Archive for the 'Medical ethics' category

Clinical Conundrum Thursday

Dec 02 2010 Published by under Medical ethics, Medicine

Mr M. is a 58 year old man with severe, chronic neck pain.  He has a history of hypertension, tobacco dependence, stomach ulcers, mild kidney disease, alcoholism (in remission for 10 years), and a "bleeding problem".  He has no history of heart disease, stroke, depression, or diabetes.  His family history is significant for heart disease in his father and alcoholism in his mother and two of his siblings. He was referred to you by a friend after expressing dissatisfaction with all his previous doctors.

His neck pain began nearly fifteen years ago after a minor traffic accident.  He has had multiple imaging studies that show significant arthritis of the spine at the level of the neck, but no compromise of the spinal cord.  There is some pressure on the nerves exiting the neck that supply the right arm.  He has some pain in that arm, but has full use of it.  His pain prevents him from keeping a steady job, and he often feels so bad that he doesn't bother to eat.

A surgeon offered to operate on several occasions, but warned the patient that the bleeding problem would increase the risk.  He takes ibuprofen tablets by the handful throughout the day, which gives him significant relief.  He says that he has been told that the ibuprofen caused his ulcer, which bled bad enough to land him in intensive care and required a transfusion of eight units of blood (that's a lot of blood).  He saw a pain specialist who tried a few different medications, but would not use any narcotics because of the risk of  "addiction".  His previous family doctor also warned him against using any narcotic pain relievers.

Today in the office, he appears tired and thin.  His blood pressure is elevated, and his brow is furrowed.  He turns his head carefully when you walk in the room.   He has full strength in all his extremities, except for some equivocal weakness in his right hand.  The rest of his exam is normal.  Laboratory examination shows mild anemia and some kidney dysfunction.  His blood is negative for alcohol and for drugs of abuse.  You review his MRIs which are consistent with what he has told you.

The patient tells you that you are the last resort; he practically begs you for help.  He has heard so many good things about you.  He has heard of some pill that starts with "V" that really helps some people.

How would you approach this case?

35 responses so far

Medical Ethics Friday: Is your doctor on the payroll, and should you care?

Oct 22 2010 Published by under Medical ethics, Medicine

I'm a medicine geek.  I love it.  I love going through cases in detail, developing a differential diagnosis, tossing around ideas with colleagues.  Medicine is great fun.   The professional organization for my specialty is the American College of Physicians, and we had our state chapter meeting recently.  One of the highlights was a session where experts were given difficult cases to solve.  These docs were sharp.  They are all respected clinicians and researchers, usually department or division chiefs.   Watching them work can be very humbling (well, not for them...).

There are no "grades" for doctors; your reputation is whatever your colleagues and patients say it is.  I like to think that these opinions will roughly track with ability.  What is certain, though, is that a real reputation can't be bought.  But that doesn't stop people from trying.

One of the big stories this week was ProPublica's Dollars for Doctors, an investigation into the relationships between pharmaceutical companies and doctors hired to speak for them.  These docs are often touted as experts in their fields.   What ProPublica found (and what is unlikely to surprise many doctors) is that many speakers are not exactly experts, and many are not exactly at the top of their fields.

Speaking for drug companies can be very lucrative.  I've been approached a number of times, and given that even a few speaking engagements per year can significantly supplement the salary of a primary care doc, it's not surprising that many say "yes".

Having a financial relationship with a drug company is not prima facie unethical.   But there are all sorts of ethical pitfalls, some subtle, some not, that emerge from such a relationship.

So, here's a case:

You're sitting at dinner and start to feel some indigestion.  You burp a few times, but aren't getting any better. In fact, you rapidly feel worse, and the "heartburn" starts to make your arm and neck ache.  You start feeling panicked, and are having a little trouble breathing.  Your spouse calls 911 and you're brought to a tertiary care hospital where you are found to be having an "acute coronary syndrome", but not an active heart attack.  The ED docs put you on medications and transfer you to the cardiac unit.  A cardiologist recommends going for an angiogram and possible stent placement in the morning.

Depending on the results of the angiogram, possible solutions to your problem may include coronary artery bypass graft surgery, angioplasty with stent placement (with either a bare metal or drug eluting stent) or medical therapy.  There may be further findings that suggest the need for an implantable device such as a defibrillator or pacemaker.

