Thursday, August 14, 2014

Three Ethical Dilemmas on Ebola Virus Medicine

The Ebola Virus outbreak in West Africa has put the spotlight on ethicists. As the health world scrambles to address the problem, bioethicists are also facing ethical dilemma related to Ebola. It is a well known fact that the Ebola virus has not treatment and no vaccine available in the market today. But there are several pharmaceuticals racing against each other to develop a medicine against it. Last week, the US government tested the new drug ZMapp on two Americans infected with the virus. There was a public protest on why the medicines were given to the Americans and not made available to the general public. This raised several ethical issues.

Here are three of the biggest ethical issues that we all need to consider.

1. Is it ethical for us to use vaccines and drugs against Ebola that has not been adequately tested on humans?

So, here is the dilemma. The drug, as reported, is still on trial stage. There has only been the animal test phase. No human trial for its safety and efficacy has been done. The ZMapp given to the infected Americans, at its best, is a human research to its efficacy. Although, early reports showed positive response to the drug, there is no conclusive evidence to show it is effective. Would it be proper then to subject thousands of people to this medicine without knowing its effect to humans?

I will not even dare elaborate on another ethical if not racist issue behind this. Suffice for me to ask the perennial questions, why are experimental drugs done in third world countries? Why subject Africans to experimental drugs with unknown risks or benefits?

The WHO ethics panel agreed that it is ethical to use experimental, non-approved drugs to fight the Ebola outbreak. They reasoned that this outbreak is a special circumstance that needs special consideration. A research protocol needs to be followed in doing human research. Are we following the proper protocol in using these experimental drugs? Human research requires that the risks and benefits to the person should be weighed. Without knowing the gravity of the risk nor any benefits it can provide to the patients, would it still be ethical to provide these medicines to humans?


2. Who would receive the limited number of this new Ebola medicine?

The second, and perhaps the most difficult, ethical dilemma is sorting out questions on the principle of justice - specifically distributive justice. Who should receive the new Ebola medicine? Pharmaceuticals have reported that they have only more than a dozen of medicines available ready. Regardless of problem #1 being resolved, the medicines are now sent to West African countries. It's now time to give them to the people affected by Ebola. As of this writing, WHO has reported that more than 1 million people are now affected by Ebola. Who among them would receive the 12 or 15 or 20 medicines?

There are 4 countries severely affected by the Ebola virus - Guinea, Liberia, Nigeria and Sierra Leone. Who among these countries should receive the most of the available medicine? Should it be the closest ally of the western world? Should it be the country with the highest death toll? Where should the pharmaceuticals developing the medicine send their products? When they have settled that issue, more ethical questions needs to be raised. Who would be the blessed people to get treated first? Two Liberian doctors are going to receive the experimental drugs. Why the doctors? Why not the mother of 8 children whose husband recently died also of Ebola?


3. Why raise the ethical dilemma for the Ebola stricken West Africa?

The third maybe a little difficult for me to explain. This was raised by my Nigerian friend which I am now only beginning to understand. I will try my best to make it simple. When the ZMapp medicines were given to the infected Americans, there was no ethical question about it. It did not bother WHO to convene a panel of ethicists. In reality, experimental medicine are given almost anywhere. Here in the Philippines, stem cell therapy is on top of them. When a patient willingly consents to receive an experimental drug, no one bothers to stop them because it is still experimental. Yet, in the case of the Ebola virus outbreak, the world has to pause and reconsider giving the drugs. At a time where the affected people are crying out to give them anything - even experimental drugs - to stop Ebola, the world has to bring up ethical questions.

Yes, for some people - especially those who desperately need them - to second guess giving a "potentially" helpful drug is tantamount to withholding any hope of cure. Are there underlying reasons behind the hesitancy? Is money an issue? Does the financial gains and costs holding the world back? Are we really concerned about the efficacy of the drug and the safety of the sick people? Are we really being ethical about this?

