Category Archives: ethics

Lance Armstrong – Cheat, Liar & Cancer Survivor

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Confession on TV..the body language speaks volumes

A serial cheat and liar he may be after his confession on the Oprah Winfrey show, but there’s no denying he’s a cancer survivor. In this blog entry, I would like to elaborate on what he suffered from – cancer of the testes with spread to the brain and lungs – and the chances of survival in patients with this condition.

In  October 1996, after delaying seeing a doctor and after his testes had swollen up to three times the normal size( he was also coughing up blood), he finally sought a medical consultation which confirmed that he had advanced stage three testicular cancer, of the subtype embryonal carcinoma. Worse, the cancer had already spread to the lungs and brain. Immediate surgery was done to remove the diseased testicle as well as the satellite tumors in the brain. Subsequently,  chemotherapy, an essential part of the two-step treatment, was planned.

Here, instead of the standard chemotherapeutic regimen (the BEP regime), he opted for one (the VIP regime) which did not contain the drug bleomycin, which has toxic effects on the lungs and would probably have meant that his cycling career would have been finished. The course of chemotherapy finished in December 1996, and in February 1997, he was declared cancer-free, which he apparently remains to this day.

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An interesting fact to note is that, prior to the surgery, he had already won two Tour de France titles. Following the cancer treatment, he was recruited by US Postals, resumed training, and was able to win the Tour de France every year from 1999 till 2005, when he officially retired.

Quite an amazing feat, even if it was tainted by the use of performance-enhancing substances. I would be hesitant to call them drugs, as the alleged substances involved (EPO, testosterone , human growth hormone, corticosteriods and blood transfusions) are all part of normal body constituents.

So, is what Armstrong the cancer survivor experiencing  something out of the ordinary? Unknown to many, testicular cancer has one of the testeshighest cure rates of all cancers –  in excess of 90 percent overall; almost 100 percent if it has not spread elsewhere. Even if the cancer had spread widely, as in Armstrong’s case, the cure rate is over 80% following chemotherapy. Indeed, it is the most common form of cancer in males aged 20-39 years.

 

Pediatrician Guilty of Child Abuse

What happens when an internationally renowned child specialist working in one of the world’s best children’s hospitals is found guilty of sexually abusing young boys? The news barely made it  into most of the world’s mass media 2 weeks ago..read on.

Phillipp Bonhoeffer..found guilty of sexual child abuse

Prof Philipp Bonhoeffer, former head of cardiology at the Great Ormond Street Hospital for Children, London until 2010, was found guilty by a panel of the Medical Practitioners Tribunal Service on 21st September 2012 of sexually molesting young boys in France and Kenya. Read the full details here.

In a subseqent meeting of the Panel a few days later, it ruled that Prof Bonhoeffer’s fitness to practise was impaired by reason of misconduct and decided to erase him from the  General Medical Council register, thereby barring him from practising as a doctor in the UK.

The punishment appears appropriate but some isuues need to be highlighted:

-Why did it take so long for the Panel to formalise the charges when the first reported abuse was as early as 1995?

-Was there any element of cover-up by peers or the hospital in an attempt to save face?

-Being struck off the GMC Register in the UK merely means being barred from working in that country. He is still able to practise in Belgium (where he hails from) as well as the Continent.

This case highlights once again that professionals,  being placed in a privileged position as a member of the medical profession, are entrusted with certain reponsibilities for which they are beholden to uphold. When this trust is abused, mechanisms must be in place to protect this trust. The question is, are these mechanisms adequate?

Licence to Practise…And Be Sued

Here’s some sobering news for doctors and those who aspire to be one. If you are a neurosurgeon or a heart surgeon, you’re going to face a malpractice claim at least once by the time you reach 65. Coming from the New England Journal of Medicine study published recently, even if you’re a doctor in a low-risk speciality eg  GP or skin specialist, the chances of being taken to court by age 65 is still high, at 75%.

Brain and Heart Surgeons Top the List of Those Being Sued (courtesy NEJM)

I’m not surprised at all..what with more well-informed patients, an egalitarian society, litigation-conscious families and the ever-present doubt on the quality of medical education..one can only expect malpractice claims to rise.

