Ethics

[Guest guest]

The clinic is not an experimental forum. If someone wants to experiment, they should design a research protocol, or try the new modality on a different patient. . . .if they are competently trained at it.

 

Clinic shifts should be set up, at an advanced level only, for exposure to different methodologies. Otherwise, one needs to follow through with the logic of a particular method from intake to diagnosis to treatment, until the scheduled treatment series is complete.

 

If, as you point out, the patient is significantly better, the student practitioner should finish up the protocol and discharge the patient, or refer out.

 

Learning a variety of treatment methods should never be done at the expense of the patient. In addition, we should not encourage a 'jack of all trades' method of learning Chinese medicine. One needs to first master the primary approach developed in the particular school (TCM, Japanese, Worsley), then one can develop exposure to other methods. Eclecticism too early leads to poor comprehension and results. At advanced training levels, one can develop other skills and logical methods.

 

 

 

 

On Tuesday, August 21, 2001, at 10:43 PM,

 

 

> Here's an ethics question for y'all.  Assume you have developed a

> successful treatment plan for your patient that has demonstrated

> progressive improvement and has alleviated all major symptoms.  Is it OK

> to then change the treatment plan for the sole purpose of conducting an

> experiment to see if an alternate plan would be equally effective.  This

> came up in the school clinic when students insisted that their need to

> learn a variety of treatment methods was of utmost importance, even if

> it disrupted the patient's care.  Any thoughts?

>

> --

>

> Chinese Herbs

>

> VOICE:  (858) 946-0070

> FAX:  (858) 946  0067

>

>

>

>

 

 

[Guest guest]

, " " <zrosenbe@s...> wrote:

 

>

> Learning a variety of treatment methods should never be done at the

> expense of the patient.

 

It seems like this should be a rhetorical question, but it provoked a

vicious argument.

 

[Guest guest]

Hello,

 

Here is my 2 cents:

 

I think with informed consent, you can do it. If I

have gone to a seminar and learned a new technique, I

will ask some of my patients if they would like to try

something new. I ask the patients who have flexible

personailities and who have been with me a while, or I

ask the ones who are not getting great results with

their current treatment. Most say yes and are excited

to get something 'special.'

 

I would not try to do this with fragile or new

patients.

 

Lorraine

 

--- Todd < wrote:

> Assume you have developed a

> successful treatment plan for your patient that has

> demonstrated

> progressive improvement and has alleviated all major

> symptoms. Is it OK

> to then change the treatment plan for the sole

> purpose of conducting an

> experiment to see if an alternate plan would be

> equally effective.

 

=====

Lorraine Wilcox L.Ac.

 

 

 

Make international calls for as low as $.04/minute with Messenger

http://phonecard./

[Guest guest]

Seems to me that Z'ev and Lorraine are both correct. Without informed

consent, it is generally accepted in the medical field since the

1960s that it is unethical to experiment on a patient. However, if the

patient consents, that is another matter. But I also agree with Z'ev,

if one wants to experiment, then one should write a research protocol,

get a grant, and run the research.

 

Not only is experimentation with disclosure on the part of the

practitioner and consent on the part of the patient generally

considered unethical by medical professionals, it may also be legally

actionable. After all, the definition of malpractice is a practice

which is not considered standard by other members of the medical

profession in the community where it was employed. If, for some

reason, the practitioner was hauled into court, and the judge or jury

heard that the practitioner was experimenting on the patient without

disclosure and/or consent, I feel confident any judgement would go

against the practitioner.

 

It sounds to me like this student needs to be informed about A)

medical ethics in the West, and B) legal responsibilities and

liabilities. Sounds to me like they are dangerously uninformed. Are

PCOM students given a course in medical ethics and laws BEFORE they

start working in clinic? If not, why not?

 

Bob

 

, wrote:

> Here's an ethics question for y'all. Assume you have developed a

> successful treatment plan for your patient that has demonstrated

> progressive improvement and has alleviated all major symptoms. Is

it OK

> to then change the treatment plan for the sole purpose of conducting

an

> experiment to see if an alternate plan would be equally effective.

This

> came up in the school clinic when students insisted that their need

to

> learn a variety of treatment methods was of utmost importance, even

if

> it disrupted the patient's care. Any thoughts?