The cardiologists at the hospital have seen their (substantial) incomes decline significantly over the last couple of years due to a combination of better treatment of heart disease (not as many people need expensive interventions) and cutbacks in what they are paid for diagnostic tests and other procedures.  Some of the docs supplement their income by speaking for drug and device manufacturers.   The department has a national reputation, however, with the cardiologists actively involved in research and publication.

You don't have a lot of time to shop around.

What sorts of ethical problems might be involved here?  Are the doctors' judgments inherently invalid?

Remember some of the basic ethical principles: beneficence, non-maleficence, autonomy, justice.

There are a number of obvious questions here, but also a number of non-obvious problems.  I'd like to hear what you think.

18 responses so far

Medical Ethics Friday

Oct 15 2010 Published by under Medical ethics, Medicine

A few readers asked if we could have more frequent ethical discussions.  That seems like a good idea.  Here's a new case.

You are a family physician practicing in a busy urban area where you take care of hundreds of families from diverse backgrounds. You care from them from birth to death, both in the office and in the hospital.  One evening, the emergency department calls you.  Mr. F., a Jehovah's Witness, is in the ED feeling weak and short of breath.  He's a 40 year-old single father of four kids.  You've cared for him since he was a young man,  through his marriage, the birth of his kids (whom you delivered and continue to care for), and the death of his wife.  Lately, he has had terrible back pain from his job at the plant and has been taking a lot of "pain pills".   He has always made it clear to you that his religious beliefs are central to his life, and among these beliefs is an abhorrence of blood transfusions.  He will never accept one, no matter the circumstance.

The ED doctor is frustrated on the phone.  Mr. F.'s blood count is dangerously low.  It looks like he's been bleeding, perhaps from an ulcer.   They are giving him IV fluids, and may consider taking him to the OR, but they are afraid he won't last long.  His kids are in the waiting room with their elderly, infirm grandmother, also your patient.  The ED doc wants to wait until he passes out, then give him an "emergency" transfusion with the patients "presumed" consent.  The ED doc sounds afraid and frustrated and is wondering what you can add to the patient's care.

59 responses so far

Update on yesterday's ethics case

Oct 09 2010 Published by under Medical ethics, Medicine

The comments on yesterday's ethics post are terrific.  Please keep them coming.  I'm working on responding to each one in context.

One, though, I'm promoting to it's own post, because the author asks particularly interesting questions that require more space for examination:

I don’t really see an ethical problem here.

I love that phrase, and what follows, so let's discuss.

First, contemporary doctors in most countries are forced to practice “defensive medicine”, i.e. they are trying to protect themselves against possible lawsuits. The most important thing is to have impeccable documentation.

I've argued previously that a medical ethics course should be a pre-requisite for medical school admission.  The ethics of our profession are not easy to follow, and before committing to being constrained by them for a lifetime, a student has the right to know what they're getting into.  The commenter's first point shows exactly why she doesn't see an ethical problem: she is focused primarily on the physician's well-being.  While the physician's well-being is important, it is not primary.  Ignoring the unfounded assumption that most doctors practice "defensive medicine", she is correct about good documentation being vital.  But it is not the "most important thing."  The most important thing is providing good care, and usually, proper documentation furthers this goal.  But not always.

After explaining to the patient that a doctor cannot lie in the chart and after informing her/him of their other possible options, they are free to choose what to do.

This is certainly true.  Transparency is important, but it's also important not to back a patient into an insoluble dilemma.  The patient wants my help and I am ethically bound to provide it, within certain parameters.  I certainly cannot lie in the chart (barring extreme circumstances such as guarding dissidents in a totalitarian regime or something), but this is not a dichotomous problem.

Second, I can’t really sympathize with such patients because what they are trying to do is shift the responsibility for their own medical problems and their consequences solely onto their doctors (not only for STDs, but even for the running nose of their children). This is not how the doctor-patient teamwork should function.

The patient has a problem.  Who "caused" the problem is largely irrelevant in providing proper care (aside from explaining to the patient the nature of disease and prevention, which she probably already understands).  I don't see her trying to "shift responsibility" as such, but she is reaching out for help.  She feels trapped, and from her perspective, my "lie" will help mitigate the harm of her actions.  I may believe her assumption to be wrong, and I will tell her that.  But it's not about blame.

