Showing 21 - 30 of 472 annotations tagged with the keyword "Medical Ethics"

Extremis

Krauss, Dan

Last Updated: Dec-05-2016
Annotated by:
Redel-Traub, Gabriel

Primary Category: Performing Arts / Film, TV, Video

Genre: Film

Summary:

Extremis, a Netflix documentary directed by Dan Krauss, follows Dr. Jessica Zitter a palliative care ICU physician at Highland Hospital in Oakland, California. The documentary begins with an exasperated Dr. Zitter trying to communicate with a patient on a ventilator: “Is this about the breathing tube? You want it out?” she asks. When the patient nods in affirmation, Dr. Zitter replies, “What if you die if I take it out?” The questions confronting the physicians, patients and their loved ones get no easier over the course of the film. The documentary is propelled by a dramatic tension between its protagonists: on one side Dr. Zitter, who is compassionate but dogmatically pragmatic, on the other side the family members of patients who are driven above all by hope and faith. This tension manifests itself in palpable ways. In one particularly powerful scene, a patient’s daughter says to Dr. Zitter: “it would feel like murder to pull that life support. That’s what it would feel like to me…I feel like maybe as a doctor, you know, being as smart, and being as knowledgeable, and being inside medical journals, it can dwindle your optimism a little bit.” Dr. Zitter replies simply, “I’m just trying to help you make a decision that’s right for your Mom.”  Of course, for Dr. Zitter there does appear to be a categorically appropriate decision in all of these cases. In most of her conversations, she is transparently trying to get family members to see that there is no realistic chance of meaningful recovery for their loved ones. That is not to say that she is insensitive to the family’s wishes or the complex bioethical conundrums which arise around her. In fact, her bravery and deftness in broaching these serious and difficult topics is on full display throughout the film. 

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The Kraken

Tennyson, Alfred

Last Updated: Oct-31-2016
Annotated by:
Clark, Mark

Primary Category: Literature / Poetry

Genre: Poetry

Summary:

This Petrarchan sonnet of 15 lines begins as a lyric contemplation of the Norwegian sea-beast of Scandinavian mythology; but it evolves into an association of the beast with other mythological representations of invisible yet vast, destructive forces that would devour from below or swallow sojourners on the seas of everyday life.  In a broader sense, then, and by means of the mythological representation, the poem may be understood as a contemplation of ideology and blind allegiances to the status quo—which lose their destructive powers only when they are recognized for what they are.

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The People in the Trees

Yanagihara, Hanya

Last Updated: Oct-10-2016
Annotated by:
Teagarden, J. Russell

Primary Category: Literature / Fiction

Genre: Novel

Summary:

The novel takes the form of a memoir written from prison. The fictional author is Dr. Norton Perina who was awarded the Nobel Prize in Medicine for discovering what caused some people on a remote Micronesian island to live for up to 250 years or longer. Dr. Ronald Kubodera, Perina’s long-time colleague, convinced him to write the memoir while he was in prison. Perina sent Kubodera a chapter at a time, which he would then “lightly edit” and add occasional footnotes to elaborate on a given section. 

Perina is in prison for being convicted on “two counts of sexual assault,” (p. 349) though we can believe he is guilty of many more counts. All of these transgressions involved children, many of whom were under his care as their adopted father. However, the bulk of the memoir is not about the behavior that lands him in prison. Instead, it tells of Perina’s successful scientific investigations of a hidden people in a secluded partition of an unknown island in Micronesia. He came to this place while stumbling around for a career direction after medical school, and then came to discover the hidden people when stumbling upon one lying on the forest floor.

Perina eventually linked the consumption of the meat of a particular turtle on this island to a prolongation of life measured in hundreds of years. Only the inhabitants who reached around 60 years were given the turtle meat and only during a ceremony to mark the milestone. While the bodies of these people remained as they were physically when they consumed the turtle meat, their minds did not. As they aged they became non compos mentis—“all they could do was jitter and babble and laugh at nothing, the neighing laughter of the brainless.” (p. 95) Perina’s published papers called attention to a possible fountain of youth and produced the expected rush among pharmaceutical companies to distill the turtle’s magic into a pill. All they managed to do instead was to destroy the island’s habitats,
corrupt its people, and hunt the turtles into extinction.
 

