

Gov.JerryBrown,onceaJesuitnovitiate

intentonbecomingapriest,isponderingthepossibilityofvetoingSB128,“abillthataffordsphysicianaidindying.”VariousmembersoftheSCBCChavejoinedarobustdiscussionaroundthisissue.

Anoralpreparationwouldbemadeavailabletoterminallyillatapatient’srequestand

withaphysician’sprescriptionforthepurposeofaffordingacompassionatedyingwhenothermeanssuchaspalliativecarearenotadequatetocontrolpainandpreservedignity.

Issuesraisedwerethepotentialforslipperyslope(“shouldtheproposedlegislationhaveincludedaconsultationaboutdepression?”)andaconcernthatpatientsneartheendoflifeareoftenagreeabletowhomeverspeakstothemlast.(CP)

Safeguardsinclude:preventinginsurancecompaniesfromconsideringthemedicationuseassuicide.“Suicideofahealthypersonisfardifferent,fromapersonwhodoesnotwanttodie,butdoeswanttoshortentheagonyofdyingbyanymethod…”(RK)“Thelaw(would)allowpeopletohaveaccesstoaformofmedicalcarethatiscurrentlyrestricted.Nopatient,nofamilymember,noHCO,andnoattorneyisobligetoparticipateintheassociatedoptions.”(CM)RonKoonlistedtheOregonian’sreasonsforaccessingthisoptionincluding:1)lossofautonomy,2)unabletoengageinenjoyablelife3)lossofdignity4)losingbodilyfunctioncontrol5)burdenonfamilyfriendscaregivers6)inadequatepaincontrol7)financial(3.2%)Ed’snote:Mighttheseconcernsbeaddressedmorecreatively?i.e.:1)--effortsmadetofacilitateremainingcommunicationskills,perhapselectronically,--permittingpersonaloptionsthatdonotnecessitateparticipationbyaphysicianthatmayfeelobligatedbyaninterpretationoftheHippocraticOaththatmayprecludedeliberatelyhasteningdeath2)enhancingrecreationaffordedfrailpeople3)recognizing/honoring,asasociety,thegiftsofage4)assistanceinpreservingdignitywhilemanaginglossofbodyhygienecontrols5)reducingburdenonfamiliesbyestablishingafundforendoflifeandrespitecareforall6)improvingpaincontrol7)socialsupportsforfinancialconcerns.

From the Halls

Implications of ‘Precision Medicine’ Richard Boudreau, MA, MBA, DDS, MD, JD, PhD

Loyola Marymount Univ. Bioethics Institute

The 2015 State of the Union contained abrief reference to the topic of precisionmedicine.President Obama was referring to the improvingabilityofcare-giverstoindividualizethetreatmentof many diseases. Despite the brevity of themessage, the development of precision medicinehas monumental implications. An improvedunderstanding of the genetic pathogenesis ofdiseasewill:1. advance our ability to assess and identify riskpreventions;2.provideameanstobetterclassifyanddiagnosisdisease;3. better target therapy using existing and novelbiologicallybasedmodalities;4. reduce treatment side effects andmake patientmonitoringmoreprecise.

The President’s budget request includesfunding to help promote the development ofprecision medicine, which already has largetailwinds at its back due to the promise ofimproved disease and deformity treatment andprevention.The concept has arisen out of the science ofgenomics, proteomics, and bioinformaticswhicharesubjectswellfamiliartobioethicists.

This new understanding of diseases isrevolutionary, permitting investigators tosubdivide diseases such as certain malignanciesthat were previously lumped together based onfactors such as patient signs and symptoms orsimilar histopathologic appearances. Each newdivision of disease could carry a differentpathophysiology, set of biochemical markers, andresponse to various treatment strategies. Thus,patients might have previously all received thesame treatment for their disease or perhaps avariety of different treatments. Some of thosetreatments seemed towork for somepatients,butnotforothers,withoutanyrhymeorreason.

However,whensubdividedby therelevantgenetic differences, it will be possible to perform

investigations that will reveal why patientspreviouslythoughttoallhavetheidenticalproblemdiffer in their response to various managementstrategies. The results will open the door to theindividualizationofmedicalcare.

Just as with many new vistas in ourabilities to control human diseases anddeformities, ethical issues arise. This isparticularly true with genomic research and care, because new boundaries of patient privacy will need to be drawn. In addition, gene manipulation is a cause for concern by many for both moral and ethical reasons.

Precision medicine brings the promise of improving our ability as clinicians to more precisely diagnose, manage, and even prevent human disease. This field also holds limitless opportunities for scientific investigations and benefits to each of us as potential patients. We, as health care providers, should recognize, appreciate, and reflect on the implications precision medicine brings.

