Table of Contents

Introduction

About This Book

Conventions Used in This Book

What You’re Not to Read

Foolish Assumptions

How This Book Is Organized

Part I: Medical Ethics, or Doing the Right Thing

Part II: A Patient’s Right to Request, Receive, and Refuse Care

Part III: Ethics at the Beginning and End of Life

Part IV: Advancing Medical Knowledge with Ethical Clinical Research

Part V: The Part of Tens

Icons Used in This Book

Where to Go from Here

Part I: Medical Ethics, or Doing the Right Thing

Chapter 1: What Are Medical Ethics?

Defining Medical Ethics

What are ethics?

The four principles of medical ethics

Differences between ethics and legality

Reconciling medical ethics and patient care

Turning to ethical guideposts and guidelines

Looking at the Common Medical Ethics Issues

Privacy and confidentiality concerns

Reproduction and beginning-of-life issues

End-of-life issues

Access to care

Moving Medicine Forward: The Ethics of Research

Chapter 2: Morality in Medicine

Distinguishing among Ethics, Morality, and Law

Looking at the Hippocratic Oath and Its Modern Descendents

Noting why the Oath was updated

Taking a new oath at graduation

Understanding humanitarian goals: The Declaration of Geneva

Rules for Engagement: Today’s Codes of Medical Ethics

American Medical Association Code of Ethics

American Nursing Association Code of Ethics

Bedside Manners: Ethics inside the Hospital

Understanding the hospital ethics panel

Patient bill of rights

Emergency room ethics

Bioethics as a Field of Study

Chapter 3: The Provider-Patient Relationship

Protecting Patient Privacy

Understanding confidentiality

Balancing privacy with public good

Confidentiality in research

Clear and Ethical Communications

Communicating with the patient

Informed consent

Understanding Full Disclosure: Telling the Patient What Matters

Decoding conflicts of interest

Deciding who has access to medical information

Choosing not to disclose information to a patient

Understanding Appropriate Referrals

Considering second opinions

Discovering the need for specialist referrals

Choosing Whom to Serve

Refusing to treat a patient

Ending a doctor-patient relationship

Giving medical advice to non-patients

Patient Rights and Obligations

Patient autonomy: Patient as decision-maker

Encouraging honesty

Balancing treatment and cost

Chapter 4: Outside the Examining Room: Running an Ethical Practice

Propriety in the Paperwork: Medical Records

Complying with the Health Insurance Portability and Accountability Act (HIPAA)

