Showing 71 - 80 of 467 annotations tagged with the keyword "Medical Ethics"

Primary Category: Literature / Fiction

Genre: Collection (Short Stories)

Summary:

This collection of 16 short stories focuses on doctors and patients in San Francisco, where a wide variety of wealth and culture impact the delivery of medical care.  Further, there are many restrictions—financial, bureaucratic, ethical, and legal —that limit what doctors can do, especially in cases of patients near death.

The author, Louise Aronson, is a geriatrician who knows this terrain very well, having trained in San Francisco and worked as a physician there. A skilled writer and close observer, she has created dramatic and often funny stories that reveal social and bioethical complexity. About half the stories describe end-of-life issues for the aged and the dilemmas for their physicians and families.

In ‘The Promise,” Dr. Westphall orders comfort care only for an elderly patient who has suffered a massive stroke, but a hospital gives full treatment because there was no advance directive and the daughter told the attending to do “what he thought best.”

When Dr. Westphall sees this barely functioning patient in a skilled nursing facility seven months later, he tenderly washes her face and hair—although the text teases us that he might have been prepared to kill her.

In “Giving Good Death,” a doctor is in jail charged with murder; he has fulfilled the request of Consuela, a Parkinson’s patient, to help her die. When it appears that she may have died for other reasons, he is released, his life “ruined.” He leaves San Francisco, and, we surmise, medicine. In three other stories, doctors also leave the profession: the cumulative stresses of work and family and/or a sense that it’s not the right path bring them to that choice.

On the other hand, one of the longer pieces “Becoming a Doctor” celebrates the profession, despite all the rigors of training including sexism against women. 

The stories bring multicultural insights; we read of people from China, Cambodia, Latin America, India, Russia, and the Philippines. Some are African-American; some Jewish, some gay. These different backgrounds color notions of health, death, and medical care. There are also pervasive issues of poverty and, at another extreme, professionalism that is hyper-rational and heartless.

Indeed, a recurring theme is care and love for people, no matter their background or current health status. A surgeon realizes (regrettably too late) that the secret of medical care is “caring for the patient—for anyone—just a little. Enough, but not too much” (p. 135). 

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Summary:

            Hillel D. Braude, a physician and a philosopher, has written an important, albeit dense and narrowly circumscribed, study. While “Intuition in Medicine” is the main title, the subtitle, “A Philosophical Defense of Clinical Reasoning” is a more accurate description of the book, which originated as a doctoral dissertation.  While some of the prose will appeal only to specialists, there are important and thoughtful analyses of such topics as Evidence-Based Medicine, modern dehumanized medicine, the relation of beneficence and automony, and principalist ethics in general. 

            Throughout, intuition is narrowly conceived and in the service of clinical reasoning, as it applies to standard, Western physicians and not to other healers (or nurses), and the emphasis is on interventive medicine to cure illness and relieve suffering more than on health promotion. 

            Braude writes in the introduction that intuition has long been understood to be “a direct perception of things,” but he resists a more precise definition: “Rather than defining and using a single concept of intuition—philosophical, practical, or neuroscientific—this study examines intuition as it occurs at different levels and in different contexts of clinical reasoning” (xviii).

            Eight chapters explore these different levels in such topics as moral intuitionism, Aristotle’s phronesis (or practical reason), the rise of statistics (a basis for Evidence-Based Medicine), and C. S. Peirce’s notion of abduction. Braude’s careful analysis traces historical and theoretical developments in analytic philosophy and how these may be applied to clinical reasoning.  He uses an impressive range of thinkers: Achenwall, Albert, Allan, Andre, Ashcroft, Aristotle, Bacon, Barrow, Barton, Beauchamp, Bergson, Bernard, Bichat, Black, Bottero, Bourdieu, Brody, Browne—just to take names headed by A or B.  

            Throughout, Braude puts in dialectic two poles on a spectrum arguing that they both have contributions to make. He believes that between them is an “ethical space,” where discoveries and applications can be made, but he clearly favors all the concepts from the lefthand list for medicine. In tabular form, we can list aspects of the two poles:

 

            Medicine                                               Philosophy

Aristotelian practical reasoning                        Kantian abstraction

Naturalist approaches                                    Nonnaturalist approaches

Primacy of beneficence                                  Primacy of autonomy

Fact and value joined                                    Fact and value separated

Case-based                                                 Evidence-Based Medecine

Individual patients                                        Large groups of patients

Narrative experience                                     Statistical correlations

Anthropocentric focus                                    Mechanist, positivist foci

Tacit, organic knowledge (Polanyi)                   Dualism (Descartes)

 

            Braude believes intuition is a cognitive process but has other dimension, the corporeal and the social. While these provide a grounding, intuition for him is generally rational. He also argues for medical care at the personal, face-to-face level, not through applications of algorithms. 

