Is this one of those “only in America” stories? On Thursday afternoon in a Philadelphia, a man brandishing a pistol stormed the psychiatric ward of Mercy Fitzgerald Hospital. He shot dead his caseworker, 53-year-old Theresa Hunt and fired at his psychiatrist, Dr Lee Silverman, grazing his head. The doctor ducked for cover behind a desk.
But this was not going to be another mass shooting. Dr Silverman was ready for this. He pulled his own pistol out of a desk drawer and returned fire. He shot the patient, Richard Plotts, twice in the torso and once in the arm. Plotts collapsed and bystanders disarmed him.
It was like a script written by the National Rifle Association. The local police chief told the media: “without a doubt, I believe the doctor saved lives. Without that firearm, this guy (the patient) could have went out in the hallway and just walked down the offices until he ran out of ammunition.”
Plotts is in a critical condition at a local hospital and Dr Silverman was treated for a slight head wound. What no one has been able to figure out is why a psychiatrist had a loaded gun at work, especially when it was against the hospital’s policy. Perhaps the American Psychiatric Association will change its tune on gun control and adopt as its motto the bumper-sticker slogan, "the answer to stopping a bad guy with a gun is a good guy with a gun".
An ongoing debate amongst physicians has broken into academic discourse – should doctors dress formally for clinical practice?
Microbiologist Stephanie Dancer says ‘yes’. In an article in the British Medical Journal Dancer asserts that ‘dressing down’ diminishes the dignitas of the medical profession and could be see as an indication of carelessness:
“Doctors are members of a distinguished profession and should dress accordingly. Untidiness erodes the image of doctors as responsible and competent…[it] might be taken as a flashing neon sign that says “I don’t care.”
Dancer also claims that scruffy dress could contribute to low hygiene standards in hospitals: “scruffiness, however defined, also intimates a lack of personal hygiene and correspondingly lower standards of hygienic behavior.”
Two Manchester University medical ethicists, Cesar Palacios-Gonzalez and David R Lawrence, have written a scathing critique of Dancer’s claims. Gonzalez and Lawrence assert that scruffy dress has no effect on the ‘intrinsic dignity’ of the medical profession:
“doctors’ attire has no bearing on the inherent dignitas of the medical profession. Even where the doctor’s appearance is, for whatever reason disagreeable to the patient, this does not change the value of the medical intervention to the health of that patient…To state otherwise would be the same as to state that the value of a doctor’s medical practice fluctuates with each patients’ perception of the physicians’ attire.”
They argue on libertarian grounds that doctors should be allowed to dress how they wish.
They also contest Dancer’s claim that casual dress contributes to poor hygiene. Even if particular kinds of casual clothes lead to infection, “this would not mean that there is a case against scruffiness in general; but it would mean that doctors should refrain from using certain types of fabrics in regard for their patients’ safety”.
Another botched execution in the USA has reignited debate over the death penalty. Arizona man Joseph Rudolph Wood took almost two hours to die after being injected with the drugs midazolam and hydromorphone. The two drugs are a new barbiturate combination being trialled in a number of US states.
According to witnesses, Wood gasped for air hundreds of times before succumbed to the drugs. “It was very disturbing to watch…like a fish on shore gulping for air”, said reporter Troy Hayden. “I counted 660 times that he gasped,” said Arizona Republic journalist Michael Kiefer.
Just two months ago BioEdge reported on a similar botched execution in Oklahoma.
Shortly after the execution, Arizona governor Jan Brewer issued a statement in which she ordered a full review of the execution process.
She was nevertheless adamant that the execution had been lawful and did not involve undue pain: “One thing is certain, however, inmate Wood died in a lawful manner and by eyewitness and medical accounts he did not suffer” her statement said.
The American Civil Liberties Union of Arizona issued a statement calling for a moratorium on executions. "What happened today to Mr. Wood was an experiment that the state did its best to hide," Executive Director Alessandra Soler said.
The new drugs being used are intended to replace others that pharmaceutical companies now refuse to sell to US correctional facilities. The drug midazolam causes unconsciousness in a patient, while hydromorphone shuts down breathing and induces cardiac arrest.
