Ethics in cardiopulmonary medicine.

Ethics in cardiopulmonary medicine. T A Raffin Chest 1988;94;230-231 DOI 10.1378/chest.94.2.230 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/94/2/230.citation

Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1988by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692

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ommend a chest x-ray examination on admission, it is apparently frequently overlooked. At least 13 smearpositive patients were admitted during their study without benefit of an intial chest x-ray film. Nearly one-third of the TB patients were admitted because of complaints unrelated to tuberculosis. The physicians in a very busy emergency room did not adequately detect the likelihood of tuberculosis from the history and physical examination even though more careful history later detected respiratory and/or systemic symptoms in most of the patients. The fact that 82 percent of the patients identified in the study were acid-fast smear-positive is somewhat disconcerting. It points up the potential danger of not detecting communicable tuberculosis early It is also likely that some cases of tuberculosis were missed since most studies of active pulmonary tuberculosis suggest that 50 percent of proven cases are smearnegative at time of diagnosis. The authors indicate that during the study 204 patients with abnormal x-ray film findings were excluded from the study because they had negative results of cultures. Surely some of these patients actually had clinical tuberculosis or were at increased risk of developing active tuberculosis in the future. The authors, unfortunately, give no follow-up data in this regard. In addition, the authors give no data concerning how many of the 31,000 admitted patients actually had a chest x-ray examination during their admission. It is likely that significant numbers ofpatients with TB went undetected because they were admitted for reasons not suggestive of tuberculosis and therefore were not evaluated with a sputum examination or possibly a chest x-ray film. Barnes et al have correctly concluded that routine admission chest x-ray examinations are indicated for hospitals serving populations where tuberculosis is common. The need is obvious for their hospital. There must be other hospitals in the US with similar circumstances. What about hospitals where the problem is not so obvious? How much tuberculosis is enough to be concerned? First of all, it will not be perceived as a problem if it is not evaluated. The nature of tuberculosis often allows us to ignore the problem of transmission to patients and/or staff since the consequences are usually months to years away. When they occur, they are not recognized as being linked to the earlier exposure episode. A few cases of tuberculosis unsuspectingly diagnosed each year in a hospital may not seem like a problem. However, unless a careful analysis is made, including the epidemiologic factors, the true magnitude may be overlooked. Today our goal should be that no transmission of tuberculosis occur within the hospital setting. This requires a careful assessment by each hospital in relationship to the nature of its staff and patients and may conclude appropriately that screening on admis-

sion with a chest x-ray examination should be done. Conclusions and recommendations made at an earlier time and under different circumstances may not apply to a present situation. Many factors about tuberculosis present problems or have changed, particularly in certain areas. The disease is no longer declining at its previous rate. Skin testing may not be practical for screening in a short-term hospital setting. Tuberculosis has emerged as a problem in increasing numbers of AIDS patients often presenting in unusual and unexpected ways. We must all, as health providers and protectors of the general public health, responsibly assess and understand our own circumstances relative to tuberculosis and apply our knowledge and the national guidelines and recommendations appropriately and judiciously Paul T Davidson, M. D., F. C. C. P. Los Angeles Director, Tuberculosis Control, County of Los Angeles Department of Health Services; Clinical Professor of Medicine, University of Southern California School of Medicine. Reprint requests: Dr Davidson, 7601 East Imperial Hwy, Bldg 308, Downey, California 90242

REFERENCES 1 National Center for Devices and Radiological Health. The selection of patients for x-ray examinations: chest x-ray screening examinations. Rockville, MD: Food and Drug Administration, 1983, Health and Human Services Publication (FDA), 83-8204 2 Tape TG, Mushlin Al. The utility of routine chest radiographs. Ann Intern Med 1986; 104:663-70 3 Robin ED, Burke CM. Routine chest x-ray examinations. Chest 1986; 90:258-62

Ethics in Cardiopulmonary Medicine WAJ ith

this issue, Chest begins a new section entitled Ethics in Cardiopulmonary Medicine. The purpose of this section is to explore and highlight the many complex ethical dilemmas which confront cardiopulmonary medicine. The first contribution to this new section is a thoughtful and balanced analysis of the total artificial heart from the Center for Clinical Medical Ethics at the Pritzker School of Medicine. (see page 409) Over the next months, Ethics in Cardiopulmonary Medicine will feature articles on withholding and withdrawing life support, ethical issues in AIDS; decision-making in neonatal intensive care; the use of animals in experimentation; the ethics of rationing health care; and the ethics of informed consent. Interested parties are invited to contact the section editor to propose either monographs they would like to produce, or topics which should be addressed in future issues of Chest.