            A brief conclusion, “Medical Ethics beyond Ontology” clarifies some of the arguments and sketches some valuable notions from Husserl and Levinas. He writes “intuition . . . does appear to be fundamental for human judgment” because “an intuition faculty” can “extract universals from the particular” (p. 170).  Drawing on Husserl, he defines phenomenological intuition as “the primary means through which objects are presented to consciousness.” This affirmation includes the basic human, which is also the focus for medicine. For Levinas (and my summary is much too brief), “interhuman solidarity” is a source for medical care, a form of responsibility that is different from Foucaultian power relationships, ethical rules and priniciples, or “an uncritical acceptance of medical authority” (p. 177). 

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This Far and No More

Malcolm, Andrew

Last Updated: Sep-12-2012
Annotated by:
McEntyre, Marilyn

Primary Category: Literature / Nonfiction

Genre: Biography

Summary:

Emily Bauer, mother of two small children, psychotherapist and teacher, social, smart, athletic, and strong-willed, finds, after a curious series of falls and other accidents, that she has ALS, "Lou Gehrig's Disease," a disease that involves slow atrophy of all muscular control, leading to complete paralysis and then death.  The disease is relentless, and treatments palliative at best. 

First in handwriting and later by means of a tape on which she can type, letter by letter, by moving her head to press a button as a cursor cruises through the alphabet, she keeps a diary up until just days before her death.  The diary, a remarkable record of her physical and emotional fluctuations, includes stories she laboriously writes for her daughters that gently mirror the confusions they encounter coming to see a profoundly disabled mother who can no longer hold them or speak to them.  The story culminates in Emily's plea for someone to turn off the ventilator that is keeping her alive, and the efforts her husband makes with the help of a meticulous and sympathetic lawyer and a courageous doctor to arrange for a voluntary death.  

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For the Love of Babies

Last Updated: Aug-30-2012
Annotated by:
McEntyre, Marilyn

Primary Category: Literature / Nonfiction

Genre: Collection (Case Studies)

Summary:

In this collection of "clinical tales," to use Oliver Sacks' term, Sue Hall, an experienced neonatologist who spent some years as a social worker before medical school, tells a remarkable range of stories about newborns in the NICU and their parents.  As memoir, the stories record moments in a life full of other people's traumas, disappointments, anxieties, and hard-won triumphs where her job has been to hold steady, find a balance point between professionalism and empathy as young parents go through one of the hardest kinds of loss.  Each story is told with clarity and grace, sketching the characters deftly and offering useful medical information along the way on the assumption that many who read the book will do so because they are facing similar challenges and decisions.  Each story is followed by a two- to three-page "Note" giving more precise medical background and offering further resources for those who have particular interest in the kind of case it was. 

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Mortal Embrace

Dreuilhe, Alain

Last Updated: Aug-27-2012
Annotated by:
McEntyre, Marilyn

Primary Category: Literature / Nonfiction

Genre: Journal

Summary:

Where many writers about illness have raised questions about the widespread and often unexamined appropriation of military metaphors to describe how doctors and patients have "struggled with," "combatted," "fought," or "defeated" illness, Dreuilhe embraces it and plays it out to the far reaches of its logic.  Part of the brilliance of this AIDS narrative lies in the way it brings new dimensions of meaning to a metaphor that has become so conventional as to be cliché or so imbedded in the language of illness and treatment, it simply fails to be recognized as metaphor.  Beginning with the "simple skirmishes at the frontier garrisons," Dreuilhe chronicles the progression of his own illness with the sharp eye of a good war reporter who sees through the chaos of the battlefield to the strategies being played out.  "Whenever I take an experimental drug," Dreulhe writes, "and people fight desperately to be among those privileged to risk their livesI feel as though I belong to a unit of shock troops parachuted behind enemy lines: already written off as a casualty, I'm entrusted with the task of spearheading the advance."

