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

[Skeptic Ginger]

And this is why there's entire courses on is-the-law-the-definition-of-ethical?

Bring on the Heinz dilemma^WP !

(sounds like you're at Level 2)

 

[Skeptic Ginger]

The complication is that the laws may not represent the societies. Sometimes they're seized by a minority who project their ethics onto the state through violence. Aparthied, for example, was not an ethic of its society. It was an ethic of a dictatorship that issued the laws.

Not if the facility was designated white. They would be literally breaking the law and many did so as acts of civil disobedience, and spent time in jail.

Bingo!

 

[angrysoba]

We live in a society.

Nobody can tell anyone else what's right and what's wrong. Each individual gets to decide that for themselves.

But we live in a society. Obviously we're going to have a collective agreement on what's tolerable and what's not. You can - and do! - have your own ethical standard, but there's also the standard you have to meet to avoid negative consequences from the people who share in the same society.

So. Every doctor, like everyone else, should follow their own ethical standard regardless of what the law says.

But we live in a society. We have a collective agreement on the baseline ethical standards and boundaries appropriate for doctors. If you want to be a doctor in our society, without consequences arising from violations of our collective ethics, you must meet our ethical standard.

If you want to live in our society. If you want to enjoy its benefits. If you want all the protections we offer, against those who would ignore our ethics to profit from your misfortune. Then you have to comport with our ethics. Not because we can tell you what your ethics are. But because we live in a society. In a sense, society is the part of the Venn diagram where most people's ethics overlap.

If you want to be a good doctor - an ethical doctor - it's not just about hewing to your own personal standard of right and wrong. It's about practicing medicine at that ethical intersection where society happens.

Therefore, in most cases, an ethical doctor is a doctor who practices medicine according to the collective ethical standards of their society. A doctor who practices medicine in violation of those standards may be true to his own ethics, but he's violating the ethics of the society he serves, which is itself unethical.

And even if it isn't unethical in the doctor's own eyes, it still invites (and justifies) negative consequences from the society he serves.

Because we live in a society.

It sounds a bit contradictory to say that no one gets to say what is right and wrong but we must live according to social norms. That just sounds like you telling us what we have to do, unless by saying we must live by social norms just means or society will shun you/persecute you, etc..., but that ultimately leads to we have to do what is in our interests or "let the Wookie win".

 

[xjx388]

In all this did you cite a law anywhere? I'll ask again:

I don't need to cite a law as I'm not arguing that there are unethical laws. That's your argument.

Is this thread about unethical laws or just your general feelings about what things doctors do that are and are not ethical?

Why can't it be about both since they are inextricably intertwined?

I get it you don't like prescribing off-label in the case of chloroquine.

If I had a patient come to me in absolute terror they were going to get COVID and die from it, and the fear was interfering with their ability to function, one could easily make an argument for trying chloroquine provided I clearly explained the risks and benefits and what the lack of supporting data meant.

Even in a shortage? For a prescription that might not even be necessary? Wouldn't it be better to treat the anxiety rather than give out a medicine that may be better deployed elsewhere?

That's different from blanket prescribing before there was evidence.

So, in your view, clinicians don't have a duty to ensure adequate supply of the meds for the patients that might benefit the most?

It's called professional judgement.

Yes, it is. And professional judgement should consider a lot more than just, "I'm going to do it because I'm a professional, I can do it and I judge that this low-risk, asymptomatic patient needs it to make her anxiety go away."

Your link's broke, BTW, but I know what it says.

So? Are you claiming this example has any relevance to this discussion? It's a straw man to take a BS example of off-label prescribing and proclaim it's all or none.

It's an example of how professional judgement in off-label prescribing can be unethical. Just because you can prescribe off-label doesn't mean you ethically should.

Real world: Dr Tiller was murdered because he took cases of third trimester abortion few others would take. Laws have been passed in a number of states banning third trimester abortions.

Working with Dr. Tiller: Staff Recollections Of Women’s Health Care Services of Wichita

Yes, that's a tragic example of how society reacts when doctors are practicing in a way that contravenes the norms of the society. Just as Dr. Tiller continued to practice against ethical and legal prohibitions (despite the legal and extralegal threats he faced), his murderer also acted against ethical and legal prohibitions to act in a way he felt personally justified. If we condemn the actions of the murderer -and I do in the strongest way possible- then shouldn't we also condemn the actions of the doctor who acted illegally, unethically; i.e., against the norms of the society he was operating in? This is exactly what I'm talking about: a doctor who performs illegal abortions creates risks for himself and his patients. Those earlier protests and firebombings put him, his staff and his patients at risk.

 

[xjx388]

It sounds a bit contradictory to say that no one gets to say what is right and wrong but we must live according to social norms. That just sounds like you telling us what we have to do, unless by saying we must live by social norms just means or society will shun you/persecute you, etc..., but that ultimately leads to we have to do what is in our interests or "let the Wookie win".