Training staff to handle records

Preventing identity theft

Releasing medical records

Safeguarding anonymity

Modern Managed Care and Today’s Office Practice

Ethical concerns of managed care

Working with midlevel providers

Prescribing good care while still getting paid

Third-Party Issues

Dealing with insurance companies and HMOs

Perks and freebies

Targeted advertising and ethics

Chapter 5: Learning from Mistakes: Disclosing Medical Errors

Types of Medical Errors and Ways to Prevent Them

Understanding diagnostic errors

Understanding treatment errors

Medication errors

Communication errors

Administrative errors

Lab errors

Equipment failures

Admitting Your Mistakes

Understanding truth telling

Disclosing an error to a patient

Balancing ethics with legal protection

Telling a higher-up that you’ve made an error

When Colleagues Don’t Disclose: Your Ethical Obligations

Healthcare Provider Impairment

Knowing the warning signs of impairment

Addressing a colleague’s impairment

Testifying before a medical board

How Reporting Errors Helps Medicine as a Whole

Creating a no-blame system for reporting errors

Understanding how to reduce errors

Part II: A Patient’s Right to Request, Receive, and Refuse Care

Chapter 6: The Ethical Challenges in Distributing Basic Healthcare

Ethics of Healthcare Distribution

Exploring Healthcare Rationing

How services are rationed

The ethics of rationing

Looking at Healthcare in the United States

The current system and its ethical challenges

The reformed system and potential ethical speed bumps

Examining universal healthcare

Chapter 7: When Spirituality and Cultural Beliefs Affect Care

Accommodating Religious Beliefs

Religions that limit or ban medical care

Discussing religion and understanding objections

Offering alternatives to care

Respecting Cultural Diversity

Attitudes and beliefs that affect care

Communicating with non-English-speaking patients

Discussing cultural beliefs

When the Patient Refuses Treatment

Determining competency

Making sure the patient understands

Validating concerns and assuaging fears

Accepting refusals

Chapter 8: Parental Guidance and Responsibilities

Acknowledging Parental Rights to Choose or Refuse Care

Responsibilities of a parent

Weighing parental choice against a child’s best interest

Caring for a child when parents disagree with you

Knowing when and how to treat impaired infants

Vaccination: The Evidence and the Ethics

Understanding vaccination as a public health issue

Considering risk-benefit analysis

Understanding full disclosure

Addressing parent opposition to vaccines

Child Endangerment: The Healthcare Provider’s Role

Discovering signs of abuse and neglect

Reporting abuse and working with Child Protective Services

Confidentiality, Care, and the Adolescent Patient

Understanding adolescent patients’ rights

Balancing privacy and patients’ rights

Talking to teens about informed consent

Mature minors and emancipated minors

Part III: Ethics at the Beginning and End of Life

Chapter 9: Two Lives, One Patient: Pregnancy Rights and Issues

Medical Intervention: Rights of the Mother versus Rights of the Fetus

Setting forth rights with the Fourteenth Amendment

Understanding self-determination

Balancing treatments for a woman and fetus

The role of technology

Considering a Father’s Rights

Birth Control

Educating your patient about birth control

Balancing your beliefs about birth control with a patient’s rights

Understanding religious ethics and birth control

Fetal Abuse

Maternal drug abuse or neglect: Crimes against the fetus

Detecting fetal abuse: Ethical and legal obligations

Limiting maternal freedom for fetal well-being

Seeing into the Future: Prenatal and Genetic Testing

Understanding the ethical use of prenatal testing

Understanding tests and accuracy issues

Genetic counseling and sharing results with parents

Chapter 10: When Science Supersedes Sex: Reproductive Technology and Surrogacy

In Vitro Fertilization

Understanding acceptable versus unacceptable harm

Pre-implantation genetic diagnosis: Choosing which embryos to implant

Multiple pregnancy reduction: When IVF works too well

Decoding embryo storage and destruction

Artificial Insemination

Understanding safe, anonymous, and consensual sperm donation

Sex selection: Is it ever ethical?

Surrogacy: Carrying Someone Else’s Child

Paying for pregnancy: The ethics of commercial surrogacy

Considering the emotional and physical health of the surrogate

Looking at the contract and surrogate responsibilities

Understanding rights of the child

The doctor’s responsibilities

Sterilization: Preventing Reproduction

Voluntary sterilization as birth control

The ethics of involuntary birth control

Understanding eugenics: Social engineering

Chapter 11: Walking a Fine Line: Examining the Ethics of Abortion

When Does Personhood Begin?

What, and who, is a person?

Applying ethical principles to personhood

Looking at Each Side’s Point of View

Understanding the pro-life stance

Understanding the pro-choice stance

Therapeutic Abortion: To Protect Maternal Health and Life

Reasons for therapeutic abortion

Informing the patient

Counseling for the family

When a patient refuses medical advice

Abortion Due to Fetal Defect

Reasons for abortion because of fetal defect

Weighing the ethics of selective abortion

Voluntary Abortion

Legal definition and limitations

A less invasive option: RU-486

Roe v. Wade: Legal Status of Abortion and Ethical Implications

Looking at changes on the state level

Accurate medical counseling

The Religious Divide

Toward Common Ground

Chapter 12: Determining Death: Not an Event, but a Process

Defining Death

Using heart and lung function to define death

Adding brain function to the definition of death

Examining Brain Death

A quick look at how the brain works

Looking at the types of brain death

Current standards of brain death

Declaring a patient brain dead

Understanding Cases That Defined Brain Death

Karen Ann Quinlan

Nancy Cruzan

Withdrawing Life-Sustaining Treatment

Weighing the benefits of further treatment

Counseling the family

Examining Euthanasia and Physician-Assisted Suicide

Relieving suffering with mercy-killing

Understanding the history of physician-assisted suicide

When a doctor aids in death

Chapter 13: Death with Dignity: The Right to Appropriate End-of-Life Care

Roadmaps for the End of Life

Understanding advance directives

Looking at living wills

Looking at Durable Power of Attorney for Health Care

Do Not Resuscitate and Do Not Intubate orders

Physician’s Order for Life-Sustaining Treatment (POLST)

Of Sound Mind: Establishing Mental Capacity

Understanding informed consent and a patient’s ability to give it

Assessing decision-making capacity

Substitute decision-makers: When a patient is declared incompetent

Relief of Pain and Suffering

Understanding palliative care

Walking a fine line: The double-effect rule

Easing pain with terminal sedation

Organ Donation and Allocation for Transplants

Legality of organ donation

Sustaining life for organ harvesting

Looking at living donation

The financial inequities of transplant eligibility

Compensation for donation: The ethical challenges

Xenotransplantation, or animal to human transplant

Part IV: Advancing Medical Knowledge with Ethical Clinical Research

Chapter 14: Toward Trials without Error: The Evolution of Ethics in Clinical Research