>

> --

>

> Chinese Herbs

>

> VOICE: (858) 946-0070

> FAX: (858) 946 0067

[Guest guest]

, pemachophel2001 wrote:

Are

> PCOM students given a course in medical ethics and laws BEFORE they

> start working in clinic? If not, why not?

 

they are and this is not a reflection of PCOM in general, but rather

the position of a few specific students. I have experienced this

attitude amongst some students at all 3 schools for which I have

worked. So it is a personal problem, not an institutional one, in my

opinion.

>

[Guest guest]

Listening in the background for a while... as a student in TCM- Todd - give us the lowdown on the current treatment and what suggestions were made for the new " experimental" one. After all, treatment should change as improvement occurs. Does "Disrupting" a patients care mean not mean seeing improvement on a different level? Is there a compromise between student and practitioner that would benefit the patient? - Todd Wednesday, August 22, 2001 1:45 AM cha ethics Here's an ethics question for y'all. Assume you have developed asuccessful treatment plan for your patient that has demonstratedprogressive improvement and has alleviated all major symptoms. Is it OKto then change the treatment plan for the sole purpose of conducting anexperiment to see if an alternate plan would be equally effective. Thiscame up in the school clinic when students insisted that their need tolearn a variety of treatment methods was of utmost importance, even ifit disrupted the patient's care. Any thoughts?--Chinese Herbshttp://www..orgVOICE: (858) 946-0070FAX: (858) 946 0067

[Guest guest]

, " Lea Inoue " <asianherb@m...> wrote:

>

> Listening in the background for a while... as a student in TCM- Todd - give us

the lowdown on the current treatment and what suggestions were made for the new

" experimental " one.

 

it was hypothetical. but it involved a complete abandonment of the

existing treatment plan for a different style. for example, switching

from a TCM style local/distal tx for pain to a Dr. Tan style or

tendinomuscular style or five element palpation or mark seem style or

orthopedic style (as taught by Matt Callison here in SD). I have seen

all these styles work and have no problem with any of them. However,

assuming that any one is effective, why would I want to change?

 

1. if the condition has changed

 

2. if the results are not satisfactory

 

I expect cumulative improvement at a certain pace. If this is

occurring, I will not " rock the boat " for " educational " purposes.

 

After all, treatment should change as improvement occurs.

 

agreed, but not from style to style on a whim. Also, this question was

posed not because it was clinically appropriate to change, but because

it was educationally desirable to see what would happen.

 

Does " Disrupting " a patients care mean not mean seeing improvement on

a different level?

 

the only " level " that interests me is the patients continued relief of

suffering

 

Is there a compromise between student and practitioner that would

benefit the patient?

 

Not really. I think it is more educational to discover that the

mundane standard treatments work most of the time and the personal

boredom of the px should never factor into clinical choices. Trying to

liven things up for oneself is a poor reason to disrupt pt. care. On

the other hand, seeking better results is a good reason. I am all for

that. for example, in stroke patients getting adequate results from

local/distal tx, I would be amenable to changing to scalp acupuncture,

which seems to have dramatic results at time.

 

[Guest guest]

At 11:00 PM -0400 8/23/01, Lea Inoue wrote:

>Listening in the background for a while... as a student in TCM- Todd

>- give us the lowdown on the current treatment and what suggestions

>were made for the new " experimental " one. After all, treatment

>should change as improvement occurs. Does " Disrupting " a patients

>care mean not mean seeing improvement on a different level?

--

What different level? The specifics of the treatment options aren't

relevant to the ethical question here. In Todd's example no-one

disputed that one option was working well and that the other was

experimental. The question was whether the student's desire to have

more variety in their teaching clinic protocols, including

experimental treatments, should supercede their duty to the patient's

welfare.

 

> Is there a compromise between student and practitioner that would

>benefit the patient?

--

The student clinician's prime motivation should be the welfare of the

patient. This is an absolute and fundamental principle, over which

there is no room for compromise or relativistic analysis. Benefit to

the patient relies on the clinician's motivation, prior to any

benefit they may receive from treatment. The way Todd posed the

dilemma was that the student/s " insisted that their need to learn a

variety of treatment methods was of utmost importance, even if it

disrupted the patient's care. " Clearly their motivation was self

interest rather than the interest of the patient, and therefore it is

unethical.