Friday, August 8, 2014

Three Reasons Why Doctors are Poorly Compensated

Medical ethics tells us that "(T)he primary objective of the practice of medicine is service to mankind..." This principle has been abused to justify poor compensation for doctors with their work. There is injustice. This is specially true for young doctors who receives retainer fees or compensated for the number of hours rendered. But what is the doctor's service worth? If its value is measured monetarily, how much would it cost?

  • The first and most common argument thrown is that, "medicine is a service and should not be profit-oriented." It seems to me that the assumption here is that only those that are cheap and free are considered a service. If you receive good money for a service rendered, that becomes profit-oriented. So doctors are made to believe that it is okay for them to receive little to no compensation for their service rendered. If doctors earn good money for their practice, they are not serving humanity.
This is where the professional fee for the professional service given becomes important. Of course, doctors are either compensated with either retainer fees or fee-for-service. But in general, what is a fair fee for the service rendered by the doctor? What will be a "just compensation" for doctors?

The PMA says the "(P)rofessional fees should be commensurate to the services rendered with due consideration to the patient’s financial status, nature of the case, time consumed and the professional standing and skill of the physician in the community."  They also explained that for self-employed professionals, there is no universal fee. It depends on the prevailing and acceptable fee among the practitioners in the community.

If there is an acceptable fee, why are doctors poorly compensated for their service? Again, this may not be true for fee-for-service doctors with good practice. But this is especially true for many young doctors on retainer fees/per-duty fee or resident physicians.

  • The second reason, doctors are told that the hospital can only afford to compensate them with a small amount for their service. It's either the doctor take it or leave it.
Let me illustrate further:

I am looking to hire a helper in our house (pun intended.) She will help cook the food, wash the dishes, clean the house and wash the clothes. I will need her services to have a decent and clean place. For such services, the acceptable rate in our area for helpers is P3000 a month. (Don't ask me where I live.) I can only offer P2000. Although the acceptable rate is P3000, the prevailing rate and the most common rate offered is P2500. Well, times are tough. It's difficult to get a job. I know people need the money. If they don't want P2000 a month, then they don't have to accept it. I am not pressuring them. I am just offering it to whoever is willing to offer their service for that fee. Is it just for me to offer compensation for the service I know is worth more than that? Is it my fault if there are people willing to receive such compensation for their service?

  • The third and most important reason why doctors are poorly compensated is because NO ONE CARES. Not even the doctors. Maybe because of reason 1 and 2. But this injustice perpetuates because no on is standing against it. A learned prophet once taught, "Learn to do good; seek justice, correct oppression... " (Isaiah 1:17).

The injustice must stop. People must do something against the unjust practices. Desmond Tutu famously said, "If you are neutral in situations of injustice, you have chosen the side of the oppressor." We must take sides now. No, one or two person cannot do it.  There needs to be a collective effort to stand against it. The government, the health industry, hospitals, doctors and even patients must do their share. Together, change can happen.



Doctors still do service to humanity. But what is its value to you?

Monday, July 14, 2014

Three Messages That Tells Me My President is Arrogant

Tatlong mensahe na nakuha ko sa DAP explanation ni PNoy. Three things that I heard from what PNoy said about his DAP explanation.

1.       “Presidente ako, kaya puede ko gastusin ang pera ng kahit sino”
-          The President can use and transfer the use of any savings from other appropriated budget according to the Administrative Order he has cited. It doesn’t matter whose money is it, the Philippine president is the most powerful person in the country and so he can touch and use anybody’s money whenever he wants to. It doesn’t matter if it was indeed appropriated and approved by congress, the president can appropriate the money according to his own budget. After all, DAP is not PDAF. According to PNoy, hindi naman pumunta sa NGO ni Napoles ang DAP kaya magkaiba yun sa PDAF. Regardless if the budget were diverted illegally, napunta naman sa mabuti kaya OK lang na i-manipulate ang budget appropriations.

