Medical Ethicists, public health hazard

[nancylebov]

Checklists in ICUs are made illegal.

The results were stunning. Within three months, the rate of bloodstream infections from these I.V. lines fell by two-thirds. The average I.C.U. cut its infection rate from 4 percent to zero. Over 18 months, the program saved more than 1,500 lives and nearly $200 million.

Yet this past month, the Office for Human Research Protections shut the program down. The agency issued notice to the researchers and the Michigan Health and Hospital Association that, by introducing a checklist and tracking the results without written, informed consent from each patient and health-care provider, they had violated scientific ethics regulations. Johns Hopkins had to halt not only the program in Michigan but also its plans to extend it to hospitals in New Jersey and Rhode Island.

The government’s decision was bizarre and dangerous. But there was a certain blinkered logic to it, which went like this: A checklist is an alteration in medical care no less than an experimental drug is. Studying an experimental drug in people without federal monitoring and explicit written permission from each patient is unethical and illegal. Therefore it is no less unethical and illegal to do the same with a checklist. Indeed, a checklist may require even more stringent oversight, the administration ruled, because the data gathered in testing it could put not only the patients but also the doctors at risk — by exposing how poorly some of them follow basic infection-prevention procedures.

I think of medical ethicists as the people who keep saying "but maybe longer, healthier lives are a bad idea", and I don't know of any good they've done. Am I doing the field an injustice?

For more about ICU checklists and other practical ways of improving medical outcomes, see Gawande's Better: A Surgeon's Notes on Performance.

Link thanks to inquisitiveravn.

Comments

[metahacker.livejournal.com]

(blink)

Okay, I understand where they are coming from. Dumb, dumb, dumb. Established medical procedure should cover this.

...Wait for someone to patent the 'process' of an ER checklist and start charging hospitals for it as a 'medical device'. "I'm sorry...this checklist isn't covered by your health insurance...we'll have to do it from memory." I wish I was kidding.

(Goes back to working on better processes for doctors ANYWAY.)

[holzman.livejournal.com]

Am I doing the field an injustice?

It is difficult to understate the severity of the injustice you're doing. Medical ethicists are responsible for concepts such as:

• Doctors should ask your permission before giving you experimental drugs
  
• Doctors should not lie to you about the risks associated with the experimental drugs they give you.
  
• Doctors should tell you about the risks associated with the well-understood drugs they propose to give you.
  
• Emergency rooms should not turn the indigent away from their doors.
  
• Doctors should not let poor patients die because rich patients need organ transplants.
  
• etc, etc, etc.
  

It's easy to take these things for granted, much in the way that it's easy to take the weekend for granted if one doesn't understand that we only have them because of labor unions.

In this instance, I think you misattribute to medical ethicists the doings of federal bureaucrats. For what it's worth, I believe the OHRP has ruled improperly.

[nancylebov.livejournal.com]

Thanks. I suppose it's likely that sensible medical ethicizing is less likely to get op ed coverage.

However, how old is medical ethics? I was under the impression that not turning the poor away from emergency rooms goes back pretty far.

[holzman.livejournal.com]

Medical ethics is pretty old. The first famous medical ethicist was probably Hippocrates, and people have been building ever since.

[stevemb.livejournal.com]

Part of it is that basics like that tend to be considered just plain "ethics" -- leaving the more specific label "medical ethicist" to more dubious positions (such as those of Leon Kass, which I think may be the real (and richly deserving) target of the unflattering description).

[holzman.livejournal.com]

Part of it is that basics like that tend to be considered just plain "ethics"

Perhaps they are now -- for certain values of "now." The Tuskeegee Syphilis experiments went on until 1972, and the Doctors who conducted it considered themselves to be behaving ethically in both the "just plain" and the medical sense.

[pocketnaomi.livejournal.com]

Mostly, medical ethicists are the people who say the end doesn't inherently justify the means, which is what they're doing in this case. It's something we do need to be reminded of; it's also, at times, oversimplistic.