February 1, 2003 Jan Pudlow Associate Editor Regular News Lawyers, doctors gather to discuss bioethics Associate Editor M any people stockpile pills so they have the means to end their life when it becomes unbearable. T o qualify for Medicare benefits for hospice care, a terminally ill patient must be within six months of death. Yet life expectancy is not easy to predict, and many doctors don’t want to declare their patients are going to die within six months.Even patients who clearly express their wishes to receive, refuse, withhold, or withdraw treatment are often ignored.Such end-of-life conundrums brought doctors, lawyers, nurses, medical students, clergy, professors, and policymakers to Tallahassee to attend the January 10 meeting of the Florida Bioethics Network.“What I hope to see out of this type of group is a sharing of knowledge and perspective, because it is so important to everybody,” said Lauchlin T. Waldoch, past chair of the Bar’s Elder Law Section who helped organize the event.“Particularly with elder law, we deal much more with incapacity issues. What happens, not if I die, but what happens if I don’t die and can’t manage my affairs — either financial or personal?” Waldoch said.In her opinion, the burning issue remains funding – not concentrating so much on stretching federal dollars for the future needs of aging Baby Boomers, but helping their parents in critical need of care right now.“The problem with Medicaid is those people in their mid-80s who need long-term care could not possibly have anticipated this situation,” Waldoch said.“Think about it: When I was growing up, my great aunt was ill, came to live with us, and my mom drove her around to the doctor. She got sick, she went to the hospital, and two weeks later she died. Same situation today: A) you don’t usually have the family support to do the assisted living level, because we’re spread all over and we’re all two-job families. And B), great aunt will go to the hospital today, and she doesn’t die in two weeks, but lives for another three years, because of medical technology. Nobody could have anticipated that. The cost of a nursing home in Tallahassee starts at about $4,000 a month. So those people who are middle class Americans, who have worked very hard all their lives and have paid their tax dollars to help be supported need the Medicaid program right now.”Lawyer Bill Allen, co-director of the Florida Bioethics Network and director of the University of Florida Program in Bioethics, Law and Medical Professionalism, led a discussion called “Death and the Legislature: A Florida Statute Update.”Even needed changes in the law are no guarantee that a patient’s end-of-life rights will be honored, he said, and educating health-care providers and patients how to communicate those difficult issues is key to changing the culture.“We need to have it be a routine question that the doctor asks, like ‘How are you doing with your blood pressure?” Allen said. “But that may be about as easy as making pain the fifth vital sign.”He suggested it be the primary care doctor’s duty to be the patient’s advocate when those end-of-life decisions to withhold or withdraw medical care are made in a hospital setting.“We need to make it part of the continuity of care,” Allen said.He said Florida is the first state in the country to have “best interest” as the default criterion for withholding and withdrawing care decisions.As detailed in F.S. 765(2), “Any health care decision made under this part must be based on the decision the proxy reasonably believes the patient would have made under the circumstances. If there is no indication what the patient would have chosen, the proxy may consider the patient’s best interest in deciding that treatments are to be withheld or withdrawn.”“In some cases, it may provide some relief, because no one knew what the patient wanted,” Allen said. “But it’s only a couple of years old and no court cases have tested it.”Florida State University’s new College of Medicine Dean Dr. Joseph Scherger said he was delighted to host the statewide conference.“The medical school was put in place to address the needs of Florida in health care, geriatrics, rural communities, culturally diverse and under-served communities,” Scherger said.“We’ve also been asked to produce humanistic positions. Well, what is a humanistic doctor? It’s one who puts the needs of the person, the patient, above all other concerns. Ethics is central to that. Medical ethics is really understanding the rights of people and helping make difficult decisions and always being a patient’s advocate.”A good doctor is an advocate, much as a good lawyer is an advocate, Dr. Scherger agreed.“Medicine done right is advocacy for people. Law done right is advocacy for people. We both know, on either side, that can be done wrong. Self-interest can be counter-productive to the welfare of society. Both professions, when not done well, can take advantage of people. When done well, they are advocates for people, taking that high road, morally and ethically. That’s what ethics is all about.”Florida Supreme Court Chief Justice Harry Lee Anstead delivered a keynote speech about professionalism in the legal profession – and all professions.He referred to a radio interview he recently heard with a business professor and an ethics professor, in which they expressed that a business’s controlling mission really is the bottom line.“We all know that if that is going to be the controlling ethic in a lawyer’s office or in a doctor’s practice, in a hospital, in the nursing home, with the public guardian, anybody providing any service, if that’s the controlling mission, my gosh, I want to bail out,” Chief Justice Anstead said.“We’ve got some serious problems if we’re going to simply be like some big automobile manufacturing company that actually writes down, ‘Well, if we go with the cheaper gas tank, we realize there will probably be 200 deaths, and we’ll value those at $1 million a piece. Yet, we will still save money in the long run.’ Can you imagine somebody actually writing that down?”Just as the court and the Bar have professionalism programs, Chief Justice Anstead said, having a conference to focus on ethics in the medical profession is to be applauded for the mistakes it will prevent. Just as lawyers help people through difficulties when they are most vulnerable, he said, so too do health care workers.“You truly come closest on the ground to carrying out this founding principle of our country that recognizes human dignity.. . . You all could not be in a more privileged position. I applaud you. You are the heroes for the rest of us. Because, at the end of the day, you are the ones who touch, in this most sensitive way, the lives of our people. All of us, whatever we are — whether we are a waitress at the greasy spoon, or the chief justice, or the dean of the medical school or the head of the nursing staff — we’re all enormously privileged to serve our fellow human beings.”Kenneth Goodman, director of the University of Miami Bioethics Program and co-director of the Florida Bioethics Network, looked around Florida State’s University Center ballroom and said: “One of the things that is noteworthy is we have a Supreme Court chief justice and the dean of a medical school in the same room. It’s very exciting. In the course of an ordinary day’s work, most people work with people doing exactly the same thing they’re doing.. . . “We’re trying to reach out. The nexus of health and policy is that we attend to issues in medicine, we attend to issues in law, we attend to issues that have to do with human values. And ultimately, the best answers come from creatively linking up resources. Ultimately, the utility of applied ethics is helping ordinary people make difficult decisions and do a good job at it.” Lawyers, doctors gather to discuss bioethics read more