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Editorials


Wherever one turns today, it is difficult to avoid frank and controversial discussions concerning medical ethics-from the bedside to the benchside. A study of the lay press reveals a constant emphasis on current ethical dilemmas which surpasses the exposure given to such important questions in our own professional journals. This is one reason why Chest has initiated this section. With biomedical science and technology continuing to exponentially uncover new and exciting insights into man, medicine, and the worlds around us it is not surprising we have such a difficult time trying to understand the framework from which we try to analyze the ethics of each particular situation. For example, what types of laboratory-created animals should be patented? Should any? Is there anything wrong with using fetal human tissues to medically help other individuals? Should it be permissible for a wife to become pregnant and then have an abortion to provide invaluable tissue to aid her husband? Should clinical investigation which cannot be approved in our country be conducted by our investigators in third world countries where informed consent is not the standard of practice? When determining whether or not to withdraw life support from a neonate, should the neonate's future potential quality of life be a factor in the decision-making? The questions are numerous and so are'the answers. From Hippocrates, Galen and Maimonides through the Nuremberg Trials and to the present we have all searched, with the aid of our personal sense of morality for reasonable answers to the ethical dilemmas which confront us. We all know the two age-old tenets of the practice of medicine: restore health, and relieve suffering. These foundations of medical practice fall under the ethical goal of beneficence or the doing of good. Also, we have all thought about primum non nocere or first do no harm. This bottom line of medicine falls under the ethical goal of non-maleficence or to not do harm. Finally beneficence and non-maleficence as key goals in the practice of ethical and humane medicine are in balance with two other ethical goals: autonomy of the patient, and justice (the fair and just distribution of health care). These four ethical goals of medicine are dynamically interrelated-sometimes in agreement and often in conflict. One of the most important tools when grappling with personal, patient, institutional or societal ethical problems is communication. Without sensitive and thoughtful communications, understanding cannot be achieved. When counseling patients whether or not to choose chemotherapy in an almost hopeless situation; whether or not to allow the physician to write a DNR order; or whether or-not to try an experimental mode of therapy, it is the quality of the communication which will

determine the success of the ethical solution. Honest and warm communication is the cornerstone of the humane practice of medicine, but communication is so difficult for all of us: so time consuming, so emotionally stressful, so difficult to listen. The article in this issue highlights the incredibly complex ethical issues surrounding the current development of this technology The authors point out that the development of TAH creates its own incentive as a way for severely ill heart patients to compete for a limited supply of donor hearts. Will this technology be used in an inappropriate fashion? How will TAH be withdrawn from languishing patients who have no change to receive a donor heart? How effective will informed consent be, and will patients activate advanced directives (living wills,2 natural death act directives, durable powers of attorney) to assist in decision-making when they are no longer legally competent? The authors identify separate priorities for public policy and physicians. For public policy how will TAH be responsibly deployed as a bridge to heart transplantation? Indeed, will the government actually develop public policy in a straightforward fashion or will they simply cut funds across the board and expect doctors to be both simultaneous patient advocates and gatekeepers. This is the usual approach of our government. However, even though it casts physicians into an impossible role, perhaps it is much better not to have government establish a myriad ofethical decisionmaking guidelines. Furthermore, when doctors are forced to choose between their patients and fiscal gatekeeping, then there is a simple solution: we care for our patients first and foremost. Thus, we have a serious difficulty Who is making public policy? Finally the article encourages physicians to facilitate optimal informed consent and the establishment of advance planning for possible termination of TAH. The underlying goal of the physician, then, is thoughtful and sensitive communication with his or her patient. As noted above, ethical decision-making often comes down to honest and humane communication. Hopefully many of you will try your hand at communicating about some of the ethical problems confronting us in this new section of Chest. Thomas A. Raffin, M.D., F.C.C. P Stanford Associate Professor and Assistant Chief of Medicine, Division of Respiratory Medicine; Medical Director, Respiratory Therapy, Stanford University Medical Center Reprint requests: Dr Raffin, Division of Respiratory Medicine, C-356, Stanford University Medical Center; Stanford 94305

REFERENCES 1 Ruark JE, Raffin TA, and the Stanford University Medical Center Committee on Ethics. Initiating and withdrawing life support: Principles and practice in adult medicine. N Engl J Med; 1988;318:25-30 2 Raffin TA. Value of the living will. Chest 1986; 90:444-46 CHEST / 94 / 2 / AUGUST, 1988


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Ethics in cardiopulmonary medicine. T A Raffin Chest 1988;94; 230-231 DOI 10.1378/chest.94.2.230 This information is current as of April 13, 2012 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/94/2/230.citation Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.
