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by Catherine Colquitt, MD

Texas is making headlines, and not in a good way. 

Our state has the highest rate of syphilis cases in the nation, and five of our metropolitan areas are in the top tier in the nation in reporting of syphilis cases. This dubious distinction comes with increasing congenital syphilis (CS) incidence, too. In 2018 (2019 data are still being compiled) Texas reported 367 cases of congenital syphilis (a 64.57 percent increase in CS compared with published 2017 state data), with 21 of them coming from Tarrant County. 

For reference, in 1998, syphilis rates in the US dropped to historic lows and the CDC and other partners wrote of eradicating syphilis in the U.S., but by 2012, syphilis rates had begun to climb rapidly and are soaring today. In 2017, the CDC issued a call to action entitled “Let’s Work Together to Stem the Tide of Rising Syphilis in the United States.” This 12-page document suggested roles for patients, clinicians, public health entities, state health departments, community leaders, biomedical science, universities, and industry partners, among others, in curbing the incidence of syphilis. 

However, syphilis rates continue to climb, and Texas is reporting marked year-on-year increases in CS as well. In 2015, the Texas Legislature amended Texas Health and Safety Code, Section 81.090, which mandates syphilis testing of all pregnant women at their first prenatal visit and in the third trimester (2015 CDC Sexually Transmitted Disease Guidelines recommend that the third trimester syphilis screening occur between 28 and 32 weeks of pregnancy). This requires the Texas Department of State Health Services (TxDSHS) to present a biennial CS report to the legislature by January 1 of odd-numbered years for its review and consideration. 

The current TxDSHS Congenital Syphilis Report (January 2019) states that “in 2017 nationally, Texas ranked fourth (case rate). There were 166 cases of congenital syphilis reported to DSHS.  The rate was 41.7 cases per 100,000 births. Texas accounted for 18.1 percent or nearly one-fifth of the total congenital syphilis cases reported in the United States.”  

The CDC estimates that 40 percent of infants born to women with untreated syphilis are stillborn or die as newborns.  Usually syphilis is transmitted to the fetus when the mother has primary or secondary syphilis while pregnant, but women with untreated or inadequately treated syphilis, early latent or late latent syphilis, still have a 23 percent chance of an adverse syphilis-related pregnancy outcome.  In order to prevent CS, maternal treatment must occur at least 30 days before delivery of the infant (if the mother is treated more than one month prior to delivery, her treatment will address the infection in both mother and fetus). 

CS is classified based on the timing of symptoms and signs in the affected child. Early CS presents with vision or hearing impairment, runny nose (“snuffles”), anemia, hepatitis, splenomegaly, long bone abnormalities, developmental delay, and rash manifest before the child’s second birthday.  Late CS (from second birthday onward) signs and symptoms include dental and bony abnormalities (remember Hutchinson’s incisors and saber shins?), hearing and vision deficits, and central nervous system manifestations such as gummas and encephalitis, and (rarely) cardiovascular pathologic effects. 

TxDSHS has piloted adding CS to regional Fetal Infant Morbidity Reviews in two areas hardest hit by the recent and ongoing rise in CS cases, Harris and Bexar Counties, and is developing an enhanced surveillance system to ensure more complete reporting. The agency is also facilitating improved pregnancy assessments of women with or exposed to syphilis, working to expedite prenatal care referrals for syphilis infected pregnant women, and is partnering with hospitals to provide assessment and management of syphilis in antepartum, intrapartum, and postpartum settings.

Even in the late 1990s and early 2000s with U.S. syphilis rates at historic lows, wide racial and socioeconomic disparities in syphilis rates were observed. Women at highest risk for syphilis during pregnancy include those without insurance (and therefore with late or no access to prenatal care), in poverty, involved in sex work, using illegal drugs, infected with another STD, and in communities with high syphilis rates. 

