Bioethical Issues in Life Stages

During one's life, ethical issues are raised from the time of conception to the time of death. We must deal with bioethical issues from the beginning of life, to the quality of life, and finally to death and dying.

     One of the ethical issues our society deals with is abortion. In 1973, "the Supreme Court ruled that women had a constitutional right to abortion, and  that this right was based on an implied right to personal privacy emanating from the Ninth and Fourteenth Amendments." (usccb.org, n.d.) Additionally, "In Roe v. Wade the Court said that a fetus is not a person but "potential life," and thus does not have constitutional rights of its own. The Court also set up a framework in which the woman's right to abortion and the state's right to protect potential life shift: during the first trimester of pregnancy, a woman's privacy right is strongest and the state may not regulate abortion for any reason; during the second trimester, the state may regulate abortion only to protect the health of the woman; during the third trimester, the state may regulate or prohibit abortion to promote its interest in the potential life of the fetus, except where abortion is necessary to preserve the woman's life or health." (usccb.org, n.d)

     The law is clear on abortion rights. However, the ethical issue still remains. "The matter of abortion, the quintessential bioethics topic, raises intensely personal issues for many people. It is a polarizing and divisive issue that raises discussions about morals, science, medicine, sexuality, autonomy, religion, and politics. A central matter is deciding what we can say about unborn children, initially known as embryos and later, fetuses. What is their moral status – how much do they matter, and what are our obligations towards them? The matter of 'personhood' arises, as a philosophical and legal discussion about what rights to grant them. 

     'Personhood' aside, what is our relationship to them, all of us as members of the human family? Should their lives be protected, or should their mothers be allowed to make decisions about killing or protecting them? If killing is allowed, under what circumstances may it take place? If their lives are not protected, what kind of crime is it to perform an abortion on a woman without her consent, or to cause her to suffer a miscarriage? The ethical aspect of abortion is related but distinct from the legal. Whether or not it is moral, should abortion be legal? Generally prohibited but with some exceptions? Should it be regulated? Publicly funded? Should doctors and nurses be able to object according to their conscience? A less prominent but still important debate focuses on the reasons why women might seek abortion. Is it at all times a free choice, or are women responding to coercion in any way?  Is it a free choice to seek abortion in desperation because of poverty, violence, or lack of support? What should be the community and policy response to women who feel unable to give birth to their children? And what is the role of the father in decisions about abortion?" (bioethics.org.au, 2013)

     All in all, there is a lot to consider when we look at the issue of abortion. I personally believe it is a woman's choice, since her life is tied to the fetus'.

     During the next stages of our lives, we can look at many issues relating to sustaining and improving quality of life. One of the issues that has been a hot topic over the last several years is genetic science. "There was a pivotal moment in the that too place in the early 1950s, which has given rise to the burgeoning field of molecular genetics. In 1952, two now famous Nobel Laureates, Francis Crick and James Watson, discovered the molecular structure of DNA (a double helix) and confirmed that DNA was indeed the genetic material. Now the race is on to decode the genetic information, to discover the genetic basis of all our human traits, and to use genetics to reveal our phylogenetic relationships. What is more exciting and controversial is the possibility of manipulating our genes so as to restore damaged health or even enhance many of our biological functions. However, as is the case with any scientific and technological developments, there are whole host of ethical problems that must be considered. The possibility of manipulating our genes in order to enhance our biological, as well as psychological nature, is hugely problematic. It is foreseeable that it may lead to a new eugenics, and a radically undesirable change in our human nature. There are also other ethical issues relating to genetic information and the implications of having such information, for example, genetic discrimination and the ethics of genetic screening."(bioethics.org.au, 2013)

    As stated,  one of the biggest issues relating to genetic science is the ability to create a biological and psychological superior person. The Human Genome Project, which goals were to, "identify all the approximately  20,000-25,000 genes in human DNA, determine the sequences of the 3 billion chemical base pairs that make up human DNA,  store this information in databases,  improve tools for data analysis,  transfer related technologies to the private sector, and  address the ethical, legal, and social issues (ELSI) that may arise from the project." (ornl.gov, n.d.) was completed in 2003. With this knowledge, we could, in theory, allow potential parents to pick out eye color, hair color, height, weight, appearance, intelligence, and lack of disease predispostion. The implications are very scary. If you stop to think about it, the people who could afford to this, are the 1% we hear so much about in the news every day. I think this would put an even bigger gap between the upper class, and the middle and lower classes.