An Introduction to Medical Research

Moving from lab experiments to research on humans

Understanding the importance of informed consent in clinical trials

Turning Points in Medical Research in America

The Tuskegee Syphilis Study: The ethics of withholding treatment

The establishment of the Office for Human Research Protections and IRBs

Guiding Principles of Ethical Studies

The Nuremberg Code: New research standards in the wake of World War II

The Declaration of Helsinki: A global roadmap for ethical clinical research

Good Clinical Practice Guidelines: Replacing the Declaration of Helsinki

The Belmont Report: Best ethical practices in U.S. research

Chapter 15: Beyond Guinea Pigs: Anatomy of an Ethical Clinical Trial

Elements of a Valid Trial: Leveling the Playing Field Ethically

Collective clinical equipoise: Asking whether a trial is needed

Understanding basic trial design

Choosing ethical controls

Preventing bias with blind studies and randomization

Minimizing any risk of harm

The Institutional Review Board: Ethical Gatekeepers of Clinical Research

Looking at the role of the IRB

Evaluating and green-lighting a clinical trial

Recruiting Study Participants

Deciding to ask patients to participate

Laying out all the risks and benefits with informed consent

Full disclosure: Explaining financial and institutional conflicts of interest

Ending a Trial Early

Remembering obligations to patients

Looking at implications for research

Publicizing preliminary results

Chapter 16: Research in Special Populations

Animal Research

Understanding why animals are used

Ethical treatment of research animals

Psychiatric Research and Consent

Assessing decision-making ability in psychiatric patients

Protecting the patient: Risk versus benefit

Pregnancy and Pediatrics

Understanding research with pregnant women

Why risk may outweigh the benefits

Research on children: Surrogate consent

Chapter 17: It’s All in the Genes: The Ethics of Stem Cell and Genetic Research

Understanding Stem Cell Research

Who will benefit? The case for stem cell research

The ethical debate over embryonic stem cell lines

Focusing on adult stem cells

Genetic Testing: Looking for Problems in DNA

Knowing what we can and can’t change

Weighing the risks and benefits

Offering emotional counseling for patients

Genome Sequencing: Mapping DNA

Gene patents: Deciding who owns what

Looking at ethical problems with patents

Deciding who can use the human genome

Gene Therapy: Changing the Code

Weighing the risks and benefits of gene therapy

Designer genes: Going beyond therapy

Cloning: Making Copies

Cloning as a reproductive option

Growing tissues with therapeutic cloning

Part V: The Part of Tens

Chapter 18: Ten Ethical Issues to Address with Your Patients

Confidentiality in the Patient Visit

Informed Consent

Integration of Religious and Cultural Beliefs into Patient Care

The Ethics of Clinical Research

Help for the Uninsured

Screening for Genetic Diseases

Ethical Dilemmas in Infertility

Minimize Suffering in Terminal Conditions

The Living Will Discussion

Honor the Patient-Provider Relationship

Chapter 19: Ten High-Profile Medical Ethics Cases

Terri Schiavo: The Right to Die

Daniel Hauser: A Child’s Right to Refuse Lifesaving Treatment

Angela Carder: Maternal versus Fetal Rights

Sister Margaret Mary McBride: Religion in Conflict with Medicine

Baby Manji: An Unclear Identity

Louise Brown: The First Test Tube Baby

Jesse Gelsinger: The Risks of Gene Therapy

Nadya Suleman: Too Much Fertility

Glen Mills: Autonomy versus Protecting Society

Baby Jane Doe: Treatment of Impaired Babies

Chapter 20: Almost Ten Ethical Issues for the Future

Cloning

Designer Babies and Future Elites

Rationing of Medical Care

Who Owns Your Genes?