Very little is said in Perina’s memoir about any activities leading to his pedophilia conviction until the very end; however, occasional hints that Perina could be a pedophile appear before then. At one point in particular he describes an encounter with a 10-year old boy from the village that might have awakened any such tendencies that had been dormant. Another time he admits “some of the only comfort (and certainly the only amusement) I’d found had been with the village’s children.” (p. 267). During subsequent trips to the island over the next few decades, Perina adopted 43 island children and brought them home to raise as his own. He was drawn to children, but in not so innocent a manner. Only at the very end of book, and only in the postscript, do we get any details about how he preyed upon these children.

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Tithonus

Tennyson, Alfred

Last Updated: Jul-28-2016
Annotated by:
Clark, Mark

Primary Category: Literature / Poetry

Genre: Poetry

Summary:

Tithonus” is a dramatic monologue that imagines the once handsome, magnificent Trojan prince to be well-advanced in an unfortunate state brought about by negligent gods and his own lack of foresight.  Exultant over the blessings of his youth, he’d asked Aurora, goddess of the dawn, for eternal life, and she had obtained Zeus’s permission to grant the request.  But Tithonus had failed to ask for eternal youth with his immortality—and neither Aurora nor Zeus had managed to recognize that this feature of the request might be important—so that Tithonus spends eternity growing increasingly decrepit.  In Tennyson’s poem, Tithonus addresses Aurora, hoping he might persuade her to reassign him his mortal status and allow him to die.

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Summary:

The aim of these reflections on uncertainty in medicine is not to discredit evidence-based medicine or to incite suspicion of the careful and caring processes by which most clinicians arrive at the advice they give.  Rather it is to change conversations among practitioners and between them and their patients in such a way as to raise everyone’s tolerance for the inevitable ambiguities and uncertainties we live with.  If the public were more aware of the basic rules of mathematical probabilities, how statisticians understand the term “significance,” and of how much changes when one new variable is taken into account—when a new medication with multiple possible side-effects is added to the mix, for instance—they might, Hatch argues, be less inclined to insist on specific predictions.  He goes on to suggest that there is something to be gained from the challenge of living without the solid ground of assurances.  When we recognize the need to make decisions with incomplete information (a condition that seems, after all, to be our common lot) we may refocus on the moment we’re in and see its peculiar possibilities. Changing the conversation requires a critical look at medical education which, Hatch observes, “measures a certain type of knowledge essential to medical practice, but it consequently engenders a conception of medicine best described as overly certain . . . .” 

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The Lady and Her Monsters

Montillo, Roseanne

Last Updated: Jun-10-2016
Annotated by:
Ratzan, Richard M.

Primary Category: Literature / Nonfiction

Genre: Criticism

Summary:

The Lady and Her Monsters is a companion monograph of literary, cultural and scientific history to Frankenstein , the masterpiece written by a 20 year old Mary Wollstonecraft Shelley (hereafter MWS). Starting, in its prologue, with late 18th Century Italian anatomists, it proceeds chronologically to add layers to the foundation on which MWS built her novel. Although many of these events and stories (grave-robbing, resurrectionists, infamous criminals like Burke and Hare, the setting of the composition of the novel in Switzerland) are well known to students of Frankenstein, the author adds less well known details and narrative flourish, ending with the 1831 edition and the remainder of Mary Shelley’s life following the death of her husband Percy Bysshe Shelley (hereafter PBS).  

The book begins with a prologue describing, narratively, the most proximate scientific influences on Mary Shelley.  The experiments of Aldini and his nephew Galvani form a significant portion of the backdrop for Shelley’s famous literary experiment approximately 30 years later, as famous for its product as it is for its lack of description of materials and methods.