      Looking now at the end of life, one of the ethical issues is the topic of Euthanasia. "Euthanasia is the intentional and painless taking of the life of another person, by act or omission, for compassionate motives. The word euthanasia is derived from the Ancient Greek language and can be literally interpreted as ‘good death.’ Despite its etymology, the question whether or not euthanasia is in fact a ‘good death’ is highly controversial. Correct terminology in debates about euthanasia is crucial. Euthanasia may be performed by act or omission - either by administering a legal drug or by withdrawing basic health care which normally sustains life (such as food, water or antibiotics). The term euthanasia mostly refers to the taking of human life on request of that person – the euthanasia is voluntary. However, euthanasia may also occur without the request of person who subsequently – euthanasia is non-voluntary. Involuntary euthanasia refers to the taking of a person’s life against that person’s expressed wish/direction.

     Central to discussion on euthanasia is the notion of intention. While death may be caused by an action or omission of medical staff during treatment in hospital, euthanasia only occurs if death was intended. For example, if a doctor provides a dying patient extra morphine with the intention of relieving pain but knowing that his actions may hasten death, he has not performed euthanasia unless his intention was to cause death (Principle of Double Effect). Euthanasia may be distinguished from a practice called physician-assisted suicide, which occurs when death is brought about by the persons own hand (by means provided to him or her by another person)." (bioethics.org.au, 2013)

   Euthanasia is one of the more complicated issues that we as a society, particularly those in health care, have to deal with. While I believe, everyone should have the right to deny treatment, it's hard to determine what the right thing to do in any given situation is. What I do know, from personal experience, is that a person might decide that death is preferable to suffering one day, they may not feel the same way the next.

      During my lifetime, I have seen many stories relating to bioethics in the media; from Dr. Kevorkian, a doctor specializing in euthanasia, to  Dolly the sheep who was successfully cloned. One of the cases that stuck with me was the Ayala family.

     The Ayala family had struggled through several treatments when their daughter Anissa was diagnosed with  chronic myelogenous leukemia. Anissa was put on the bone marrow donor list, but a donor was not found through the national database. When Anissa's parents realized their daughter might succumb to the disease, they decided to conceive a child that could possibly be a bone marrow match to their daughter. The family received national attention, as they were the first family to publicly announce this decision. The Ayala's successfully conceived a daughter, Marissa, who was born on April 3, 1990. In late May of 1991, a bone marrow transplant was performed and both girls(women now) are both healthy and thriving.(Chang, 1991)

     This issue is one I have struggled with. I think the Ayala family did what was best for them, and it worked out for the family. I think this happened because the family was emotionally stable, loving, and supportive. However, what if the bone marrow transplant wasn't the end of the journey for baby Marissa? What if her sister had multiple problems, and Marissa was subjected to more procedures? What if she had to give an organ? Should she have a say in the process? What if she felt she was only conceived to be a spare body to save her sister? I agreed with the outcome of the situation, because it was the family's decision. However, I think that a decision such as this needs to be considered very carefully, as it could have a negative outcome on both children, depending on the family situation and how far any procedures go.

   As we have seen, there are many bioethical issues throughout our individual lives, but also those that affect society as a whole. While there are always choices to be made, there will be people to argue both sides of any ethical issues.

SOURCES

usccb.org, (n.d.) Summary of Roe v. Wade and Other Key abortion Cases retrieved July 1,

   2013 from http://old.usccb.org/prolife/issues/abortion/roevwade/CaseSummariesforwebsite4-

   18.pdf

Bioethics.org.au, (2013) Abortion retrieved July 1, 2013 from

     http://www.bioethics.org.au/Resources/Resource%20Topics/Abortion.html

Bioethics.org.au, (2013) Genetics retrieved July 1, 2013 from

     http://www.bioethics.org.au/Resources/Resource%20Topics/Genetics.html

Bioethics.org.au, (2013) Euthanasia retrieved July 1, 2013 from

     http://www.bioethics.org.au/Resources/Resource%20Topics/Euthanasia.html

 Chang, I., (1991) Baby Girl's Bone Marrow Transplanted Into Sister : Health: Parents conceived

     the child in an attempt to provide a donor for leukemia-stricken sibling., Los Angeles Times,

     retrieved July 1, 2013 from http://articles.latimes.com/1991-06-05/news/mn-212_1_bone-

