Friday, June 27, 2014

Medical Doctors Should Remain "Medical" Doctors

By Naomi Scheinerman

Earlier this year, Britain’s Faculty of Sexual and Reproductive Health, a faculty of the Royal College of Obstetricians and Gynaecologists (RCOG), issued guidelines establishing that the faculty’s Diploma qualifications include a “willingness to prescribe all forms of hormonal contraception, including emergency contraception, regardless of personal beliefs.” Though welcome to undergo the training, those who “hold moral or religious reservations about any contraceptive method,” will not be able to “complete the syllabus [rendering] candidates ineligible for the award of FSRH Diploma” - a legal requirement to practice obstetrics and gynecology in England. Though clinicians may abstain from both performing and counseling regarding abortions, they are required to provide full information on options for unplanned pregnancy and make “timely arrangements” for the patient to see a doctor who is comfortable counseling on abortions.

In this post, I will address three questions: Does the Faculty have the authority to issue guidelines on this matter? If so, are these the correct guidelines to issue? And should we make exemptions to those who hold conscientious objections for religious reasons?

Does the Faculty have the authority to issue guidelines on this matter?
The medical world offers numerous examples of authoritative bodies passing rules of ethical and appropriate treatment. For example, guidelines have codified that informed consent must be acquired from a patient undergoing a medical procedure or participating in a clinical drug trial. Another example: U.S. federal law (HIPPA) protects a patient’s privacy of personal health information such that doctors may not share information with others without the patient’s permission. The authority of the Faculty to issue program guidelines regarding its training is perfectly consistent with our expectations that the medical community governs practitioners’ medicine to ensure ethical and safe care. Medical care cannot be divorced from value judgments, and thus medical training must be considered alongside medical decision making.

Is requiring willingness to prescribe contraception an acceptable use of the Faculty’s power to dictate appropriate medical practice?
I argue that the job of prescribing birth control has become a central part of the job of a gynecologist, and it should be for a number of reasons. Birth control is an ethical and safe option. Women have the right to control their reproduction, and doctors therefore have an obligation to provide access to the means to do so. Patients do not have unlimited rights to services from their doctor - a doctor could and should refuse to operate on an individual who does not need to be operated on. Contraceptive access, in contrast, is not an extravagance, but rather is an important tenant of women’s health. More than just allowing her to regulate her period and perhaps mitigate the negative and uncomfortable experiences of her “natural” cycle, contraception allows women to practice family planning, which has far reaching implications for her overall wellbeing by affecting her job, income, relationships, social network, and status. These results may also be beneficial for her family relations and friendships, as well as, of course, the wellbeing of a child from a pregnancy she neither planned nor wanted. Furthermore, denying a woman access to birth control denies her valid medical desires. Granted, what constitutes a medical necessity is illusive: ultimately numerous medical and nonmedical treatments lead to better welfare and happiness, but it seems strange to classify them all as necessary. However, because birth control affects the body chemically and hormonally, it should be classified under the purview of medicine, and therefore falls within the medical profession.

Should we make exceptions for conscientious objectors, particularly religious conscience objectors?
Just as a conscientious objector to informed consent should be barred from conducting clinical trials, so too should a gynecologist who refuses birth control to women. First, the merits of an argument for conscientious objections must be evaluated, regardless of whether it is religious or nonreligious. One of the primary arguments against contraception is that they are akin to abortions and therefore immoral. This argument is invalid because it relies on a false claim: contraception prevents pregnancy, it does not terminate it. Take for example the anti-vaccine movement: when deciding whether to allow doctors to refuse to vaccinate children, we should only give weight to arguments that are based on scientific claims regarding the safety of vaccines.

Another argument given against contraception is that it increases the rate of casual sex, in particular sex out of wedlock. First, this is a faulty understanding of statistics: access to birth control neither increases nor decreases rates of sexual intercourse, but instead makes it safer. A similar argument was made in the case against the HPV vaccine trials: developing a vaccine that protects against certain kinds of cervical cancers would make girls more promiscuous. This value-loaded claim attempted to maliciously bar an important way to increase sex safety for women and was then proved to be factually incorrect. Even if contraception did increase the rates of sex, either before or after marriage, the argument must prove why this is negative.

Religious reasoning should be scrutinized as vigorously as nonreligious reasoning. For example, the value of having a family is often cited in opposition to contraceptive use by referring to religious texts. However, one could just as easily interpret the value of family in another way: birth control allows women (and their partners) to choose when to have a family, thereby making a more secure, safe, and well-off household. Religious preferences in the medical world should be tolerated only if they do not harm the patient’s welfare. Denial of birth control can and does cause such harm. Religious objectors claim that a patient could see a different doctor, but there are many examples in which this is unfeasible. For instance, a young teenager who wants to become sexually active and is hiding her doctor’s visit from her parents may not simply be able to switch physicians or may be too intimidated to try after being driven off the first time.

