The Ethics of Everyday Medicine

Explorations of Justice

Erwin B. Montgomery Jr.

• Publisher: Academic Press
• Year: 2020
• ISBN:
  9780128230664
• Topic: Biological Sciences
• Subtopic: Cell Biology
• Index: Biological Sciences

Ethics of Everyday Medicine: Explorations of Justice examines and analyses the relatively unexplored domain of ethics involved in the everyday practice of medicine. From the author's clinical experience, virtually every decision made in the day-to-day practice of medicine is fundamentally an ethical question, as virtually every decision hinge on some value judgment that goes beyond the medical facts of the matter.

The first part of the book is devoted to medical decision cases in several areas of medicine. These cases highlight elements of the current healthcare ecosystem, involving players other than the physician and patient. Insurers (private, commercial, and governmental), administrators, and regulators' perspectives are surfaced in point of care case analysis. Part two contributes to the development of actionable tools to develop better ethical systems for the everyday practice of medicine by providing a critical analysis of Reflective Equilibrium and ethical induction from the perspective of logic and statistics. The chapter on Justice discusses the neurophysiological representations of just and unjust behaviours. The chapter on Ethical Theories follows, describing the epistemic conundrum, principlism, reproducibility, abstraction, chaos and complexity. The following chapter approaches ethical decisions from the logic and statistic perspectives. The following chapter, The Patient as Parenthetical, the author discusses patient-centric ethics, and the rise of business- and government-cetric ethics. The final chapter, A Framework to Frame the Questions for Explore Further, proposes a working framework to deal with current ethical issues.

Ethics of everyday Medicine: Explorations of Justice acknowledges that there are no answers yet to the ethical dilemmas that confront the everyday practice of medicine, but proposes a framework for deeper analysis and action. This reading would be useful to all healthcare professionals. Regulators and policy makers could also benefit from understanding how the complex healthcare environment influences medical decisions at point of care.

• Offers an overview of the current health care ecosystem and the ethical questions posed by divergent interests
• Includes cases for ethical analysis of common medical practice
• Proposes a framework for ethical decision making in the clinical setting
• Provides critical analysis of Reflective Equilibrium and ethical induction from the perspective of logic and statistics

Part 1

Case 1

Abstract

This case reviews the ethical issues surrounding a physician’s refusal to follow the recommendations of a speech language pathologist who had recommended a video fluoroscopic examination of swallowing. The patient had Parkinson’s disease and at risk for aspiration pneumonia. The medical facts of the matter are explored. An ethical analysis is provided emphasizing: (1) the importance of checking the effects of an purely emotional response, (2) the complexity of the ethics that extend beyond the patient, physician, and speech language pathologist, (3) the respective obligations of the physician and the speech language pathologist, (4) the autonomy of the parties involved, particularly as it relates to privileges according to the physician and the speech language pathologist, and (5) approaches to resolving the conflicts.

Keywords

Swallowing assessments; Risk for aspiration phenomena; Video fluoroscopic examination of swallowing; Ethical obligations; Primacy of the privilege of diagnosis

Case 1—A speech language pathologist was asked to evaluate a hospitalized patient with Parkinson’s disease who was complaining of choking and coughing each time she ate or drank. Following the evaluation, the speech language pathologist recommended to the attending physician that the patient undergoes a video fluoroscopic examination of swallowing (VFES), otherwise known as a modified barium swallow. The attending physician refused. When asked, the physician said it was not necessary. The attending physician turned, walked away, and refused further discussion.^a

Medical facts of the matter

As a medical fact, the speech language pathologist was correct. Pneumonia is the single leading cause of death in patients with Parkinson’s disease—most likely from aspiration from dysphagia (problem with swallowing) (Akbar et al., 2015; D’Amelio et al., 2006; Suttrup and Warnecke, 2016; Wirth et al., 2016). Dysphagia affects more than 80% of patients with Parkinson’s disease. It presents with oropharyngeal dysphagia (a type that involves the upper food passages, resulting in swallowing impairments) over the course of disease progression (Suttrup and Warnecke, 2016; Wirth et al., 2016). If the risk is recognized and the nature of the altered swallowing mechanisms determined, treatments can be instituted to reduce the risk of aspiration pneumonia and death. Treatments include modification of the diet, how the patient swallows, and, if necessary, finding an alternative means of nutrition that does not involve ingesting food or liquids. The treatments differ depending on the exact nature of the swallowing disorder.