     marrow-transplantation

 Beaty, K. (2013) Bioethical Issues in Various Life Stages

Telemedicine Applications

There are many ways in which telemedicine has been a success. One of these is Health services. Health services includes a variety of specialties. Health services allow doctors to interact remotely with patients and other specialists. For example, doctors can monitor vital signs, labs, and patient care in multiple ICU's simultaneously.      Within Health services you can find many specialties, including telepsychiatry. Telemedicine can be used to link the patient and the clinician over a "real time" video connection. According to Hyler, et.al., "Out of a large telepsychiatry literature published over the past 40+ years, only a handful of studies have attempted to compare telepsychiatry with I-P directly using standardized assessment instruments that permit meaningful comparisons. However, in those studies, the current meta-analysis concludes there is no difference in accuracy or satisfaction between the two modalities. Over the next few years, we expect telepsychiatry to replace I-P in certain research and clinical situations." (2005) Based on these studies it appears that there is not a significant difference between in-person (I-P) assessments and remote assessments.      According to Norman,  regarding his paper on telepsychiatry in the UK, "This paper concludes that the use of video conferencing can enhance psychiatric services within the UK especially for those patients who live in rural areas. Current advances in technology make this an increasingly more reliable and cost-effective method for assessing patients. The limitations of telemedicine are discussed and it is clear that this type of care is not suitable for all patients. Further research is required to assess the types of patients that telepsychiatry is most suitable for." (2006)      I think telepsychiatry can be very successful based on these studies. For me personally, it would make my life easier. I see my doctor every three months for medication management, this could easily be done via video conferencing. The cost effectiveness is also an important factor. However, based on my own experiences, there are some cases where seeing a psychiatrist  in person is important.     In remote areas, I think telepsychiatry could be extremely beneficial and cost effective. It allows those in rural areas get the care they need without having to drive long distance to see their doctor.  References: Hanson, C.W. (2007) Healthcare Informatics McGraw-Hill (2005) Can telepsychiatry replace in-person psychiatric assessments? A review and meta-analysis of comparison studies. Hyler SE, Gangure DP, Batchelder ST. CNS Spectr. 2005 May;10(5):403-13. Review. PMID:15858458 (2006)  The use of telemedicine in psychiatry S Norman J Psychiatr Ment Health Nurs. 2006 December; 13(6): 771–777. doi: 10.1111/j.1365-2850.2006.01033.x

  

             Beaty, K. (2013) Telemedicine Applications

The Impact on the Electronic Medical Records Integration and Advanced Reporting Systems

       When implementing a strategic implementation plan for an electronic health record (EHR), a facility must consider the benefits of the system vs. the cost of implementation, including training. While most hospital systems throughout the country are already using some form of an EHR, consideration must be given when implementing a new system or upgrading an old system. One of these systems, EPIC,  has been growing rapidly in the medical community.  In 2003, EPIC was chosen by Kaiser Permanente to provide the electronic system to cover 36 hospitals and over 8 million members. Currently, its systems will cover 127 million patients with active electronic health records by July 2013. (Freudenheim, 201One of the core functions of a successful EHR is enhanced reporting systems. One of EPIC's department or module EHR is the Radiant Radiology Information System, this system "combines tools for rules-based scheduling, documentation, results communication, chart/film tracking and detailed statistical reporting in a unified system that is fully integrated with our clinical systems. Radiant allows clients to link images and reports with a single system that can be accessed simultaneously by multiple users in multiple departments." (EPIC, 2012)

     Enhanced reporting systems are an essential part of the EHR. This allows for health care providers to keep track of patient information, doctor orders, and results of tests. For the administrator, enhanced reporting systems show the statistics of the department and see the cost/benefit ratio.

     Assuming a hospital has already begun to implement the EPIC system, a strategic plan needs to be in place for each of the departments within that hospital. The Radiant Radiology Information System that EPIC offers is to be implemented, and as such, a strategic plan needs to be enacted to successfully integrate the department's functions.

    According to healthit.gov, there are six steps in implementing an EHR.

·         Assess your department's readiness - The first step in EHR implementation is to conduct an assessment of the current department and its goals, needs, and financial and technical readiness. With an accurate view of your level of preparedness, your department can design an implementation plan that meets specific needs.

·         Plan your approach - Planning draws on the information gathered during the assessment phase, to outline the department's EHR implementation plan.

·         Select an EHR - In this case, EPIC is the system that has been chosen to meet the needs of the hospital as a whole.

·         Conduct training and implement the system - EHR implementation involves the installation of the EHR system and associated activities, such as training, mock “go-live,” and pilot testing.

