My advice would be for your friend to seek out the care of a palliative care specialist. (This move does not equal hospice or giving up.) That would ensure the best possible comfort while the cancer is being treated. The palliative care specialist would also be a powerful advocate. They can take up your friend’s case directly with the oncologist and, with their clout and credentials, talk some sense into them. That would allow the cancer care to proceed along with cannabis augmentation. The oncologist would also likely benefit from the learning experience and grow as a professional and person.
1
One reason the cancer patient was denied cannabis may be that his physician's practice is involved with federal contracts. The federal government still considers cannabis a Schedule One narcotic along with heroin and LSD, meaning it has no accepted medical use.
If a subcontractor (the physician's practice) permits the use of a Schedule 1 narcotic, the government can cancel the contract at any time without penalty.
Bureaucrats and law enforcement are now practicing medicine.
2
My husband got very sick while we were traveling in Tennesseee, so I took him to the urgent care clinic next to our hotel. Inside was a sign stating this was a faith-based Christian establishment, and they reserved the right to refuse treating people in the name of their religious values. Drug use was cited specifically. We were shocked, but my husband was too ill for us to search elsewhere. There were bible verses on the walls of the examining room. Ironically, none about the people Jesus turned away.
2
Regarding the person who was "concerned" about the thin woman at the gym?
Unbelievable! And...I'm not referring to the woman being thin.
2
Hmmmm forcing a patient to take dangerous addicting opioids and refusing to care for them if they use a totally natural herb, a great gift form Mother Nature, medical marijuana, is outrageous and cruel. Are they working for the Big Pharma companies and pushing drugs or tying to serve their patients? Medical marijuana. is very effective and should be allowed...the question is why are opioids given out like candy by so many doctors? It makes you question their qualifications & motivations as doctors. Time for this anti-marijuana nonsense to an end...it's more propaganda from Big Pharma....follow the money.
2
“I’m not a medical professional, I don’t know her, I don’t work at the gym and I don’t have any information that isn’t plainly visible.”
The letter writer provided the answer to his or her own question right there. If you think about approaching a stranger with nothing more than your own inferences, take a step back and reconsider — then walk in the opposite direction. And if your conscience gets a radar return when you even think of asking the question — then run in the opposite direction.
Save yourself from being Exhibit A for that old saw about assumptions. It really isn’t that difficult, and it is definitely not an ethical quandary.
3
I live in Canada and surprisingly, given our legalization of recreational cannabis, I have encountered a great deal of prejudice against medical cannabis which I use exclusively as a pain management medication for degenerative disk disease and other arthritis-related pain issues. I made the decision to switch to cannabis when my family physician recommended a morphine patch since my dosage of opiates was increasing and I did not like needing more and more pain killers for less and less relief. I have been on the same prescription of medical cannabis for 3 years with no increase in dosage and I supplement this medication with a very healthy whole foods diet which includes anti-inflammatory foods and spices - any foods high in omega fatty acids, turmeric, ginger, hot peppers, etc. And no processed foods. That being said, I moved recently and went to a walk-in clinic and the physician refused to consider my medical cannabis prescription and had the effrontery to demand blood test for HIV and hepatitis B and C "due to my circumstances." In other words, she thought I was a drug addict....sad, sad, sad
9
I'm surprised an MD would make the statement:"The medical literature is fairly consistent on the efficacy and minimal side effects of cannabis, which has specifically been shown to help patients decrease opioid dependence." I would like to see the medical literature he is referring to. I work in substance use treatment/recovery, and as far as I know there is no rigorous study that backs up this claim. Some people with opioid use disorder provide anecdotes that cannabis helped them, and these stories are probably true, but that doesn't make their claims "medical literature" and certainly not science.
4
With the rise in hospitals and medical practices controlled by the Catholic church the ability to find appropriate medical care for issues where the Catholic church feels they have the moral authority to refuse treatment is becoming more and more problematic.
At what point is our society going to put the rights of the patient over religious beliefs? This isn't Saudi Arabia.
5
An oncologist who has a cow about pot? Give me a break. There are oncologists here who work with chemo and radiation and the first thing they do is give you a medical cannabis card! It's the first thing they do. Another medication that significantly improves outcomes after chemo or radiation are the SSRI antidepressants - that should be a prophylactic action on their part, putting patients on Prozac to aid the effectiveness of treatment. This doctor is bringing their personal beliefs to bear on the treatment protocol If he can't get another physician (might be worth the drive) remember that it's your body and your life. Suffering from cancer treatment is acute. Opiates contribute to sepsis - my partner almost died of opiates for his cancer treatment. CBD is the thing to use for pain. It also works for depression (beautifully), stress and appetite. You can't learn about yourself from other people - you learn about them.
8
I’ve been being treated as LW2’s friend and would like to point out that LW2 might not know what’s going on.
I always wanted kids, so when I met my partner in my 30s we talked children immediately. We were in agreement we wanted them and set to work. We didn’t tell friends we were trying, because why would we? Over the last six years we’ve had 14 babies lost and we’ve gone heavily in debt doing multiple rounds of IVF. We haven’t married, we have spent all time and money family building.