Third, if a patient doesn’t want to to disclose a piece of sensitive information, he/she is not obliged to but once it’s on the table, there is little they can do about it.

An actual, dynamic doctor-patient relationship does not close doors.  Yes, she cannot make me "forget" the information, but neither should I tell her she no longer has any control over what happens.  This may cause harm to someone I'm trying to help.

The comment is one I expect to hear from many of my colleagues.  It is much more biased toward paternalism than patient respect and autonomy, a set of values that has shifted but that many clinicians still need to catch up with.

It is important to remember that the first goal is to provide care that helps the patient, minimizes harm to the patient, and does so respecting her autonomy, privacy, and dignity.  How the physician feels is much less important.

16 responses so far

Friday ethics coffee klatsch

Oct 08 2010 Published by under Medical ethics, Medicine

There was a time, you may remember, when I was off caffeine.  It was horrible. Those times are past, and lately, I've been favoring espresso over American coffee.   I usually pop out of bed about seven, hop in the shower, get dressed, and wake up PalKid. She's been a delight lately---I wake her up out of a sound sleep, and yet she's cheerful, cuddly, and ready to start her day.

Most of which she does without me.

I set her up with breakfast, and I'm out the door.  Depending on traffic patterns,  I stop at one of two coffee shops, both of them chains, unfortunately, but good chains.  I order a doppio in a real cup, stand at the bar and enjoy it briefly, and I'm on my way.

From there, I fight traffic to my office, stamp out disease, and then head over to my hospital's resident clinic to stamp out more disease.  One of the great things about working at a teaching institution is the ability to bounce ideas off each other.  We share clinical conundrums, and often enough, ethical ones.
I love ethics discussions.  I always imagine them taking place over coffee, with my brilliant colleagues explaining to me how in this case my definition of beneficence is not congruent with my patient's. That's not always the way it goes.
Many ethical discussions involve problems that are very real, and that are temporally constrained.  A patient laying in the ICU may need the care team and doctors to come up with a solution immediately.  And the various parties are emotionally tied to their firmly held opinions.  Consequently, ethical discussions are sometimes a bit of a, well, you can imagine, I think.  This is where tools like ethics committees can be very helpful.

In medicine, ethics discussions are very real.  They deal with real people in need if real guidance.  Let me share a (somewhat constructed) case with you.  But first, a favor. Pour yourself a cup of your favorite beverage, place yourself in the position of both parties, and give me some feedback.


A young woman comes to see you in the office.  She has been having some depression and anxiety.  She also has some pain on urination and a change in her normal vaginal secretions.  As a good doctor, you take a thorough history, paying special attention to the patient's chief complaints, trying to tease out connections to other problems and thinking of possible causes .  In the standard format of a medical chart note, you complete the HPI (history of present illness).  You move on to past medical history, family history, allergies, medications, and social history.  Social is a catch-all category for living situation, employment, habits, etc.  She is married with a teenage son.  She works full time. The patient tells you that she smokes cigarettes on the weekend when he goes to the bar, and that last week at the bar she met a man with whom he had unprotected sex.

As you continue the exam, you are thinking about her chief complaints.  Is she anxious because of the sexual encounter?  Was the encounter consensual? Is she worried about being pregnant or having an STD?  Is this a simple urinary tract infection? The sexual encounter is the piece of the history that ties everything together.

The patient stops.  She says, "Doctor, look, I need you to not write that down---the stuff about the guy.  You know my husband and I have been having problems, and we're working on it.  I can't risk him finding out.  You can't write it down."

Well, yes, I can.  The medical record is my record of observations, formulations, and plans.  I own it. I need it to be complete  in order to make intelligent decisions.  In some states, patients may addend their medical record to get in "their side", but from a practical standpoint, the chart is a tool the doctor uses to care for a patient and to fulfill certain legal requirements regarding documentation.

I need to use the information about her sexual encounter.  She may very well have an STI,  and without the complete sexual history, the visit doesn't make sense. But must I include this information?  What are my obligations to myself, the patient, the law, and my profession?

When something like this happens, it's important to set down the pen or the keyboard and focus on the patient.  Can she tell me more about why she wants this left out of the chart?  Is she afraid her husband may get access to it?  Or is it more of a personal privacy concern?


