F a l l E d i t i o n 2 0 1 5 M E D I C A L E T H I C S I N U T A H

Publ ished by the Divis ion of Medical Ethics and Humanit ies of the Department of Internal Medicine at the Universi ty of Utah School of Medicine

I N S I D E T H I S I S S U E :

Ethical Issues in

Telemedicine

1&2

Linda Ganzini, MD, PhD

& Evening Ethics

3

Physicians Literature

& Medicine

4

Calendar 5

Division Member

updates

6

Ethical Issues in Telemedicine By: Linda Carr–Lee Faix

On June 24th, Evening Ethics discussants pondered ethical issues surrounding

Telemedicine. Teneille Brown, JD, facilitator for the discussion, explained that

telemedicine covers a broad array of services. According to Wikipedia, “Telemedicine is the

practice of medicine over a distance in which interventions, diagnostic and treatment

decisions and recommendations are based on data, documents and other information

transmitted through telecommunication systems.” These connections can be between

facilities, facility to field, or provider to patient. Examples might include such different

things as texting photos of a child’s rash to a pediatrician to see if a visit is warranted,

having academic centers serve as remote training consultants for physicians in more rural areas, talking or skyping with

psychiatric, palliative or diabetes patients, providing nurse-staffed call centers for OB patients, prescribing to patients of

colleagues via the phone, or emailing or importing radiological scans to an EMR.

Benefits:

Benefits and risks of telemedicine were identified by the group. Benefits are numerous, with (1) reaching out to rural

communities that might lack adequate health care access and (2) reducing readmissions by managing care via distance,

topping the list. Telemedicine provides healthcare access, a major justice concern, in several ways: It opens a door to

care—especially in small communities where people often won’t go for HIV testing, psychiatry, or oncology concerns,

as they are worried about people finding out; it reaches diverse groups and requires a greater degree of cultural

competency as people are reached that previously had little access to healthcare; and it provides outreach to families that

otherwise might not be able to manage clinic visits. Telemedicine also provides specialist services such as genetics,

decentralizing information previously only gotten at large medical centers. It can provide easier second opinions

(consultations) and can provide pro-active treatment by sending devices home, inviting patients to be more active

participants in their own care, thereby increasing quality of care and providing cost savings through efficiency. In

addition, advocates predict greater patient satisfaction as patients are able to reach doctors at any time they need them.

Risks: the pushback

In our discussion, privacy led the list of concerns about telemedicine. A decade ago, videoconferencing to connect

patients and specialists were held in controlled environments--at clinics, doctor’s offices, or hospitals. Today,

smartphones, tablets, and laptops allow access from just about anywhere. When skyping, for example, who else may

be in the room and overhear?

Jeopardizing the physician-patient relationship, especially in the long term, is a second

risk concern. Although telemedicine may be helpful for individual transactions, does it

undermine an ongoing, long-term relationship between doctor and patient that we do not

want to lose? In the long term will there be a transition of relatedness (no face to face

relationships)? In the short term, it is supplementation of care, but in the long term,

might it become replacement of face to face care?

Thirdly, some were concerned about misdiagnoses through this medium. All agreed that

there is an ethical responsibility on the part of a provider to say no to a telemedicine

request if one thinks good care cannot be gotten through this medium as patient safety

overrides all other concerns.

At this point, it is not clear whether telemedicine provides better outcomes or saves

money. Data comparing telemedicine and traditional medicine show that although

outcomes are not compromised, traditional medicine has higher the edge on patient

satisfaction, contrary to predictions of telemedicine advocates. And although virtual visits

are less expensive than ER visits, it might be that the people who use telemedicine might

otherwise have stayed home, so that telemedicine might increase overall health care

spending. Additionally, the set up costs of telemedicine—the cables, computers,

bandwidth access—should be calculated into the cost equation for telemedicine.

Continued on page 2

Here in Utah:

Health systems are increasingly offering telemedicine services, hoping to save money and reduce pressure on overextended

primary care while providing more convenient, cheaper and empowering care to patients. Many doctors are training to

become virtualists, citing the less hurried pace of an ER or urgent care. The University of Utah School of Medicine offers a

telemedicine elective for HSC students, and Utah became the first state in 2015 to pass legislation to harmonize credentialing

across state lines, in order to facilitate telemedicine.