The Faculty’s rules are not only permissible, they are imperative for women’s health. They do not suggest that all women should seek birth control or will, nor do they demand that all gynecologists prescribe birth control to all women. Ultimately, the Faculty’s rules are valid because they demand that doctors provide ethically valid and vital medical options to their patients.

Naomi Scheinerman is a Research Assistant at The Hastings Center. She graduated Phi Beta Kappa, with high honors and in distinction from the University of Michigan in Ann Arbor, where she received bachelor’s degrees in philosophy, political science, and Hebrew and Jewish Cultural Studies. She contributes a bi-weekly column on reproductive health.

Friday, June 20, 2014

Reevaluating Mandated Reporting: A Case Study in Sexual Assault

By Douglas Meyer

In light of recent personal events, I have been forced to reevaluate my views on mandated reporting. By mandated reporting, I am referring to the collection of laws and professional codes of conduct that force people to file a variety of reports for situations including, but not limited to, child and elder abuse, sexual assault and self-harm. While the specifics of the situations that must be reported vary widely, a general theme is that an adult must report any risky situation they observe in a professional capacity so that those involved can get necessary help. What follows should not be taken as a comprehensive argument against mandated reporting, but rather as a suggestion for why “getting someone the help they need” is not strong enough to warrant mandated reporting.

Imagine a sixteen year old, we’ll call him Sam, who was recently sexually assaulted. Sam is showing mild signs of depression and has night terrors almost every night as a result of the assault. He knows that some psychological help may prove beneficial, but is unwilling to forfeit his privacy, even if necessary to get the help he needs. I’m going to make a few assumptions for the purposes of analyzing Sam’s case:

1.     Sam’s peers would be supportive, but lack sufficient training to help him.
2.     Sam’s high school has guidance counselors who are well trained in helping sexual assault survivors.
3.     Sam would not be able to afford a psychiatrist without financial assistance.

One of Sam’s options would be to seek the help of a Mental Health Professional (MHP). For the purposes of this discussion, I will define an MHP as a person who has received extensive training in offering psychological assistance and who maintains patient confidentiality. This would be Sam’s best chance of getting the help he would need for his depression and night terrors because the mental health professional would be able to help Sam work through his traumatic experience. In addition, this option would let Sam maintain his privacy, since the only person who would find out about his experiences would be the MHP. Unfortunately, Sam would likely need to explain why he was in need of an MHP to his parents in order to receive their financial assistance. Sam’s unwillingness to forfeit his privacy coupled with his inability to afford an MHP on his own means that this option is unavailable to him.

There are likely only two free options available to Sam. First, are anonymous helplines (AHs) which include services such as online support groups and hotlines Sam could use. AHs would be helpful to Sam, but they would only be beneficial as supplements to other forms of help. Most support groups are comprised of well-meaning peers who bond over shared tragedies, but without sufficiently trained professionals included, they just do not have the capacity to provide all the help Sam needs. Hotlines are very often staffed by volunteers who have minimal training to provide basic guidance and support to callers, but these volunteers would only be able to guide Sam in finding MHPs and another type of assistance, which will be discussed momentarily. As a result, AHs could provide Sam with a lot of support, but only supplementally.

The other possibility would be a cluster of psychological services, which I’ll call Nonconfidential Psychological Agents (NPAs.) As the name suggests, NPAs are services and people, including school guidance counselors and teachers, who cannot offer their clients confidentiality because of their mandated reporting obligations. NPAs can be assumed to have sufficient training to provide Sam with the help he is seeking, and I’ll assume that there are sufficient NPAs available at little to no cost such that cost would not be a barrier to Sam.

Unfortunately for Sam, these three options are insufficient to deal with his case. Option 2 (AHs) would only be able to provide supplementary assistance, but on its own, couldn’t provide Sam with the necessary assistance. Options 1 and 3 (MHPs and NPAs, respectively) would be able to provide the necessary assistance to Sam. However, option 1 would be inaccessible to Sam due to financial barriers.

Earlier, I mentioned that my interpretation of the purpose of mandated reporting was to get someone the help they need. However, this would seem to fall apart when applied to Sam’s case. Mandated reporting does nothing to alleviate the financial burden associated with psychological counseling, and so it would not make MHPs a valid option to Sam. Mandated reporting does have a very strong effect on Sam’s access to NPAs. By preventing NPAs from protecting client confidentiality, mandated reporting actually acts as a barrier to these services. Ironically, the program that was implemented to get people help actually prevents many people seeking counseling from accessing those services. Moving forward, programs that promote access to counseling, like financial assistance programs, should be considered as replacements for mandated reporting strategies.