Medical records are a type of information known as PHI (protected health information).  The law (specifically HIPAA) protects PHI from inappropriate disclosure. But this information can be legally shared with the insurance company and can be shared for other medical uses, usually if needed to benefit the patient.  In this case, the husband may be the actual holder of the insurance policy, and the bills and EOBs (explanation of benefit forms) may come right to him.  In addition, any lab bills may list the labs I ordered and the diagnosis justifying the lab.  I have no idea how likely this actually is, and that's part of the problem---I cannot reassure my patient of her privacy.


I cannot lie in the chart.  I can, I suppose, choose not to include everything I know, and I can word things carefully, but I cannot lie.  If the patient tells me she has had three sexual partners in the last year, I cannot write, "the patient has been sexually active only with her husband in the last year."   I can fail to explicitly write the sexual history, but any other doctor (or lawyer) reading the chart would wonder why I left out a sexual history when someone clearly has a suspected STD.  If I fail to mention the sexual encounter, and a test  for chlamydia comes back positive, someone may assume that the husband was sleeping around and gave the patient chlamydia---which may or may not be true, but the implication is quite different than if a proper history had been noted.


I should not add the information to the chart without telling her.  Transparency encourages trust, deception destroys it.  And if she cannot trust me to include her in decisions about her data, she is less likely to share important data with me in the future.  On the other hand, I may be less likely to trust a patient who asks me to treat her without proper documentation.  Poor documentation leaves me open to potential liability.

Quality of care

I see many, many patients.  I cannot remember everything about every patient. What is written in their charts strongly influences my decision-making.  If I  fail to note this fact, I (or another physician) may fail to include important diagnoses in our future thinking.

Putting some of this into the language of medical ethics, how can I balance beneficence, non-maleficence, autonomy, and privacy/dignity?

Some ethical problems (most, really) do not have a clean answer.  I want to properly diagnose this patient's problem while maintaining her trust.  I want to avoid harming her by potentially exposing her private information.  And I want her to feel she has some control over herself and her information.

But as always, it's a balance.  I would tell her directly that I understand her concerns, and share some of them, but that failing to document properly may lead to other problems.  She engaged in a perfectly legal behavior that she wishes to remain private, but that may have led to a serious medical problem.  I can't change that, and she is left with no perfect choices.  I don't want her to avoid treatment in order to avoid having her problem documented, but I have to decide as a clinician whether I'm willing to leave out that information (a very tough call.  Also, no cheats here.  We are assuming there is no way for her to obtain confidential/unidentified testing and treatment elsewhere).

So, go refill your cup, sit down, and tell me what you think.

(Dr. FreeRide is an invaluable resource for me when I'm confused about how to approach ethical problems.  She rocks.)

64 responses so far

What about the ethics we don't share?

Sep 22 2010 Published by under Medical ethics, Medicine

As I thought a bit more about the doctor who wrote the letter to the editor we discussed yesterday, I wondered how two similarly-trained doctors (he and I) could come to such different conclusions about ethical behavior.

The generally agreed upon set of medical ethics we work with has developed over centuries.  Patient confidentiality, for example,  was demanded by Hippocrates of Kos.  But many of the medical ethics we work with are fairly modern developments that reflect the thinking of our surrounding society.  The changing weight of patient dignity and autonomy vs. physician paternalism is such an example.

Of course, not everyone agrees on all ethical principles.  Ideally, formal ethical statements for a profession are developed as part of a continuous, representative discussion.   Not all ethics are the result of a formal process however.  In the U.S., there is no one organization that represents all doctors; doctors generally operate independently, with the only legal requirement to practice being a state licence.

Decisions about ethics (or meta-ethics) should normally be made transparently.  The American Medical Association (a group that many doctors---including me---do not belong to) publishes a code of medical ethics.  They keep an online public record of past codes of ethics and of the process itself.   Though the AMA isn't representative of all doctors, it does represent many, and has had an ongoing discussion on ethics for well over a century.  Many other professional groups, including my own (the American College of Physicians) also have  detailed ethics manuals.

There are currently nine core principles listed by the  AMA, principles reflected in the more specific ethical statements published in the Code.  And while laws may reflect ethics, ethics aren't laws.  Just as there are no universally accepted set medical ethics, there is no universal mechanism for enforcing ethical behavior.  When an ethical violation intersects with a legal one, doctors may be punished.  Beyond that, what makes an ethical physician?

Why should physician's adhere to any code of ethics? Can't we just each rely on ourselves as individuals to do what's right?