We are still using the same medication to treat syphilis that were transformative in the 1930s and 1940s, and we still rely on syphilis diagnosis and response to treatment which measure antibody titers, having no gold standard for directly establishing active infection (except dark field exam of clinical specimen, rarely done these days).  

We need a vaccine against syphilis and new medications to treat it, especially in penicillin-allergic pregnant women with an absolute contraindication to desensitization (such as Stevens-Johnson syndrome).  In the meantime, we can use the tools we have to better serve our patients and prevent tragic vertical transmission of an infection we once thought was on its way out.

by Stuart C. Pickell, MD, FACP, FAAP

As a result of early twentieth century atrocities, respect for the individual’s autonomy correctly became a foundational principle of medical ethics.  But has our desire to honor patient autonomy resulted in the subjugation of other foundational principles and competing values?   

From our founding as a nation we have valued personal liberty and freedom.  While we have been inconsistent in our implementation of these values – civil rights come readily to mind – they remain at the core of what it means to be an American.  

Ethical codes encompass more than American values and ideals, of course.  Western nations united around the barbarity of unethical experiments conducted by Nazi Germany before and during World War II.  Determining that this should never happen again, the international community reached a consensus resulting in landmark ethical codes, declarations and reports.  These included:

• The Nuremberg Code – 1947 – in response to Nazi experimentation on Jews;

• The Declaration of Helsinki – 1964 – written for the World Medical Association regarding research on humans;

• The Belmont Report – 1979 – drafted, in  part, in response to the Tuskegee Syphilis  experiments.

All three of these initiatives focused on the individual’s right to decide what can and cannot be done to their bodies.  The Belmont Report, drafted by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, a committee that included Tom Beauchamp (yes, that Beauchamp), codified this as the “respect for persons.”  Beauchamp and James Childress further developed this concept in their seminal tome, Principles of Biomedical Ethics (Beauchamp & Childress, 1979).  Referring to it as “respect for autonomy” it was the first of three ethical principles or “pillars” along with “beneficence” and “justice.”   

Today we live in an era of shared decision making, a byproduct of the patient autonomy movement.  We are rightfully expected to explain risks and benefits and to obtain informed consent regarding recommended courses of action – all to make certain that the patient’s autonomy is respected.  The generation of “doctor knows best” is no more as physicians have become the resident experts who provide information regarding diagnoses and treatment options without prejudice, allowing patients to decide for themselves what they want to do.  This movement has and should be celebrated.  But what if what the patient wants to do runs up against competing community interests, values, and ethical principles?

This is not a hypothetical question.  Tarrant County is the epicenter of the tension between patient autonomy and the common good.  A national survey of kindergartners recently revealed that Tarrant County has one of the highest rates of kindergartners with non-medical exemptions for vaccinations. (Olive and Hotez 2018)  Now we are seeing the downstream effects of this behavior in the form of preventable diseases like measles, a development that places the greater community in danger.  At some point we must ask where the line between the patient’s autonomy and the public good must be drawn.

This issue has broad public implication.  Case in point.  On December 16th, the U.S. Supreme Court refused to hear an appeal of a 2018 decision made by the 9th U.S. Circuit Court of Appeals.  The case in question centered on two Boise city ordinances that prohibit camping or “disorderly conduct” by people sleeping in public places.  Those who violated the ordinances were given a nominal fine or briefly jailed.  Six homeless residents sued the city in federal court in 2009, itself a testament to judicial efficiency, claiming that the practice violated their constitutional rights under the 8th amendment which prohibits “cruel and unusual punishment.” (Chung 2019).  The 9th Circuit sided with the plaintiffs.  

This case, like most, is nuanced.  The ordinances are predicated on there being temporary shelter options for the homeless.  Two Boise shelters have policies to never turn away anyone for lack of space, so the city ordinances had been continually enforced.  However, these shelters, run by Christian organizations that have mandatory religious programming and enforce limits on the number of days a person can stay, raised the question as to whether or not the homeless truly have viable options.  This factored heavily in the 9th Circuit’s decision.  Still, does this decision not undercut a municipality’s ability to maintain public health and safety?  Again, where do we draw the line?