Medical students in particular should take note of this trend. Medical schools need to also address this issue in their curriculum. As it is well-known that, even after an untoward event, whether the patient decides to sue is largely dependent on effective doctor-patient communication – medical schools would do well to introduce communication skill as an integral part of a medical course.

Good patient-doctor communication can make the difference in whether a malpractice claim surfaces

A good doctor is more than just being adept at diagnosing and treating diseases – they have to be skilled at managing information and communicating with their patients.

Doctor, Bill Thyself

Bring up the subject of doctors’ bills and many patients will have their anecdotes, but an interesting court trial is currently shaping up in Singapore regarding the way doctors there charge for their services.

A well-known surgeon in Singapore is fighting in the High Court there to disallow the Singapore Medical Council from setting up a disciplinary committee to investigate charges that the surgeon had over-charged her patient from Brunei, who happened to be the Brunei Queen’s sister.

Dr Susan Lim and doctors' charges - how much is too much?

 

The surgeon, Dr Susan Lim, had begun treatment for breast cancer on the patient in 2001 right till her death in 2007. In the process, she had referred the patient to several colleagues who had their bills directed to her for onward transmission. Here are some astounding facts that were heard in court last week:

The Bill Mark-Ups (courtesy of Straits Times,Singapore,24 Feb 2011)

  • The overall bill for the year 2007 alone came to USD 19.5 million.
  • She charged as high as USD 354,000 per day for her services.
  • The surgeon would inflate her colleagues’ bills dramatically and bill the patient. For instance, doctors’ bill for USD 315 forwarded to her was bumped up to USD 166,000.

When the patient eventually passed away in 2007, the Ministry of Health of Brunei, alarmed at the high fees, complained to their Singapore counterparts. It was alleged the surgeon then gave a 25% discount of the bills accompanied by an apology on “inadvertent mistakes made by her office”; but when this did not work, she then offered to waive all her bills in return for a “letter of good standing” to state that the matter would not be pursued further. The Brunei government did not respond.

In her defence, the lady surgeon said that the patient had been forewarned on her fees of between USD 79,000-168,000 per day and that the patient had agreed to it, saying that the Palace would pay. In addition, the patient had become so dependent on her that no other doctors could provide treatment without her physical presence.

The above anecdote makes grim reading and raises several questions related to medical ethics and human psychology. Can a doctor justify such charges no matter what challenges are faced? Can a patient, assuming he or she is in a mentally fit state, make a financial undertaking  on behalf of  the body paying for the bills? The issue is made complicated by some of the doctors backing the surgeon on the inflated bills. See here.

It also calls attention as to why a developed country like Singapore does not have an approved fixed fee schedule upon which doctors’ charges are based. Most countries have one in place that makes such charges transparent.

Whichever way  you look at it,  healthcare has become an industry; like all industries, standard-operating procedures and adequate legislation must be in place to protect the consumer. This includes a transparent doctors’ fee schedule. Until this is done, Singapore’s credibility as a medical hub is seriously affected.

For Real or Just Hype?

Reading the media, many doctors are fascinated as to the plethora of new drugs claiming to provide a ‘cure’ against diseases which hitherto were considered incurable. Why, new drugs have even pervaded the social media – pharma companies have started posting widgets on Facebook in a bid to attract readers. Last month, FDA cautioned the drug company Novartis for overstating the benefits of a drug without pointing out the ill-effects (see here).

Social Media as a Marketing Tool - even Big Pharmas Use It

 

 

This rampant form of advertising naturally may confuse the public about the efficacy of new medications. In fact, its sometimes difficult to know the validity of claims made in the media.

Here are  some tips on how to evaluate the validity of medical news items that you may come across..