2.       “Mali sila, dahil tama ako.”
-          The Supreme Court is wrong in their decision for the simple reason that they do not agree with the President’s interpretation of the law. It implies that only and only the President’s understanding and interpretation of the law is the correct interpretation. Any other interpretation by the 13 magistrates who have dedicated their lives in studying and upholding the law are definitely mistakes. I can even hear the threat to the SC, when he said “gusto nila ng personalan.” I will not wonder if another “Corona Impeachment” will happen to any of the justices sometime soon.

3.       “It’s okay to disobey the law, as long as your intentions are good.”
-          Obviously, for PNoy, the end justifies the means. Yes, even if it means breaking the law. Using the example of parking on a “no parking zone,” PNoy justifies that even if DAP was deemed illegal, it is still to be lauded for the good intentions of the program. We should not wait for another two years following proper procedure to use the money saved. Forget the bureaucratic procedure. It is okay to disobey the law, as long as one aims to help the needy. It is okay to beat the traffic light because you are rushing to help another. It is okay to steal, because you will give the money to the poor. It is okay to kill a person because you will save the innocent. I can hear PNoy shout at me saying, “Let us forget the law and order, and do what is convenient in the guise of doing good towards a matuwid na daan.”

Thursday, June 19, 2014

Para Kay Pepe sa Iyong Kaarawan

Pareng Pepe,

Isang maalab na pagbati mula sa mga bagong bayani. Oo, mga bayani daw kami. Hinahanay kami sa mga katulad mo at ilan pang nagbuwis ng kanilang buhay para sa ating bayan. Marahil tinawag kami ng gobyerno na mga bayani dahil inaaasa nila sa amin ang pag-angat ng bayan na dapat sana'y kanilang sinumpaang tungkulin. Ngunit ang liham na ito ay hindi pagpuna sa kakulangan ng gobyerno. Mahirap pag-aksayahan ng panahon ang hindi nagbibigay ng tamang panahon para sa iyo. Nais ko lamang gunitain ang iyong kaarawan bilang tanda ng pasasalamat sa Poong Maykapal sa ginamit niyang buhay bilang huwarang Kristiyano upang mapulutan ng aral ng kapwa Pilipino.

Ang iyong dedikasyon sa pagpapahalaga sa kapakanan ng iyong kapwa Pilipino ay tanda ng isang mabuting Kristiyano. Katulad ng isa sa mga mahalagang pangaral ni Hesus, "mahalin mo ang iyong kapwa katulad ng iyong sarili, (Marcos 12:31)" ang buhay mo ay naging halimbawa ng aral na ito. Hindi mo inalintana ang mga puedeng mangyari sa iyo, sa iyong pamilya at sa sarili mong buhay alang-alang sa ikabubuti ng maraming Pilipinong nagdurusa sa pang-aabuso at kawalang ng hustisya. Nagbunga ang iyong mga pasakit at nakalaya nga ang iyong bansa mula sa mga dayuhang mananakop. Ngunit nakalaya nga ba sila sa mga pahirap ng pang-aabuso at walang katarungan?

Ang tinuro sa iyo ng nanay mo na magdasal sa Diyos ay dala mo hanggang sa huling hininga mo. Hindi ka nakalimot sa iyong Diyos sa lahat ng pagkakataon lalo't higit sa mga panahong ikaw ay sinusubok. Ang tunay na Kristiyano ay laging inuuna ang kanyang Panginoon sa lahat ng bagay. Hindi ka nakalimot sa kung ano ang tunay na mahalaga. Nang ang simbahan ay lumihis sa turo ng Biblia, binatikos mo ito. Hindi ka lumayo, bagkos ang pag-ibig mo sa Diyos ang naging dahilan ng pagtuligsa mo sa mga mali na iyong nakikita. Hanggang sa huli, nananalig ka sa Diyos at siya ang iyong naging sandalan. Ang paglapit mo sa Panginoon sa huling sandali ng iyong buhay ay tanda ng mataimtim na pananampalataya na dapat tularan. Ang hinahon ng Diyos ay bakas sa iyong mukha bilang tanda ng lubos na pagsuko ng iyong buhay sa Kanya.