 

Rory

[Guest guest]

I thoroughly to agree with your points- quite logical and well thought. - Friday, August 24, 2001 8:45 AM Re: ethics , "Lea Inoue" <asianherb@m...> wrote:>> Listening in the background for a while... as a student in TCM- Todd - give us the lowdown on the current treatment and what suggestions were made for the new " experimental" one.it was hypothetical. but it involved a complete abandonment of theexisting treatment plan for a different style. for example, switchingfrom a TCM style local/distal tx for pain to a Dr. Tan style ortendinomuscular style or five element palpation or mark seem style ororthopedic style (as taught by Matt Callison here in SD). I have seenall these styles work and have no problem with any of them. However,assuming that any one is effective, why would I want to change?1. if the condition has changed2. if the results are not satisfactoryI expect cumulative improvement at a certain pace. If this isoccurring, I will not "rock the boat" for "educational" purposes.After all, treatment should change as improvement occurs.agreed, but not from style to style on a whim. Also, this question wasposed not because it was clinically appropriate to change, but becauseit was educationally desirable to see what would happen. Does "Disrupting" a patients care mean not mean seeing improvement ona different level?the only "level" that interests me is the patients continued relief ofsuffering Is there a compromise between student and practitioner that wouldbenefit the patient?Not really. I think it is more educational to discover that themundane standard treatments work most of the time and the personalboredom of the px should never factor into clinical choices. Trying toliven things up for oneself is a poor reason to disrupt pt. care. Onthe other hand, seeking better results is a good reason. I am all forthat. for example, in stroke patients getting adequate results fromlocal/distal tx, I would be amenable to changing to scalp acupuncture,which seems to have dramatic results at time.Todd

[Guest guest]

Since TCM is an empirical art every treatment given is an experiment. Its a little like a golf game. You hit the ball and then re-evaluate and change

Alon

[Guest guest]

Alon,

 

I hope that we can steer any resulting

discussion in a productive direction, but

I have to begin by stating a disagreement

with your argument.

 

, <alonmarcus@w...> wrote:

> Since TCM is an empirical art every treatment given is an

experiment.

 

You're collapsing two meanings of the word

" experiment " here. One is to undertake something

the results of which are unknown, the other

is a much more closely defined scientific

term. These are not equal terms. Everything

that we do in life that is experimental, in

the first sense, does not constitute a scientific

experiment. There are acknowledged and accepted

patterns of thinking, of knowledge, and of demonstrating

the accuracy and effects of theories and ideas.

 

Medicine is an empirical art, and not all

medical treatments are experiments. Flying

an airplane is an empirical art and not

all flights are experimental.

 

Its a little like a golf game. You hit the ball and then re-evaluate

and change

 

True enough, but so what? As I understand

the point under discussion, at issue is

the ethics of altering clinical procedures

for the benefit of students. Your attitude

here in response to this issue suggests a

policy of " anything goes " . I think the whole

field currently suffers from widespread

versions of this attitude and policy.

 

Chinese medicine is highly systematic; Unschuld

calls it the medicine of systematic correspondence.

One of the keys in a golf game, or so I'm told...

I'm not a golfer, is knowing when to take which

club out of the bag. I think Tiger Woods pays

his caddy $1,000,000.00 US every year, and it's

not just to carry the clubs, but to advise him

on when to use which one.

 

Chinese medicine has an extensive array of

tools that can indeed be used in a wide

range of clinical situations, but only those

who know them well know when to use which one.

 

Part of the proper education of a student

is the imparting of a series of principles,

axioms, precepts, as well as a method of

thinking and reasoning. Of primary importance

in this whole set of tools is the attitude

of the practitioner towards the patient.

 

To regard the patient as a subject of

experiment runs counter to the traditional

attitude of doctors of Chinese medicine,

both in my experience and as recorded in

the collective experience of generations

past.

 

Always bearing in mind the fundamental

principle that different patients at

different times in different places

require different treatments, we are

not thereby given some sort of unrestricted

liberty to do as we please with those

who present themselves for care.

 

Clearly there are circumstances which

justify the conduct of clinical experimentation.

But these are the relatively rare exceptions

to the established rule.

 

The extent to which there is no

established rule is a measure of the

extent to which we have yet to incorporate

the roots of the subject in our version

of it.