The crisis in the the US Veterans Affairs Department is fundamentally a crisis of ethics, according to the former hospital ethicist at the Philadelphia Veterans Affairs Medical Center, Evelyne Shuster.
The VA’s director, Eric Shinseki, was forced to resign after it was discovered that employees were generating fraudulent statistics to improve their performance reports. The problem was particularly acute in Phoenix.
The New York Times decried “poor management, a history of retaliation toward employees, cumbersome and outdated technology, and a shortage of doctors and nurses and physical space to treat patients.” The Wall Street Journal lamented a “corrosive culture” which had damaged patient care.
But not long ago, VA was at the forefront of quality care and patient safety. It had identified weaknesses in its ethical culture and had set up a multi-million dollar program to deal with it called Integrated Ethics. How did things go so wrong?
The fundamental reason, Shuster writes in Bioethics Forum, a blog at The Hastings Center, is that ethics was an also-ran behind statistics and key performance indicators:
“Ironically, the very programs that made it possible for the VA to outpace other health care institutions in quality care, efficiency, and accountability also seem to have contributed to ethics failure in actual performance. The VA’s focus on quantifiable performance measures and accountability took a life of its own and helped foster the creation of a culture where ethics, integrity, and responsibility were simply overlooked or perceived as an impediment to achieving quality care.”
The Integrated Ethics program was supposed to promote ethical behaviour. Instead, she says, it “quickly became overwhelmed by a vast and rigid organization that valued documentation over action and reduced ethics to compliance and risk management. As a result, ethics in the VA became bureaucratized, an exercise of filling out forms and managerial compliance.”
"My view is that the focus on consent in contemporary biomedical research has become the modern equivalent of a fetish".
Koenig believes that the ‘full disclosure’ model of informed consent is impracticable. She recounts her experience developing genetic testing protocol after the mapping of the human genome in the 1990s:
“Even then, we recognized that the ideal of full disclosure of all risks and benefits of a particular genetic test, ideally by a trained genetic counselor,would collapse once the volume of genomic data increased. If it took an hour to counsel a patient about one condition, what would happen if panels of test could simultaneously offer multiple findings?”
Koenig proposes a model of consent whereby decision-making is outsourced to a ‘representative citizens group’ educated in basics of genetic testing. This group would be able to make informed decisions on behalf of patients, saving time, money and significant patient distress:
“The focus turns away from a ceremony of individual control and choice. Instead, consent is about giving up control, agreeing to accept a set of procedures and practices created and interpreted by a group of fellow citizens; it is ‘consent to be governed.’”
Koenig argues that this model preserves rather than undermines individual freedom:
“Personal sovereignty is not violated when research participants who will share in the benefits of genomics knowledge are given the opportunity to consent to be governed.”
In 2006 the anonymous woman attended a Portuguese hospital where tissue containing olfactory stem cells were taken from her nose and implanted in her spine. The hope was that these cells would develop into neural cells and help repair nerve damage in the woman's spine.
Eight years later she had a spinal growth removed in a US hospital. Doctors investigated the growth and discovered it to be composed of “mostly of cysts lined by respiratory epithelium, submucosal glands with goblet cells, and intervening nerve twigs”.
The cells had continued to grow as olfactory cells rather than morph into neural tissue. The growth was secreting a “thick, copious mucous-like material” which seems to have been pressing against the patient’s spine, causing considerable discomfort.
“It is sobering,” says George Daley, a stem cell researcher at Harvard Medical School who has helped write guidelines for people considering stem cell treatments. “It speaks directly to how primitive our state of knowledge is about how cells integrate and divide and expand.”
The case shows that experimental stem-cell treatment remains risky even when carried out in respectable hospitals.
A prestigious international group of scientists has called for a limit on the creation of potential pandemic pathogens (PPPs). The scientists, calling themselves the Cambridge Working Group (CWG), drafted a statement earlier this month warning of “fallibility” of even the safest virology laboratories:
“Recent incidents involving smallpox, anthrax and bird flu in some of the top US laboratories remind us of the fallibility of even the most secure laboratories, reinforcing the urgent need for a thorough reassessment of biosafety.”
