Medicine, ethics and law: What are doctors supposed to do?

[Skeptic Ginger]

I used to work IT for an online executive MBA program and, because we sucked up to our students, I sat in on most classroom lectures to ensure the technology behaved. Each business ethics class would discuss the same case study and there was usually the same response across all the classes.

The case study in question involves the toy store corporations Toys R Us and Kaybee Toys. Kaybee toys offered a $50 gift card if at least $150 was spent. The only rules were you couldn't use the card on the day you got it and you had to spend at least $100 when you redeemed the card. Toys R Us sent employees from every store that was near a Kaybee Toys to purchase and cry the gift cards. They purchased diapers, cleaning supplies, and other things that are sold at cost just to bring parents into the store. The cards were then used to purchase more of the same items, all of which Toys R Us just turned around and sold from their own stores. Toys R Us got no direct benefit from this as the price of the gift cards didn't cover the overhead of paying employees to go to the other stores. The only thing that happened was Kaybee lost money.

In general the students agreed that Toys R Us' actions were unethical with the few exceptions being that the Toy R Us employees got some extra hours that were basically paid by their competition. However, we had one student who could not separate "ethical" from "legal." He asserted that anything legal was, by definition, ethical and that things could only be ethical if they were legal. The other students kept disagreeing and the discussion got rather lively with the instructor only stepping in to keep emotions in check. In the end the dissenting student got a poor grade, not because he disagreed, but because he was unable to define "ethics" to the instructor's satisfaction.

I came to the conclusion that laws are basically our attempts to define ethics. Some things are easy, like don't murder. But, even then there are exceptions like self-defense.
Sent from my SM-G975U1 using Tapatalk

Exactly and this is especially true in the issue in the other thread when it comes to professional association position papers.

 

[theprestige]

Well technically, society approves of giving health care providers the leeway to prescribe off-label. It isn't subject to the whims of the daily news reports.

First, that doesn't have anything to do with the more general argument that I'm making about personal ethics and the law. It probably informs how I judge xjx's scenario, but it is not based on that scenario.

Second, in xjx's scenario, there is still a serious ethical question, in my opinion, even though the actions described are legal. It's the other side of the coin: It can sometimes be ethical to do something illegal; and it can sometimes be unethical to do something legal.

It wasn't illegal to buy all the toilet paper three and a half weeks ago, but it was probably unethical.

 

[Skeptic Ginger]

First, that doesn't have anything to do with the more general argument that I'm making about personal ethics and the law. It probably informs how I judge xjx's scenario, but it is not based on that scenario.

Second, in xjx's scenario, there is still a serious ethical question, in my opinion, even though the actions described are legal. It's the other side of the coin: It can sometimes be ethical to do something illegal; and it can sometimes be unethical to do something illegal.

It wasn't illegal to buy all the toilet paper three and a half weeks ago, but it was probably unethical.

Your point, if there is one, is all over the place.

What ethical issue was that? A shortage that's enough to discourage hoarding but it isn't so bad one can't prescribe the meds?

The news media describes a shortage but sources of medical information say the shortage isn't drastic and there is no ethical issue with my hypothetical scenario. There's only an ethical issue because lay people think they understand the situation enough to pass judgement on a professional provider's judgement.

Get the pitchforks out.

 

[theprestige]

Your point, if there is one, is all over the place.

My point was pretty focused. My replies to you are all over the place because your responses to me are all over pretty much every place except the place where my actual point can be found.*

What ethical issue was that? A shortage that's enough to discourage hoarding but it isn't so bad one can't prescribe the meds?

The news media describes a shortage but sources of medical information say the shortage isn't drastic and there is no ethical issue with my hypothetical scenario. There's only an ethical issue because lay people think they understand the situation enough to pass judgement on a professional provider's judgement.

Get the pitchforks out.

My understanding of the OP is that the scenario is used as an example to prompt discussion about ethical frameworks. What kind of ethical framework do you use to judge the situation? What judgement does your ethical framework recommend? Things like that.

Passing judgement on that specific scenario is secondary to the purpose of the thread. If you're reading my posts narrowly as judgements of that particular scenario, then I think you're missing xjx's point. You're definitely missing my point.