The central problem in this case is how to recognize if the patient is at risk and, if so, how to reduce the risk. Apparently, the physician made an assessment of the risk being sufficiently low, as otherwise a refusal to conduct tests would have been arbitrary and capricious. Perhaps the physician made the decision because he never heard the patient manifest dysphagia, for example, by coughing or choking. However, many patients at risk for aspiration, as evidenced by subsequently developing pneumonia, never have a history of choking, coughing, or similar symptoms—silent aspirators. In a study of patients without symptoms of dysphagia, such as coughing or choking, over 50% demonstrate abnormal swallowing on objective testing, such as direct visualization of the swallowing act such as the VFES as recommended by the speech language pathologist (Suttrup and Warnecke, 2016; Wirth et al., 2016).

A number of alternative assessments exist for the risk of dysphagia. These include a clinical or bedside examination during which the patient is given foods and liquids of different viscosities and consistencies and the speech language pathologist listens for sounds of choking or coughing. In addition, the speech language pathologist looks into the mouth and throat for any residual foods or liquids (Hassan and Aboloyoun, 2014; O’Horo et al., 2015). From systematic reviews, it was concluded that the majority of bedside examinations reviewed “lack the sensitivity to be used as a screening test for dysphagia across all patient populations examined” and that “no bedside screening protocol has been shown to provide adequate predictive value for presence of aspiration” (O’Horo et al., 2015). Yet, the clinical or bedside examination is widely used for the diagnosis and treatment of dysphagia (Hassan and Aboloyoun, 2014).

Another problem with a clinical or bedside examination is its lack of specificity for the actual nature of the dysphagia. The specificity for the question of risk is very high. In other words, a patient who tests positive on a bedside or clinical examination, that is, demonstrates findings indicative of aspiration, has a high probability of actually having aspiration. However, even if the clinical or bedside examination was “positive,” demonstrating a risk for aspiration, one cannot know the mechanisms and, therefore, cannot know what treatment to recommend. Thus, a patient with a positive clinical or bedside examination will have to be referred for objective testing but only after incurring a delay (Steele et al., 2007), often lengthy (see Case 2). Also, the sensitivity of the test is poor. Even those who “pass” or test negative on the clinical or bedside evaluation still have a high risk of aspiration and, consequently, should undergo objective testing. Thus, a referral for clinical or bedside testing only delays what needs to be done (see Case 2).

A VFES is an objective test with high specificity and high sensitivity even in patients who are silent aspirators (Martin-Harris and Jones, 2008; Miles and Allen, 2015). An alternative objective test is a fiberoptic endoscopic examination of swallowing (FEES), where a fiberoptic cable is inserted through the nose and lies just above the throat internally. The speech language pathologist is able to visualize the parts of the throat through the fiberoptic cable. Comparisons between VFES and FEES are complicated with some authors, suggesting an equivalence in diagnostic utility (Giraldo-Cadavid et al., 2017). However, in this author’s opinion, often there is a confusion of terms, for example, claims to accuracy based on specificity, sensitivity, or some combination. The FEES looks for material administered by mouth remaining in the throat following a swallow. However, the FEES cannot visualize the actual swallow because the soft palate elevates and the pharynx constricts, obstructing the view. Also, FEES cannot provide the extent and range of information that is obtained by a VFES (Karkos et al., 2009).

The issue in this case is not whether the VFES or the FEES be performed. Rather, the question is whether any objective test beyond the clinical or bedside evaluation should be done. The speech language pathologist’s opinion was that the VFES should have been performed, while the physician did not. The science that is known would support the position of the speech language pathologist, and one could argue that failure to perform the VFES was unjust.