  • It is a fact that competition is intense among medical journals, research bodies and medical journals to attract media attention. Media themselves compete with each other to come out with the latest. Try to read the same news from several sources. Obviously, if the item is reported in just one obscure source, it should carry less weight.
  • Look for key-words like suggestive or may (as opposed to will) as this does not always indicate a cause and effect meaning. Many people make hard-core assumptions based on such words.
  • It is the nature of scientific studies that, for a given topic, several would say one thing and a few would say the complete opposite. It is for the trained professional and their peer-groups to make an informed decision to advise consumers. Bear in mind that space is a premium with the mass media and such reports usually omit vital details which will affect accuracy.
  • Separate the wheat from the chaff..make sure the website you’re looking at is a reliable one!
  • Personally, I feel reports originating from researchers and pharma companies should not appear in the mass media without vetting by an appropriate professional body so as to convey the proper perspective to the audience at large. So if a news report originates from a known professional body, this should carry a lot of weight; as opposed to a solitary item in a nondescript health magazine.

Choosing To Die..Australia Bans Euthanasia Ad

Take a look at this TV advert..its about a terminally-ill man sitting on a hospital bed talking about the choices he made in life, including the choice to die. But this advert will not see the light of day in Australia where it was made because the regulatory authority which decides what is fit for screening on free-to-air commercial stations has decided that “material which promotes or encourages suicide will invariably be unsuitable for television.”

Australia’s Northern Territory introduced the world’s first voluntary euthanasia legislation in 1995 but it was overturned by the federal government and euthanasia remains a crime in the country. Euthanasia advocates appear unfazed and are pressing for the ad to be released on TV. You decide…

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Abortions: Cry For Argentina

This South American country is considered one of the most liberal in Latin America, what with a female President and  legalised same-sex marriage in a predominantly Roman Catholic country.

Cristina Fernandez de Kirchner - Argentina's second female President, lawyer, mother of two, who replaced her husband as President

The largest Spanish-speaking country, it is renowned for its beef, wines and football. But, on the darker side, according to the Human Rights Watch, women and girls suffer needlessly in Argentina because of negligent and abusive reproductive health care. Argentina has the highest abortion rate in the world – a shocking 40%, double the average for any othe Latin American country.

Because abortion is banned (not surprising in this Roman Catholic country), illegal abortions are widespread. Legal abortions are allowed only if the mother’s health is medically at risk or when it is the result of rape, but even then there are several bureaucratic obstacles. As such, unsafe abortions form the leading cause of maternal mortality in Argentina.

The irony of it is that  the Argentine President was a strong advocate of human rights when she came into power – and yet, enforcement of womens’ reproductive rights have fallen to an all-time low. Well, the women are not taking it sitting down – female activists are now campaigning for legalised abortion and this looks imminent, after the legalisation of same-sex marriage.

Female activists press for social justice - the banner reads "Ensure legal & free abortion"

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The Right To Die..The Way You Want It

Walking out of the ICU the other day, my mind was occupied by the thought of the patient who had just passed away . A proud, self-made man, he had leapt from obscurity to popularity on his own blood,sweat and tears. Surrounded by drips,  lines and pumps he laid helplessly in the ICU bed, knowing  that the end was nigh and that his will to survive had drawn on the last straw. The nurses sensed that and the doctors knew that; but we were all trained to keep him going. Deep inside, we were wondering if he knew about  living wills

A Living Will determines how medical staff will manage end-of-life care

A living will is quite different from a last will and testament which specifies beneficiaries and funeral arrangements. Quite simply, a living will speaks on your behalf when you are medically seriously ill and unable to communicate,such as when in a coma, and is a healthcare directive made in advance instructing medical personnel and family as to what medical treatment you wish to receive at end of life, including matters such as organ donation.

For doctors in attendance and family members, this relieves them from making agonizing decisions like when to turn off the respirator at end of life; or for that matter, whether to use that life support machine in the first place.

Living wills can also stipulate whether blood transfusions can be used, artificial feeding implemented or even the use of organ transplantation.

To make your living will legally binding:

* It must be witnessed by two people who are legal adults

* Witnesses must not be related to you in any way

* They cannot be beneficiaries of your estate

* They are not directly involved with your health care providers

* They have not been named as your agent in a medical power of attorney document or in your living will.

Signed copies of the living will should be handed to one’s personal doctor as well as close family members and need to be seen by the attending doctors at any possible end-of-life scenario. Take a look at a typical living will here.