I’ve had friends advise me that “nobody understands why we’re still together” because we’re not married and don’t have kids. When I finally had to tell some friends because surgery for an ectopic caused me to miss get togethers I was advised that if I wanted kids I should have started earlier (ectopics are not age related). People are very outspoken and judgmental about child bearing choices, I have spent years telling people we want kids someday within moments of quietly excusing myself to a restroom to inject fertility medications. LW2’s friend might be, too... I thought I was alone in my secrecy until I joined support groups and found it’s the norm.
5
Is a physician required to treat a patient who has chosen to self-medicate?
1
If the oncologist specializes in a type of rare cancer he may be the only one on the patient's medical plan as well as the only one within a reasonable distance.
3
Unlikely that cannabis will negatively impact this patient's treatment. The doctor is biased based on their personal feelings towards cannabis and not on scientific data. Cannabis is unlikely to be cause of treatment failure and there are plenty of patients who have unfavorable outcomes from all cancer treatments who don't use cannabis. Many doctors have conservative upbringings and limited social interaction that may have kept them from trying cannabis or knowing highly functional people who use cannabis. I had a friend and study partner at Harvard, now a well respected physician, who smoked weed the night before our premed exams and would ace the tests and outperform the nerds who never touched cannabis. My view of cannabis is influenced by witnessing the people who failed because of it and those who it did not effect at all. Real life experiences can help in the practice of medicine.
6
Not all oncologists deliver chemo; I only had a radiation oncologist when I had cancer. And he was very concerned about what I ingested, telling me that I could not even take a multivitamin. His reasoning was that anything that was good for regular cells might be even better for cancer cells, which are robust little fellows. Might that be a reason for no marijuana?
In any even, this doctor should explain himself more clearly.
10
Like many letters here, some claims don't ring true. What insurance plan doesn't allow a patient to change doctors?
2
Well, welcome to my world.
I live about 2 hours out of nyc, and the closest network specialists for many types of treatment are 50 miles away. If there is only one provider at that location, I have no “choice” about my network doctor.
9
@Tina Trent---It's a question of availability, as much as anything. If you're not situated in an urban area, often physician options are quite limited.
4
@Tina Trent I have a friend who lived in Chicago. Her health insurance plan had no specialists in severe hand injuries, so she ended up paying for it out of pocket at the county hospital because her hands are her livelihood (musician).
This was an ACA-qualified plan in one of our largest cities and there wasn't even a doctor to change from.
Happens a lot.
3
How about this answer to your letter writer with concerns about a woman at the gym who is underweight: "It is never polite to comment on another person's body. Don't do it. Feel free to befriend the woman, if she is genuinely of interest to you as a human being." Your response displays terrible stereotyping and misinformation about people who have anorexia, a poorly understood mental illness with a high mortality rate. Some corrections: 1) All people with anorexia do not have BDD. 2) You cannot identify a person with an eating disorder by his or her weight. 3) Telling a person with anorexia she is underweight is not going to make her feel good. What after school movie about anorexia did you get your information from, anyway? The comment may reinforce her mental illness, which is trying to kill her, but she is not her disorder and anorexia is not a vanity project. More likely, a comment about her body might cause a person with anorexia embarrassment to have been seen as an affront. She may be working hard at recovery, or aware she is relapsing: who knows! Whatever the case: rest assured if she has anorexia, she is suffering enough without some stranger having the actual gall to say something to her about her body. That is never polite. The letter writer can express her concerns to management at her gym, if she will feel better about herself, but the gym shouldn't disclose any personal information to her.
12
@Sarah--A very underweight person is not necessarily someone who has anorexia nervosa. I was very underweight after cancer treatment, and due to problems with my feeding tube could not gain weight for quite a while. I looked terrible, I know. But I also know that had a stranger tried to intervene it would have been terrible for me. If you have no skin in the game, you have to right to butt in.
That said, you could try to develop a real relationship (not just a snoopy one) with this person, and if one happens, then you might be able and entitled to help her. But that takes a big commitment of time, and possibly also resources. She knows how she looks, so anything you can tell her as a stranger will not be helpful.
14
@Susan For sure I wasn't suggesting the person who is underweight has anorexia, not sure where you got that! I also was not suggesting the letter writer get to know the underweight person in order to then comment on her weight or her appearance.
A feeding tube is painful. I am sorry you went through that.
My main concern in posting was that the Ethicist's response contained egregious misconceptions about anorexia, which is a deadly mental illness, not a vanity project and different from BDD. His medical information was incorrect. I don't see how his response made it past the NYT fact checkers, with whom I have worked and who are pretty harsh usually.
2
OK, a few words here from 1. A person who has actually smoked marijuana, and 2. A person who has seen their spouse die in pain from cancer. As a person who has taken this drug I can attest to the effects that is takes away pain, much like nitrous does if you use the latter at a dentist. Anyone who tells you that marijuana doesn't ease pain hasn't tried it. And unless someone has watched their spouse die in pain from cancer, and seen how marijuana can alleviate pain can't really comment either on the helpful affects of this drug.
22
The additional ethical matter here is the doctor’s considering an addiction to opiates as preferable to the use of cannabis.