The CWG suggested PPP researchers convene and establish stricter guidelines, just as in the Asilomar process:
“A modern version of the Asilomar process, which engaged scientists in proposing rules to manage research on recombinant DNA, could be a starting point to identify the best approaches to achieve the global public health goals of defeating pandemic disease and assuring the highest level of safety.”
Many more academics, including three Nobel laureates, have signed the CWG statement since its publication on the 14th.
Thailand has become a top tourist destination for women seeking gender-selective IVF. The country is one of just three that permit gender selection – the other two are the US and South Africa – and it offers the most affordable procedures.
Hundreds of women from China and Hong Kong travel to Thailand each year, and that number is set to increase. Alfred Siu Wing-fung - just one of a number of Hong Kong health tourism agents - sells ‘gender selection IVF packages’ to about 200 Chinese couples a year.
Siu estimates about 10,000 gender selection cycles were carried out in Bangkok last year, at an average cost of $15,000 per treatment.
While medical equipment and drugs are imported, clinics are staffed mostly by Thai doctors and nurses trained overseas.
Around a dozen clinics in Bangkok offer the procedure.
The Medical Council of Thailand is campaigning to have the practice banned. However, in light of recent political instability, the legislative change remains low on the government’s list of priorities.
Although bioethicists are believed to provide fearless independent advice, challenging policy-makers to make the “right” decisions, a Swiss expert in bureaucracies contends that this is often not the case. Writing in the journal Governance, Annabelle Littoz-Monnet, of the Graduate Institute of International and Development Studies, in Geneva, contends that bureaucrats use ethical experts to get their own way when they have to deal with controversies like GM foods or embryonic stem cell research.
“… establishing ethical experts as a new category of expertise alongside scientific experts actually bolsters the technocratic domain in areas where it is contested, thus reinforcing the authority of experts and bureaucrats in the policy process, rather than democratic control.”
After studying the decision-making process in various issues in the European Union, Littoz-Monnet concluded that “ethical experts have become a crucial tool of governance in the hands of policymakers who might wish to protect technocratic decision making in contested, value-based policy issues related to specific scientific or technological developments”.
One case was the controversy over embryo research around 2005. A number of members of the European Parliament were adamantly opposed, as well as several member states, like Germany and Austria. But “By shifting the debate away from irreconcilable ethical positions back toward the technicalities of the issue, the opinion of the [European Group on Ethics in Science and New Technologies] designed a workable policy scenario… By putting the ‘ethics’ experts at the core of the policy process, the European Commission succeeded in retechnocratizing the mode of conflict settlement (outcome controlled by experts and technocrats) despite the blatant politicization of the policy debate.”
Of course the European Union is the last circle of Paradise for bureaucrats. Still, ethics committees in other countries might be subject to the same pressures. Remember the classic line in Yes, Minister: "The three articles of Civil Service faith [are]: it takes longer to do things quickly, it's more expensive to do them cheaply and it's more democratic to do them in secret."
As the debate on assisted suicide in the British House of Lords approaches, a group of five academics from Switzerland and the UK have come up with a novel idea to keep the incidence of euthanasia from rising rapidly: legalise assisted suicide.
In a July 12 letter to The Lancet they observe that the incidence of “hastened deaths” in countries with carefully regulated assisted suicide is much lower than in Belgium or the Netherlands where euthanasia is legal.
The exception to this is Switzerland, where assisted suicide has been legal since 1918. But the authors point out that Swiss suicide is not tightly regulated. In the Netherlands and Belgium, where both assisted suicide and euthanasia are on the books, patients overwhelmingly choose euthanasia. Why? The authors believe that it is easier to ask someone else to kill you rather than to do it yourself.
“ … if patients are given the choice, they prefer to have their doctors do the procedure. Since overall incidence rates of hastened death are much higher in these two countries than in regions where only assisted suicide is allowed, the availability of euthanasia done by a physician could lower the psychological threshold for requesting hastened death.”