Consider contexts outside of medicine: "My pesonal code is that if someone sexually abuses my children, my duty is to kill them." I'm sure you'd agree that if they acted on such a self-imposed duty that they would be wrong and should be prosecuted according to the law. We don't get to make up our own rules in society and that's true for regular folk and it's also true for medical professionals.

 

[theprestige]

It sounds a bit contradictory to say that no one gets to say what is right and wrong but we must live according to social norms. That just sounds like you telling us what we have to do, unless by saying we must live by social norms just means or society will shun you/persecute you, etc..., but that ultimately leads to we have to do what is in our interests or "let the Wookie win".

I'm not saying we must live according to social norms. I'm saying the opposite: We must each live according to our own personal ethics. Indeed, we can't live any other way. Even those who choose to conform to society are making a personal ethical choice to do so.

If your personal ethics allow for going along to get along, that's on you, not society. If your personal ethics demand that you oppose society, that's also on you.

For some people, some times, letting the Wookie win is the most ethical choice. But it's their choice, not society's.

In the context of the thread: A doctor is asking a group of people to agree that he is a competent and ethical medical practitioner. He's asking them for a blanket license to practice medicine on them, and on anyone who looks to them for guidance in such matters. If he values their approval, if he'd rather practice with their approval rather than against it, then he must consider how much his ethics overlap with theirs. He must conform to their ethics if he wants their approval.

This not to say that their ethics trump his, or that social norms trump personal ethics. They don't. I believe the opposite, in fact. But it is to say that a doctor can't claim to be ethical according to the collective standards of the society he serves, if his ethics don't actually conform to theirs.

"You think I'm doing the wrong thing, but I think I'm doing the right thing, so you should treat me like I'm doing the right thing" is not a compelling ethical argument for a doctor in society, in my opinion.

 

[xjx388]

"gets to make"?

Once again you are saying all laws are ethical and no one should defy said laws.

I am saying that modern US laws are ethical according to the norms of the society that created them and that a personal judgement that the law is unethical or invalid is not enough justification to break the law.

 

[theprestige]

And this is why there's entire courses on is-the-law-the-definition-of-ethical?

Bring on the Heinz dilemma^WP !

(sounds like you're at Level 2)

(Having given this some more thought, I think you missed an important part of my argument.

I've consistently expressed "level 3" ethics for many years. It looks like "level 2" is basically "ethics are whatever society says". I disagree entirely with this. Ethics are what you yourself say. The ethics of society only come into play when you want society's approval, or you want to avoid society's disapproval. What's right and wrong is up to you and you alone. What's practical and impractical in the society you live in is up to the society you live in. Whether you do what's practical or impractical, based on your sense of right and wrong, is again up to you.

Conforming to society's collective sense of right and wrong isn't "level 2" thinking. It's simply an acknowledgement that even "level 3" ethics have to take society's sense of right and wrong into account, if you want society's support. Whether or not it's ethical to seek society's support is, of course, up to you and you alone to decide.)

 

[xjx388]

The complication is that the laws may not represent the societies. Sometimes they're seized by a minority who project their ethics onto the state through violence. Aparthied, for example, was not an ethic of its society. It was an ethic of a dictatorship that issued the laws.

So are there examples of US, either federal or state, law that you feel doesn't represent the society? I get it, things might change ethically when a dictatorship imposes laws that don't represent the society. But in democratically elected governments with checks and balances, it's much harder to make that case.

Not if the facility was designated white. They would be literally breaking the law and many did so as acts of civil disobedience, and spent time in jail.

Do you have some examples of doctors who treated black patients and were arrested for it?

And I think it's important to make a distinction between the situation in Jim Crow America. The Constitution had freed the slaves and guaranteed them equal rights, if weakly, through the 13th, 14th and 15th Amendments. The States were acting against the Constitution, which has supremecy over State law. I can see ethical arguments for the idea that doctors can act contrary to certain State laws that are clear violations of US Constitutional law, as a means to challenge the Constitutionally invalid State laws.

 

[theprestige]

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

 

[Skeptic Ginger]

....
Even in a shortage? For a prescription that might not even be necessary? Wouldn't it be better to treat the anxiety rather than give out a medicine that may be better deployed elsewhere?

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

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

So, in your view, clinicians don't have a duty to ensure adequate supply of the meds for the patients that might benefit the most?

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

Update: Chloroquine Availability
Chloroquine phosphate is available, according to Rising Pharmaceuticals, a manufacturer of the drug. Anyone having difficulty obtaining the drug can call their offices at 800-521-5340 to request assistance in locating a distributor.

https://www.cdc.gov/malaria/new_info/2016/chloroquine_shortage.htm

Edit, the above is an old advisory after a shortage in 2017. More recent information is different. I'm trying to find FDA and/or CDC guidelines directly.