23
Re: the person who wondered if she should talk to the underweight virtual stranger about her thiness: here we go again. So many people who ask questions for this column seem to have boundary issues. Even if the writer had a long-standing, intimate relationship with the thin woman, her weight would be a topic that would have to be addressed with great delicacy. I can imagine the possible conversation: "Hello. We've never spoken, but I've been noticing for months that you're too thin. I'm concerned for you. How can I help?" I'd be very interested to know what reaction the writer hoped to receive if the ethicist had given her the go-ahead. She then could approach people with a variety of issues, e.g., obese people, smokers, alcoholics, drug abusers, etc. If she wants to help others, maybe she could volunteer at a program that feeds needy people, or she could tutor children.
10
When I read the third letter from the woman who is concerned about the very thin woman in her gym, I initially misread the description as "overweight," which offers another dimension of thinking about this issue. If she were seriously overweight, would you even consider approaching her? For whatever reason, we give ourselves entitlement to say things about a person's being underweight, but never that they are overweight.
12
Find another oncologist. I’m sure more than one exists even In your coverage plan
3
Re Grad Student
Are you concerned about burning bridges or just doing the right thing?
Rest assured, there is no bridge. You’re a mercenary, a hired gun that can and will be replaced at the company’s pleasure.
Also keep in mind 99% if employees in the US work on an “at will” basis. That means they can fire you at will, no notice, no compensation. Obviously there are some (very few) laws that protect employees, and most employers will pay some severance but you have no guarantees and no contract of employment.
Generally the only people who are protected by a contract are at the very top and very bottom. The CEO and CFO have a contract as does the janitor through a union. The VP of Widgets, and First Year Analysts however, do not.
If your employer wanted you for two to three years they had every opportunity to offer you a contract. Of course, that contract would likely guarantee you compensation were they to break that contract.
The other thing they could have done was to offer to pay for your grad school, or a portion of it, if you met certain conditions, e.g. stayed for two years before and three years after.
They didn’t want to be on the hook for either of these options.
I wonder, how you would have been treated if they decided to lay you off after six months. I’m guessing less than two weeks pay and benefits.
Don’t be shy about negotiating a better deal now. If they like you they may be willing to keep you.
15
@Johannes de Silentio Yes, perfect response and great advice for this individual. I see too many diligent workers worrying too much about their companies when unfortunately the courtesy would not be reciprocated if circumstances changed for the company.
As a more a practical matter, the competition for top talent right now is intense in the market, and HR managers are well aware of the challenges in retaining workers.
7
A better question is "Can a physician refuse to treat someone for a medical condition caused by the person refusing to be inoculated for that condition?"
Hate to say it, but if someone is too ignorant to be inoculated, or have their children inoculated against a preventable disease then doctors should refuse to treat them. Perhaps this is how we are supposed to swamp out the gene pool, and the sooner the better.
2
@Chuck Roast The child is the patient, not the parent. How about both treating the patient -- and educating the parent?
5
The gym rat needs to keep her teeth together. So this woman is thin, so what? Maybe she has an eating disorder. If she does, she isn't going to believe you anyway as she still sees herself as fat. Maybe she has a chronic illness like Crohn's. In which case she is well aware of her situation and does not need a stranger commenting on her body.
8
On the extremely thin woman at the gym: years ago I asked the manager of the workout area of our club if she thought it was ethical for a young teen whose family were members and was working that summer a lifeguard to spend hours running on the treadmill before and after her shift. And she was so thin she was almost skeletal. She said she had the same concerns and my comment to her made her decide to contact the girl’s mother. Turns out she was in treatment for anorexia and was NOT supposed to be working out in this extreme way. They were monitoring her food intake but this was her way of staying so thin. I guess if a minor is involved a parent has the right to know. Tough question.
9
My grand-nephew runs a pediactric practice with four other doctors. Before a parent can make an appointment for a child, the parents are asked they object to vaccinations. If the answer is yes, the child is declined as a patient. (The parent is also asked if there is a handgun in the home, and how it is stored. If the gun isn't stored in a lockbox, the child is declined as a patient.)
If during the course the child's treatment, the parent refuses vaccinations, the practice immediately refers the child to another doctor.
In most states, doctors in private practive have no legal obligation to treat anybody for anything, and can dismiss a patient for any reason at any time.
Is that ethical? In his answer to LW 1, Kwame Anthony Appiah never actually addresses the question.
10
@camorrista
A physician-patient relationship is never established in these scenarios. The question is answered in the response. Physicians are obligated to patients they have assumed care for. In addition it is generally accepted that patients seeking emergency treatment must have an initial evaluation in the emergency department where they present.
7
@camorrista, the question is addressed. As stated in the answer, doctors have obligations to patients they are already seeing. In your second example, the patient is referred to another doctor. But in this case, there is no other doctor the patient can be referred to. So you haven’t provided a comparable situation.
5
I have been using a cbd tincture for chronic pain relief (inflammation that won't go away) for just over a year. It works very well. In fact it replaced a low dose long-acting morphine. The cbd is markedly more effective than any other pk I have used. My doctor was upset when I quit the MS prescription but was willing to accept what I told him. I think he might have been worried that I'd be looking for MS again at some point but one year later, I don't think that is going to happen. Research is finally being done in Canada. Prior to legalization, I think the only legal use for marijuana was as evidence in law courts to throw people in jail. I don't think it's an all-encompassing panacea by any means. The medical profession has a history of having difficulty accepting change. It took them 20 years to accept that going from autopsy to surgery using the same instruments on the living patient without cleaning the instruments or themselves after Joseph Lister proved that that practice was a very bad idea. I hope the attitude to medical marijuana doesn't take that long to change.