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The Sickness

Tyszka, Alberto

Last Updated: Aug-23-2012
Annotated by:
Miksanek, Tony

Primary Category: Literature / Fiction

Genre: Novel

Summary:

It started with a faint. Javier Miranda, a generally healthy 69-year-old man living in Venezuela, attributes his episode of dizziness to the summer heat and humidity. His only child, Andres Miranda, is a physician whose intuition tells him something is seriously wrong with his father. The doctor obtains blood work and schedules a CT scan and MRI of the brain for Javier. The medical work-up reveals rapidly progressing lung cancer with metastases to the brain. Violating his credo of complete honesty with patients, Dr. Miranda lies to his father and reassures him instead. Dr. Miranda's mother died when he was just 10 years old. Now his father's remaining lifespan has dwindled to a couple of months. The doctor must find a way to break the bad news to his dad.

Meanwhile, Dr. Miranda receives multiple messages - phone calls, e-mails, and letters - from a difficult and persistent patient. Ernesto Duran suffers from dizzy spells and multiple other symptoms. It could be panic disorder or maybe Ernesto is a hypochondriac. Dr. Miranda instructs his office secretary, Karina, to deal with these communications and remind the patient that there is nothing more that can be done for him. When Ernesto admits he is stalking the doctor, Karina worries. Pretending to be Dr. Miranda, she begins corresponding with Ernesto via e-mail. Before long, Karina develops symptoms similar to Ernesto's and experiences empathy for him.

When his physician-son finally summons the courage to announce the terminal diagnosis, everything changes for Javier - his mood, personal relationships, and awareness of his body's metamorphosis. He perceives the smell of rot associated with his physical deterioration. Dr. Miranda's frame of mind also changes as he copes with his father's impending death. Javier's deathbed request is simply for his son to shatter the terrible silence by talking about the two of them.

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Puncture

Evans, Chris; Kassen, Adam; Kassen, Mark

Last Updated: Aug-15-2012
Annotated by:
Duffin, Jacalyn

Primary Category: Performing Arts / Film, TV, Video

Genre: Film

Summary:

Drug-addicted but high functioning lawyer Mike Weiss (Chris Evans) and his partner Paul Danziger (Mark Kassen) run a small personal injury firm in Houston.
They agree to represent an emerency room nurse who has sustained a needle-stick injury and become infected with HIV. Through this work, they discover that a new safety syringe could avoid such injuries in the future, but the innovators are unable to bring it to market because of legal opposition from giant corporations.
The young lawyers become more and more engaged with the case, but  they meet sinister opposition and the outcome is gloomy.

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Illness as Narrative

Jurecic, Ann

Last Updated: Jul-03-2012
Annotated by:
Schilling, Carol

Primary Category: Literature / Nonfiction

Genre: Criticism

Summary:

In Illness as Narrative, Ann Jurecic thoughtfully examines the unruly questions that personal accounts of illness pose to literary studies: What is the role of criticism in responding to literature about suffering?  Does the shared vulnerability of living in a body, which stories of illness intimately expose, justify empathic readings?   What is the place of skepticism in responding to stories of suffering?  Does whether or how we read illness narratives matter?  Jurecic's questions entice discussion at an interesting cultural moment.  The numbers of memoirs and essays about illnessand their inclusion in medical school and other humanities coursesmultiplied from the later decades of the 20th century to the present.   However, their increase, and their potential to encourage empathic readings, coincided with dominant literary theories that advocated vigorously skeptical, error-seeking responses to texts and their authors.  Jurecic reminds us that Paul Ricoeur called such responses "the hermeneutics of suspicion" (3). 

Jurecic's astutely researched, nuanced answers to those questions propose a corrective to the extreme skepticism of "disembodied criticism." Such criticism, she claims, dismisses testimonial writing from "a position of distance and privilege."  But her answers also affirm that intellectually "rigorous" responses to texts are central to the critical humanities (15).  To further her position, she offers attentive readings of accounts of illness by Virginia Woolf, Reynolds Price, and Jean-Dominique Bauby, as well as the theoretical writing of literary and other scholars.  For instance, Jurecic speculates that the condition of a reader's body aligns with his or her responses to texts.  In a chapter called "Theory's Aging Body," she observes that as skeptical scholarly readers ageStephen Greenblatt, Michel Foucault, Judith Butlerthey have turned their attention to "illness, vulnerability, and mortality" (93).  Jurecic also suggests that a function of criticism is to uncover the cultural conditions that memoirs and essays about illness respond to.  Living "at risk" is a recent one.  In stories of living with the risk of experiencing a particular illness in the future, potential patients create narratives of uncertainty to discover the "personal meaning of the impersonal statistics" that medical research now regularly delivers (18). 