·         Achieve meaningful use - The final phase of EHR implementation includes successfully attesting to demonstrating meaningful use of EHRs, and reassessing what you have learned from training and everyday use of the system

·         Continue quality improvement - Emphasizes continuous evaluation of your practice's goals and needs post-EHR-implementation to continue improving workflows that achieve the individual practice's goals while leveraging the functionality of electronic health records. (healthit.gov, 2013)

     Once the EHR has been implemented, it is now time to see the benefits of the system, particularly the enhanced reporting systems for the radiology department. According to Danton, Radiology reports contain a wealth of data that could be used for research purposes if it were easily extractable. (2010) These reports could be standardized and structured with an EHR. Structured reporting has been characterized as having 3 features: headings, such as history and findings must be consistent; the report is itemized, with short, descriptive terms, and; the report uses a standard lexicon with codified terms.(2010)

    Additionally, Danton goes on to say, "Many current structured reporting systems use a click-based approach where reports are constructed by pointing the mouse at a series of options. These systems are most commonly used for mammography, but are available for the entire body. Unfortunately, the large number of clicks to generate a report can be discouraging and requires the radiologist to spend time looking at the reporting screen and away from the images. An ideal structured reporting system allows radiologists to keep their eye on the image as much as possible with little glancing away at the dictation. Once the dictation technique is learned, structured reports can be standardized throughout a practice or institution and can be designed to include information required to maximize billing, decrease TAT and improve readability. With codified terms that can be catalogued, research institutions will be able to efficiently extract data from accumulated patient reports." (2010)

     An EHR system such as EPIC can greatly improve the reporting system in the radiology department. EPIC has currently worked with NUANCE to include voice recognition software to their systems. This is especially important in the radiology department, where a radiologist can dictate and have it transcribed immediately into the system. (Terry, 2012)

     Once the department has been set up with its new EHR system, and has enhanced its reporting methods, it is essential that the hospital and the department follow the Health Insurance Portability and Accountability Act(HIPAA) and comply with all regulations.

    According to Healthit.gov, "The HIPAA Privacy Rule establishes a set of national standards for the use and disclosure of individually identifiable health information – often called protected health information (PHI) – by covered entities, as well as standards for providing individuals’ with health information privacy rights and helping individuals understand and control how their health information is used."

In general, HIPAA Privacy Rule requirements:

• Apply to most health care providers;
• Set a federal floor for protecting individually identifiable health information across all mediums (electronic, paper, and oral);
• Limit how covered entities may use and disclose individually identifiable health information they receive or create;
• Give individuals rights with respect to their PHI, including a right to examine and obtain a copy of information in their medical records and the right to ask covered entities (that’s you!) to amend their medical record if information is inaccurate or incomplete;
• Impose administrative requirements for covered entities; and
• Establish civil penalties.

     Additionally, Healthit.gov goes on to say, "An EHR alters the mix of security needed to keep patient health information secure, and it brings new responsibilities for safeguarding your patients’ health information in an electronic form.

The HIPAA Security Rule establishes national standards to protect individuals’ electronic protected health information (e-PHI) that is created, received, used, or maintained by a HIPPA covered entity. The Security Rule requires appropriate administrative, physical and technical safeguards to ensure the confidentiality, integrity, and security of ePHI.

These safeguards, when applied well, can help you avoid some of the common security gaps that lead to cyber attack or data loss. They can protect the people, information, technology, and facilities that you may depend on to carry out your primary mission: helping your patients.

The HIPAA Security Rule requires covered providers to implement security measures, which help protect patients’ privacy by creating the conditions for patient health information to be available but not be improperly used or disclosed." (2013)

     In conclusion, it is easy to see how an electronic medical system is implemented with a strategic plan can be used to improve data collection and reporting within not only a radiology department within a hospital, but the entire hospital.

Sources:

Freudenheim, M. (2012) Digitizing Health Records, Before It Was Cool retrieved February 18,
     2013 from http://www.nytimes.com/2012/01/15/business/epic-systems-digitizing-health-
     records-before-it-was-cool.html?pagewanted=all&_r=0

Epic (2012) Departments and Ancillaries retrieved February 18, 2013 from
     http://www.epic.com/software-ancillaries.php

Healthit.gov (2013) How to Implement EHRs retrieved February 18, 2013 from
     http://www.healthit.gov/providers-professionals/ehr-implementation-steps

Gary, H. D. (2010). Radiology reporting: Changes worth making are never easy. Applied 
     Radiology, 39(5), 19-23. Retrieved from
     http://search.proquest.com/docview/346164814?accountid=32521

Terry, K. (2012) Nuance Adds Voice Recognition To Mobile EHRs retrieved February 18, 2013
    from http://www.informationweek.com/healthcare/electronic-medical-records/nuance-adds-
     voice-recognition-to-mobile/240009721

Healthit.gov (2013) Integrating Privacy & Security Into Your Practice retrieved February 18,
     2013 from http://www.healthit.gov/providers-professionals/ehr-privacy-security/practice-

     integration

Beaty, K. (2013)  Enhanced Reporting Systems for the Electronic Medical Record