---
*It's a literal place, too: My very first post in this thread. Let me know if you need directions for getting there.

 

[Skeptic Ginger]

I'm saying professional judgement for the most part (not counting unethical providers) is where one gets their ethical guidelines.

Xjx has made the argument that the law is presumed ethical which is obviously unsupportable as examples have shown in the thread. He also said one should work to change laws rather than ignore them. That is simply not always possible.

Another issue I have pointed out, you simply cannot make laws or even professional guidelines for every aspect of medical care.

I posted before, despite not being believed, that I define my scope of practice. There is not, in this state anyway, laws that specify every aspect of one's clinical practice.

My education and licensure assures I am qualified to make a professional judgement about my scope of practice. Shock: there is no law that says I cannot perform neurosurgery. But my professional judgement stops me from doing things I am not qualified to do.

 

[xjx388]

Given this is a hypothetical scenario, why drug someone with sedatives when this drug has not proven ineffective?

Huh? Her issue, as you phrased it, is not actual risk of Covid infection but the anxiety the situation is provoking. Treating the anxiety with meds or a referral to mental health seems the proper course of treatment rather than issuing a prophylactic medicine that has no proven benefit AND is in short-supply.

Your focus on one narrow aspect of my hypothetical patient's needs demonstrates why professional judgement is important.

No, your narrow focus on "I can make that professional judgement if I want to" is clouding your arguments. You don't seem to be considering all the other factors that should help you decide whether or not to prescribe plaquenil. To wit:

Straw man. Obviously if my hypothetical patient was able to fill the prescription, there wasn't a shortage.

Just because a patient was able to pick it up does not mean there isn't a shortage. What the evidence (the scant anecdotal evidence there is) shows is that it's most useful in treating people who get the disease, especially the most severe cases. If all prescribers thought like you (and, obviously a lot of them do) and prescribed it to non-sick patients -well . . . what good is it doing sitting in their medicine cabinets just in case when there are severe cases who could die because they can't get it?

Your "professional judgement" seems very narrow -it doesn't consider the larger situation we are in.

This is from Newsweek: https://www.newsweek.com/fda-shortage-hydroxychloroquine-chloroquine-1495555
So the hypothetical decision was still reasonable.

I totally disagree. It is not reasonable to prescribe chloroquine for a patient who has no clinical indication in a time when a shortage is happening and there are more critical patients who need it. And that's if the damn drug even works! What if the evidence shows it isn't really effective at all?

Are you suggesting you know better than said professionals? And you are arguing a straw man again.

It's not a straw man. Those prescriptions are being written today. If those professionals are writing prophylactic, just in case prescriptions for patients without a clinical indication or that fall under the FDAs emergency use authorization, then yes, I do know better than those professionals.

Straw man.

Not at all. Your position is that you can exercise your professional judgement and prescribe off-label. You describe a scenario in which you might prescribe chloroquine off-label. You justify that decision in the face of a shortage when critically ill patients might benefit from it more than your anxious patient without any clinical indication/evidence for the drug. Like I said, off-label in that situation is unethical, and quite clearly so.

Oh for pity's sake.

Dr Tiller was practicing in a state where third trimester abortions were legal.

OK, great. So we have a murderer who did not agree with the society's law because of his own personal ethical code. Surely, you agree that his own personal belief in the righteousness of his ethics does not mean that he acted ethically?

 

[xjx388]

Your point, if there is one, is all over the place.

What ethical issue was that? A shortage that's enough to discourage hoarding but it isn't so bad one can't prescribe the meds?

The news media describes a shortage but sources of medical information say the shortage isn't drastic and there is no ethical issue with my hypothetical scenario. There's only an ethical issue because lay people think they understand the situation enough to pass judgement on a professional provider's judgement.

Get the pitchforks out.

If the shortage isn't drastic, why are so many states issuing orders to stop prescribing if there is no established clinical indication or it falls under the EUA issued by the FDA?

In your position, there is nothing wrong with every prescriber in the USA writing just in case prescriptions to patients without indications. Do you think they should?