Care giving “A moral act with unique power to enrich the lives of both giver and receiver. “The worst thing we can do is try to circumvent the…struggle for real human connection and steer medicine further in the direction …of becoming a massive customer service agency.” Caleb Gardner, Lancet 9/12/15, Art of Medicine

Student’sCornerWhatwouldyoudo?“OURFAMILYSECRETS”:PHYSICIANABUSE&MEDICALSTUDENTETHICALDILEMMAShttp://annals.org/article.aspx?articleid=2427613(SubmittedbyananonymousmedicalstudenttoAnnalsofInternalMedicine)Ed’snote:Thereaderisforewarned:thefollowingisadisturbingaccountofamedicalprofessional’simpropriety“’Whilehewascleansingandscrubbingherlabiaandinnerthighs,helookedatmeandsaid,‘Ibetshe'senjoyingthis.'Myattendingwinkedatmeandlaughed…Man,Iwasjuststandingtheretryingtolearn.Theguywasadirtball.Itstillpissesmeoff.’

Davidglancedatme.Iasked,‘Whenyourattendingsaidthatandlaughed,didyoulaugh,too?’Myquestiontouchedanerve;perhapsmytonewasaccusatory.Davidsnappedback,‘Yeah,Ilaughed,butwhatwasIsupposedtodo?Haveyoueverbeeninasituationlikethat?’IlookedupatDavid.‘Yes,Ihave.’[TheattendingphysicianhadjustperformedabimanualinternaluterinemassageandsuccessfullystoppedthebleedingintheanesthetizedLatinapatientwithuterineatony.]‘ButthensomethinghappenedthatI'llneverforget.Dr.Canbyraiseshisrighthandintotheair.Hestartstosing‘LaCucaracha.'Hesings,‘LaCucaracha,lacucaracha,dada,dada,dada-daaa.'Itlookslikeheisdancingwithher.Hestompshisfeet,twistshisbody,andwaveshisrightarmabovehishead.Allthewhile,heholdsher,hiswholehandstillinsidehervagina.Hestartslaughing.Hekeepsdancing.Andthenhelooksatme.Ibegintoswaytohisbeat.Myfeetshuffle.Ihumandlaughalongwithhim.Momentslater,theanesthesiologistyells,‘Knockitoff,assholes!'Andwestop.’”

“AfterIfinishmystory,Iglanceatthestudents;somegazedownatthetableinfrontofthem,whileafewotherslookatmewithblankstares.Theyareallquiet.Iknowthisismysilencetobreak.” ***************************************************Itisbrokenbya4thyearmedicalstudentVamsiArbindi,apologistresponderwhoexplainsinanonlineoffering:

“Someofthatdesensitizationisnecessaryforallmedicaltrainees.Toomuch,andwebecomethedoctorsinthispiece.Itiseasytocondemnotherdoctorsasbeingterribledeviantsandaberrationsupontheprofession.Itishardertofacethetruththatwewillallmovealittleclosertobeingwhattheyareduringresidency.Forthesakeofourpatients,careers,andsouls,wemustremembertonotgotoofarinthatdirection,andrememberthatourpatientsarepeoplefirst,andproblemssecond.http://www.kevinmd.com/blog/2015/09/you-can-easily-become-the-physician-that-you-judge.html

“Anyonewitnessingthistypeofconducthasanethicaldutytoreportit…”RichardBoudreau,MD,JD Murray’sMusingsKenMurrayisaretiredfamilyphysician,authorof“HowDoctor’sDie”andcontributortoNEJMandotherpopularperiodicals.ETHICSOFIDENTITY

IrecentlyreadanarticleintheWashingtonPosthavingtodowithapoet,Michael,whocouldn’tgethispoempublisheduntilhesubmittedittomagazinesunderthename“Yi-FenChou.”Hebelievedthathehadafarbetterchanceofpublicationwiththepseudonym---andhewasright.NowitisbeingpublishedintheanthologybookBestAmericanPoems.Hewasopenaboutthepseudonym,andcontactedtheeditortomakesuretheyknew.

Well,therewasanexplosioninthepoetrycommunityovertheseactions.Myfavoriteline:“Inamatterofaboutaday,thescandalwasallover“PoetryTwitter,”whichcanbejustasrancorousandswifttooutrageasregularTwitter,butwithawidervocabulary.”