 

Ken

[Guest guest]

Medicine is an empirical art, and not allmedical treatments are experiments. Flyingan airplane is an empirical art and notall flights are experimental

>>>>I really do not have any disagreement with your statements. I came back from vacation and read only a portion of a discussion. That said, I think there is a big difference in for example testing thyroid levels and then balancing them, a process for the most part is very predictable and what we can do with TCM, which is truly an empirical science. Evidence base medicine is not an empirical art or science. That said, as I am getting older I believe less and less in the present scientific metrology in medince

Alon

 

-

yulong

Tuesday, August 28, 2001 10:53 AM

Re: ethics

Alon,I hope that we can steer any resultingdiscussion in a productive direction, butI have to begin by stating a disagreementwith your argument. , <alonmarcus@w...> wrote:> Since TCM is an empirical art every treatment given is an experiment.You're collapsing two meanings of the word"experiment" here. One is to undertake somethingthe results of which are unknown, the otheris a much more closely defined scientificterm. These are not equal terms. Everythingthat we do in life that is experimental, inthe first sense, does not constitute a scientificexperiment. There are acknowledged and acceptedpatterns of thinking, of knowledge, and of demonstratingthe accuracy and effects of theories and ideas.Medicine is an empirical art, and not allmedical treatments are experiments. Flyingan airplane is an empirical art and notall flights are experimental.Its a little like a golf game. You hit the ball and then re-evaluate and changeTrue enough, but so what? As I understandthe point under discussion, at issue isthe ethics of altering clinical proceduresfor the benefit of students. Your attitudehere in response to this issue suggests apolicy of "anything goes". I think the wholefield currently suffers from widespreadversions of this attitude and policy.Chinese medicine is highly systematic; Unschuldcalls it the medicine of systematic correspondence.One of the keys in a golf game, or so I'm told...I'm not a golfer, is knowing when to take whichclub out of the bag. I think Tiger Woods payshis caddy $1,000,000.00 US every year, and it'snot just to carry the clubs, but to advise himon when to use which one.Chinese medicine has an extensive array oftools that can indeed be used in a widerange of clinical situations, but only thosewho know them well know when to use which one.Part of the proper education of a studentis the imparting of a series of principles,axioms, precepts, as well as a method ofthinking and reasoning. Of primary importancein this whole set of tools is the attitudeof the practitioner towards the patient.To regard the patient as a subject ofexperiment runs counter to the traditionalattitude of doctors of Chinese medicine,both in my experience and as recorded inthe collective experience of generationspast.Always bearing in mind the fundamentalprinciple that different patients atdifferent times in different placesrequire different treatments, we arenot thereby given some sort of unrestrictedliberty to do as we please with thosewho present themselves for care.Clearly there are circumstances whichjustify the conduct of clinical experimentation.But these are the relatively rare exceptionsto the established rule.The extent to which there is noestablished rule is a measure of theextent to which we have yet to incorporatethe roots of the subject in our versionof it.KenChinese Herbal Medicine, a voluntary organization of licensed healthcare practitioners, matriculated students and postgraduate academics specializing in Chinese Herbal Medicine, provides a variety of professional services, including board approved online continuing education.

[Guest guest]

 

I seriously doubt that anyone at the student level could effectively

switch from TCM style to such totally different methods with any sense

of competence, unless they had previous training. If they use any of

these methods, they would also need to start from scratch with their

diagnosis, and have a supervisor handy who is proficient in the

particular method chosen. Otherwise, what is the point?

 

 

On Friday, August 24, 2001, at 05:42 AM, wrote:

 

>

>

> it was hypothetical.  but it involved a complete abandonment of the

> existing treatment plan for a different style.  for example, switching

> from a TCM style local/distal tx for pain to a Dr. Tan style or

> tendinomuscular style or five element palpation or mark seem style or

> orthopedic style (as taught by Matt Callison here in SD).  I have seen

> all these styles work and have no problem with any of them.  However,

> assuming that any one is effective, why would I want to change?

>

[Guest guest]

, " " <zrosenbe@s...>

wrote:

>

> I seriously doubt that anyone at the student level could

effectively

> switch from TCM style to such totally different methods with any

sense

> of competence, unless they had previous training. If they use any

of

> these methods, they would also need to start from scratch with

their

> diagnosis, and have a supervisor handy who is proficient in the

> particular method chosen. Otherwise, what is the point?