The Doctor Is Online

Pandemic Influenza Outbreak

Future Clinical Trials

Artificial Wombs

The Global Spread of AIDS

Table of Contents

About This Book

Conventions Used in This Book

What You’re Not to Read

Foolish Assumptions

How This Book Is Organized

Part I: Beginning with Clinical Anatomy Basics

Part II: Understanding the Thorax, Abdomen, and Pelvis

Part III: Looking at the Head, Neck, and Back

Part IV: Moving to the Upper and Lower Extremities

Part V: The Part of Tens

Icons Used in This Book

Where to Go from Here

Chapter 1: Entering the World of Clinical Anatomy

Studying the Body in Different Ways

Looking under the microscope or with your eyes

Speaking clinically: Terms used in clinical anatomy

Dividing the Body into Systems and Regions

Organizing the body by systems

Organizing the body by regions

Chapter 2: Getting a Grip on Terms Used in Clinical Anatomy

Describing Anatomy by Position, Region, and Plane

Beginning with the anatomical position

Figuring out what goes where in anatomical regions

Knowing what’s up, down, back, and front in specific terms

Slicing the body into anatomical planes

Labeling Anatomical Movement

Bending and straightening

Going away and getting closer

Moving in circles

Surveying other ways to move

Chapter 3: Examining the Integumentary, Musculoskeletal, and Nervous Systems

Showing Interest in Integument

Looking at the layers and structures of the skin

Going in farther to the fascia

Boning Up on the Skeleton

Figuring out what makes a bone

Surveying the shapes of bones

Feeling out bumps, ridges, and indentations

Catching Up to Cartilage

Joining the Joints

Making the Body Move with Muscles

Moving the bones with skeletal muscle

Keeping the heart ticking with cardiac muscle

Having no control over smooth muscle

Getting on Your Nerves

Determining what’s in (and on) a neuron

Coordinating input and signals with the central nervous system

Touching and moving with the peripheral nervous system

Feeling and reacting with the somatic nervous system

Taking control with the autonomic nervous system

Chapter 4: Moving Along with the Cardiovascular and Respiratory Systems

Tracing Circulatory Pathways in the Cardiovascular System

Making the rounds: Systemic circulation

Fueling up: Pulmonary circulation

Moving Blood Away from the Heart with Arteries

Looking inside large elastic arteries

Moving to medium muscular arteries

Surveying small arteries and arterioles

Taking Blood Back to the Heart with Capillaries and Veins

Exchanging gases, nutrients, and wastes in capillaries

Peeking into veins and venules

Breathing In and Out: The Respiratory System

Chapter 5: Looking at the Immune and Lymphatic Systems

Beginning with Red Bone Marrow and Leukocytes

Fighting infection with lymphocytes

Binging on bacteria with phagocytes

Controlling histamines with basophils

Surveying the Lymphatic System

Networking with lymphatic capillaries and vessels

Filtering lymph through nodes

Collecting lymph in ducts

Assessing Additional Lymphoid Organs

The thymus

The spleen

The tonsils, the appendix, and the gut

Chapter 6: Delving into the Digestive, Urinary, and Endocrine Systems

Breaking Down and Absorbing Your Food: The Digestive System

Starting in the mouth

Continuing through the esophagus and into the stomach

Finishing in the small intestine with help from the pancreas, gallbladder, and liver

