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2014 – Expect the Unexpected

Happy New Year! It is a brand new year and added to the age-old dilemmas surrounding death and dying, abortion and maternal-fetal conflict, and distribution of limited health resources, we can expect brand new bioethical dilemmas brought on by newly emerging technologies, changing lifestyles, politics, and economics ... oh, and let’s not forget to mention those ethical dilemmas that seem to come right out of left field. No, I’m not talking baseball or sports, although performance enhancing drugs and prosthetics are advancing faster than a speeding bullet. I’m talking about those bizarre events you read about but never expect to deal with in your own life – bioethical dilemmas that are so rare some may think that they are hardly worth public debate. But the unexpected can and will happen to every single one of us -- so often in my case, that I’ve come to expect the unexpected. To help prevent any one from being blindsided by patients and cases that appear out of left field, I will describe a couple examples that shed light on ethical responses that can be generalized to whatever bizarre situation you may face.

Spit Kits - If you think it’s a challenge to deal with patients demanding prescriptions based on something they saw on TV, wait until you have to deal with patients demanding treatment for diseases they don’t even have yet but plan to get in the future based on the results of DNA "spit kits.” For less than $100, any one can be tested for hundreds of health conditions and genetic traits.1 The price also includes updates on the latest research on diseases such as Parkinson’s, ALS, scoliosis, and schizophrenia. Mark my words, someone, somewhere in the world, reading this issue of IJAHSP, will have a patient come in for care this year, convinced he or she should receive treatment or disability based on the results of an over-the-counter DNA spit kit. Some bioethicists argue that it is always a good thing to empower the patient with information, and spit kits offer preventative medicine at a bargain price.

Other bioethicists point out that no one really understands how genetics and most diseases are related. If television pharmaceutical ads are any indicator, long-winded and protracted disclaimers won’t deter perfectly healthy patients from seeking care – something we used to refer to as Munchausen syndrome. Even if the FDA convinces these companies to market their spit kits for "entertainment purposes only,” it is hard to imagine anyone who will interpret having all the positive markers for schizophrenia as amusing. Imagine the ethical repercussions of screening and testing, false positives, false negatives, confidentiality, and patient privacy. The very same principles of beneficence and non-maleficence underlying the continuity of care and treatment of patients who demand antibiotics for a viral infection apply to patients who come to you with spit kit diagnoses out of left field. These principles provide a universal structure to all patient interactions that is far better for health care relationships than a) surrendering to every patient demand, b) ignoring and neglecting patient concerns, or c) referring all your difficult patients to a cross-town competitor. Patient education and information about benefits and risks will address concerns and establish boundaries that support rather than erode trust and respect for autonomy.

Health 2.0 –The practice of medicine is all about one person caring for another. Health care practiced in isolation from caring is epitomized by futuristic, sci-fi worlds of cloning and Starfleet medical tricorders. Yet approximately one in five diagnoses are incorrect, contributing to untold numbers of unjustified expenses and medical errors. If only there was a way care providers could mine all the medical information relevant to effective care – both from the patient’s chart and the literature – many of the mistakes in diagnosis and treatment may be avoided. Recently, Watson, the IBM supercomputer, graduated from defeating contestants on Jeopardy to replacing human decision-making in healthcare. It seems that Dr. Watson is as proficient at processing medical information as he is eclectic and inane trivia.

The world of Jeopardy and the world of medicine are not that different – both depend on extracting significant information from visible clues in order to arrive at the most probable answer (or diagnosis). If you think the chances are slim that you will ever surrender your medical decision-making capacity to a machine, think again – you already have. The other day someone asked me for my wife’s cell phone number and I had to scroll through my own phone to find it. I don’t know what I’d do if my computer didn’t automatically remember my passwords for me. Consider the growing number of medical apps for health professionals: Medscape is the number one downloaded medical app, available in both iPhone and Android platforms. Most of have used Medscape as drug reference to check dosages and interactions, but did you know the app is also packed with treatment protocols?

There are dozens of other medical apps for everything from performing CPR to interpreting X-rays. In the late 60s, the infamous con man Frank Abagnale impersonated a chief resident pediatrician at a Georgia hospital, getting away with it by ordering interns to handle any real medical work. Imagine what he could have done with an iPhone! Facing a continued shortage of doctors and other health professionals, 2014 will prove ripe for the increased automatization of health care. Machines are already doing primary care in Brazil and India because there is no human labor available to do it.2 Medical ethicists would remind us that caregivers do more than process data. They listen each patient’s unique story and respond to questions, fears, and concerns, respecting their shared humanity and ultimate mortality. When was the last time you were respected as a fellow human being by an app?

Debt Buyers – Insurance coverage aside, this past year I had to decline recommended treatments, medications, and referrals simply because I could not afford them. Still, my dentist cannot fathom why I keep delaying that appointment to restore a crown, and my GP wonders why I haven’t filled a prescription for pain medication simply because it isn’t on my insurance’s formulary. The fact is, about half of all bankruptcies in the U.S. are caused by overwhelming medical debt – and that worries me, both as a patient and a health provider.

Ever wonder what actually happens to medical bills that aren’t paid? Hospitals and medical practices sell the bills they are unable to collect to debt buyers for pennies on the dollar. The debt buyer then sells them to collection agencies for a hefty profit. Debt buyers make millions of dollars off people who had the misfortune of an accident or illness and now can’t afford to pay their medical bills. Some care providers may argue that the principles of beneficence and non-maleficence are threatened by the strong-arm tactics of some collection agencies. Other providers sleep easy, believing that no society produces anything without the effort and responsible contribution of all its members. Payment in cold hard cash is often viewed as the only acceptable form of reward for services offered. Gone are the days when a chicken paid for a house call.

Ethical solution? Enter, the Good Samaritan. RollingJubilee.org has stepped into the debt buyer’s position, raising $645,207 to abolish $14,734,569.87 of debt (as of writing this commentary…see the Website for live counter). The big difference between Rolling Jubilee and other debt buyers is that after Rolling Jubilee buys out the hospital bill, they notify the patient that the bill has been paid in full – no pink envelopes in the mail, no dinner-hour phone calls from collection agencies, no ruined credit reports. According to the Rolling Jubilee Website, "We are proud to offer a lifeline to debtors who fell victim to the horror of medical debt.”3 What a concept! So, sometime during 2014, be prepared for the homecoming of the prodigal patient who fell from your care. In fact, why not set up a similar organization to buy patient debts with your physicians and allied health professionals?

The nature of economics, both personal and national, makes the delivery of health care subject to challenges that seem to come out of left field. No doubt, bizarre challenges will increase in 2014, but the key to their ethical resolution is no different than in the past – challenges out of left field should not stand in the way of health care relationships. Traditional principles that have guided competent and ethical care – medical competence, beneficence, and nonmaleficence, respect for autonomy and dignity, empathy, compassion, and fidelity – are enduring principles. For 2014 and beyond, rely on these established principles to resolve expected as well as unexpected ethical dilemmas that are out of left field.

References

  1. 23andme.com
  2. Cohn, J. The robot will see you now. The Atlantic , March 2013. Accessed from http://www.theatlantic.com/magazine/archive/2013/03/the-robot-will-see-you-now/309216/
  3. Rollingjubilee.org

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