The adage “Your right to swing your fist ends where my nose begins” – which originated in the nineteenth century temperance movement – is often cited in arguments regarding personal freedom and the exercise of one’s liberty.  Prohibitionists, seeking to restrict the sale and consumption of alcohol, which they considered to be a public nuisance and societal ill, sought to impose their will on the larger community.  That particular issue has long been settled, but the underlying sentiment continues to raise its head as we consider the ways in which the exercise of perceived individual rights and autonomy have crept into the national dialog.  For instance:

• In an era of limited resources and escalating costs, how do we manage the expectations of patients who want “everything done” when the interventions they seek will not improve their outcome, may be harmful and divert resources from places where they might be better utilized. 

• Are physicians obligated to provide services even if they consider them to be unethical or fiscally irresponsible?

• How do we address those in our community who opt out of public health initiatives, like vaccination, when their failure to participate puts others in the community at risk?

• How should the community manage the health consequences emanating from patients exercising their rights to engage in at-risk behaviors?  Should        government impose public smoking bans?  Should patients who engage in high-risk behaviors that result in chronic illness or injuries that utilize limited        resources be managed differently within the system? If so, how?

• How should we address hot-button political topics like gun control and firearm safety, especially in the current political climate?

• Should a discussion of the public good become part of all ethics consultations?

Recognizing the importance of our respect for patient autonomy while also honoring our commitment to the public good, the Tarrant County Academy of Medicine’s Ethics Consortium will devote its annual symposium,
Healthcare in a Civil Society, to this topic. The program, which will be February 1st (see related information on page 18), will feature healthcare leaders representing public health, the law, clinical ethics, and public policy.  While we don’t expect to solve all of the problems, we do plan to take some first steps toward finding local solutions to this important healthcare issues. You are welcome and encouraged to join us for this engaging CME event.

by Prachi Thapar, TCOM 2021

It was my surgery rotation. I was still adapting to the rotation life, attempting to appear confident while trying to recall minute details from first year anatomy to impress my attending. As we rounded on patients, my attending informed me that one of our patients had an extremely poor prognosis as surgery was unable to completely resect a tumor. When we approached the patient’s room to break the unfortunate news to her and her family, my heart was pounding, and I clumsily grasped my clammy hands in front of me. Thoughts were racing through my head – how were we going to break the news? Will I be able to keep my cool? What was the right thing to say in this situation? Where did one even start when talking to a patient about dying? 

As a child, my first impression of doctors was akin to that of superheroes. I saw them as healers whose profession was dedicated to helping patients lead quality lives against adversity. To my simple mind, I found it astounding as doctors worked with their team to do the impossible from putting broken bones back together or performing delicate surgeries to remove a malignant tumor. The doctors with their team were Avengers donning white coats, always there to help save the day. While I shed my idealistic perspective as I grew older, I continued to hold on to the essence of my initial view of doctors as healers who worked diligently to do everything they could for their patients.

When I began volunteering with a hospice, I realized I had yet to uncover and consider a vital concept in the patient-provider relationship – death. It was an obvious and inevitable experience within the healthcare field, but somehow, I had never given pause to what it meant. In my classroom years of medical school, I was constantly focused on the treatment. The end goal was “what can I do to help this patient get better?” or “how can I get this patient discharged?” But here, I was faced with patients who were terminally ill and had accepted their outcome in life. These patients were not necessarily looking to get better but instead wanted to comfortably live out their remaining days. The care team was doing their utmost to ensure the patient felt no pain and helped empower the patient in the face of death. They worked alongside the patient to ensure their wishes were clearly expressed and would be fulfilled upon their death. As I spent time with the patients, listening to their life stories and dreams, I started to refocus my understanding of medicine and what it meant to be a doctor. 