Forming and removing bulk in the large intestine

Removing Wastes: The Urinary System

Handling Hormones: The Endocrine System

The master gland: The pituitary

The pituitary’s assistants: The hypothalamus and pineal glands

The body’s metabolism booster: The thyroid gland

Fighting infection: The thymus

Stressing out: The suprarenals

Digestive aid: The pancreas

Mars and Venus: The testes and the ovaries

Chapter 7: Checking Out the Thoracic Cage and Coverings

Getting Under Your Skin: Thoracic Bones, Joints, Muscles, and More

Forming the thoracic cage: The bones

Moving just a little: The joints

Helping you breathe: The respiratory muscles

Running through the thorax: The nerves and blood vessels

Covering It All Up: The Surface Anatomy of the Thorax

Using imaginary lines in your assessment

Looking at the anterior chest wall

Examining the posterior chest wall

Chapter 8: Assessing the Thoracic Organs

Understanding the Mediastinum and Pleural Cavities

The mediastinum

The pleural cavities

Looking at the Lungs

Surveying the lungs’ surfaces and borders

Getting air in and out with the trachea

Branching into the bronchi

Checking out the lobes

Flowing with nerves, blood vessels, and lymphatics

Having a Heart

Surrounding the heart with the pericardium

Examining the surfaces of the heart

Putting together the four chambers

Feeding the heart: Arteries and veins

Giving the heart its spark

Exploring Thoracic Circulation

Circulating blood in the major vessels

Moving lymph through the lymphatic vessels

Discovering What Else Is in the Thoracic Cavity

Chapter 9: Bellying Up to the Abdominal Wall

Drawing Quadrants and Regions on the Abdominal Wall

Using two lines: The four quadrants

Using four lines: The nine regions

Making Up the Abdominal Wall: Muscles and More

Absolutely fabulous abdominal muscles

Nerves, blood vessels, and lymphatics for maintaining tissues

Lining the abdomen: The peritoneum

Inspecting the Inguinal Region

The inguinal ligament and the iliopubic tract

The inguinal canal

The spermatic cord

The testes

The scrotum

Seeing the Skin and Surface Anatomy of the Abdominal Wall

Chapter 10: Probing the Abdominal Organs

Poking Around the Peritoneum

The mesentery and the peritoneal folds and ligaments

The greater and lesser omentums

Digging into the Main Digestive Organs

Entering the esophagus

Churning in the stomach

Winding through the small intestine

Moving into the large intestine

Observing Organs that Assist with Digestion

Locating the liver

Glancing at the gallbladder

Pinpointing the pancreas

Identifying Renal Anatomy

Knowing the kidneys

Tracing the ureters

Spying the suprarenal glands

Figuring Out What Else Is in the Abdominal Cavity

The spleen

Nerves

Major abdominal blood vessels

Lymphatics

Chapter 11: Seeing the Pelvis and the Perineum

Pinpointing the Pelvic Structures

Forming the pelvic girdle: Bones and joints

Making note of muscles and fascia

Personal space: The peritoneum

Feeling out the nerves of the pelvis

Viewing blood vessels

Looking at lymphatics

Comparing Pelvic Organs

Locating pelvic organs that everyone has

Finding Mars: The male pelvic organs

Finding Venus: The female pelvic organs

Exit Strategy: The Perineum

The male perineum

The female perineum

Chapter 12: Head of the Class

Sticking to the Skull Bones

Cradling the brain in the cranial cavity

Facing forward with the facial bones

Encasing the Brain: The Meninges

The dural infoldings

The dural venous sinuses

Locating the Areas and Structures of the Brain

Thinking about the cerebrum

Going inside the diencephalon

Balancing the cerebellum

Surveying the brainstem

Draining the brain with the ventricles

Getting the glands

Counting the cranial nerves

Serving the brain: The blood supply

Putting on a Face

Expressing yourself with facial muscles

Moving with motor nerves

Feeling out sensory nerves

Viewing blood vessels

Getting a handle on lymphatics

Enveloping the Head: Facial Surface Anatomy and the Scalp

Chapter 13: Seeing, Smelling, Tasting, and Hearing

Seeing into the Eyes

Taking cover with eyelids

Having a ball — an eyeball, that is

Rolling your eyes with extraocular muscles

Serving the eyes: The nerves

Providing blood flow to and from the eyes

Knowing the Nose

Sniffing out the exterior of the nose

Scoping out the nasal cavity

Insinuating your way into the paranasal sinuses

Sensing the nerves, blood vessels, and lymphatics

Investigating the Mouth

Open wide: The oral cavity

Chew on this: The teeth and gums

Picking on the palate

Sticking out your tongue

Making spit in the salivary glands

Tapping into the temporomandibular joint

Noting nerves

Viewing blood vessels

Sorting through lymphatics

Entering the Ear

Examining the external ear

Moving into the middle ear

Diving deeper into the inner ear

Keeping an ear out for nerves and vessels

Chapter 14: It’s Neck and Neck

Sizing Up the Superficial Structures: Muscles, Nerves, and Blood Vessels

Dividing the triangles: The sternocleidomastoid

Going back to the posterior triangle of the neck

Understanding the anterior triangle of the neck

Neck Deep: Diving into the Deep Structures

Flexing the neck: The prevertebral muscles

Rooting around the root of the neck

Homing In on the Neck Organs

Front and center: Thyroid and parathyroid glands

Speaking of the pharynx, larynx, and trachea

Locating lymphatic vessels and nodes

Surrounding the Neck: Skin and Surface Anatomy

Chapter 15: Back to Back

Stacking Up the Vertebral Column

Analyzing a typical vertebra

Putting the vertebrae into groups

Connecting with the vertebral joints

Studying the Spinal Cord and Meninges

Spying on the spinal cord and nerves

Coverings and cushions: Understanding the meninges and cerebrospinal fluid

Flexing Your Back Muscles

Shouldering the load: The extrinsic muscles

Twisting and turning: The intrinsic muscles

Nodding your head: The suboccipital muscles

Providing Blood Flow and Lymphatic Drainage in the Back

Assessing the Surface Anatomy of the Vertebrae and Back Muscles

Looking for curves in the spine

Seeing bones on the back’s surface

Viewing the back muscles

Chapter 16: Shouldering the Load: The Pectoral Girdle and the Arm

Boning Up on the Shoulder and the Arm

Looking at the bones of the pectoral girdle

It’s not funny, but it’s humerus

Joining the Parts

Collaring the sternoclavicular joint

Reviewing the acromioclavicular joint

Hanging on to the humerus

Sniffing around the Axilla (Armpit)