Nationally, there is a trend toward expanding telemedicine, although some states line Texas are notably trying to slow this

down. Jefferson University Hospitals, for example, allow follow-up visits with internists, urologist, and ENT’s. New York

allows telemedicine primary care visits, and Mercy Health system (based in St. Louis) has urgent and primary care consults

for the chronically ill and other high risk patients who need frequent assessments and advice. 1

Here in Utah, ECHO, (Extension for Community Health-Care Outcomes) is a form of telemedicine consultation that

operates doctor to doctor, which puts the power and responsibility into the hands of primary care providers. It is CME

(education) based rather than clinically based. Otherwise, if a doctor in one state were to advise patients in other states, s/he

would need to be licensed in every state where they provided guidance. ECHO de-identifies patients so there is no record

tied to an individual patient protecting this telemedicine advice from being discoverable in legal cases. Local physicians

remain responsible, using their own legal counsel and risk management departments. The layers of medical risk can be

cumbersome for rural communities.

Questions that remain:

1) Should licensing of physicians remain state-specific, or cross state lines when telemedicine is employed? Should there be

a duty to the telemedicine patient consulted?

2) What are the standard of care obligations around the cost of creating telemedicine efficiency? Who proves the cables,

computers, Ipads, education, etc. to make telemedicine possible?

3) Should there be telehealth parity for insurance coverage?

Despite push backs from some traditional sources, (eg. Medicare strictly limits reimbursements for telemedicine services,

fearing that costs and misdiagnoses may increase) there have been notable advancements in granting telehealth parity.

Washington State in April 2015 passed legislation requiring insurers to cover a range of telemedicine procedures if they

already cover those procedures in person, making Washington the 24th state to ensure some telemedicine reimbursement.

The Washington law does not cover virtual urgent care outside a medical facility, but some insurers, such as Molina

Healthcare of Washington, without a law requiring it, are covering virtual urgent care. Some large insurers such as United

Healthcare, the nation’s largest insurer, announced in April 2015 that it would cover virtual visits for most of its 26

commercial members by next year due to shortage of primary care doctors and the cost of less than $50 per visit of

telemedicine. 1

4) Are there medical situations that just don’t work for telemedicine? Are there unique issues when dealing with kids, cancer

diagnoses, the demented, end of life discussions, addicts? (On the other hand, people have been shown to be more honest

with computers than in talking with clinicians!)

5) Should we be concerned about automated decision trees sometime down the road? Who bears the risk for a nurse who

follows the prompts of a computer-algorithm that directs a patient to stay home rather than go to the ER ?

6) Should telemedicine physicians be allowed to prescribe medicine? (There is a Texas law that prohibits prescribing if the

physician has never met the patient.) We should remember that the original scams of telemedicine were in order to get drugs.

While there are not easy answers to some of these questions, the great potential for telemedicine was discussed, along with

the unique way that the University of Utah is meeting a great need through its ECHO program.

1. Goodnough, Abby. The New York Times, Sunday, July 12, 2015, “Modern Doctors’ House Calls”: Skype Chat and Fast Diagnosis”, p. 1, 21.

Ethical Issues in Telemedicine Continued from page 1

Evening Ethics Discussion with Linda Ganzini, MD, MPH

Wednesday, October 28, 5:30-7:00pm, RAB 117* 1.5 CME Approved

Death with Dignity Laws: What do they Mean for Physicians?

Anticipating a fuller presentation of data the following morning at Internal Medicine Grand Rounds,

Oregon’s principal researcher on Physician Assisted Suicide, Linda Ganzini, MD, MPH, professor of

Psychiatry and Medicine, Oregon Health and Science University (OHSU)will introduce an open

discussion of what a Death With Dignity Act should and should not require of physicians, how the

law might be perceived by physicians, and what impact physicians might expect about the effects

on themselves of legally assisting a patient to die. Background reading for this discussion include

two articles by Linda Ganzini, MD, Steven K Dobscha, MD, Ronald T. Heintz, MD, and Nancy Press,

PhD, “Oregon Physician’s Perceptions of Patients Who Request Assisted Suicide and Their

Families,” (2003), J of Palliative Medicine; 6:3, and “Oregon Physicians’ Responses to Requests

for Assisted Suicide: A Qualitative Study,” (2004), J of Palliative Medicine, 7:3.