>

>

>

 

This is an excellent point. One can't just switch gears on a whim

and expect to be effective. Japanese Meridian Therapy, for example,

while seemingly very simple actually requires a very different set of

skills (point location, needle tq, etc)

which require very experienced supervision. When I was a student I

was lucky enough to find someone with some experience in the style to

intern with. But I have to say it took me MORE time (5 years of

study) and MORE money than I spent on school to get to the point

where I have been able to use Meridian Therapy effectively on a

consistent basis in the clinic.

 

Robert Hayden, L.Ac.

http://jabinet.net

[Guest guest]

Hi Kath Bartlett,

 

I mean no disrespect to Robert, but I was wonder what your sense was of charity.

Is there an ethical basis for treating a low wage factory worker who is a single

parent of four children? Is it possible that charity is the unethical treatment

of rich people? Is charity possibly disruptive of " balance, synchronicity and

the uninhibited flow of qi " ?

 

Many practitioners of merit have the view that they need to do a certain amount

of service to the community. That is, they feel they must waive their charges

or greatly reduce them for some of their patients. I get it that you are

suggesting that this is unethical .... in addition to the notion that it is

illegal.

 

Irrelevant of the law, you seem to be taking this issue from a purely ethical

perspective regarding the moral and philosophical grounds for treating or not

treating people based purely on economics and not on need. That is, they will

or will not get service based on whether they pay a set fee.

 

So would you or could you in good faith treat a patient who could not pay you?

Or who could only pay you a fraction of your charges? If you treated such a

patient, would you be ethically abusing your well to do patients? I'm wondering

how you view this personally. Thanks.

 

Additionally, if you had two clinics in different regions 100 miles apart, would

you view it as ethical to charge different rates in the different clinics based

on regional economics, or possibly to cover you cost of travel? Thanks again

for your consideration.

 

Respectfully and gratefully,

Emmanuel Segmen

 

 

 

 

[Guest guest]

emmanuel:

 

i think you are reading too much into my post. the issue here is

uniformity. singling out certain groups or individuals and providing more

benefits to them (including lower fees) that are not available to you entire

patient population is a discriminatory practice against those who are not

offered/eligible said benefit.

 

i'm am not saying do not help the indigent. what i am saying is you have to

be careful how you do it so that your fee schedule is not discriminatory.

 

if you will kindly go back to my original post, i gave a couple of examples

of how you could do this legally and ethically:

 

you can offer a discount on a particular day or time: monday mornings are

10% off. again, you have to offer it to all your patients so that anyone

who wanted to could take advantage of the opportunity, but you could steer

the indigent into those time slots.

 

if you want to offer a lower price to a particular population, you need a

separate location: $45tx at x,y, z clinic. again, anyone who comes to that

location gets the $45 tx. you would need to be able to show that the lower

overhead at location B enables you to offer the tx at the lower rate: the

location across town is a bare bones setting in a low rent district, with

fewer amenities and staffing needs.

 

hope this speaks to your concerns,

 

kath

 

 

 

On Wed, Aug 20, 2008 at 10:50 PM, Emmanuel Segmen <mrsegmenwrote:

 

> Hi Kath Bartlett,

>

> I mean no disrespect to Robert, but I was wonder what your sense was of

> charity. Is there an ethical basis for treating a low wage factory worker

> who is a single parent of four children? Is it possible that charity is the

> unethical treatment of rich people? Is charity possibly disruptive of

> " balance, synchronicity and the uninhibited flow of qi " ?

>

> Many practitioners of merit have the view that they need to do a certain

> amount of service to the community. That is, they feel they must waive their

> charges or greatly reduce them for some of their patients. I get it that you

> are suggesting that this is unethical .... in addition to the notion that it

> is illegal.

>

> Irrelevant of the law, you seem to be taking this issue from a purely

> ethical perspective regarding the moral and philosophical grounds for

> treating or not treating people based purely on economics and not on need.

> That is, they will or will not get service based on whether they pay a set

> fee.

>

> So would you or could you in good faith treat a patient who could not pay

> you? Or who could only pay you a fraction of your charges? If you treated

> such a patient, would you be ethically abusing your well to do patients? I'm

> wondering how you view this personally. Thanks.

>

> Additionally, if you had two clinics in different regions 100 miles apart,

> would you view it as ethical to charge different rates in the different

> clinics based on regional economics, or possibly to cover you cost of

> travel? Thanks again for your consideration.

>

> Respectfully and gratefully,

> Emmanuel Segmen

>

>