Ikaw ay bayani. Ngunit huwaran ka ding Kristiyanong matuturing. Nawa'y ang iyong halimbawa ay makita at maging inspirasyon para sa mga sisibol na tunay na bagong bayani.

Wednesday, May 28, 2014

A Daughter's Love for Her Mother: A Kidney Transplant Story

I just want to appreciate my sister who donated her kidney to our mother who has end-stage renal disease. God has a plan but we never saw it.

When there was too little option for a donor for our mother, we started looking for relatives. Although it may have higher chances of familial disease, we had to take the chance. Now there were only a handful of our relatives who were willing to donate their kidneys. You can count them on one hand. However, all of them failed the matching test. Then we started looking to those people beside us. We candidly asked ourselves, would anybody from the family would like to donate a kidney to mom?

How much does a child love one's parent when the child is not willing to donate a kidney? Would donating a kidney a test of a child's love to one's parent? Maybe not. But how much then does the child love the parent?

A child choosing not to donate a kidney to one's parent is not a measure of a child's love to the parent. But donating a kidney to one's parent speaks a thousand words.

People ask, why would a daughter donate her kidney to her mother?

She never answered it. She just did. Even the ethics committee never bothered to ask the question because they saw the answers in her eyes.

My sister is a social worker. She once explained to me why she loves doing good deeds. I always thought she would do good deeds because as Christians that is expected of us. I never understood what she meant when she explained that most people would imitate a movie star idol or an athlete. She was doing good to imitate Christ. Jesus sacrificed his body, his career, his future and eventually his life for other people's sake. I never thought my sister would go that far imitating Christ.

When it was time to have the transplant, every body was anxious. What will happen? Will it be successful? What if something goes wrong? What if the kidney was rejected by the body?

It was a test of faith. It was a simple pure surrender to God's plan. It helped that we are a God fearing family. It is cliché that "a family that prays together, stays together."

More than that, there were people, relatives, church family and friends who showed support. It was an outpouring of God's love through the people around us.

Then the time has come. The nurses and the doctor came to the room. There was silence. As the nurses prepared my sister, she was calm. Everything was set, then they started rolling her bed out of the room. There was one last thing that needs to be done. The family gathered around her... and Auntie Bing, who is a clergy, thanked God for a daughter's courageous act... The doctor assured her, the single kidney she will donate is healthy enough to support her mother. My brother squeezed my sister's hand and said, "it is all part of God's plan"... tears fell.

Tuesday, April 29, 2014

How to Celebrate a Birthday Away from Home

I have always emphasized the importance of celebrating birthdays. No, I do not mean that I love to party. Christians should always be grateful to God's goodness. Nothing more important to be thankful than to the life God has breathed on us. Our birth-days are a reminder of the gift of life God has graciously given to us. We ourselves celebrate in gratefulness to the life God has given us and the opportunity to experience life and worship God.

As Christians, our family members and friends must celebrate birthdays with us. They are the people God blesses through our life (I hope). Our family and friends show their thanksgiving to God for the blessings that flows through our Christian life. But what if we are far from our family and friends? How do we celebrate?

I am out of town to begin a new job - in the Middle East - with not too many Christians around me. How can I show gratitude to God? How can I share the celebration with my family and friends? To add spice, how can I praise God among non-Christians?

This is not the first time that I will celebrate my birthday away from the closest people in my heart. I have always wondered though how to celebrate my birthday if it was a thanksgiving for God's gift of life to me.  I did three simple ways  to celebrate my birthday perfectly.

- First, you've guess it right - I prayed. Of course, we talk to God and express our gratitude for our life and the blessings in the previous years. We also thank God for the opportunity to be a channel of blessing to more people in the coming years.

- Second, dine with your family and friends through Skype. While there is no substitute for physical presence - it is never the measure of fellowship. We Christians have long known that physical presence or absence does not define our relationship with our fellow Christians. Even time cannot be a hindrance to our fellowship with other Christians of old and the future we anticipate. As such, our fellowship can be spiced up by the social media available in our finger tips.