Doctors encountering patients with living wills vary. In New Jersey,USA 1 in 6 adults have one. In Asia, the exception is the rule. But with increasing awareness of patient rights, an egalitarian society and the rising costs of end-of-life care, it would not be surprising, in the near future, to see more patients with a living will in hand. The dying, not doctors, should have the final say in the type of treatment they receive.

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A Tale of Three Doctors

Woke up one day this week to read about how the medical profession was  put in a rather unfavorable light, in various parts of the globe.

In Los Angeles,USA, it was reported that the late Michael Jackson’s doctor, Dr Conrad Murray, who practises in Houston was going to be charged in a few days time  for involuntary manslaughter. It was alleged that the doctor had administered the powerful anaesthetic drug, propafol, plus two other sedatives in a concerted attempt to make the pop star go to sleep. Propafol needs to be administered intravenously by an anaesthesiologist in a hospital setting and requires continuous monitoring as the drug can cause suppression of breathing, lowering of heart-rate and blood pressure. See my earlier posting “MJ’s Death Explained for details.

Dr Daniel Ubani - still practising in Germany

In Cambridge,UK, a foreign-trained doctor, on his first work assignment for the NHS after arriving in the UK the day before, administered an injection of diamorphine (an opioid used for pain relief) of twenty times the recommended dose to an elderly patient at his home for relief of kidney pain. Not surprisingly, the patient stopped breathing soon after the doctor had left. At the coroner’s enquiry, it was discovered that the doctor, originally from Germany, had failed his English test earlier and had never given the drug before. It was also not possible to extradite the doctor from Germany to face charges, where latest reports say he is still practising.

Dr Suresh Nair -1991 Sydney Uni graduation pic

Meanwhile, in Sydney,Australia, a neurosurgeon has been charged over the cocaine-related deaths, in November 2009, of two young women who had visited his apartment. Post-mortem results showed both women had died of cocaine toxicity. Having been suspended by the New South Wales Medical Board, he now remains in custody pending trial. Some unanswered questions remain, like having been a known cocaine abuser since 2004, why was he still allowed to practise by the Medical Board?

Having read these stories, I just wonder whether this is a trend of things to come, or whether the virtues of a noble profession are being eroded in the face of changing times? Perhaps, most tellingly, when I asked a student who had aspirations of being a doctor, why he had chosen the profession, his answer was, So that I can make a lot of money!”

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Obama’s Oration to Doctors..and Some Boos Are Heard

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President Obama at the AMA Meeting, Chicago

“We have to tackle the model that has taken the pursuit of medicine from a profession — a calling — to a business. You didn’t enter this profession to become bean counters and paper pushers. You entered this profession to be healers. And that’s what our health care system should let you be.”

-President Barack Obama, addressing doctors at the Annual Meeting of the American Medical Association,15th June 2009

By all accounts, many, including myself, will agree with the President on this. How often have we seen administrative paperwork eat into time that would be better spent looking after patients? And the preoccupation amongst some doctors in private practice to improve the financial bottom-line at all costs, sometimes at the expense of the patients’ well-being?

Somewhere in the middle of the President’s oration, however, boos erupted when he told doctors that he wouldn’t try to help them win their top priority – limits on jury damages in medical malpractice cases. What else could the President say? If he said otherwise, you can bet lawyers, trade unions and consumer groups would stand up in protest!

This is the problem with healthcare anywhere in the world – every stakeholder in the healthcare debate will have their own unique  list of priorities. For instance, private insurance companies do not want competition from a government-funded single-payor financial scheme. Drug companies want to charge to the hilt to maximise profits. Hospitals want no more cuts from Medicare or any payor system. Employers want to minimise employee coverage and benefits. And the public of course demand universal access whatever the cost.

Healthcare GDP of countries

With Healthcare Exceeding 16% of GDP presently, Its Reform is the Top Priority For the Obama Administration

No leader, President Obama included, can give all of them what they want. In fact, leaders over the decades have been grappling on a tightrope as to how much to give to keep as many as possible happy, without alienating others.

Its not often that a President receives boos (from doctors at that!), but he has to be prepared for more as he tackles sensitive and dicey issues like healthcare..

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