Internal Medicine Grand Rounds * 1.0 CME Approved

Thursday, October 29, 7:45-8:45am, HSEB 1750

"Oregon Health Care Providers' Experiences with Legalized Physician-Assisted Death"

Based on data from Oregon, where a Death With Dignity law has been in force since 1997, that

state’s principal researcher, Linda Ganzini, MD, MPH, will address what the statute does and does

not require of physicians, how the law is perceived by physicians, and what impact physicians

report about the effects on themselves of legally assisting a patient to die. Similar statutes are in

effect in Washington state and Vermont, and a similar bill has now been introduced in the Utah

legislature. Panelists from oncology, palliative care, and general medicine will comment on some

of these issues.

Linda Ganzini, MD, MPH, Noon Lecture* * 1.0 CME Approved

Thursday, October 29, 12:00-1:00, HSEB 2600

(box lunches and CME provided)

"The Oregon Death with Dignity Act: Why do Patients Request Assisted Death?”

"Intersex-The blurred lines of biological sex” with visiting speaker, Jeanne Nollman

September 17, 2015, 5:30-7pm, RAB 117

Watch for more information closer to the event!

Medical Ethics In Utah Page 3 Guest Speaker: Linda Ganzini, MD, PhD

Dr. Linda Ganzini

Evening Ethics

Physicians Literature and Medicine Discussion Group

August 12, 2015 (please note date change)

LDSH Pugh Boardroom 6:00-8:30p, Facilitated by Aden Ross, PhD

All the Light We Cannot See by Anthony Doerr

“All the Light We Cannot See,” by Anthony Doerr, is one of the most compelling and best written

novels in years, justifiably earning the 2015 Pulitzer Prize for fiction. Set in the final months of World

War II, the novel follows the lives of Marie-Laure, a blind French girl, and Werner, a German orphan

conscripted by the Hitler Youth. When the Nazis occupy Paris, Marie-Laure and her beloved father flee

to the walled citadel of Saint-Malo by the sea, taking with them one of France’s most valuable jewels from the

Museum of Natural History.

Jumping back and forward in time, Doerr slowly interweaves the lives of both characters, paralleling Werner’s

growing expertise with electricity and radios and Marie-Laure’s exquisitely rendered exploration of the natural and

emotional worlds through her father’s eyes. The plot, suspenseful enough to keep you up at night, culminates in a

scene where Marie-Laure is trapped in her hiding place as the town burns under Allied bombardment and a Nazi

officer tracks her to steal the jewel. Apart from complex characters and an appropriately labyrinthine structure,

Doerr’s style mixes vivid scientific details with gorgeous poetic metaphors, a true symbiosis of science and art.

More than that, he explores vital issues. How can anyone remain good in the face of the violence and destruction

of war? How is science simultaneously an instrument of wonder—and death? What comprises a person’s

conscience—or an apparent lack thereof? How can one distinguish “good” and “evil” in war?

At one point, Doerr reminds us that all light is mathematically invisible and that the brain can create light in

darkness. Between Marie-Laure’s blindness and Werner’s entrapment in radio waves, this novel ultimately asks

each of us, what is all the light we cannot see?”

September 2, 2015

U of U Hospital Large Conference Room W1220 6:00-8:30p, Facilitated by Gretchen Case, PhD

Can’t We Talk about Something More Pleasant? : A Memoir by Roz Chast

Roz Chast’s book Can’t We Talk About Something More Pleasant? is subtitled A Memoir, and it

is a memoir, but not of just one person. This is a memoir of a family. The book centers on the

relationship between Chast, a nationally celebrated cartoonist, and her parents as they age and pass

away. Chast’s words and images work together in this book to tell a complicated story of love,

frustration, fear, and peace. The story is not a simple one and not told in an entirely linear fashion,

but will resonate with anyone who has participated in the aging and dying process with elders.

Although the subject matter is sometimes grim, Chast’s wit and sharp attention to detail leads to

many humorous moments and a satisfying conclusion.

