Controversial Issues in Health Care

Controversial Issues in Health Care

• Controversial topics will always surround healthcare due to the complex nature of people and their needs.
• Many controversies gain media attention, especially during presidential elections or new scientific discoveries.
• Understanding these issues is important for healthcare professionals, even if they aren't faced with them daily.

Stem Cell Research

• Stem cell research was once very controversial, mainly due to the utilization of embryonic stem cells and public funds.
• Advancements in the field have decreased the necessity for human embryos.
• It is now possible to stimulate an individual's cells to function as stem cells, which reduces the need for donated stem cells.
• Any research related to genetics is still controversial.

Genetic Testing and Engineering

• In 2003, the Human Genome Project successfully mapped human DNA sequences.
• DNA, or deoxyribonucleic acid, contains the code in human cells that determines individual characteristics.
• DNA mapping allows scientists to perform genetic testing for various reasons.
• Genetic testing is used to match crime scene samples to suspects.
• Genetic testing is used to establish paternity.
• Genetic testing can help determine the potential for developing certain disorders and diseases.
• Genetic testing raises ethical concerns.

Burlington Northern Santa Fe Railroad Case

• In 2001, Burlington Northern Santa Fe Railroad settled a case for secretly genetically testing employees.

• The company screened employees for a predisposition to carpal tunnel syndrome after they filed worker's compensation claims.

• Employees were required to take the blood test without explanation

• The company paid court costs as part of the out-of-court settlement.

• Genetic testing can reveal a predisposition for certain cancers and the likelihood of passing it to biological children.

• Genetic testing is relatively new and not entirely reliable.

• Predisposition for cancer does not guarantee that a patient will develop cancer.

• Preventative measures, like mastectomy, are an option if genetic testing shows a predisposition for breast cancer.

• It is under debate if health insurance companies should cover such preventative treatments.

• BRCA (BReast CAncer susceptibility gene) typically prevents the development of cancer cells

• Those with BRCA mutations cannot suppress tumor development.

• The Genetic Information Nondiscrimination Act of 2008 protects individuals from discrimination based on genetic information.

• Employers cannot use genetic information to discriminate against employees or applicants.

• Employers are not allowed to collect genetic information or test for certain genetic traits.

• Healthcare organizations cannot share genetic information with third parties without patient consent.

• Genetic testing is primarily used to screen for diseases, promoting awareness and understanding.

• Screening children for certain traits, before or after birth, raises ethical concerns.

• The Human Genome Project requests that individuals not be reduced to their genetic characteristics and that uniqueness and diversity be respected.

• Parents may want certain characteristics for their children or to prevent certain traits/diseases.

• Eugenics, which was used by Nazi Germany, aims to improve the genetic makeup of a population.

• Certain non-consenting adults were sterilized to reduce the risk of continuing the genetic line.

• Cloning involves copying cells to create copies with similar genetic content and is acceptable for research purposes.

• Cloning life forms is too controversial at this time.

• Healthcare professionals should be able to address patient concerns about genetic testing and engineering by referring them to a primary caregiver.

Organ Allocation

• Advance directives include the right to donate organs.
• The Uniform Anatomical Gift Act in 1968 allows people 18+ to donate body parts for transplantation after death.
• Next of kin also can grant this permission
• The law also allows for the donation of bodies for medical research/study.
• Anyone can volunteer to donate organs through an advance directive.
• The National Organ Transplant Act was passed in 1984, creating a network to register and match organ donor recipients.
• The Organ Procurement and Transplantation Network (OPTN) contracts with the federal government.
• UNOS (United Network for Organ Sharing) was awarded the contract in 1986.
• UNOS focuses on efficiently and equitably sharing organs from deceased donors.
• UNOS maintains a waiting list of potential organ recipients.
• UNOS works to increase organ donations nationwide.
• UNOS raises awareness of live donations due to the shortage of organs.
• Organ donation in the U.S. comes either from deceased or living patients voluntarily.
• There are more people waiting for organ donation than there are organs available.
• Some countries pay organ donors.
• Singapore pays almost $36,000 per organ.
• Iran has eliminated its kidney transplant waiting list by paying donors.
• In Israel, people who are not organ donors are placed at the bottom of the recipient list if they need one.
• The UK operates under "presumed consent," so body parts are taken at the time of autopsy.
• Corneas and tissue samples can be used for research, even if organs are not viable for transplant after an autopsy.
• As of August 2017, 116,000 people were on the national transplant waiting list.
• In 2016, 33,611 transplants were performed.
• 20 people die each day while waiting for a transplant.
• 95% of U.S. adults support organ donation, but only 54% have signed up as donors.
• The primary cause of promoting organ donation in the US is through marketing, education, and state laws requiring citizens to specify donation status on driver's licenses.
• Ethical issues arise when considering paying for donated organs.
• It is under debate if this type of policy would prey on lower-income families or if it would fulfill needs for extra income while meeting the health needs of patients.
• It is under debate if quality control would be difficult if selling organs became legal.
• Recent internet matching services have raised some ethical concerns about informed consent with volunteers willingly giving an organ to people they are unfamiliar with.
• Volunteers may not really understand the long-term consequences of their decisions, even if they are compensated for travel and medical expenses.
• A complex process begins when an organ becomes available for transplant.
• UNOS uses a computer database to find a matching recipient for the donated organ involving factors like compatibility, location, and the age/size of both parties.
• The health condition of both the donor and recipient is taken into consideration.
• Patients are not guaranteed to receive the next available organ, even if they are at the top of the waiting list.
• Donors and recipients are matched.
• A large percentage of donated kidneys come from Caucasian patients, but one-third of patients on the kidney waiting list are African-American due to higher risk of disease.
• It is not always necessary to match race for kidney transplantation, but there are certain factors that make it easier to match a donor to a recipient from the same race.
• Patients of Caucasian descent wait a shorter time because there is a greater chance of a match being available.
• Patient health is another key issue.
• Waiting a long time for an organ transplant can diminish health and lead to lower transplant status.
• Geographic location is another key problem.
• Organs can only survive for a short period after they are harvested.
• Some waiting lists depend on proximity to the available organ
• Steve Jobs was able to get a liver transplant after placing himself on several waiting lists and use of a private plane to jet to the location