This is from Newsweek: https://www.newsweek.com/fda-shortage-hydroxychloroquine-chloroquine-1495555

Both hydroxychloroquine and chloroquine, which are used to treat malaria, lupus and rheumatoid arthritis, are listed as "currently in shortage" by the agency. This is "due to a significant surge in demand," the body said.

The FDA stated: "all manufacturers are ramping up production" and the agency is ensuring this is happening "expeditiously and safely."

The announcement follows FDA approval of the drugs for use in patients hospitalized by and in clinical trials for the treatment of COVID-19, after it issued the first Emergency Use Authorization for a drug related to the disease over the weekend.

The U.S. Department of Health and Human Services (HHS) said in a statement on Sunday that it accepted 30 million doses of hydroxychloroquine sulfate from an arm of the pharmaceutical company Novartis, and one million of chloroquine phosphate from Bayer Pharmaceuticals.

On Wednesday, the FDA said the 30 million doses "is expected to help ease supply pressures for the drugs....

Explaining the reasoning behind the FDA giving the green light for the medications on Sunday, the HHS said: "Anecdotal reports suggest that these drugs may offer some benefit in the treatment of hospitalized COVID-19 patients. Clinical trials are needed to provide scientific evidence that these treatments are effective."

So the hypothetical decision was still reasonable.

Yes, it is. And professional judgement should consider a lot more than just, "I'm going to do it because I'm a professional, I can do it and I judge that this low-risk, asymptomatic patient needs it to make her anxiety go away."

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

It's an example of how professional judgement in off-label prescribing can be unethical. Just because you can prescribe off-label doesn't mean you ethically should.

Straw man.

Yes, that's a tragic example of how society reacts when doctors are practicing in a way that contravenes the norms of the society. Just as Dr. Tiller continued to practice against ethical and legal prohibitions (despite the legal and extralegal threats he faced), his murderer also acted against ethical and legal prohibitions to act in a way he felt personally justified. If we condemn the actions of the murderer -and I do in the strongest way possible- then shouldn't we also condemn the actions of the doctor who acted illegally, unethically; i.e., against the norms of the society he was operating in? This is exactly what I'm talking about: a doctor who performs illegal abortions creates risks for himself and his patients. Those earlier protests and firebombings put him, his staff and his patients at risk.

Oh for pity's sake.

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

 

[Skeptic Ginger]

Consider contexts outside of medicine: "My pesonal code is that if someone sexually abuses my children, my duty is to kill them." I'm sure you'd agree that if they acted on such a self-imposed duty that they would be wrong and should be prosecuted according to the law. We don't get to make up our own rules in society and that's true for regular folk and it's also true for medical professionals.

IOW your anti-abortion beliefs, the fetus is a child, are going to make this discussion impossible because you cannot be objective.

And you really need to stop with this, "we don't get to" crap. Find another way to word it because right off the bat with that claim you are wrong. Yes I do get to prescribe off-label, and yes Dr Tiller did get to legally perform third trimester abortions.

 

[Skeptic Ginger]

[snip stuff I agree with ] If he values their approval, if he'd rather practice with their approval rather than against it, then he must consider how much his ethics overlap with theirs. He must conform to their ethics if he wants their approval.....

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.

 

[theprestige]

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.

My argument wasn't about the patient's approval. It was about society's approval. It was about society licensing him to treat members of their society according to his evaluation of the risks and benefits of all the treatment options.

 

[Skeptic Ginger]

I am saying that modern US laws are ethical according to the norms of the society that created them and that a personal judgement that the law is unethical or invalid is not enough justification to break the law.

Round and round the mulberry bush...

What law was broken?

And bull **** all modern US laws are ethical. There are many anti-abortion laws that result from the tyranny of the minority.

 

[Skeptic Ginger]

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

It can be ethical. There are doctors right now refusing to abide by some of the back-door anti-abortion laws. Latest example, states declaring an abortion is an elective surgery and therefore banned by public health order during the current crisis.

 

[Skeptic Ginger]

My argument wasn't about the patient's approval. It was about society's approval. It was about society licensing him to treat members of their society according to his evaluation of the risks and benefits of all the treatment options.

There is no special prohibition on prescribing chloroquine off-label at the moment.

That was a false assumption xjx made.

 

[theprestige]

There is no special prohibition on prescribing chloroquine off-label at the moment.

That was a false assumption xjx made.

This has nothing to do with the argument I was making.

 

[Dragonrock]

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

 

[Skeptic Ginger]

My argument wasn't about the patient's approval. It was about society's approval. It was about society licensing him to treat members of their society according to his evaluation of the risks and benefits of all the treatment options.

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.