Forming the apex, the base, and the walls

Tracking the axillary artery and vein

Moving the Shoulder and the Arm

Taking a look at the anterior muscles

Moving to the posterior muscles

Shaping up the shoulder muscles

Maintaining the Tissues

Acknowledging the nerves and blood supply

Remembering the lymphatic vessels

Covering Your Shoulders and Arms: The Surface Anatomy

Chapter 17: Bending the Elbow and Focusing on the Forearm

Forming the Elbow and the Forearm: The Bones

Handling the humerus

Regarding the radius

Understanding the ulna

Joining the Elbow and the Forearm

Bending the elbow

Reviewing the radioulnar joints

Making the Elbow and Forearm Move: The Muscles

The muscles of the arm

The muscles of the forearm

Giving a Nod to the Nerves and Blood Supply

Nerves

Blood supply

Looking Only Skin Deep: The Surface Anatomy

Chapter 18: Shaking Hands and Grabbing the Wrist

Putting Your Hands (and Wrists) Together

Starting with the carpal bones

Moving to the metacarpal bones

Finding the phalanges

Waving and Wiggling with the Help of Joints

Looking at the wrist joints

Handing over the hand joints

Pointing to the finger joints

Making the Most of Wrist and Hand Muscles

Flexing and extending the wrist

Sticking out your thumb with the thenar muscles

Honing in on the hypothenar muscles

Investigating the interosseous muscles and the lumbricals

Knowing the Nerves and Blood Supply of the Wrist and Hand

Getting a feeling for the nerves

Uncovering the arteries and veins

Fitting Like a Glove: The Surface Anatomy of the Wrist and Hand

Chapter 19: Getting Hip to the Hip and the Thigh

Honing In on Hip and Thigh Bones

Understanding the Hip and Thigh Joints

Seeking the sacroiliac joint

Surveying the symphysis pubis

Looking at the acetabulofemoral joint

Swaying Your Hips and Moving Your Thighs with the Help of Muscles

Minding the muscles of the buttocks

Turning with the thigh muscles

Maintaining the Hip and Thigh Tissues

Knowing the nerves

Flowing through the arteries and veins

Looking at the lymphatics

Summing Up the Surface Landmarks

Chapter 20: Knowing the Knee and the Leg

Logging the Knee and Leg Bones

Knocking the Knee Joint

Coming up with cartilage and the joint capsule

Balancing the menisci

Hanging on with the ligaments

Bumping up against the bursae

Kneeling on the patellofemoral joint

Supervising the superior tibiofibular joint

Mastering the Muscles that Affect the Knee and Leg

Starting with thigh muscles that work with the knee

Aiming at the anterior compartment

Looking at the lateral compartment

Pondering the posterior compartment

Noticing the Nerves, Blood Vessels, and Lymphatics of the Knee and Leg

Noting the nerves

Analyzing the arteries and veins

Listing the lymph nodes

Summing Up the Surface Landmarks

Chapter 21: Finding the Ankle and the Foot

Looking at the Framework of the Ankle and Foot

Aiming for the ankle bones

Assessing the architecture of the foot bones

Taking In the Ankle and Foot Joints

Moving up and down: The ankle joint

Supporting your weight: The foot and toe joints

Bending Your Ankle and Curling Your Toes: The Muscles

Turning to leg muscles that move the ankle and the foot

Minding the muscles of the foot

Getting Maintenance with Nerves, Blood Vessels, and Lymphatics

Naming the nerves

Looking at blood vessels and lymphatics

Summing Up the Surface Landmarks of the Ankle and the Foot

Chapter 22: Ten Helpful Clinical Anatomy Mnemonics

Thinking about the Cranial Bones

Focusing on the Facial Bones

Memorizing the Cranial Nerves

Summing Up the Heart-Valve Sequence

Ordering the Abdominal Muscles

Tracking the Intestinal Tract

Remembering the Rotator Cuff Muscles

Concentrating on the Carpal Bones

Looking at the Lateral Rotator Muscles of the Hip

Taming the Tarsal Bones

Chapter 23: Ten Ways to Look into the Body without Cutting It Open

Conventional Radiography

Computerized Tomography

Magnetic Resonance Imaging

Positron Emission Tomography

Fluoroscopy

Mammography

Ultrasonography

Opthalmoscopy

Upper Endoscopy

Colonoscopy

Table of Contents

Introduction

About This Book

Conventions Used in This Book

What You’re Not to Read

Foolish Assumptions

How This Book Is Organized

Part I: Medical Ethics, or Doing the Right Thing

Part II: A Patient’s Right to Request, Receive, and Refuse Care

Part III: Ethics at the Beginning and End of Life

Part IV: Advancing Medical Knowledge with Ethical Clinical Research

Part V: The Part of Tens

Icons Used in This Book

Where to Go from Here

Part I: Medical Ethics, or Doing the Right Thing

Chapter 1: What Are Medical Ethics?

Defining Medical Ethics

What are ethics?

The four principles of medical ethics

Differences between ethics and legality

Reconciling medical ethics and patient care

Turning to ethical guideposts and guidelines

Looking at the Common Medical Ethics Issues

Privacy and confidentiality concerns

Reproduction and beginning-of-life issues

End-of-life issues

Access to care

Moving Medicine Forward: The Ethics of Research

Chapter 2: Morality in Medicine

Distinguishing among Ethics, Morality, and Law

Looking at the Hippocratic Oath and Its Modern Descendents

Noting why the Oath was updated

Taking a new oath at graduation

Understanding humanitarian goals: The Declaration of Geneva

Rules for Engagement: Today’s Codes of Medical Ethics

American Medical Association Code of Ethics

American Nursing Association Code of Ethics

Bedside Manners: Ethics inside the Hospital

Understanding the hospital ethics panel

Patient bill of rights

Emergency room ethics

Bioethics as a Field of Study

Chapter 3: The Provider-Patient Relationship

Protecting Patient Privacy

Understanding confidentiality

Balancing privacy with public good

Confidentiality in research

Clear and Ethical Communications

Communicating with the patient

Informed consent

Understanding Full Disclosure: Telling the Patient What Matters

Decoding conflicts of interest

Deciding who has access to medical information

Choosing not to disclose information to a patient

Understanding Appropriate Referrals

Considering second opinions

Discovering the need for specialist referrals

Choosing Whom to Serve

Refusing to treat a patient

Ending a doctor-patient relationship

Giving medical advice to non-patients

Patient Rights and Obligations

Patient autonomy: Patient as decision-maker

Encouraging honesty

Balancing treatment and cost

Chapter 4: Outside the Examining Room: Running an Ethical Practice

Propriety in the Paperwork: Medical Records

Complying with the Health Insurance Portability and Accountability Act (HIPAA)