 Jurecic also reflects on the ways theorists have understood the possibilities of representing and responding to pain in the varied approaches of philosophers Elaine Scarry, Martha Nussbaum, and Richard Rorty and of anthropologists Jean E. Jackson, Byron Good, and Veena Das.  In an exceptionally comprehensive and nuanced reading of Susan Sontag's theoretical, fictional, and journal writing about suffering, Jurecic uncovers Sontag's inconsistent, yet revelatory positions on the human capacity for responding to representations of pain.  The chapter on Sontag is enriched by Jurecic's reading of Annie Lebovitz's and David Reiff's responses to Sontag's suffering: in Lebovitz's controversial photographs of Sontag's final days (included in A Photographer's Life: 1990-2005) and Reiff's memoir about his mother's illnesses (Swimming in a Sea of Death). 

Illness as Narrative closes with examples of what Jurecic calls reparative writing and reading practices.  In the first instance, ill writers such as Jean-Dominique Bauby (The Diving Bell and the Butterfly) both recreate "a more coherent sense of themselves" and dislodge "fixed ideas and narratives" about illness (109).  In the second instance, Jurecic outlines the limits of two competing readings of Anne Fadiman's The Spirit Catches You and You Fall Down.  One assumes that readers will by nature empathically imagine those who are culturally different from themselves.  The other looks skeptically at the assumption that what medical educators call cultural competence can be acquired by reading a book.  Jurecic suggests that strategies for reading and teaching informed by Janelle S. Taylor, Eve Kosofsky Sedgwick, and Rita Felski can encourage more complex habits of response, such as Taylor's "'empathic curiosity'" (quoted 122).

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Remedies

Ledger, Kate

Last Updated: Apr-30-2012

Primary Category: Literature / Fiction

Genre: Novel

Summary:

Simon Bear is a hard-charging physician; his wife Emily is a successful public relations executive, now a senior partner in her firm. Although they have a lavish house, a teen-aged daughter, and much wealth, their marriage is troubled, in large part because they have never fully mourned the death of their baby Caleb.

The title “Remedies” fits well with the long struggle for how to heal their grief. The remedies that clearly have not worked are obsessions with career, professionalism, rationalism, and the trappings of American materialism.

Simon has two obsessions about his practice. The first is that he is a rescuer, the perfect doctor who listens to his patients and gives them what they want. As a self-appointed expert on pain, he is free and easy about prescribing opiates. When his father-in-law feels no pain after a car accident, Simon is sure that a drug that the man is taking is, in fact, the Holy Grail of pain medications. Simon becomes obsessed with this “discovery,” promoting it to his patients, without a scientific study or consideration of ethical implications. When he flies to a national medical meeting to trumpet the news of this remedy, no one will listen to him.

While Simon is the point of view for Parts One, Three, and Five, Emily—structurally separated—is the voice and focus of Parts Two and Four. She is troubled by her distance from Simon and, increasingly, her 13-year-old daughter, who is sullen and rebellious. When she meets Will, a former lover, she seeks another kind of remedy in an affair with him, even prospects of marriage. Contrasting with her strategic, rational approach to life, Will is an open, easy-going man, conveniently separated from his wife.

A series of crises rock Emily, then Simon. Emily begins to understand her anger; she has a breakthrough with her daughter. Simon has several setbacks, including humiliations, but he is not crushed. Although ordinarily a secular Jew, Simon attends the Kol Nidre service the evening service before Yom Kippur, the Day of Atonement. In a powerful and moving passage, he finds healing, relief, and a new direction for his life—a true remedy.   

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The Courtroom

Layton, Elizabeth

Last Updated: Apr-26-2012
Annotated by:
Bertman, Sandra

Summary:

This is an aerial view of a comatose patient being force-fed by a funnel leading directly into her stomach. Surrounding the consultation table are six (identifiable) black-robed supreme judges gleefully pouring nutritious foods (grapes, fish, Quaker Oats, peanut butter, water and 7-Up) into her. Two tiny symbols, the scales of justice and a red-white-and-blue eagle contribute to the otherwise empty courtroom decor.

In the upper right corner, barely visible, is an open door with a "Keep Out" sign dangling from its knob, through which a doctor and nurse peer in. Four tiny red paper-doll figures holding hands, symbolizing the family, are also by this door. Hanging precariously over the patient and consultation table is an ugly, large, bare 25-watt light bulb.

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