 

[xjx388]

I'm saying professional judgement for the most part (not counting unethical providers) is where one gets their ethical guidelines.

This makes absolutely no sense at all. An "unethical provider" has ethical guidelines that differ from yours. Why is your ethical framework superior to theirs? Why can they not say, "I disagree with that law/ethical rule," and not be unethical like you can?

Xjx has made the argument that the law is presumed ethical which is obviously unsupportable as examples have shown in the thread. He also said one should work to change laws rather than ignore them. That is simply not always possible.

Of course it is! That's how "abortion is elective surgery" bans got blocked so quickly.

Another issue I have pointed out, you simply cannot make laws or even professional guidelines for every aspect of medical care.

I posted before, despite not being believed, that I define my scope of practice. There is not, in this state anyway, laws that specify every aspect of one's clinical practice.

As i posted before, your state nursing board disagrees with you. Your scope of practice is limited to the specific certification you have. You can't be a Psychiatric NP because you are a Family NP.

My education and licensure assures I am qualified to make a professional judgement about my scope of practice. Shock: there is no law that says I cannot perform neurosurgery. But my professional judgement stops me from doing things I am not qualified to do.

You are very wrong here. Your State law will not allow you to perform neurosurgery because an FNP's certifying body does not train/certify you for that. You are certified for the limited scope of practice of Family Nurse Practitioner which does not include surgery. APRNs are not ever licensed to perform surgery because there are no certifying bodies for surgery.

 

[theprestige]

Another thing to think about is that "professional judgement" doesn't emerge from a vacuum. It's not whatever idea about good doctoring you got in the shower this morning.

Professional judgement is a viewpoint that matures over time. It is based on your years of education in that profession, your years of training in that profession, and your years of ongoing interaction with other professionals in the same profession.

All of this is informed by the laws and rules about the ethics of your profession.

Med students don't show up at med school on day one with "professional judgement" about medicine. If they're lucky, they'll graduate from med school with the beginning of mature professional judgement. But even that is probably still a few years a way. And much of that beginning is going to be based not on "do whatever you think is right", but on "here's what the ethical standards for the profession are; consider them carefully when making your judgements".

 

[Skeptic Ginger]

Huh? Her issue, as you phrased it, is not actual risk of Covid infection but the anxiety the situation is provoking. Treating the anxiety with meds or a referral to mental health seems the proper course of treatment rather than issuing a prophylactic medicine that has no proven benefit AND is in short-supply.

That's stupid, we are all at risk of COVID. Some people are managing the stress better than others.

It's my clinical judgement the risks and benefits favor chloroquine. You're off on your high horse trying to override my clinical expertise with your judgmental opinion.

No, your narrow focus on "I can make that professional judgement if I want to" is clouding your arguments. You don't seem to be considering all the other factors that should help you decide whether or not to prescribe plaquenil. To wit:

Just because a patient was able to pick it up does not mean there isn't a shortage. What the evidence (the scant anecdotal evidence there is) shows is that it's most useful in treating people who get the disease, especially the most severe cases. If all prescribers thought like you (and, obviously a lot of them do) and prescribed it to non-sick patients -well . . . what good is it doing sitting in their medicine cabinets just in case when there are severe cases who could die because they can't get it?

Your "professional judgement" seems very narrow -it doesn't consider the larger situation we are in.

I totally disagree. It is not reasonable to prescribe chloroquine for a patient who has no clinical indication in a time when a shortage is happening and there are more critical patients who need it. And that's if the damn drug even works! What if the evidence shows it isn't really effective at all?

It's not a straw man. Those prescriptions are being written today. If those professionals are writing prophylactic, just in case prescriptions for patients without a clinical indication or that fall under the FDAs emergency use authorization, then yes, I do know better than those professionals.

Not at all. Your position is that you can exercise your professional judgement and prescribe off-label. You describe a scenario in which you might prescribe chloroquine off-label. You justify that decision in the face of a shortage when critically ill patients might benefit from it more than your anxious patient without any clinical indication/evidence for the drug. Like I said, off-label in that situation is unethical, and quite clearly so.