10
While accompanying my spouse on a bone marrow transplant journey we queried the Oncologist about the use of vitamins and supplements. He told us, "we don't know what they do for sure or how they might interact with your treatment, if you are concerned about your nutrition make an effort to eat a balanced diet."
That was years ago, spouse is alive and doing well, and I still think of that when I throw a $7 bag of oranges into my cart.
Treatments for blood cancers or any cancer are based on trials and research. Don't muddy you chances by going off the protocol.
10
@Ginger
Excellent point about supplements. I never thought of it that way before, but I guess if they are intended to do something there could be an effect on treatment which is based on strict protocols.
1
Based on my own (patient side) multiple myeloma insight, I hardly see this as a question of ethics. If this patient is indeed in the early stages of treatment by an oncologist with solid experience treating multiple myeloma he needs to carefully follow the guidance provided by his oncologist.
12
In his letter, Dr. Kinderlherer says that cannabis is "rountiney recommended for cancer patients to improve appetite, decrease nausea, and alleviate pain."
He is correct regarding the first two but there are no quality studies that support the use of cannabis for cancer pain or any pain for that matter.
I am a pain management physician and have had many patients with cancer who have used cannabis for appetite and nausea. I can't recall any who said it offered relief of their pain.
Yes, I know people will write in and say how much cannabis helps their pain. However, these are anecdotes and anecdotal evidence is not synonymous with data from controlled studies. The FDA does not approve any drugs based on anecdotal evidence with the rare exception of people with life threatening illnesses for which there are no other treatments.
12
@Steve The reason there is no data from a controlled study is that cannabis is scheduled incorrectly. The government is lying to its citizens by stating that cannabis has no medicinal use. This can breed distrust between a patient and doctor on the issue.
16
@Steve The experience of pain is inevitably, and always, a subjective one, including in the controlled studies you mention. How do these studies ultimately, then, differ from anecdotal evidence, other than that the studies have a two separate groups of patients offering anecdotal responses?
4
@tsshiro i have been smoking weed for 50 years and no amount of it will cut through my back pain..i hear all kinds of tales about its pain relieving power but i have never heard about anyone asking for just some cannabis before surgery or a root a canal
6
Medical non- compliance is certainly a legitimate and morally acceptable reason to terminate a relationship with a patient after fair warning.
8
Greetings; I would suggest that your friend refer her doctor, to the following: ( https://www.webmd.com/drugs/2/drug-9308/marinol-oral/details)
Dronabinol or Merinol , has also become a ‘Go To’ therapy drug for some types of pain- post-surgical cardiac pain - at leading some institutions - one which may or may not, have JH as its initials.
“Dronabinol is used to treat nausea and vomiting caused by cancer chemotherapy. It is usually used when other drugs to control nausea and vomiting have not been successful. Dronabinol is also used to treat loss of appetite and weight loss in patients with HIV infection. Dronabinol (also called THC) is a man-made form of the active natural substance in marijuana (cannabis). “
Natural marijuana:
2018 - Additionally, the research on natural marijuana is clear: https://www.health.harvard.edu/blog/medical-marijuana-2018011513085
Conclusion: The patient needs to seek a different oncological approach to her own care.
4
This falls below the standard of care and is a board violation. This is the path, followed by a civil action. This doc needs to loose their license.
7
@Steve Sisler
HIS license
@Iancas No gender is indicted in the essay.
1
@HT
"The oncologist told him that he would refuse to treat my friend if..."
The physician is male.
1
Short of an emergency, if you don’t know someone well enough to know their name, you don’t know them well enough to mind their health business.
15
Medical malpractice is not just negligence: it also includes a failure to adequately treat the patient by limiting their care. There is sufficient medical, scientifice evidence of the benefits of cannabinoids with regard to pain management, especially in treatments for side effects of chemotherapy and radiation. The very existence of medical marijuana legalization bolsters this evidence; no longer anectodal. The doctor had the right to drop the patient, but clearly an explanation was in order as to why he was so vehemently opposed to cannabis use. Perhaps asking for disclosure of any associations with drug companies would provide some insight.
7
@dda
More likely to be threats of government prosecution; see Sessions, Jeffrey. A friend with cervical spine stenosis--incredibly painful--was told by his pain clinic that if he tested positive for marijuana he would be "outta here." Unethical and immoral; should be considered criminal.
4
my mother succumbed to multiple myeloma after a seven year battle. That is how good her doctor was. Though experimental at the time she was on cannabis, which provided great relief. Also experimental then was Thalidomide, for god sakes, which worked very well in slowing the cancer cells. The doctor here, refusing the patient cannabis should be fired immediately.