Theissueofhonestyinidentityisinteresting.Wehaveavastexperienceofpeopleusingpseudonymsbecausetheyseeadisadvantagetousingtheirown.Thisisverycommonforwomen,aprominentexamplebeingJoanneRowling(J.K.Rowling).WasCharlotteBrontedoingsomethingwrongwhenshepublishedJaneEryeasCurrerBell? Wewholiveherein“GreaterHollywood”shouldalsobesensitivetotheissueoftheHollywoodBlacklist…..Ofcourse,inscientificliterature,identityisimportant---itispartoftheabilitytoidentifyandreplicate---andreputationsmatter.Wedohaveonedisguisestyle,though,oftenreferredtoas“GiftAuthorship.”Example:anauthorwithoutanMDinvolvinghumanresearch,who“needs”aphysicianonthearticletogiveitauthenticity.Sooneissoughtout,askedtodosomecursoryreview,andthenaddedtotheauthorship.Thisiscommon,apparently,andquitecontroversialinthejournalismindustry.It’sabigdeal!

Medicinehasarichhistoryofpseudonymsintheliterature.OnefamousexamplethatproducedenduringcitationinmedicaltextbooksfordecadeswaswrittenbyEdgertonYorrickDavis---WilliamOsler.Perhapstheconceptthat“fake”researchersmightbegettingpublishedundersomeoneelse’snamemightnotbesofar-fetched. Itisgoodtobeskeptical.Summary Meeting of SCBCC 5-20-15 CompiledbyNealeSheade(abbreviatedbyEd.)*RonMiller,MDspokeinoppositiontoAB637whichwouldallowNPsandPAsasindependentpractitioners to sign POLST forms. He felt thatmany physicians have abandoned theirresponsibility in this matter. In subsequentdiscussion there was agreement that many non-physician health professionals do a good job ofPOLSTdiscussionswiththeirpatients,andthatitisunfortunate that somanyphysicians (fordifferentreasons) do not engagewith their patients in thisprocess.The relativemeritsof restrictingPOLST formsignature authority to physicians as a means ofensuring that physicians do not abandon thisresponsibility as opposed to broadening access byallowingotherproviderstosignwasdiscussed.*MiriamCotler,PhDmadeaverythoughtfulpresentationabouttheproblemswithSB128:PhysicianAidinDying/PhysicianAssistedSuicideincludingthefollowingpoints:1)Potentialforabuseofthemostvulnerable;2)Notenoughisdonetoimprovethecareofthedyingandclearlyexplainingallavailableoptionstopatientsinterminalstages;3)AutonomyisnotunderstoodbythepublicorevenmanyMDsandotherhealthcareproviders–autonomyisa“negativeright”torefusetreatments/procedures,nota“positiveright”tohavespecifictreatment/procedureadministeredbyaphysicianwhobelievesitisinappropriate,contraindicated,futile,etc.Commentsafterherpresentationincluded:

--“Thedefinition/understandingofautonomyhasgoneunchained;”--CMAchangeditsposition,from“oppose”SB128to“neutral,”reportedlyinresponsetopressurefrommedicalstudentandresidentphysicianmembersofCMA*ElizabethBromley,MDspokeabouttheincreasedriskofsuicideamongphysicianscomparedtogeneralpopulation,andgreaterriskamongfemalethanmalephysicians.Pre-disposingfactorswerediscussed.Q&AincludedAaronKheriaty,MD,psychiatristandethicistfromUCIaddinghisperspectivefromworkingwithphysicians.Factorsconsideredwerepredisposingpersonalitytraitsfosteredbythemedicaltrainingprocess,moralstress,burn-out,unrealisticexpectationsbythepublicandpromisedbyhealthcareorganizationmarketing.*TheBalintGroupProcess,focusedongivingthepractitionerinsightintoproblematicinteractionhe/sheisexperiencingwithhis/herpatientwasdemonstrated.Ina“closedgroup”onememberpresentsatroublingcase,thenobservesthediscussionofthecasebyothergroupmembers,whotrytoputthemselvesinthepositionsofthevariouspeopleinvolvedandimaginewhattheymightbeexperiencing.SCBCC Steering Committee PaulSchneider,MDPaul.Schneider@med.va.govJimHornstein,MDjimfamdoc@sbcglobal.netNeilWenger,MDNWenger@mednet.ucla.eduKendraGorlitsky,MDgrngasalud@aol.comKennethLandis,MDkwlsccrdoc@aol.comTheresaDroughtTheresa.s.drought@kp.orgRonaldB.Miller,M.Drbmiller@uci.eduRobertoDell’Orordelloro@lmu.eduStuart Finder* Stuart.Finder@cshs.org *also Webmaster