OK, great. So we have a murderer who did not agree with the society's law because of his own personal ethical code. Surely, you agree that his own personal belief in the righteousness of his ethics does not mean that he acted ethically?

This is more of the same crap you posted in the other thread.

Go get your medical degree and come back when you actually have enough expertise to debate these topics.

 

[Skeptic Ginger]

If the shortage isn't drastic, why are so many states issuing orders to stop prescribing if there is no established clinical indication or it falls under the EUA issued by the FDA?

In your position, there is nothing wrong with every prescriber in the USA writing just in case prescriptions to patients without indications. Do you think they should?

You haven't produced a single law or directive backing this up. In any case, it's not a federal law or directive by any means.

It's impossible to debate a person who keeps tossing out assertions and doesn't post anything suggesting they know what the **** they are talking about.

I see no reason to make another gazillion page thread just to repeat the same foot stamping stuff you posted in the other thread.

 

[theprestige]

That's stupid, we are all at risk of COVID. Some people are managing the stress better than others.

It's my clinical judgement the risks and benefits favor chloroquine. You're off on your high horse trying to override my clinical expertise with your judgmental opinion.

In your clinical judgement is chloriquine the right treatment for managing C19 stress?

 

[Skeptic Ginger]

This makes absolutely no sense at all. An "unethical provider" has ethical guidelines that differ from yours. Why is your ethical framework superior to theirs? Why can they not say, "I disagree with that law/ethical rule," and not be unethical like you can?

Of course it is! That's how "abortion is elective surgery" bans got blocked so quickly.

As i posted before, your state nursing board disagrees with you. Your scope of practice is limited to the specific certification you have. You can't be a Psychiatric NP because you are a Family NP.

You are very wrong here. Your State law will not allow you to perform neurosurgery because an FNP's certifying body does not train/certify you for that. You are certified for the limited scope of practice of Family Nurse Practitioner which does not include surgery. APRNs are not ever licensed to perform surgery because there are no certifying bodies for surgery.

You really need to stop believing you know what the law in WA State says.

I have to keep one certification up (in my case FNP) in order to keep my ARNP license. That doesn't limit me to family practice. I practice occupational health and infection prevention. I don't need to go back and get board certification to do that.

https://apps.leg.wa.gov/wac/default.aspx?cite=246-840-302

ARNP designations, certification, and approved certification examinations.
(1) ARNP designations recognized by the commission include:
(a) Nurse practitioner (NP);
(b) Certified nurse-midwife (CNM);
(c) Certified registered nurse anesthetist (CRNA); and
(d) Clinical nurse specialist (CNS).
(2) An ARNP must maintain current certification within his or her designation(s) by a commission approved certifying body as identified in subsection (3) of this section. An ARNP license becomes invalid when the certification expires.
(3) To be eligible for licensure as an ARNP, an applicant must pass an examination from one of the following certifying bodies within the ARNP's specialty designation:
(a) For NP designation:
(i) The American Academy of Nurse Practitioners;
(ii) The American Nurses Credentialing Center;
(iii) The National Certification Corporation;
(iv) The Pediatric Nursing Certification Board;
(v) The American Association of Critical Care Nurses; or
(vi) The Oncology Nursing Certification Corporation.
(b) For CNM designation, the American Midwifery Certification Board.
(c) For CRNA designation, the National Board of Certification and Recertification for Nurse Anesthetists.
(d) For CNS designation:
(i) The American Nurses Credentialing Center;
(ii) The American Association of Critical Care Nurses; or
(iii) The Oncology Nursing Certification Corporation.
(4) An ARNP recognized in more than one designation must obtain and maintain education, training, and practice in each area.

IOW in order to have an ARNP license with those certifications.

It doesn't limit my scope of practice as an ARNP.

I posted this in the other thread. Repeating your flawed argument doesn't change the fact your assertions are unsupported.

 

[Skeptic Ginger]

Another thing to think about is that "professional judgement" doesn't emerge from a vacuum. It's not whatever idea about good doctoring you got in the shower this morning.

Professional judgement is a viewpoint that matures over time. It is based on your years of education in that profession, your years of training in that profession, and your years of ongoing interaction with other professionals in the same profession.