Training staff to handle records

Preventing identity theft

Releasing medical records

Safeguarding anonymity

Modern Managed Care and Today’s Office Practice

Ethical concerns of managed care

Working with midlevel providers

Prescribing good care while still getting paid

Third-Party Issues

Dealing with insurance companies and HMOs

Perks and freebies

Targeted advertising and ethics

Chapter 5: Learning from Mistakes: Disclosing Medical Errors

Types of Medical Errors and Ways to Prevent Them

Understanding diagnostic errors

Understanding treatment errors

Medication errors

Communication errors

Administrative errors

Lab errors

Equipment failures

Admitting Your Mistakes

Understanding truth telling

Disclosing an error to a patient

Balancing ethics with legal protection

Telling a higher-up that you’ve made an error

When Colleagues Don’t Disclose: Your Ethical Obligations

Healthcare Provider Impairment

Knowing the warning signs of impairment

Addressing a colleague’s impairment

Testifying before a medical board

How Reporting Errors Helps Medicine as a Whole

Creating a no-blame system for reporting errors

Understanding how to reduce errors

Part II: A Patient’s Right to Request, Receive, and Refuse Care

Chapter 6: The Ethical Challenges in Distributing Basic Healthcare

Ethics of Healthcare Distribution

Exploring Healthcare Rationing

How services are rationed

The ethics of rationing

Looking at Healthcare in the United States

The current system and its ethical challenges

The reformed system and potential ethical speed bumps

Examining universal healthcare

Chapter 7: When Spirituality and Cultural Beliefs Affect Care

Accommodating Religious Beliefs

Religions that limit or ban medical care

Discussing religion and understanding objections

Offering alternatives to care

Respecting Cultural Diversity

Attitudes and beliefs that affect care

Communicating with non-English-speaking patients

Discussing cultural beliefs

When the Patient Refuses Treatment

Determining competency

Making sure the patient understands

Validating concerns and assuaging fears

Accepting refusals

Chapter 8: Parental Guidance and Responsibilities

Acknowledging Parental Rights to Choose or Refuse Care

Responsibilities of a parent

Weighing parental choice against a child’s best interest

Caring for a child when parents disagree with you

Knowing when and how to treat impaired infants

Vaccination: The Evidence and the Ethics

Understanding vaccination as a public health issue

Considering risk-benefit analysis

Understanding full disclosure

Addressing parent opposition to vaccines

Child Endangerment: The Healthcare Provider’s Role

Discovering signs of abuse and neglect

Reporting abuse and working with Child Protective Services

Confidentiality, Care, and the Adolescent Patient

Understanding adolescent patients’ rights

Balancing privacy and patients’ rights

Talking to teens about informed consent

Mature minors and emancipated minors

Part III: Ethics at the Beginning and End of Life

Chapter 9: Two Lives, One Patient: Pregnancy Rights and Issues

Medical Intervention: Rights of the Mother versus Rights of the Fetus

Setting forth rights with the Fourteenth Amendment

Understanding self-determination

Balancing treatments for a woman and fetus

The role of technology

Considering a Father’s Rights

Birth Control

Educating your patient about birth control

Balancing your beliefs about birth control with a patient’s rights

Understanding religious ethics and birth control

Fetal Abuse

Maternal drug abuse or neglect: Crimes against the fetus

Detecting fetal abuse: Ethical and legal obligations

Limiting maternal freedom for fetal well-being

Seeing into the Future: Prenatal and Genetic Testing

Understanding the ethical use of prenatal testing

Understanding tests and accuracy issues

Genetic counseling and sharing results with parents

Chapter 10: When Science Supersedes Sex: Reproductive Technology and Surrogacy

In Vitro Fertilization

Understanding acceptable versus unacceptable harm

Pre-implantation genetic diagnosis: Choosing which embryos to implant

Multiple pregnancy reduction: When IVF works too well

Decoding embryo storage and destruction

Artificial Insemination

Understanding safe, anonymous, and consensual sperm donation

Sex selection: Is it ever ethical?

Surrogacy: Carrying Someone Else’s Child

Paying for pregnancy: The ethics of commercial surrogacy

Considering the emotional and physical health of the surrogate

Looking at the contract and surrogate responsibilities

Understanding rights of the child

The doctor’s responsibilities

Sterilization: Preventing Reproduction

Voluntary sterilization as birth control

The ethics of involuntary birth control

Understanding eugenics: Social engineering

Chapter 11: Walking a Fine Line: Examining the Ethics of Abortion

When Does Personhood Begin?

What, and who, is a person?

Applying ethical principles to personhood

Looking at Each Side’s Point of View

Understanding the pro-life stance

Understanding the pro-choice stance

Therapeutic Abortion: To Protect Maternal Health and Life

Reasons for therapeutic abortion

Informing the patient

Counseling for the family

When a patient refuses medical advice

Abortion Due to Fetal Defect

Reasons for abortion because of fetal defect

Weighing the ethics of selective abortion

Voluntary Abortion

Legal definition and limitations

A less invasive option: RU-486

Roe v. Wade: Legal Status of Abortion and Ethical Implications

Looking at changes on the state level

Accurate medical counseling

The Religious Divide

Toward Common Ground

Chapter 12: Determining Death: Not an Event, but a Process

Defining Death

Using heart and lung function to define death

Adding brain function to the definition of death

Examining Brain Death

A quick look at how the brain works

Looking at the types of brain death

Current standards of brain death

Declaring a patient brain dead

Understanding Cases That Defined Brain Death

Karen Ann Quinlan

Nancy Cruzan

Withdrawing Life-Sustaining Treatment

Weighing the benefits of further treatment

Counseling the family

Examining Euthanasia and Physician-Assisted Suicide

Relieving suffering with mercy-killing

Understanding the history of physician-assisted suicide

When a doctor aids in death

Chapter 13: Death with Dignity: The Right to Appropriate End-of-Life Care

Roadmaps for the End of Life

Understanding advance directives

Looking at living wills

Looking at Durable Power of Attorney for Health Care

Do Not Resuscitate and Do Not Intubate orders

Physician’s Order for Life-Sustaining Treatment (POLST)