Ethics from the “gut”

When the case was presented to a Master’s graduate degree class of speech language pathology students, there were several different initial responses. Perhaps the most common was to default to the physician’s decision. Note that this was not the same as deferring to the physician based on some presumed greater knowledge or expertise on the part of the physician. Rather, the response was in the vein that the physician is the “Captain of the Ship” and has the ultimate authority. (The origin of the concept of Captain of the Ship is interesting and derived from the problematic nature of assessing medical liability as discussed in Chapter 1. Captain of the Ship was not a statement of authority but rather responsibility. The latter has morphed into a concept of authority.) In this case, it is likely that the speech language pathologist knew considerably more than the physician about the diagnosis of swallowing, which is different than a diagnosis of the cause (in this case Parkinson’s disease), and treatments that can be offered by the speech language pathologist. A good physician would take the expertise of the speech language pathologist into consideration, even if ultimately not pursuing the recommendations.

The question is what is the origin of this default deference to the physician? It is not due to a presumed greater knowledge on the part of the physician. In part, such deference may be institutionalized through history, such as a physician-centric ethic (see Chapter 4), and in the very structure of the practice of everyday medicine. Perhaps it is the historical institutionalization that renders the default to the physician as a “gut reaction,” meaning requiring little declarative deliberative consideration. It is just “procedural” that the physician has defaulted to. It would be hard to deny that some part is the historical male-gendered physician dominance in medical decision-making. Feminist ethics shines a valuable light on this history. Most of these future speech language pathologists would not have pursued the matter further.

A smaller proportion of graduate students would have sought out the physician for further discussion in an attempt to convince the physician of the necessity of a VFES. When it was pointed out that the physician refused further discussion, most of these students then defaulted to the physician’s decision and would not pursue the matter further, as described previously. A small number of students suggested discussing the situation with the patient and the patient’s family; thinking that, at the very least, the patient and family should know what the correct course should have been. Perhaps there was the unspoken hope that the patient and the family would lobby the physician to perform the VFES. A rare student sought support from policies of their professional organization supporting the role of speech language pathologists in administrating a VFES.

The first observation is that every student had an opinion, the ethical soundness of that opinion notwithstanding. This should not be surprising, as most humans, even children as young as 2 years have a sense of justice (see Introduction and Chapter 1) (Li et al., 2016; Surian and Franchin, 2017). Whether that sense of justice is innate or learned rapidly is an interesting subject that will be pursed in Chapter 1. The question of whether such reactive initial ethical opinions (gut reactions) on the part of the students help or hinder subsequent ethical judgments is an open question. Note that this is not to deny the role of such reactions, indeed such reactions likely are the neurophysiological first response and the necessary precursor for all ethics. However, philosophers and ethicists have long held that such a reaction is primary but emphasized the ability and hence necessity to mitigate or channel those initial responses through learning and deliberative experiences. In this case, it is possible that the initial “gut” reaction may be counterproductive, leading to injustice (see Chapter 5).

Complex ethical ecology

At first, it would appear that the ethical challenge involves two parties, the physician and the speech language pathologist. The patient at this juncture is the object of the challenge instead of a means of or participant in resolving the challenge. It can be stipulated that both the physician and the speech language pathologist want good for the patient, which, in the Principlist approach, can be defined as an obligation to the ethical principles of beneficence and nonmaleficence for the patient. Alternatively, the intent to do good can be seen as a virtue, in virtue and care ethics. The issue is how can justice, good for the patient, result when the perspectives of both the physician and the speech language pathologist are different? Also, at this point, achieving justice or producing injustice would seem to center over the issue of obligation to the autonomy due each of the physician and speech language pathologist, the obligation to autonomy of each relative to each other. Certainly, a few speech language pathologists sought to involve the patient and the patient’s family, thereby invoking an obligation to the autonomy to the patient; however, this is very problematic for many reasons. Yet, the obligation to autonomy of the patient would seem central to any pluralistic modern liberal democracy. In other words, a patient-centric ethic. Yet, historically, this is rarely the case (Chapter 4).

What would happen if the speech language pathologist, acting as an advocate, told the patient that she needed a VFES in order to effectively treat her swallowing problem, which, if left untreated, increases the r...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Dedication
• Preface
• Introduction
• Part 1
• Part 2
• Postscript: COVID-19 pandemic and Black Lives Matter
• Index