October 7, 2015

LDSH Pugh Boardroom 6:00-8:30p, Facilitated by Susan Sample, MFA, PhD

The Anatomy Lesson: A Novel by Nina Siegal

This historical novel artistically fleshes out one of medicine’s most well-known paintings, Rembrandt’s

The Anatomy Lesson of Dr. Nicolaes Tulp, on multiple levels. Nina Siegal draws upon six years of

research in Amsterdam to vividly reimagine the city in 1632, a significant time for the evolving science

of medicine. Tulp, newly appointed city anatomist, commissioned the artwork to memorialize himself

as well as instruct apprentice surgeons; attendees paid to view the dissection, in contrast to the prior

raucous public executions and dissections of the criminals’ corpses.

The novel creatively conveys this historical shift through characters’ alternating points of view in what might be termed

a literary dissection. Siegal infuses life into the painting’s corpse by giving voice to various body parts. Chapters

entitled “The Hands” provide a personal portrait of Tulp; “The Eyes” describe Rembrandt as a young artist; and “The

Mind” tells of Renee Descartes whom the author imaginatively places at the dissection. Straddling history and fiction

are “The Body” chapters, based on historical details about Aris Kindt, a petty thief whose body is the famed corpse.

Siegal poignantly imagines not only Kindt’s early life but also Flora, a young woman who reveals yet another

perspective on life in “The Heart.”

Like the painting, the novel raises provocative questions concerning dissection and anatomy, science and art, religion

and epistemology. How does the scientific truth Tulp presents relate to the artistic truth Rembrandt strives for in his

novel group portrait? How does Descartes’ presence influence the anatomy lesson? As you read, consider whether the

novel influences the ways in which you look at the individuals in the painting, particularly Tulp and Kindt. What is the

relationship between what we see and what we know?

Resident Ethics Conferences 12:30-1:15 pm

DNAR/Advance Directives/POLST/LDO: Talking with Patients and their families about withholding

resuscitation

IMC: Jay Jacobson, MD

VAMC Tsagaris Conference room: Jeffrey Botkin, MD & Leslie Francis, PhD

UUMC Cartwright Conference room: Susan Sample, PhD & Estelle Harris, MD

Withholding/Withdrawing Medical Care: How to introduce palliative care as an option

IMC: Jay Jacobson, MD

UUMC Cartwright Conference room: Holli Martinez, NP & Peggy Battin, MA, PhD

VAMC Tsagaris Conference room: Peter Yarbrough & Lelsie Francis, PhD, JD

When, How, and Why We Evaluate Patient Competence

IMC: Jay Jacobson, MD

UUMC Cartwright Conference room: Jim Tabery, PhD & Maureen Henry, PhD

VAMC Tsagaris Conference room: Maureen Henry, PhD

Medical Mistakes/Malpractice

IMC: Jay Jacobson, MD

VAMC Tsagaris Conference room: Leslie Francis, PhD, JD

UUMC Cartwright Conference room: Leslie Francis, PhD, JD

Wed. July 8

Thurs. July 23

Tues. July 28

Wed. Aug. 19

Tues. Aug. 25

Thurs. Aug. 27

Wed. Sept. 16

Tues. Sept. 22

Thurs. Sept. 24

Wed. Oct.21

Thurs. Oct. 22

Tue. Oct. 27

*The Physicians Literature and Medicine Discussion Group 6:00-8:30 pm

All the Light We Cannot See by Anthony Doerr, Facilitated by Aden Ross, PhD

LDSH Pugh Boardroom

Can’t We Talk about Something More Pleasant? : A Memoir by Roz Chast

Facilitated by Gretchen Case PhD

U of U Hospital large Conference room

The Anatomy Lesson: A Novel by Nina Siegal Facilitated by Susan Sample, FA, PhD

LDSH Pugh Boardroom

Wed. Aug 12

Wed. Sept. 2

Wed. Oct. 7

*Evening Ethics Discussions

“Intersex-The blurred lines of biological sex” with visiting speaker Jeanne Nollman

5:30-7:30 pm RAB 117

“Death with Dignity Laws: What do they Mean for Physicians?

5:30-7:30 pm RAB 117

Thurs. Sept. 17

Wed. Oct. 28

Internal Medicine Grand Rounds

"Oregon Health Care Providers' Experiences with Legalized Physician-Assisted Death"

7:45-8:45 am HSEB 1750

Thurs. Oct 29

*Linda Ganzini, MD, MPH, Noon Lecture

"The Oregon Death with Dignity Act: Why do Patients Request Assisted Death?”