All of this is informed by the laws and rules about the ethics of your profession.

Med students don't show up at med school on day one with "professional judgement" about medicine. If they're lucky, they'll graduate from med school with the beginning of mature professional judgement. But even that is probably still a few years a way. And much of that beginning is going to be based not on "do whatever you think is right", but on "here's what the ethical standards for the profession are; consider them carefully when making your judgements".

Who the hell is arguing that? A med student doesn't have a license to practice or prescriptive authority.

 

[Skeptic Ginger]

In your clinical judgement is chloriquine the right treatment for managing C19 stress?

In the hypothetical patient case I presented, absolutely.

"In my hypothetical patient scenario, this is a false assumption. The decision is not based on seeking the patient's approval. The decision is based on evaluating the risks and benefits of all the treatment options."

 

[Roboramma]

Is it ethical, having received the state's license, to violate the state's rules without also renouncing the state's license?

Sometimes, when there are other more important ethical considerations, the carrying out of which would require not renouncing said license.

But in general, no.

 

[xjx388]

That's stupid, we are all at risk of COVID. Some people are managing the stress better than others.

What if you issued the script and the patient never needs it? Or she gets a mild/asymptomatic form? While the drug sits useless in her cupboard, people with lupus (like my wife, who couldn’t fill her script yesterday) go without and get flare ups. People with the severe form of Covid 19, dying in hospitals go without. Do you honestly think the anxious patient NEEDS the script, in the face of a crisis, ahead of those patients that definitely need it? Especially since the only evidence for its efficacy is small studies and anecdotes?

It’s irresponsible, plain and simple. Your moral calculus is off.

It's my clinical judgement the risks and benefits favor chloroquine. You're off on your high horse trying to override my clinical expertise with your judgmental opinion.

Damn right I’m on a high horse. Your “clinical judgement” is faulty if you would prescribe it to a patient who doesn’t have the disease and doesn’t have another indication. Benefits=unknown, close to zero given her chance of actually contracting Covid-19; Risks= known cardiotoxicty, vision changes, psychiatric, etc. Your ethical judgement is flawed if you think the anxious patient’s needs outweigh the people who are actually ill.

This is more of the same crap you posted in the other thread.

Go get your medical degree and come back when you actually have enough expertise to debate these topics.

I am a member of the society that licenses healthcare providers. I am a member of the medical community. My wife is a doctor. I have all the expertise I need to debate the ethics and laws of the medical profession.

 

[xjx388]

You haven't produced a single law or directive backing this up. In any case, it's not a federal law or directive by any means.

It's impossible to debate a person who keeps tossing out assertions and doesn't post anything suggesting they know what the **** they are talking about.

I see no reason to make another gazillion page thread just to repeat the same foot stamping stuff you posted in the other thread.

You have to live under a rock if you are a member of the medical community and don’t know about the shortage of the drug and all the States who have taken action.

Several States have issued restrictions including
Texas. Others have issued guidance

If anyone is stomping their feet, it’s you. Your posts sound like a more sophisticated Cartman sometimes: “Respect my authoritah! Whateva! I do what I want!” Why can’t you simply argue the ethical/legal principles? Respond to my arguments instead of just saying, “Thats stupid,” or “go get a medical degree?” Show your reasoning, IOW, not your expertise.

 

[Skeptic Ginger]

Not taking the bait xjx. You just want to argue the same thing you did in the other thread: Your ethics supersede anyone you don't agree with.

You weren't exactly winning over converts in the Trump has dangerous narcissism. You're not going to win this one using the same failed foot stamping arguments here.

 

[Roboramma]

I notice I didn't reply to this. That was because I think my answer was implicit in my subsequent posts, but just in case:

Fair enough . . . however, who decides a law is unethical? Is that a decision that an individual clinician gets to make?

Each of us decides for ourselves what we consider ethical. As a society we come together and each inputs their own views to determine social judgements, including laws. This process is imperfect and certainly doesn't result in a consensus.

An individual clinician makes their own judgement about their own actions, as well all do. Society may judge them differently, and there may be consequences to that.