Summary of chapters 1 through 9:

Chapter 1: “The Spark of Life”: biographical information about William Godwin, Mary Wollstonecraft and the early years of MWS

Chapter 2: “Waking the Dead”: a return, with more detail, to late 18th C Italian anatomists and scientists using electricity to stimulate dead animals and their tissues: Vesalius, Galvani, Volta, Aldini

Chapter 3: “Making Monsters”: more on Aldini and the rise of resurrectionists in late 18th C and early 19th C England

Chapter 4: “A Meeting of Two Minds”: Paracelsus and Agrippa as antecedent scientists of interest to PBS and MWS; the couple’s romance

Chapter 5: “Eloping to the Mainland”: the famous story of the trip of the Shelleys, Byron, and Polidori to Castle Frankenstein in Switzerland

Chapter 6: “My Hideous Progeny”: more on the literary history behind the creation of Frankenstein and the continuing soap opera of the lives of the Shelleys, Polidori, Claire Claremont and Lord Byron

Chapter 7: “Frankenstein, or the Modern Prometheus”: suicide of Fanny Imlay (half-sister of MWS), marriage of Shelleys, publication of Frankenstein

Chapter 8: “The Anatomy Act”: more 19th C body snatching; Burke and Hare; and the passage of the Anatomy Act of 1832 in the U. K., controlling the supply of bodies to anatomy labs

Chapter 9: “A Sea Change”: death of PBS and Lord Byron

Epilogue: modern day (2004) grave-robbing; remainder of MWS’s life

Following the epilogue are notes to the chapters, a bibliography and index.

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Summary:

This is the third book in a series on the history of medicine and medical education by Kenneth M. Ludmerer, a practicing physician and historian of medicine at Washington University of St. Louis. The first, Learning to Heal: The Development of American Medical Education, published in 1985, dealt with the history of medical schools and medical education in the US from their origins in the 19th century to the late 20th century. In 1999 he published Time to Heal: Medical Education from 1900 to the Era of Managed Care. This book, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine, published in 2015, is a sweeping history of graduate medical education in the United States from its inception to the current day.

In 13 chapters and 431 pages (334 pages of text, 97 of reference and index), Ludmerer traces the residency from early apprenticeship days to its metamorphosis (at Johns Hopkins, of which he is a justly proud medical school alumnus) into the embryonic form of what we now call an internship and residency. Giants like “The Four Doctors” (to use the title of John Singer Sargent’s famous portrait of William S. Halsted, William Osler, Howard A. Kelly and William H. Welch - but known simply as “The Big Four” at Hopkins) were the godfathers of the American postgraduate medical model which emphasized clinical science, teaching, patient care and research. The rise of acute care teaching hospitals as the venue of postgraduate medical education, and not the medical school or university, is an interesting story and one which Ludmerer tells in great detail over a number of chapters. It is one replete with predictable turf wars, professional turmoil and politics, and societal change in all aspects of the 20th century. This last phenomenon receives its due attention in every chapter but is dissected in meticulous detail in the final chapters dealing with the Libby Zion case, duty hours and the increasing role of the Accreditation Council for Graduate Medical Education (ACGME) in postgraduate medical education.

Beginning in the 1930’s, American medicine grew increasingly specialized and, in the ensuing decades, subspecialized, much to the consternation of pre-WW II general practitioners who, suddenly and for the first time, found themselves in the minority, in numbers and in influence, of their own profession. Concomitant with the phenomenon of specialization was the imprimatur by academic medicine of the structured, sanctioned residency as the sole route to specialty practice with, of course, the birth of associated accrediting agencies. Along with the move, physically, academically and politically, of postgraduate medical education to acute care teaching hospitals, the control of this education moved from medical schools to the profession at large.

Ludmerer deftly describes the “era of abundance”, the salad days of postgraduate medical education in the 1950’s and 1960’s when giants still made rounds on the floors of postgraduate medical venues; funds were plentiful; outside criticism was an as yet unborn bête noir; and social, economic and governmental curbs were only a tiny distant cloud in an otherwise blue sky. Ludmerer is correct in attributing much of medicine’s professional and social hegemony as well as its transient immunity to criticism in this era to the following evident successes of medicine: antibiotics; initial inroads into antineoplastic therapies; startling technological innovations in imaging; a burgeoning spate of life-saving vaccines; and spectacular advances in surgery, especially pediatric, cardiothoracic and transplant. Fatal diseases of the 1930’s and 1940’s were now often cured in days and of historical interest only.

