Synthetic Biology and the future

I found the following video on Paul Levy's "Not Running a Hospital" blog. Engineering living beings is certainly exciting and filled with sober questions about what may be possible. I wonder about the applicability of our patent systems. I suppose that our legal scholars and others have already concluded that life (to a point) can be owned by those who "create" it.

High technology prosthetic devices

This video is about the use of technology to improve prosthetic devices and to potentially modify and extend abilities of human bodies. Where does the right to healthcare end in the United States? Is it rationing to provide these devices to some people and deny them to others? Is the "line" the point at which the device provides enhancement beyond natural abilities, contrasted with "merely" restoring a lost functionality?

Kidney donation a condition of release?

This news story appears to me to raise ethical questions.

http://www.cnn.com/2010/CRIME/12/30/mississippi.sisters.prison.release/index.html?hpt=Sbin

Apparently, two sisters in Mississippi received life sentences for an armed robbery that netted $11. Having each served 16 years in prison they are now each consider rehabilitated and no longer a threat to society. One sister's dialysis treatments three times per week is costing the state $190,000 a year. Governor Barbour's decision is apparently being well-received by all.

But ethically, an organ donation must be voluntary. Not even a court of law can require a person to become an organ donor even if a specific death will result for lack of a suitable organ. If this were a research proposal being considered by an Institutional Review Board (IRB) I think the IRB reviewers would be hard pressed to believe this is not a coerced consent. The state has apparently concluded that the sisters should not be in prison. Assuming the sister receiving dialysis will be eligible for Medicaid upon release, it is in the financial interest of the state for her to receive an organ transplant. From an ethical perspective, it seems to me that the better sequence of events would be to immediately release the two women and then ask the potential donor if she wants to make the organ donation. Is it possible that the prospective donor has refused to make the donation unless both sisters are first released from prison? If this is the case, does this amount to selling one's organ, which may be a violation of law?

Does this news story suggest that in the future a convicted criminal's "debt to society" might be paid by "voluntary" organ donations (to unknown others) in Mississippi? It seems to me that the state has a conflict of interest regarding the medical care of the sister needing dialysis and that making release contingent upon the organ donation may not be ethical or wise.

Challenges of managed care

The movie titled, Damaged Care is based on the experiences of Physician Linda Peeno. The movie, a Showtime docudrama staring Laura Dern in the role of Dr. Peeno, is a hard-hitting representation of the practices of "managed care" healthcare by some large providers prior to 2002, the date of the distribution of the movie. The movie can be no more shocking than the real testimony of the real Dr. Linda Peeno before a Congressional committee several years ago.



In reflecting upon this I remember the book title, "No Margin No Mission," by Stephen Pearson and others. I also think of the concept, Balanced Scorecard, which is a strategic management tool. The core idea behind Balanced Scorecard is that financial and other non-financial measures each be compared in a single report. In a personal communication several years ago a management consultant in Mexico told me had never been able to earn any money by selling the Balanced Scorecard concept to managers in a variety of industries. I conclude that business schools have reinforced the management concept of maximization rather than balance. It is certainly true that without financial margin an organization cannot continue to pursue its mission. The interests of owners (including stockholders) are usually defined in terms of the greatest possible profits. The pressures of competition that would force executives into more of a Balanced Scorecard perspective does not work as well in healthcare as in some other industries. How can the profit motive and the care motive coexist in large healthcare organizations? Can these motives somehow find balance both in individuals and in large organizations in which roles produce a splitting into factions with different primary interests?

What is a Physician to do?

I am recoving for nasal surgery this holiday season and preparing to be both a teacher and a student this spring semester. I am thankful for the opportunity to become a student at Medical College of Georgia while continuing to teach at Albany State University.

In reading about ethics as related to medical care I read recently that ultimately decisions are to be made by the patient and the physician is responsible to fully inform the patient regarding all available options. But if I recall, physicians are also responsible to practice evidence-based medicine in order to do those things that have been shown to be be most effective given the diagnosis. Forgive me if I am missing something, but if the patient chooses the treatment how can the physician be responsible for the patient making choices that are not evidence-based? I have no problem with patients participating in decisions about their treatment. But is it realistic to hold the physician responsible to explain every option and every possible consequence of every option? Given the power of suggestion, is it really in the interest of the patient to be told every awful thing that might possibly be the result of a medical decision? And must a physician identify treatment options that are clearly far beyond the patient's scope of options for reason of cost? Might doing so be said to be unethical behavior? Under some form of managed care, telling the patient want is technically possible but not financially feasible is not going to earn the appreciation of the physician's employer and/or partners.

To me, a professional relationship involves agency and trust. Agency does not require a blind trust. Patients certainly should participate in their care and be as alert as the situation permits. But how can a physician fully inform patients of all choices, follow patients' choices, and also be held accountable to practice evidence-based medicine? We are going to need all the good physicians we can find in coming years. Let's define the practical and ethical responsibilities of physicans in reasonable ways in order not to cause good physicians to seek other lines of employment.