As doctors, it is an unfortunate truth that we cannot save each and every patient. It is a difficult and bitter fact, especially considering the motivation for many of us entering the healthcare field stems from a want to help people. At first, I felt insecure, scared, and anxious when approach the topic. I was afraid I would somehow offend the patient, or they would be angry with me thinking that I had failed them. However, as I watched my surgery attending, I realized talking about death while an unfortunate topic, could be liberating. My attending quietly sat next to our patient, held her hand, and talked with her honestly. He assured her that while we would be doing as much as we could to help her, we wanted her to start considering her end-of-life wishes. The patient turned to my attending with tears in her eyes and told him she was thankful for his honesty. She appreciated that instead of leaving her in the dark to incessantly worry and question her future, his guidance allowed her to maintain her autonomy in death. 

As I continue my own journey in medical school, I hope to continue to face my own insecurities regarding the topic of death so I can be a better doctor for my patients. Rather than superheroes who go around fixing and saving everyone, I now see doctors as companions who guide a patient on their journey of healing and empowerment through emotions of joy, relief, and grief… even in death. 

by Tilden Childs, III, MD, TCMS President

As I begin this year, please let me say “Thank you!” for the opportunity to serve as the president of the Tarrant County Medical Society. It is truly an honor and a privilege to be allowed to serve my peers in this capacity. Indeed, participating in organized medicine has become my passion and is an integral part of my professional life. My medical “family” extends from coast to coast. At the Interim AMA meeting in late November, for example, I enjoyed visiting with and collaborating with friends from the TCMS, the Texas Medical Association, the American College of Radiology, and from the other state medical  and specialty societies from around the country while working on the myriad issues facing the medical profession today. It is through my participation in organized medicine that I have come to realize and appreciate the diversity of our profession, both in the range and breadth of our opinions and approaches to the practice of medicine as well as the diverse, and sometimes divisive, internal and external  pressures and issues facing the House of Medicine. However, I am more than ever convinced that the goal of service to and care of our patients remains the number one priority. The House of Medicine needs to remain unified in this mission. I encourage all of us, no matter what our employment or practice situation, to maintain unity by participation in organized medicine. 

From time to time people ask me how to become involved in or how to further their participation in organized medicine. As I reflect on the many opportunities that abound for one to serve in this capacity, I wish to share with you some of the things I have learned and observed on my journey in this complex and exciting world of organized medicine. This is not an all-inclusive listing of opportunities and venues but rather a “how to” guide based on some of my experiences and thoughts.

Participation
“The action of taking part in something”

So, first and foremost, show up! Be present! Within the overall context, start by recognizing that there are local, state, and national general medical organizations/associations (TCMS, TMA, and AMA, for example) as well as numerous specialty colleges and societies (local, state, and national). So, join the appropriate organizations. Then, get involved in the activities of your society. Make the effort to attend meetings. Within each organization, there are committees, councils, commissions, and/or delegations pertaining to the various issues and aspects of medicine. So, find an area of interest and help by attending the meetings and getting involved with a committee, council, commission, and/or delegation. Also, understand that colleges, societies, and associations are interconnected, to some extent, such that participation in one can result in participation in others. So, for example, consider becoming an alternate delegate and then a delegate representing your organization at other societies. This could include helping to represent the TCMS at the TMA. Also follow the same steps in your specialty college and sub-specialty societies. Importantly, consider finding a mentor to help advise and guide you as your participation increases and as you ascend to new levels of leadership.

Another parallel path, particularly for those with a bent for politics, and not exclusive to the discussion above, is to be involved in the political process through advocacy, which has become a primary function of organized medicine.

Advocacy (from Wikipedia)
“Is an activity by an individual or group that aims to influence decisions within political, economic, and social systems and institutions. Advocacy includes activities and publications to influence public policy, laws, and budgets by using facts, their relationships, the media, and messaging to educate government officials and the public. Advocacy can include many activities that a person or organization undertakes including media campaigns, public speaking, commissioning, and publishing research. Lobbying (often by lobby groups) is a form of advocacy where a direct approach is made to legislators on a specific issue or specific piece of legislation.”