Like all salad days, those of medicine eventually succumbed to new historical forces: foreign medical graduates in the workplace; the ever-growing financial burden of the residency; and economic pressures like Medicare and its associated regulation. There were other factors, too: professional and societal expectations of standardization and quality care; the explosion in subspecialties; the horrid wastefulness of unnecessary diagnostic tests and therapies borne of an earlier undisciplined abundance; the supercession of the intimate primary physician-patient relationship by the fragmented care of specialists and the rising supremacy of technology over personalized histories and careful physical examinations (why percuss the abdomen when you can get a CAT scan?). Dissatisfaction amongst residents is a dominant theme Ludmerer rightly raises early and often: the conflict and tension between education and service, between reasonable work and “scut”, between being a student and a worker (at times, quite a lowly one).

”High throughput” - the much more rapid turnaround time between admission to an hospital and discharge - has radically changed forever the entire nature of postgraduate medical education, and not for the better in the eyes of the author and of this reviewer, who were fellow residents a lifetime ago at Washington University in St. Louis. This decreased length of stay, a result of the remarkable improvements in diagnosis and therapy mentioned above, meant that the working life of providers (attending physicians, residents, physician assistants and nurses) was in high gear from admission to discharge, thereby increasing tension, likelihood for error and, exponentially, the workload for the resident while simultaneously and irrevocably damaging the possibility of a meaningful, careful provider-patient relationship (like a friendship, of which it is a subspecies, such relationships can not be rushed) and decreasing opportunities for learning. Medicare; changing patient populations; societal and professional disgruntlement; the Libby Zion mess and the ensuing cascade of regulations from all sides, but most especially the ACGME - all receive careful and systematic treatment in the final chapters of this monograph.

Ludmerer ends with a chapter listing what he sees as opportunities for achieving (or re-achieving) excellence. Indeed, he has made it the book’s subtitle. They are the following: a plea for the ACGME to revise its 2011 duty-hour regulations; an equally earnest hope that interns and residents will soon realize a more manageable patient load; a related wish for academic medicine to decrease the unfortunate occurrence of economic exploitation of house officers; a suggestion that this annotator shares, i.e., that the process of supervision, improved (but inadequately) with recent ACGME requirements, be further strengthened; and a hope that medical schools will restore teaching to the central place in the institutional value system it used to enjoy. Ludmerer issues a call for the more vigorous promotion of “an agenda of safety and quality in patient care” (page 312) and suggests that the education of residents be expanded to include venues outside in-patient sites. Elsewhere in the book, he also expresses the expectation that the inclusion into clinical teaching of private patients alongside “ward” patients, more feasible with recent improvements in the re-imbursement of medical care, be routine and maximized to the enjoyment and benefit of all concerned.

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Summary:

Samuel Shem's (Stephen Bergman) The House of God, first published in 1978, has sold over two million copies in over 50 countries (see annotation).  Its 30th anniversary was marked by publication of Return to The House of God: Medical Resident Education 1978-2008, a collection of essays offering historical perspectives of residency education, philosophical perspectives, literary criticism, and women's perspectives, among others. Contributors include such well-known scholars as Kenneth Ludmerer, Howard Brody, and Anne Hudson Jones, as well as physician-writers Perri Klass, Abigal Zuger, Susan Onthank Mates, and Jack Coulehan.  The closing section, "Comments from the House of Shem," includes an essay by psychologist and scholar Janet Surrey (Bergman's wife) and one by "both" Samuel Shem and Stephen Bergman. 

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The Heart

de Kerangal, Maylis

Last Updated: Apr-25-2016

Primary Category: Literature / Fiction

Genre: Novel

Summary:

The story of The Heart is a simple, linear structure.  A car accident renders a young Frenchman, Simon, brain-dead. A medical team proposes harvesting organs, and his parents, after some turmoil, agree. That’s the first half of the book, the provenance of this specific heart. The second half describes its delivery for transplantation. Administrators find recipients, one of them a woman in Paris. Simon’s heart is transported there by plane and sewn into her chest. All this in 24 hours.  
            