Of Sound Mind: Establishing Mental Capacity

Understanding informed consent and a patient’s ability to give it

Assessing decision-making capacity

Substitute decision-makers: When a patient is declared incompetent

Relief of Pain and Suffering

Understanding palliative care

Walking a fine line: The double-effect rule

Easing pain with terminal sedation

Organ Donation and Allocation for Transplants

Legality of organ donation

Sustaining life for organ harvesting

Looking at living donation

The financial inequities of transplant eligibility

Compensation for donation: The ethical challenges

Xenotransplantation, or animal to human transplant

Part IV: Advancing Medical Knowledge with Ethical Clinical Research

Chapter 14: Toward Trials without Error: The Evolution of Ethics in Clinical Research

An Introduction to Medical Research

Moving from lab experiments to research on humans

Understanding the importance of informed consent in clinical trials

Turning Points in Medical Research in America

The Tuskegee Syphilis Study: The ethics of withholding treatment

The establishment of the Office for Human Research Protections and IRBs

Guiding Principles of Ethical Studies

The Nuremberg Code: New research standards in the wake of World War II

The Declaration of Helsinki: A global roadmap for ethical clinical research

Good Clinical Practice Guidelines: Replacing the Declaration of Helsinki

The Belmont Report: Best ethical practices in U.S. research

Chapter 15: Beyond Guinea Pigs: Anatomy of an Ethical Clinical Trial

Elements of a Valid Trial: Leveling the Playing Field Ethically

Collective clinical equipoise: Asking whether a trial is needed

Understanding basic trial design

Choosing ethical controls

Preventing bias with blind studies and randomization

Minimizing any risk of harm

The Institutional Review Board: Ethical Gatekeepers of Clinical Research

Looking at the role of the IRB

Evaluating and green-lighting a clinical trial

Recruiting Study Participants

Deciding to ask patients to participate

Laying out all the risks and benefits with informed consent

Full disclosure: Explaining financial and institutional conflicts of interest

Ending a Trial Early

Remembering obligations to patients

Looking at implications for research

Publicizing preliminary results

Chapter 16: Research in Special Populations

Animal Research

Understanding why animals are used

Ethical treatment of research animals

Psychiatric Research and Consent

Assessing decision-making ability in psychiatric patients

Protecting the patient: Risk versus benefit

Pregnancy and Pediatrics

Understanding research with pregnant women

Why risk may outweigh the benefits

Research on children: Surrogate consent

Chapter 17: It’s All in the Genes: The Ethics of Stem Cell and Genetic Research

Understanding Stem Cell Research

Who will benefit? The case for stem cell research

The ethical debate over embryonic stem cell lines

Focusing on adult stem cells

Genetic Testing: Looking for Problems in DNA

Knowing what we can and can’t change

Weighing the risks and benefits

Offering emotional counseling for patients

Genome Sequencing: Mapping DNA

Gene patents: Deciding who owns what

Looking at ethical problems with patents

Deciding who can use the human genome

Gene Therapy: Changing the Code

Weighing the risks and benefits of gene therapy

Designer genes: Going beyond therapy

Cloning: Making Copies

Cloning as a reproductive option

Growing tissues with therapeutic cloning

Part V: The Part of Tens

Chapter 18: Ten Ethical Issues to Address with Your Patients

Confidentiality in the Patient Visit

Informed Consent

Integration of Religious and Cultural Beliefs into Patient Care

The Ethics of Clinical Research

Help for the Uninsured

Screening for Genetic Diseases

Ethical Dilemmas in Infertility

Minimize Suffering in Terminal Conditions

The Living Will Discussion

Honor the Patient-Provider Relationship

Chapter 19: Ten High-Profile Medical Ethics Cases

Terri Schiavo: The Right to Die

Daniel Hauser: A Child’s Right to Refuse Lifesaving Treatment

Angela Carder: Maternal versus Fetal Rights

Sister Margaret Mary McBride: Religion in Conflict with Medicine

Baby Manji: An Unclear Identity

Louise Brown: The First Test Tube Baby

Jesse Gelsinger: The Risks of Gene Therapy

Nadya Suleman: Too Much Fertility

Glen Mills: Autonomy versus Protecting Society

Baby Jane Doe: Treatment of Impaired Babies

Chapter 20: Almost Ten Ethical Issues for the Future

Cloning

Designer Babies and Future Elites

Rationing of Medical Care

Who Owns Your Genes?

The Doctor Is Online

Pandemic Influenza Outbreak

Future Clinical Trials

Artificial Wombs

The Global Spread of AIDS