8
To the writer who winders whether he/she must inform her new employer about applying for grad school. No, especially since it’s not a done deal yet. But here’s something to consider: if the writer is accepted and gets the needed aid, he/she might be able to defer for a year ( Alot of schools will do this, guaranteeing a slot for the following year.) That way, the writer could gve the employer at least one full year and save up some money as well. If all this works out, the writer needn’t inform the employer immediately either. A month’s or two weeks’ notice is fine.
7
LW 1, it is truly sad that you cannot take advantage of the incredible benefits that some people accrue - without fear of addiction or other negative consequences - from marijuana. Our government, and the entire medical establishment, seems to have no problem prescribing OxyContin, a drug that is highly addictive and, directly or indirectly, is causing the deaths of thousands of Americans, while on the other hand has a knee-jerk reaction to the relatively benign marijuana.
Although it may not help the current letter writer, it may help others in the future, if you write to your Congressperson to support the recently introduced bill to legalize marijuana
https://www.forbes.com/sites/tomangell/2019/02/08/feds-would-tax-marijuana-under-new-senate-bill-actually-numbered-s-420/amp/
6
I really don't understand why anyone would feel it appropriate to approach a total stranger, comment on their appearance and offer unneeded advice.
56
Many doctors are insufferable condescending schlemiels when it comes to control questions. They will not tolerate a patient capable of thinking for themselves (given access to competent informational output. This MD (?) sounds like a card carrying member of Trumps's "Illiterati". Dump this relationship as soon after filing a complaint with the AMA as is humanly possible.
17
You have actually scuffed over the chalk line in the sand. You have said, without a doubt that there is as a fact that so-called- licensed doctors refuse to provide access or prescription to medical treatments for non-medical reasons such as their unjustified beliefs, execution of which are actually criminal.
But in fact your slim excuse for this column is so you can spread a skim of butter upon whichever side of the bread greases you better we should all learn that ethics were always a code whose denial was always a code preferable to facts or the Rule of Law.
3
As has been noted in other responses, there are currently several FDA approved THC-containing drugs (Dronabinol (Marinol, Syndros), Nabilone (Cesamet)) available in the US. However, a 1:1 combination of THC and CBD (Nabixomol) has been found to be more effective in relieving certain symptoms (chemotherapy-induced nausea and vomiting in particular) than THC alone. And, the addition of CBD eliminates or dramatically reduces the psycho-active (the "high") associated with THC virtually eliminating the possibility that it will be abused/used recreationally.
The problem: nabixomols have been approved and are currently available by prescription in Canada, UK and other European countries but not in the US.
An interesting article re: the use of marijuana in cancer care in the US:
US National Library of Medicine
National Institutes of Health
https://www.ncbi.nlm.nih.gov/pubmed/29449262earch
Curr Oncol. 2016 Mar; 23(Suppl 2): S8–S14.
Published online 2016 Mar 16.
Integrating cannabis into clinical cancer care
D.I. Abrams, MD
10
Of course, you can fire your doctor. Sometimes it is sorely needed.
And in this case it is certainly time to fire this guy.
Many many folks are cowed by so-called "authority figures" & never question a thing.
6
Letter writers # 1 and #4 - never, never offer information. Pretend your life - regarding doctors and employers - is one long deposition with adversarial overtones. Letter writers #2 and #3. MYOB. People like you who think they are looking out for the interests of others lack the insight to realize it's always about themselves.
22
Regarding LW3, the person writing seems like a busybody. You don’t even know this person. Until the age of 30, I was 5’ 7” and 108 pounds. I was perfectly healthy and active, rode my bike everywhere in Manhattan, skied and played squash, and ate everything and anything I felt like eating, including my favorites, spaghetti and ice cream.
I have an adult daughter who is 5‘10“ and wears a size 4. She also is extremely active and eats whatever she likes.
You have no clue whatsoever why this person is so thin. If she has an eating disorder, it is most assured that she already knows it. Perhaps you should consider why you are so concerned about her.
21
Regarding the thin woman at the gym; like several others have commented, mind your own business. I have long skinny arms and legs; due to some structural issues, I have rib and shoulder bones that stick out, so I look much thinner than I actually am. I probably eat more than most people but burn it off because of a high metabolism. I have been like this 70 plus years, it is my body type. And yet “friends” will make comments about how thin I look and ask if I lost weight. Do I ever dare ask if they gained weight? This thin woman is well aware of whatever issues are the cause of her thinness amd she does not need anyone pointing out the obvious, and perhaps making her more self conscious about her appearance. The Ethicist continues to give balanced and sound advice.
21
First time reading. Just another knock off of "Dear Abby". Abigail was the consummate advice giver. Her mostly sound advice came from a solid base of good will and common sense. Too many others have tried and failed to reinvent Dear Abby, even her sister. Giving advice on life is often tainted by the advice giver's background of intellectualism. A deep rooted sense of humanity, is a gift or talent. Not one that can be learned or intellectualized.
5
@Deano
I hope you don't think that intellectuality and empathy are mutually exclusive, or that intelligence and empathy are mutually exclusive.
3
@Deano
Actually, Dear Abby copied her sister, who was the first of the two to write an advice column. But even that wasn’t the first column ever. Nathaniel West’s 1933 novel Miss Lonelyhearts was about an advice columnist. Also, Dear Abby wrote an entirely different kind of column. Her three sentence answers aren’t comparable to the answers here.