The Conscience Clause

• The conscience clause is a federal regulatory law that protects healthcare professionals from discrimination if they refuse to participate in sterilization procedures or abortions due to religious or personal objections.
• The original law protected pharmacists and hospitals, but in 2012, the Obama administration replaced it with one that only protects healthcare professionals who don't want to assist with sterilization/abortion procedures.
• One of the ethical dilemmas posed by the conscience clause is whether healthcare professionals should be allowed to decline normal job duties that they find offensive.
• Healthcare professionals have an ethical obligation to research duties carefully.
• It is under debate if a job involves duties a person objects to then should the person have taken the job in the first place.
• Legally, healthcare professionals have to inform an employer about wishing to utilize the conscience clause during the process of being hired.

Catherina Cenzon-DeCarlo Case

• In 2009, a devout Catholic operating room nurse at Mount Sinai Hospital, was asked to assist with an abortion procedure.
• Ms. Cenzon-DeCarlo had expressed religious objections to these situations.
• The abortion was performed on a patient who had preeclampsia leading the supervisors to threaten charges of patient abandonment.
• Ms. Cenzon-DeCarlo filed a lawsuit against the hospital.
• The Cenzon-DeCarlo case highlights the need for healthcare workers to know their rights plus ethical issues involved in opting of certain procedures.
• Original interpretations allowed pharmacists to refuse to fill prescriptions used to prevent/terminate pregnancies.
• States laws have been written to address the ethical issues related such as prescriptions.
• If a nurse refuses to participate in an abortion, then a replacement can be found; however, in other cases, the solution is unclear if a small town only has one pharmacy.
• The conscience clause was tested during the Obama administration.
• The ACA originally required that all insurance policies provide contraception to patients at low or zero cost.
• The Catholic Church believed that contraception was a violation of its moral code.
• The Catholic Church does not refuse to allow its employees to use contraceptives as a benefits package.
• The Supreme Court ruling of King v. Burwell says that employers with a historical religious foundation could be exempt from some ACA rules like birth control/sterilization coverage.
• Ethical arguments focus on employers forcing moral standards on employers.
• Healthcare will continue to debate questions like should an employee be able to opt out of job requirements simply because of moral differences.
• It is possible a revised conscience clause will include options for pharmacists and employees against the physician-assisted suicide options.
• As a healthcare professional, you must be aware of conscience clause laws in your state.
• Tell your employer at the time of hire and be aware of these rights in order to do this.

Medical Research

• According to the Patient Bill of Rights, patients have the right to decide whether to participate in research studies.
• Generally, research must involve informed consent, willing/knowing participants, and minimal risk to those involved in order to be ethical.
• There are some gray areas like patients rarely being aware that their blood/tissue samples become the organization's property once donated.
• If working in a research activity, you need additional training/certification.
• It is important to lessen the risks involved in research vulnerable population and ethical guidelines/laws exist to guide it.
• It is important to note if a patient is in the final stages of cancer then is it ethical in offering experimental treatments or better offer palliative care.
• It is best to provide both options and let the patient choose.

Henrietta Lacks Case

• Henrietta Lacks developed cervical cancer at 30 years of age and her tissue samples were taken and given to a scientist trying to grow lines of human cells.
• Ms. Lacks' cells became the first human cells to grow successfully in an artificial environment.
• HeLa cells were used by researchers who eventually benefited from their research.
• The Lacks family was unaware her cells were being used for profit until many years later.

Medical Marijuana

• The growth of medical marijuana has led to a growing legal and ethical issue in healthcare.
• Marijuana is a controlled substance so it is heavily regulated.
• The federal government bans the sale of marijuana (and other controlled substances).
• Some states have legalized the use and/or sale of marijuana.
• The federal government has not pursued taking action on these regulations.
• Medical marijuana is recommended for therapeutic use by some medical professionals.
• Studies have found it helps reduce pain, controls nausea/vomiting, and is less addictive than other controlled substances, especially opioids.
• Opponents argue that long-term effects are not fully understood, is not FDA approved, and existing legal drugs are better for the patient.
• It is important to know state laws about marijuana use in the event that patients have questions.

Other Public Health Issues

• Public health issues change constantly.
• These include obesity, gun control, and opioid addiction.
• States/cities have tried to regulate the sale of consumer products such as soda.
• Many of these have been unsuccessful due to civil rights or being beyond the governing body.
• The same issue exists with gun control due to the right to own firearms being morally divided.
• Opioid addiction is a current public health emergency.
• This can be shifted and utilized more easily under the Public Health Emergency Act.
• The U.S. Department of Health and Human Services efforts are focused on treatment/recovery access, promote overdose-reversing drugs, strengthen our understanding via public health surveillance, support cutting-edge research, and advance better practices for pain management.
• The National Institutes of Health (NIH) is focused to prevent opioid misuse, treat opioid disorders, and manage pain accelerating formal pharmaceutical companies and academic research centers.
• To accelerate progress, NIH is exploring formal partnerships with pharmaceutical companies and academic research centers to develop safe/effective nonaddictive relief, treat opioid disorders, and reverse interventions.