The first and quickest way to start your advocacy effort is to join the Political Action Committees (PACs) associated with your organizations. PACs are integral to advocacy (and lobbying), providing structured organizations which provide you the opportunity to help in the selection and support of candidates and issues relevant to medicine. Next, take an active role in the political process as afforded by the various organizations and PACs. Begin to establish a relationship with your representatives and senators (state and national). This seems difficult to most people, but the TCMS and the TMA can help facilitate this. An excellent venue to begin the dialogue at the state level is to attend the TMA First Tuesdays during the biennial legislative session by accompanying the TCMS to the Texas Capitol. This immersive exercise is a great first step. This will “break the ice” to help you become comfortable talking with your elected officials and their staff. You can then explore additional ways to become more effective in advocating for your causes. However, rather than wait for the next legislative session (January 2021), consider meeting with your elected officials or their appropriate staff in their district offices to introduce yourself and then to offer to give help and insight on issues and policies being developed during the “interim” year (2020) prior to the next session. During the session, follow the action at the Capitol online through the Texas Legislature Online link which includes live and recorded access to committee meetings and sessions of the House and the Senate. (We are fortunate to have such robust access to our Texas political process.) Even more, consider going to Austin to testify in committee hearings on issues of importance to you. For those with higher level commitment ambitions, service opportunities exist through participation in state agencies. And finally, consider running for public office! (Or, at least actively support those who do.)

Participation in organized medicine has become my avocation as well as my current passion, and I hope others (many others) will come to see the wisdom and necessity of this stance. The future of medical practice always has and always will evolve, both in what we do and how we do it. It is our responsibility, as it always has been, to be on the forefront of this change and to guide this process along the path that will best benefit our patients and society as a whole, without leaving any individual patient unaccounted for. We have been fortunate to have such active participation with so many excellent leaders in Tarrant County. We can and should all work together to continue to grow the atmosphere of collegiality and cooperation by supporting the House of Medicine. As physicians, we are all leaders and we should, we must, recognize and accept this challenge and responsibility.

In my next article, I plan to give longitudinal examples of how an individual’s participation in medical organizations can help to guide and facilitate medical policy development and implementation. Again, thank you for this opportunity to serve!

By Stuart Pickell, MD, FACP, FAAP

This is a letter to the Editor at the Fort Worth Star-Telegram from the Tarrant County Ethics Consortium. Reprinted with permission.

We have monitored the scenario surrounding Tinslee Lewis at Cook Children’s for the last two months as it has moved the issue of the Texas Advance Directives Act (Texas ADA, 1999) in general and the 10-day rule in particular, back onto the front burner.  While we agree with the Fort Worth Star-Telegram’s assertion that the Texas ADA is imperfect, we do not agree that extending the 10-day period that hospitals have to find an alternative facility is the solution (“Don’t paint Cook Children’s as a villain in tragic Tinslee Lewis life support case,” January 04, 2020). 

As technology has advanced, so have the options available to treat critically ill patients.  Many people facing acute life-threatening events find aggressive medical intervention a life-saving bridge until their bodies can recover.  But there is a point past which no amount of medical intervention will help.  In fact, it may hurt. 

For the last 40 years healthcare facilities have increasingly relied upon ethics committees to aid them with the unenviable task of examining clinical situations in which medical technology contributes to a moral conundrum in which there are no good options.  The typical ethics committee consists of an interdisciplinary team of healthcare workers, often employees of the institution, and also community members who have no official relationship with the facility.  In the rare instance when a family insists on aggressive treatment that the medical team believes is non-beneficial or even harmful, either party may request a formal hearing before the ethics committee.  The committee’s objective is to hear the concerns of both the family and the medical team and discern the ethical thing to do for the patient.  If the committee decides to withdraw aggressive interventions that the family wants continued, the facility may invoke the Texas ADA. 