12:00-1:00 pm HSEB 2600

Thurs. Oct 29

C A L E N D A R O F A C T I V I T I E S A N D P R O G R A M S

CME Statements Accreditation: The University of Utah School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical educa-

tion for physicians. AMA Credit: The University of Utah School of Medicine designates these live activities for a maximum of 1.5AMA PRA Category 1 Credit(s)™. Physicians should claim only the

credit commensurate with the extent of their participation in the activity. NONDISCRIMINATION AND DISABILITY ACCOMMODATION STATEMENT: The University of Utah does not exclude,

deny benefits to or otherwise discriminate against any person on the basis of race, color, national origin, sex, disability, age, veteran’s status, religion, gender identity/expression, genetic information, or sexual orientation in

admission to or participation in its programs and activities. Reasonable accommodations will be provided to qualified individuals with disabilities upon request, with reasonable notice. Requests for accommodations or

inquiries or complaints about University nondiscrimination and disability/access policies may be directed to the Director, OEO/AA, Title IX/Section 504/ADA Coordinator, 201 S President’s Circle, RM 135, Salt Lake

City, UT 84112, 801-581-8365 (Voice/TTY), 801-585-5746 (Fax).

1.5 CME for Evening Ethics and Literature & Medicine. 1.0 for Ganzini noon lecture. 1.0 for Grand Rounds

DIVISION OF MEDICAL ETHICS

AND HUMANITIES

75 South 2000 East #108

Salt Lake City, Utah 84112

DIVISION OF MEDICAL ETHICS AND HUMANITIES

Division Faculty: Margaret P. Battin, M.F.A., Ph.D. Jeffrey R. Botkin, MD, M.P.H. Samuel M. Brown, MD, M.S. Teneille R. Brown, JD Gretchen A. Case, Ph.D. Leslie P. Francis, Ph.D., J.D. Brent Kious, MD, Ph.D Erin Rothwell, Ph.D James Tabery, Ph.D. Jay Jacobson, M.D. (Emeritus)

Program Associates: Howard Mann, MD Mark Matheson, D. Phil. Susan Sample, M.F.A.

Division Associates: Rebecca Anderson, RN, Ph.D Philip L. Baese, M.D Maureen Henry, JD Thomas Schenkenberg, Ph.D

Academic Program Manager: Linda Carr-Lee Faix, M.A., Ph.C

Executive Assistant: Heather Sudbury

Phone: (801) 581-7170 or (801) 587-5884 Fax: (801) 585-9588

D I V I S I O N M E M B E R S O N T H E R O A D A N D I N P R I N T

Under a cooperative arrangement between the U's J. Willard Marriott

Library and Oxford University Press, The Ethics of Suicide: Historical

Sources, edited by Margaret Pabst Battin (our own Peggy), is in the final

stages of production. This very large project combines a print volume

published by OUP (744 pages) and an extensive Digital Archive, accessible

by means of QR codes embedded in the print text, hosted by the U's

academic library. The print volume will be released in late August, and

the project will be celebrated at a launch luncheon ceremony October 5, 12:00-2:00, in

Marriott's Gould Auditorium. If you are interested in attending, please email

Linda Carr-Lee Faix , linda.carrlee@hsc.utah.edu, Heather Sudbury,

heather.sudbury@hsc.utah.edu, or email Peggy directly, battin@utah.edu.

Sam Brown attended the inaugural meeting of the THRIVE initiative as a committee

member, where they are working on developing support systems for survivors of intensive

care. For more on THRIVE, see

http://www.sccm.org/Research/Quality/thrive/Pages/default.aspx

In May, Gretchen Case attended the 4th Annual International Health Humanities

Conference, held in Denver, CO, where she had a chance to catch up with DMEH alumna

Tess Jones, who is now at the Center for Bioethics and Humanities at the University of

Colorado. Also in April, Gretchen Case was honored to learn that her article “Moral

Imagination Takes the Stage: Readers’ Theater in a Medical Context“ written with Guy

Micco was chosen for inclusion in Brian Dolan’s new anthology, Humanitas: Readings in

the Development of the Medical Humanities.

The U of U School of Medicine now has a chapter of the Gold Humanism Honor Society.

Gretchen Case is the faculty advisor.

Leslie Francis became President of the Pacific Division of the American Philosophical

Association (APA) on July 1st.