The narration is complex, with flashbacks, overlapping times, and literary art that is compelling. There are 28 sections to the story but without numbers or chapter headings, and these are often broken up into half a dozen shorter sections. We have an impression of stroboscopic flashes on the action, with high intensity focus. These create a mosaic that we assemble into dramatic pictures. Even major characters arrive without names, and we soon figure them out.  
 

Simon.  He’s called the donor, although he had no choice in the matter. At 19 years of age he’s trying to find a path in life.  A Maori tattoo is a symbol for that search. He has a girlfriend, Juliette. He fades away as a character (except in others’ memories) and his heart takes center stage.  

Marianne and Sean, Simon’s parents.  Her emotions, as we would expect, range widely, especially during discussion of whether Simon’s organs can be transplanted. Father Sean has a Polynesian origin and cultural heritage.


Pierre Révol, Thomas Rémige, and Cordélia Owl are respectively the ICU physician, nurse, and the transplant coordinator. These are vividly drawn, with unusual qualities. Skilled professionals, they are the team the supplies the heart.  

Marthe Carrare, Claire Méjan, and Virgilio Breva are a national administrator, the recipient, and a surgeon. Described in memorable language, they are the receiving team.              

The characters’ names give hints of de Kerangal’s range. S
ince the 1789 Revolution Marianne has been a well-known French national symbol for common people and democracy, but Virgilio Breva is from Italy and Cordélia (recalling King Lear) Owl (as in wise?) has a grandmother from Bristol, England. We learn of personal habits regarding tobacco, peyote, sex, and singing. Medicine is part of a larger world of people of many sorts.              

Even minor characters, such as Simon’s girlfriend Juliette and other medical personnel are touching and memorable.
             

These characters animate the story with their passion, mystery, even heroism. While we don’t know the final outcome of the implanted heart, the text shows the professionalism of the medical team, the French national system that evidently works, sensitive care of patients and families, and in the last pages, rituals of affirmation for medical art and for patients.
             

There is richness in de Kerangal’s style. At times it is direct, reflecting the thoughts of characters. At times it is ornate, even baroque. She uses many images and metaphors, often with large, epic qualities. A very long sentence about the over-wrought parents describes them as “alone in the world, and exhaustion breaks over them like a tidal wave” (p. 141).  The style uses many similes, often with dramatic and unexpected comparisons. There are references to geology, astronomy, even American TV hospital drama. The style is at times lyric…we might say “operatic.”  One page about Cordélia is very, very funny.
        
  
In a different tone, the details of medicine, law, and ethics are carefully presented, and visual imagery puts us in the hospital rooms, the OR, and crowded streets around a soccer game. Throughout it appears that translator Sam Taylor has done an admirable job. 
             

The text invites us to consider large visions of wholeness. All the major characters seek some comprehensive unity to their lives, and they avoid orthodoxies such as religion, patriotism, and economic gain. Sean has his Polynesian heritage and boat-building passion, which he has shared with Simon. Cordélia, at 25, is an excellent nurse, wise beyond her years in some ways, but is as dazzled by a man as any teenaged girl. Nurse Rémige has his master’s in philosophy, loves the song of rare birds, and is, himself, a serious singer.  

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Attending Others

Volck, Brian

Last Updated: Apr-11-2016
Annotated by:
McEntyre, Marilyn

Primary Category: Literature / Nonfiction

Genre: Memoir

Summary:

This memoir of a life in medicine takes the writer from St. Louis to a Navajo reservation to Central America to the east coast and from urban hospitals to ill-equipped rural clinics. It offers a wide range of reflections on encounters with patients that widen and deepen his sense of calling and  understanding of what it means to do healing work.  He learns to listen to tribal elders, to what children communicate without words, to worried parents, and to his own intuition while calling on all the skills he acquired in a rigorous medical education.  Always drawn to writing, Volck takes his writing work (and play) as seriously as his medical practice, and muses on the role of writing in the medical life as he goes along.

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