The Texas ADA leverages the expertise of healthcare and ethics professionals to promote a deliberative process at the bedside, carefully considering the family’s desires for treatment in light of the medical realities to discern the best treatment options available for the patient.  As medical professionals, we have an imperative to honor our patients’ treatment desires.  While we sympathize with the Lewis family, their desire to continue aggressive interventions does not give them – or anyone – the right to demand treatment that violates the norms of the medical profession, the caregivers’ moral integrity or the long-standing ethical precept of “do no harm.”  

Much of the criticism of the Texas ADA focuses on the section that allows a health care facility caring for a patient to discontinue life-sustaining treatment ten days after giving written notice.  During this time the treating facility and the family seek to identify another facility willing to assume care.  Opponents claim that ten days is not long enough to do this.  We disagree. 

First, every case that gets to the point of invoking the Texas ADA has been thoroughly vetted by the medical team in consultation with the family.  When it becomes clear that an impasse is imminent the search for an alternative facility begins, usually weeks if not months before any formal hearing of the ethics committee.

Second, the law allows a judge to grant an extension if, given more time, there is a reasonable likelihood that another facility would be willing to accept the patient.  Finding a willing facility usually does not happen since a situation deemed futile by a medical team in Fort Worth would be considered no less futile anywhere else.  Even so, judges often grant extensions, especially in high profile cases.

Third, many families have not dealt with the gravity of their loved one’s condition, a reality they can no longer ignore once the 10-day rule is invoked.  Extending the 10-day period will not make their grief any less and will not increase the likelihood of finding a facility willing to assume the patient’s care.

We understand that the Texas Advance Directives Act is imperfect, but this law, including the 10-day rule, are better than what we had before when actively dying patients with no hope of recovery were subjected to indefinite pain and suffering because well-meaning loved ones were unwilling to let them go.  A longer waiting period will not bring hope to a hopeless situation; it will only prolong suffering.  So, while we strongly advocate for initiatives that will improve the health and wellbeing of Texans, we believe that extending the 10-day rule is not one of them.

The Tarrant County Academy of Medicine Ethics Consortium is a diverse, non-partisan group of people interested in health care and ethics in Tarrant County.  We are physicians, lawyers, educators, nurses, chaplains, administrators and other interested citizens who seek to improve the health and well-being of the diverse communities that make up North Texas by sharing the application of ethical principles to current healthcare issues through education, advocacy, and collaboration, and by encouraging civil conversation and dialogue.

By Stuart Pickell, MD, FACP, FAAP

As a result of early twentieth century atrocities, respect for the individual’s autonomy correctly became a foundational principle of medical ethics.  But has our desire to honor patient autonomy resulted in the subjugation of other foundational principles and competing values?  

From our founding as a nation we have valued personal liberty and freedom.  While we have been inconsistent in our implementation of these values – civil rights come readily to mind – they remain at the core of what it means to be an American. 

Ethical codes encompass more than American values and ideals, of course.  Western nations united around the barbarity of unethical experiments conducted by Nazi Germany before and during World War II.  Determining that this should never happen again, the international community reached a consensus resulting in landmark ethical codes, declarations and reports.  These included:

• The Nuremberg Code – 1947 – in response to Nazi experimentation on Jews;
• The Declaration of Helsinki – 1964 – written for the World Medical Association regarding research on humans;
• The Belmont Report – 1979 – drafted, in part, in response to the Tuskegee Syphilis experiments.

All three of these initiatives focused on the individual’s right to decide what can and cannot be done to their bodies.  The Belmont Report, drafted by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, a committee that included Tom Beauchamp (yes, that Beauchamp), codified this as the “respect for persons.”  Beauchamp and James Childress further developed this concept in their seminal tome, Principles of Biomedical Ethics (Beauchamp & Childress, 1979). Referring to it as “respect for autonomy” it was the first of three ethical principles or “pillars” along with “beneficence” and “justice.”  