As doctors we are given extraordinary privileges and responsibilities.  Physicians have always recognized that this demands high standards of behavior.  The way we act professionally must take into account not just what we each believe, but what our patients and our society believes.  Ethics are easy if we all have the same values.  Ethics get hard when we don't share beliefs. And when we don't share beliefs, we must at the very least remember our core principles, those of helping our patients, and not causing them harm; of granting them autonomy and privacy; of treating them with basic human dignity.

One of the more modern ethics in medicine is that of justice, especially justice as it relates to supporting the availability of health care for everyone.  I know many physicians who would look at AMA principle #9 ("A physician shall support access to medical care for all people") and think, "that sounds a lot like socialism. I hate socialism." The justification for this ethic is laid out in detail, and reminds us that health care is a societal good, and that it should be available to all, especially the most vulnerable.  What it doesn't say is how we should provide this care, only that these decisions should be made through an ethical process.

Some doctors bristle at any ethics that appear on first glance to conflict with their personal political beliefs.  What these doctors must remember is that their responsibilities as doctors is to their patients and to society.  If they truly believe the poor are more likely to receive adequate, affordable health care when it is delivered without a contribution from a public welfare system, then they are wrong, but not necessarily unethical.  If they simply wish to abolish government provision of health care for the poor because they don't approve of certain behaviors, they are behaving in a way that does not best serve their patients or society.

9 responses so far

Miscellania in tres partes

Sep 20 2010 Published by under Medical ethics, Medicine

First, a big "Willkommen" to my new German readers.  Apparently my Pope post was picked up by a German blog, and some of those folks have been nice enough to come by and leave some comments.  I often wonder if the war created a clearer message for the German post-war generation than it did for others.  Even among Americans who have heard of the Holocaust, few seem to understand its historical context.

Next, go get a cup of coffee and read today's post at Respectful Insolence. It addresses questions raised in a New York Times article last weekend, important questions about research ethics and how they mesh with the discovery of new, promising chemotherapy drugs.

Finally, there is a horrid little letter circulating on facebook.  According to Snopes, it was published as a letter to the editor in a Mississippi newspaper last year.  I present it here as further evidence that a certain subset of Americans are immoral, clueless, shitbags (Hey, Deutschlanders, check this out.)

Why Pay for the Care of the Careless?

During my last shift in the ER, I had the pleasure of evaluating a
patient with a shiny new gold tooth, multiple elaborate tattoos and a
new cellular telephone equipped with her favorite R&B tune for a

Glancing over the chart, one could not help noticing her payer
status: Medicaid.

She smokes a costly pack of cigarettes every day and, somehow, still
has money to buy beer.

And our president expects me to pay for this woman’s health care?

Our nation’s health care crisis is not a shortage of quality hospitals,
doctors or nurses. It is a crisis of culture — a culture in which it is
perfectly acceptable to spend money on vices while refusing to take
care of one’s self or, heaven forbid, purchase health insurance.

Life is really not that hard. Most of us reap what we sow.


First, let's be clear who he is writing about.  This doctor uses very clear dog whistles that imply that the patient is African American (gold tooth, R&B ring tone).  This immediately sets a specific tone: the patient is poor, Black, and therefore beneath being treated with basic human dignity.

But even pretending for a moment that this isn't an obvious racist screed, there are even more flaws with Dr. Jones's "analysis". This doctor objects to the government spending money on health care for someone with "bad habits" and who isn't, in the doctor's estimation, sufficiently frugal.

He uses this example to show how Medicaid (government medical assistance for the poor) is a waste of resources since poor (and presumably Black) people don't conform to a certain set of behavioral standards.  (Medicaid, by the way, primarily targets children and their parents, rather than childless adults.)

Physicians are, of course entitled to their own political beliefs, so let's assume that the obvious tone of disdain for his patient was absent from the letter.  The question then becomes,  should public assistance (for health care, food stamps, etc.) be tied to specific behavioral goals?  If so, why?  And how?

It is impossible to set behavioral goals for public assistance.  Do we really want to be in a position to punish people for being dependent on nicotine?  Do we want a panel to judge if a particular purchase made by a welfare recipient was non-frugal enough to cut off their assistance check?