Douglas Meyer recently completed his first year at UCLA studying microbiology and the intersection between advancements in biology and society. Next fall, he will serve as Co-president of UCLA's Undergraduate Bioethics Club.

Thursday, June 12, 2014

The Home in Nursing Homes

By: Rebecca Kaebnick

The sitting room, living area, and community space of the skilled nursing facility in my grandparents’ staged living community was often the hallway. There was a harshly-lit room with tables and a TV around the corner, and a cafeteria-like dining room down the hall. However, the aides tended to gather residents in the hallway, lined up in their wheelchairs in front of the nurses’ and aides’ station. The forbidding front of this station, a pedestal for charts and computers, was an impossible height for many of the wheelchair or walker-bound residents. Strung along this main hall and around some corners were the residents’ spaces, not quite oriented to watch the activity outside the windows, but not quite arranged to focus inward, on each other, either.

On paper, this wing had it all: compliance to health codes, caring nurses and aides, physical therapy. In fact, the facility was top-of-the line. But there was also an unsettled feeling that upset any possibility for a homey feel. Time moved bizarrely: residents sat silently in their rooms or in their wheelchairs in the hallway while the aides swept around and shifts turned over; the clock by the aides’ desk seemed to be counting down to many things and to nothing. When my family visited, we perched in odd places around my grandmother’s room, or gathered near the doorway. When we passed residents, we did not feel as if we were supposed to smile and greet them; one does not greet patients she passes in a hospital, and that’s what it felt like. This was a place where people were on their way to somewhere else; like a hospital, nurses and visitors and patients moved in and out, but these spaces were not a home.

Why are such facilities like this? If they were designed differently, could they feel different? While many of the residents living in this area need careful medical attention, this phase of life is not just about medical and physical care, and doesn’t always have to feel like a hospital.

There are some successful efforts to break the mold, mainly sprung from the culture change movement in the nineties to “deinstitutionalize” nursing homes. The Green House project, developed in the early 2000s, is a key example of an accessible and efficient elder care home that still manages to create a more hospitable environment. Green Homes look more like houses than institutions. They are set up like family residences too, with a living room containing a hearth, a dining table seating all 7-10 of the residents, and the appearance of few medical instruments and technology. Green Homes redesign personal and communal space to make residents feel they are living in a home, rather than a glorified hospital, and give nursing assistants the role of “universal workers” who do everything from dispensing medications to cooking dinner. They have more interaction with residents than do aides in traditional nursing homes, and reportedly increased job satisfaction. The new physical characteristics of the homes and different roles of the aides reconfigure interactions between residents and staff, between residents, and even between residents and their family, during visits.

Another inspiring nursing home is Beatitudes Campus in Phoenix, Arizona. In a New Yorker article published last May, “The Sense of an Ending,” Rebecca Mead describes efforts made to replicate the comfortable, residential feel like that of the Green Homes in a more traditional facility. Tena Alonzo, the Beatitudes director of education and research, adjusts details of a resident’s lifestyle in unconventional ways that can make the resident much more comfortable. For example, a resident’s bed is lowered when there is a higher risk of falling out during the night. The “neighborhood,” as the staff call the facility, is not run on strict schedules; individuals create their own timetables based on what works for them. Food is available around the clock. The layout of the space and interactions between residents and staff are influenced by the characteristics of dementia, not by what is the cheapest or easiest. Instead of a heavy metal door at the entrance of the facility, residents are more subtly reminded not to wander by a velvet rope, like that of a classy restaurant, and a large black carpet, which dementia patients don’t like to walk on because they might interpret it as a hole. Alonzo develops strategies like these to make residents comfortable in more respectful and logical ways than those of traditional nursing homes. She also wishes for the staff to be more understanding of the lifestyle and needs of their residents; she encourages the staff members to try acting as residents for a day, in situations that can be embarrassing or uncomfortable, such as wearing a diaper.  This is another take on the Green House “universal worker” idea, to create more equal and warm relationships between residents and their caretakers. Mead mentions several other establishments that apply concepts similar to Alonzo’s. Like Beatitudes, the Pioneer Network in Chicago attempts to satisfy residents without the heavy use of psychotropic medications. The Isabella Geriatric Center and the Cobble Hill Health Center, both in New York City, are working to integrate Alonzo’s ideas into their practices.