Coincidentally, Ann Landers died of multiple myeloma.
5
A year and a half ago, my sister ran into the same problem about the cannabis with her doctor, and this was at Mass General Hospital in Boston. He claimed it was a policy. This was a highly respected and recommended physician. She chose to stick with him, and not use the cannabis.
Perhaps doctors do this because they cannot control the usage.
5
@Nancy Spivey - And they can control the usage of other "drugs?" How? By limiting the number of dosages the invalid is permitted to have, regardless of the need. No, it is because they have some preconditioned response. It is the same with other medications. Dentists commonly deny treatment to patients who they presume only want pain medication. Podiatrists will deny prescriptions for nail anti-fungal treatments so the patient will come back to these toe-nail clippers and pay for the humiliation of being tended by them.
They give blood-letting a bad name.
8
Its unethical to urge someone to have babies in a situation that may not be good for the children. If she is ambivalent, there are probably some very good reasons. Children deserve to be raised in a happy, healthy situation.
12
It seems to me that a marijuana user, committing a federal crime, is not entitled to care by the physician. The physician should be able to prioritize patients who are not committing criminal activity, because perhaps they are more deserving of the care and time of the physician. Marijuana possession and distribution is still federally illegal and until that changes I don’t believe that physicians have an obligation to use their time, often quite limited, to treat patient who engage in criminal acts before every patient who is not is treated.
2
@Symin Charpentier
While you are technically correct, you must know that the Federal Government is not enforcing its anti-marijuana laws. This is probably because most Americans, including most trump supporters are in favor of legalization.
Do you really think it is morally correct for a doctor to refuse to treat a patient who is using a completely harmless drug that helps with cancer pain?
Suppose the patient was drinking raw milk, which is usually illegal. Should the doctor refuse to see this patient?
If this doctor is the only one available, as it implied in the article, I would travel or move to see a caring one. And complain the to local medical board.
8
@akamai
Move to see a new doctor? Wow, you must have no financial concerns. I’d be hard pressed to pull up stakes for any reason. My livelihood and home and support system are where I live. I would have difficulty finding employment—ageism is alive and well—and affordable housing in many places. I do not think I am alone.
13
@Symin Charpentier--Lots of people commit crimes and yet are still worthy of medical care. What are you thinking? To follow this line of reasoning, those with speeding tickets are slightly less worthy than those who always obey the limit. And prisoners or those out on parole are less deserving of medical than law-abiding citizens?
4
With respect, a doctor can refuse to establish a doctor-patient relationship with a patient for any reason whatsoever. Once the relationship is established, a doctor may also choose to terminate the relationship for non-compliance, provided they insure access to another provider of similar training and skill. In the US system, where a doctor’s time has become one of the major factors limiting access to care, it is wasteful and unethical of a patient to continue to waste a limited resource by using the physicians time while ignoring the advice. It is also often the case that doctors terminate the relationship because the patient represents a threat to other patients in the practice. Is this patient trying to convinceothers in the practice to use marijuana for pain control? Has he/she violated the terms of a pain control contract? Is he/she attempting to sell marijuana to others in the practice? Is he/she attempting to smoke marijuana in the office/hospital? Is this a lung cancer patient that insists on smoking marijuana as the route of administration? All of these would be legitimate reasons to terminate the doctor-patient relationship. We do not know, because the entire story provided is hearsay; the person receiving care is not the one requesting the ethics advice. In that setting, it seems to me to be unethical for you to advise a possible complaint against the doctor. A more ethical stance would be to suggest that the patient obtain an ethics consult or a second opinion.
3
Family doctor here, 30 years in the game.
Getting upset about a myeloma pt on opioids who takes cannabis strikes me as odd. If cannabis is a one on the dangerous medication scale, opioids are a ten.
I'm no oncologist, but I have not heard of cannabis having significant drug-drug interactions with chemo.
I have many pts on cannabis for one thing or another. Can't say it's a good medicine but firing a pt over it is a bit much.
Refusing to see or take on a pt in a non-emergent situation is not unethical, at least according to the AMA. But most of us will put up with a fair amount of irrationality or generalized cussedness on the part of our pts--otherwise whom would we see?
49
@vbering the main concern has to do with impaired driving. Both opioids and cannabis (based on more recent evidence) are known to impair driving. There is an additive effect, so being on both increases the chances for an adverse effect. A patient who causes an accident and tests positive for cannabis as well as a prescribed intoxicant can attract law enforcement attention to that prescriber, in addition to the moral injury of having contributed to whatever harm occurs as a result of the accident.
1
@Mary May Hm, interesting rationalization. I wonder if this doctor also refuses to treat any patient who drinks any alcohol, or takes an antihistamine for allergies or a cold...Also, it seems quite a stretch to say the police would come after the precriber if a driver is impaired due to nonprescribed marijuana. Never heard of such a thing.
9
@Mary May
There's evidence that cannabis causes impaired driving? That's surprising. I'd rather be on the road surrounded by pot smokers than near one driving drunk.
3
To LW 4,
As a freelancer, I have worked at many different companies. The experience at each was always a function of the people who ran the company. At some places, the employers were truly wonderful people, considerate, open, and honest. At other workplaces they were quite the opposite - rude, demanding and offensive.