Some people would like to do just that, or more likely, they would like to eliminate any form of government assistance.  This is a view born out of an inability to empathize in any way with the suffering of others.  This and his punitive desires  are clear in his letter when he suggests that a poor person purchase insurance, and when he states that life isn't hard and we should reap what we sow.

This point of view is objectionable in the way it dehumanizes the poor, the way it demands certain behaviors from the poor in exchange for basic human services.  As the letter shows, certain behaviors---those associated with minorities---are particularly despised.

While Dr. Jones's political views reveal him to be a  crappy human being, they also show him to be lacking in the basic empathy necessary to be a good doctor.  "Why pay for the care of the careless?"  Because we are "careless" from time to time, and because it's the right thing to do.

As physicians, we are daily in grave danger of rendering unhelpful judgments on our patients based on behaviors which we consider "bad". It is our calling, our responsibility, not to render judgment but to help them change in whatever way they can.

As physicians we must continually ask ourselves, "is what I am doing or planning in the best interest of this patient, or am I doing it more to please myself?"

In Jones's case, the answer is obvious.

27 responses so far

In Soviet Russia, your vote determined your job; In America...

Apr 12 2010 Published by under Medical ethics, Medicine, Politics

In the Soviet Union, party membership was everything. Your job, your access to food and other consumer goods, and your apartment all depended on your standing with the party. And votes were simply a tool to provide a patina of legitimacy. No one who liked warm weather voted against the Party.

One of the many advantages of the protections provided by the U.S. constitution is that we generally cannot be hired or fired based on our personal or political beliefs. We also get to elect our leaders frequently. So it should be with a great sense of irony that various teabagger groups shout and stomp about the US becoming a socialist regime, while simultaneously threatening armed rebellion for not getting their way in an election. And it is with disgust and disdain that I view professionals punishing others based on their vote or their political views.

When a physician fired an employee for voting for Obama, that was---I assume---a clearly illegal act. It was also immoral. But it has nothing to do with medical ethics.

But when a doctor refuses to see patients based on their politics, this is a gross violation of medical ethics. In fact, it's hard to think of a precept of medical ethics not violated by this sort of behavior.

Continue Reading »

25 responses so far

Crowd-sourcing your medical care

Mar 15 2010 Published by under Medical ethics, Medicine

The work up of "fever of unknown origin" (FUO) is a classic exercise in internal medicine. Originally defined as a temperature greater than 38.3°C (101°F) on several occasions for more than three weeks with no diagnosis after one week of inpatient study, the definition has shifted. This reflects the dramatic increase in the sophistication of outpatient work ups in the fifty or so years since the term was formally defined. About a third of cases turn out to be infection, another third cancer, a smaller percentage so-called collagen vascular diseases such as lupus. A significant percentage go undiagnosed. The work up can be time-consuming and difficult, and various consultants are often called in. In a modern twist, a Chicago man has asked "the internet" to help with his own FUO work up (h/t reader HP). It is just the sort of puzzle internists love, and it looks like he and his significant other have been getting a lot of input.
I have nothing to add to the work up at this point, although it's interesting. What has me thinking is the potential pitfalls, ethical and otherwise, of crowd-sourcing one's medical care. The problems can be divided into two broad categories: those centered on the patient, and those centered on health care professionals.

Continue Reading »

13 responses so far

More on Lacks ethics

Feb 03 2010 Published by under Medical ethics, Medicine

I'm heartened by the discussions of medical ethics arising out of The Immortal Life of Henrietta Lacks. From reading and listening to interviews with writer Rebecca Skloot, and from my brief conversations with her, I know that medical ethics were very much on her mind during the ten years it took her to create the book. If you read the book, you will see that she was also very concerned that she not be just another exploiter of the Lacks family. That's one reason comments such as this one are disturbing----and at the same time not really disturbing at all. It helps to highlight the amount of distrust the scientific community has managed to bank.

(As a reminder, Henrietta Lacks was an African American woman who died of cervical cancer in the 1950s and whose cancer cells, taken without her explicit consent, became one of the most important tools of modern biology.)

We've all benefited from research made possible by Henrietta Lacks and countless others whose names have been forgotten. The amount of distrust we've banked with the public over the years is considerable, and will take a long time to mitigate. But there are many reasons to try to improve our trust balance sheet, not the least of which is our own self-interest. 

But let's back up a bit and get a little deeper into how we understand medical ethics.

Continue Reading »

10 responses so far

Older posts »