- Third, receive a gift. A gift is offered to show how special is the person. God gives us gifts because we are special to God. Birthday gifts for us are expressions of how meaningful and special we are to others. But more than that, receiving gifts is a reflection of how important we are to God. Now since, I am alone - I bought myself a gift that tells me I am special.

These three simple ways was the best way to celebrate a birthday away from home. It made me happy. I saw my family and friends happy as well. I am sure God is happy too.

Friday, March 21, 2014

Three Things a Former Secretary of Health Taught Me


The Dr. Alfred Bengzon, the former Secretary of Health now the CEO of Medical City, met to welcome us in the Medical City family. He shared his insights and thoughts in his 5 decades of being a medical professional. In our meeting, I learned three things from him:


1.       “Doctor’s should go beyond medicine” 
2.       “Heroes can come from the government”
3.       “Patients are partners”

I appreciated that Dr. Bengzon opened our meeting with a prayer from Bishop Desmond Tutu. He said it was something that he wants to be done in all other meetings. We were off to a good start.

The first thought that really had a big message for me was when Dr. Bengzon shared how he was able to appreciate being a doctor by going beyond the scope of medicine. He shared his story how a doctor like him ended up being a manager and taking an Master’s in Business Administration in Ateneo. But that “deviation” from the field of medicine allowed him to have a wider perspective and appreciation of medicine.  He was resolute to tell us that doctors must not only know medicine. He asked me who I was and what’s special about me and I told him that I am a doctor and a physician – the wholistic approach to medicine in person. Our talk turned to spirituality and I was impressed by his wide knowledge of the subject. He talked about Mitch Albom and his books and offered some of his insights on the topic of spirituality. He asked about how a loving God would allow unrepentant people to go to hell. He left it for us to theologize on it. He admonished the other doctors to also read Albom’s “Tuesday’s with Morrie” and not just be limited to their Schwartz, Harrison’s or del Mundo’s. He reminded us that doctors will be able to appreciate medicine better if they know other than medicine.

The second thing I learned from the good doctor is that heroes can still come from the government sector. The recent current events and forever have focused on how government officials and their cohorts have been stealing the people’s money. The inefficiency and ineptitude of the government to address the country’s problem has been an acceptable fact for many. But Dr. Bengzon told the story of an underpaid midwife in the mountainous typhoon-zone part of northern Luzon and her dedication to uplifting the health condition of her community. The midwife would travel on foot for several hours climbing mountains and crossing rivers just to be able to deliver vaccines for the children. Not even her surgical operation that required her to rest could stop her from performing her duty. It was no wonder that she died in the line of duty because she drowned when she was caught by a flashflood while crossing the river one stormy season. Some people in the government are still doing their best to improve the health condition of others. There are still heroes in the government. The field of medicine is like that – sacrificing more of ourselves for the health of others. Medicine is service oriented. He reminded us to help the government in serving the people because anybody can be a hero even in their own little way.

The third lesson I learned from Dr. Bengzon is in looking at the patient as partners in health. This concept has been taught to me in my residency training as a medical doctor and was not something new. But the experience and the examples he gave made it real and practical. It was no longer just a concept. He shared how one of his protégé applied the concept that patient are partners through the design of his clinic. The clinic did not have the traditional doctor’s table where the doctor sat on one side and the patient on the other side while the medical consult is ongoing. Rather, the clinic only had a couch and a center table. The doctor and the patient sat in the same couch to emphasize that the doctor-patient relationship was a partnership. The clinic structure allows the patient to look at the doctor at eye level and sit shoulder to shoulder to emphasize that both of them works in partnership and has equal role in the patient’s health. Dr. Bengzon reminded us how doctors love to go ego-tripping and that this culture must come to a stop. He challenged us new doctors that in our practice, we will treat our patients as partners who must also be given the responsibility and control of their own health.