You don’t say anything about your current employers, nor about your intended field of study. If you are working in a place where you are happy, and your employers are sincere and treat you well, I would consider staying! There is almost no field today that you cannot study online. Perhaps you can begin your PhD that way, and later transition into a full-time program.
Also remember that your employers will be your future references.
9
To the writer who changed their mind about applying to grad school after accepting a new job...be aware that this style of decisionmaking is what's giving Millennials a bad reputation in the workplace. It's not that you shouldn't have the freedom to make important life decisions but it may appear you weren't transparent when taking the job or that you chose not to listen to a very important request when you accepted it. How you handle your exit, should you chose an early departure in favor of grad school, will make a difference. For instance, you might offer to overlap with & train your replacement for 2 weeks without pay. You certainly want to give your employer more than the cursory 3 weeks notice. Even if it means being uncomfortable short term during the transition, you're valuing the importance of continuity and coverage in your workplace. I don't think you have to sacrifice your grad school goals but how you exit matters....to both you and your employer.
5
@at. US employment laws are somewhat facnitating if not draconian. In what could be described as the worlds largest capital economic country you suggest working without pay!!! My goodness, people change their minds all the time, I’m sure an employer can deal with that without expecting something for nothing.
15
@at Millennials grew up in the age of routine layoffs, when a person could give 110%, burn the midnight oil, and be fired anyway. They saw CEOs from Enron, WorldCom, Polaroid, and other companies run the business into the ground and escape with a golden parachutes wile everyone beneath them lost their jobs. They learned early that loyalty to an employer is a fool's game. I don't blame them one bit.
1
LW 2, if the person you are writing about really is a friend, and not just an acquaintance, I am surprised that you have never expressed your opinion on the matter before. My friends and I all discuss our personal lives and give each other advice routinely. We may not act on each other’s advice, but it is always welcomed.
You say that your friend wants to have children, so it seems quite possible to me that her reluctance to move forward with her current relationship is just as you see it. And it seems equally possible that she does not realize it.
Whether or not you are correct, if she is your friend, she will listen to your assessment and either agree or disagree without affecting your friendship.
1
My wife and I enjoy discussing both the questions and answers in your column. Our default idea in life is mostly "mind your own business" unless there's a really really good reason not to. We think your advice too often favors intervention. So bravo! for this week's answers.
6
I thought your response about not intervening unless there was an expectation of a positive outcome was right on.
However, the response regarding the patient using marijuana was incomplete. Because of the opioid crisis, doctors now routinely test patients who are taking OxyContin for THC in the blood stream, it may even be required. A friend was fired from a pain doctor because a test result showed use of marijuana. It precipitated a family crisis, scrambling to find another doctor, cancellation of a family vacation and severe distress.
6
@TLF Portland You are absolutely correct. The FDA will not allow hospital-based pain medicine clinics to continue to treat patients who take ANY type of unauthorized scheduled drugs. The issue is not cannabis per se, but that no one knows how these meds interact with opioids. Further, there is concern that unsupervised cannabis use could impair the judgement or memory of the patient, causing them to forget doses. If the friend wants to try cannabis, his physician will allow him to withdraw from the program and try another provider. If it doesn't work, he can return after the cannabis is out of his system.
3
LW#2 and #3 both ask if they should prod, investigate, and give advice about a situation they think another might be facing. I agree that they should not. However, the Ethicist offers only to leave the other person alone. There are many OTHER bases for genuine contact. If LW#3 has spotted this woman at the gym for over a year, she has probably been seen herself this whole time and could say hello, commiserate over weather, a challenging workout, just offer a sincere smile etc. LW#2 has a friendship, strengthen that relationship without feeling the need to offer advice.
Unsolicited advice is a sign that the advice-giver has judged another person and thinks changes are in order. Non-judgmental conversation is something worth practicing for us all.
31
As a physician, my problem with anybody taking supplements including cannabis is this. Supplements can give false positive and false negative lab tests. With many of these supplements, we do not know which tests will be skewed. For example, biotin (vitamin B7) can can cause abnormality in about 80 lab tests. This may cause patients being treated for thyroid disease and even miss patient having a heart attack. Biotin is added to so many supplements like skin, nail care preparations etc, that we do not even recognize that they are taking this. If this patient with multiple myeloma is on a experimental protocol , I would not use any supplement including cannabis.
15
Regarding the friend who hasn't gotten around to marrying and having children: It's at least as likely that she is ambivalent about motherhood, not her partner, and that she has found a way to manage the ambivalence -- doing nothing. She may well be aware only of her wish for children, but that is often the nature of ambivalence, consciousness of only one of the wishes. Many women don't feel comfortable articulating negative feelings about motherhood, especially to friends who are already parents.