Today we live in an era of shared decision making, a byproduct of the patient autonomy movement.  We are rightfully expected to explain risks and benefits and to obtain informed consent regarding recommended courses of action – all to make certain that the patient’s autonomy is respected.  The generation of “doctor knows best” is no more as physicians have become the resident experts who provide information regarding diagnoses and treatment options without prejudice, allowing patients to decide for themselves what they want to do.  This movement has and should be celebrated.  But what if what the patient wants to do runs up against competing community interests, values, and ethical principles?

This is not a hypothetical question.  Tarrant County is the epicenter of the tension between patient autonomy and the common good.  A national survey of kindergartners recently revealed that Tarrant County has one of the highest rates of kindergartners with non-medical exemptions for vaccinations. (Olive and Hotez 2018)  Now we are seeing the downstream effects of this behavior in the form of preventable diseases like measles, a development that places the greater community in danger.  At some point we must ask where the line between the patient’s autonomy and the public good must be drawn.

This issue has broad public implication.  Case in point.  On December 16^th, the U.S. Supreme Court refused to hear an appeal of a 2018 decision made by the 9^th U.S. Circuit Court of Appeals.  The case in question centered on two Boise city ordinances that prohibit camping or “disorderly conduct” by people sleeping in public places.  Those who violated the ordinances were given a nominal fine or briefly jailed.  Six homeless residents sued the city in federal court in 2009, itself a testament to judicial efficiency, claiming that the practice violated their constitutional rights under the 8^th amendment which prohibits “cruel and unusual punishment.” (Chung 2019).  The 9^th Circuit sided with the plaintiffs. 

This case, like most, is nuanced.  The ordinances are predicated on there being temporary shelter options for the homeless.  Two Boise shelters have policies to never turn away anyone for lack of space, so the city ordinances had been continually enforced.  However, these shelters, run by Christian organizations that have mandatory religious programming and enforce limits on the number of days a person can stay, raised the question as to whether or not the homeless truly have viable options.  This factored heavily in the 9^th Circuit’s decision.  Still, does this decision not undercut a municipality’s ability to maintain public health and safety?  Again, where do we draw the line?

The adage “Your right to swing your fist ends where my nose begins” – which originated in the nineteenth century temperance movement – is often cited in arguments regarding personal freedom and the exercise of one’s liberty.  Prohibitionists, seeking to restrict the sale and consumption of alcohol, which they considered to be a public nuisance and societal ill, sought to impose their will on the larger community.  That particular issue has long been settled, but the underlying sentiment continues to raise its head as we consider the ways in which the exercise of perceived individual rights and autonomy have crept into the national dialog.  For instance:

• In an era of limited resources and escalating costs, how do we manage the expectations of patients who want “everything done” when the interventions they seek will not improve their outcome, may be harmful, and divert resources from places where they might be better utilized.

• Are physicians obligated to provide services even if they consider them to be unethical or fiscally irresponsible?

• How do we address those in our community who opt out of public health initiatives, like vaccination, when their failure to participate puts others in the community at risk?

• How should the community manage the health consequences emanating from patients exercising their rights to engage in at-risk behaviors?  Should government impose public smoking bans?  Should patients who engage in high-risk behaviors that result in chronic illness or injuries that utilize limited resources be managed differently within the system?  If so, how?

• How should we address hot-button political topics like gun control and firearm safety, especially in the current political climate?

• Should a discussion of the public good become part of all ethics consultations?

Recognizing the importance of our respect for patient autonomy while also honoring our commitment to the public good, the Tarrant County Academy of Medicine’s Ethics Consortium will devote its annual symposium, Healthcare in a Civil Society, to this topic. The program, which will be February 1st, will feature healthcare leaders representing public health, the law, clinical ethics, and public policy.  While we don’t expect to solve all of the problems, we do plan to take some first steps toward finding local solutions to this important healthcare issues. You are welcome and encouraged to join us for this engaging CME event.