In a study  published in The American Geriatrics Society Rosalie A. Kane et al. assess the success of Green Houses, finding that “GH residents reported significantly higher satisfaction with the nursing home as a place to live than residents of the [comparison facilities].” These feelings of comfort and happiness go hand-in-hand with particular trends in emotional and physical health, such as depression and the loss of independence in a set of activities called Activities of Daily Living, which include eating and using the bathroom. Alonzo and her co-director, Long, found strong trends in weight-maintenance and even healthy weight gain among their residents, due to their adaptive, flexible eating and daily schedules. Pam Belluck, in her New York Times article “Giving Alzheimer’s Patients Their Way, Even Chocolate,” cites various studies showing that space, activities, and medication can be adapted to make a dementia patient more comfortable. Making the lights brighter can have a big effect. Prescribing medication specifically for pain instead of an antipsychotic for dementia can keep side effects under control. Alonzo’s tendency to allow residents comforting rituals, such as sucking on chocolate and playing with dolls, has scientific basis: habitual pleasurable activities have been proven to correlate to depression and decreased cognitive activity. Belluck mentions a University of Iowa study that found that although many dementia patients no longer have the strongest memories, a happy mood can persist hours after the activity ends.  Living in an environment that makes them happier has significant effects on many dimensions of the residents’ health, interpersonal relations, and can help them see themselves as people fit to live in a real home, even if it requires some new accommodations.

If my grandparents’ experience is typical, then it is difficult for the average elder care consumer to ascertain just how homelike the nursing facility is when looking at retirement communities.  Many attempt to channel cheerfulness and hospitality into their built environments by adding special features to their more independent-living wings— fire-lit libraries, easy-access greenhouses, and welcoming dining rooms. Yet it is just as important for the visitor to learn about the functional wings. Maybe consumers do not expect areas designated for increased medical attention to have the same atmosphere, or maybe these areas are just not fully presented to them. Do companies tend to push some aspects of the independent living options and downplay some of the dependent ones? When potential customers visit, they may be more focused on the near future, when they will be living in the apartments and visiting the dining rooms. It is hard to fully picture a time when one’s health may have changed enough to need around-the-clock care, but many will arrive at that point.

Welcoming and peaceful environments seem even more important in the wings where residents deal with more advanced conditions and illnesses. Many residents, like my grandmother, juggle health-related anxieties with the pressure of moving somewhere entirely unfamiliar. Much of the stress my grandmother experienced seemed to be derived from a feeling of displacement. She was always someone who took great pains to make her living space feel like hers, and in this wing she lost this capability. Green Houses and Beatitudes illustrate that it is possible to unite medical care to homeliness, even though a straightforward set-up following the lines of a hospital wing might seem more efficient. Green Houses are certifiedskilled nursing facilities, run by a dependable team of certified nursing assistants, and a “clinical support team” made up of professionals who supervise the medical experience of the residents. Half of the residents in the studied Green House were certified dementia patients, and InformeDesign, a research tool for design professionals, asserts in a short piece about Green Homes that this model could be applied to “even the most heavy-care facility.” Quality of care is not compromised in this environment; reports on the quality of care by the Green House residents overall were either at the same level or better at the Green Houses than at the comparison nursing facilities. At Beatitudes, the directors found that patients were happier months after their arrival, and sometimes were able to make health gains: one resident was able to stop taking insulin because she began eating so well. Beatitudes won an award from the American Association of Homes and Services for the Aging. These models have found ways to successfully integrate medical technology and accessibility into a warm environment.

The basic premise of the Green House project is to find a way to make living areas cohesive units in which the medical structure isn’t the dominant aesthetic factor, detracting from the quality of life of the residents. While it is unclear how affordable Green Houses are, and it is true that the movement is not big enough to be an option for everybody, the success of Beatitudes proves that the goals of the project can be successfully applied to traditional models that still make up the most common elder care options. Beatitudes’s innovations go farther than the built environment, to making the schedules and activities of the patients, and the responses of the staff to residents’ distress, more adaptive to the individual patients themselves. Learning this makes me optimistic and hopeful that this trend will grow. Thinking back to my grandparents’ situation, I can see that my grandmother would have been well suited to be cared for by a collection of staff who are not afraid to make unconventional changes to make a resident more comfortable. Green Homes and homes like Beatitudes take the time to organize themselves according to what they see helps their patients, not according to tradition. They create environments in which conversation between residents, and between residents and staff, is encouraged. Visitors can join the residents in these spaces, bringing in pieces of the outside world but at the same time integrating themselves into this life, at least for a day. The residents can feel like they belong there; they aren’t stored in their rooms or lined neatly in the hall. Instead they can congregate around a puzzle, meet with a friend, pick out a book for themselves. They don’t just stay here until the end—they live here, enjoying each moment with vigor.

Rebecca is a junior at Ithaca College where she is majoring in Sociology and minoring in Spanish, art, and honors. She is interested in issues relating to globalization and vulnerable populations.