25
Some unhelpful stereotypes are being perpetuated here. Most eating disorders do not manifest as anorexia, and most eating disorders (including anorexia) do not involve much dysmorphia. They are about shame, as Appiah notes, and a concomitant abusive relationship with food. The shame is the root. (For me, some 20 years ago, anxieties about adulthood prompted an inordinate preoccupation with “eating healthy”—and it spiraled into a stupid and ultimately obsessive focus that led to excess weight loss, which took me a while to correct. It was fundamentally about shame and control.) Focusing on the outward manifestations is unhelpful. When I first read the question, I had thought the gym goer was extremely overweight and that the letter writer was worried about binge eating disorder—and I can’t imagine confronting people paternalistically about that, or their smoking, or the moral frailties implied by their wearing leather or expensive fashion labels or whatever. What is it about low weight that prompts this kind of meddling and paternalism?
18
@Scientist It’s interesting that it appears ok to you for an observation or potential intervention if the gym going was overweight but you struggle with understanding why the same sentiment would allly if they are grossly underweight. The same principles apply to both cases and the writer should stay out of the person’s business. However, eating disorders at both ends of the spectrum present equal concerns and one (overweight) doesn’t warrant more general interest/concern than the other (underweight). Sounds like you’ve overplayed your own judgment on the medical issues underlying both circumstances.
2
@Nancy
Perhaps you missed "I can’t imagine confronting people paternalistically about that" -referring to overweight people.
2
Why are there so many letters asking something along the line of " I am concerned by Appiah's lack of expertise to answer LWs question re:..."?
The column is "The Ethicist." If I want an informed opinion on the ethics of a situation, I would write Mr. Appiah.
If I wanted advice regarding a social issue, dealing with families, friends, partners, etc. I would write to Mr. Galanes.
I give all letter writers to both columnists credit for having considered these issues as well.
9
LW #4 I would not lie at the interview, and you didn't. But plans change, and the employer's plan might change, too. At best, I would guarantee the employer the same amount of time at the job as they guaranteed employment!
13
@Roger That attitude will not be appreciated by the employer. You might make your point, but unemployment is in your immediate future.
1
@Robert Employment is "at will" in the U.S.A. with few exceptions. No specific time is guaranteed period in most jobs . So what is wrong with an employee giving proper notice?
4
@Robert They have requested that the worker stay for a specific period, but have not committed to keep said employee. I would, as this employee, feel free to leave if grad school came up, and do not feel it is unethical to do so, since there was no promise of employment, and they, too, might terminate at any time.
1
I used to see a young man biking by my condo. He was skin and bones. Literally. I saw him often but not daily, still, I believed he was there biking everyday. I once saw him in a snow parka and sweatpants biking in the heat of the summer. As someone who has dealt with an eating disorder I felt that this was going on with the young man. My heart broke for him. I wanted to speak to him. But, I didn't. I understand the concern you felt for the young woman at the gym. I think it's wonderful you felt this compassion and wanted to help. Would it really be the worst thing in the world to approach this woman? I don't know.
3
@fish out of Water Some years back a woman who lived around the corner from me died of organ failure due to anorexia. She'd lived in the neighborhood awhile before I moved in, and I was told that she came from a banking family in NC, that they and her ex husband were doing everything they could to get help for her. She had joint custody of her six year old daughter. One afternoon she didn't show to pick the child up at school, so her ex was called and he found her dead in her home. Nobody was surprised. She'd seemed, by the time I met her, to be in kind of a starvation induced euphoria, she'd walk through the neighborhood smiling, her anorexia so advanced that she had a dark fuzz of hair over her body—her body's attempt to warm itself during starvation. We all knew she was killing herself, but she also knew this. I have no idea what anyone could have said to stop her. I do, however, know a couple of physical fitness instructors who did an intervention with a woman who needed to stop exercising and start eating. She was not in an advanced state of anorexia, if she was anorexic at all—she just looked dangerously thin and was showing up to every workout class imaginable. These 2 women teachers stepped in and told her she had to cut her routine back and put some weight on, they weren't going to watch her kill herself—so she did. She is pushing 80 now, I would think, and she's still walking around the neighborhood.
1
@fish out of Water In my view, any person should be approached simply as a human being first. If the writer has no other interest in the thin woman than offering her (unasked for) advice, then stay away. We project our own anxieties onto other people. Perhaps the write would benefit from turning her question around and ask: Am I okay? Do I need help?
3
The cannabis patient scenario is entirely consistent with the VA policy regarding marijuana prior to 2018. If a physician discussed marijuana then he or she put his or her DEA license at risk. The current policy still forbids any coverage for cannabis, but allows for it to be discussed and recorded in the medical record.
17
LW#3--what exactly do you think you could accomplish by approaching the woman at the gym? Do you expect her to say, "gee, I never knew I was so underweight, but now that you point that out, I will start taking better care of myself!"
It's possible that she has a medical condition or is otherwise naturally very thin. In that case, she surely wouldn't appreciate a stranger commenting on how bad she looks. No one would appreciate that.
It's possible she has a major eating disorder or other problem. If that's the case, a stranger in the gym can't fix that.
It's never appropriate to comment on a stranger's weight or appearance.
121
re: underweight at the gym- and what is a possible outcome of expressing concern? she might feel so shamed she never exercises in public again.
17
@Itsy
Note that the writer didn't storm up to the woman and discuss her appearance, but wrestled with thoughts about it for a long time. And then took the trouble to seek an expert opinion, because the LW felt unsure.
S'he wrote wondering if s/he were failing ethically, perhaps taking the easy way out, by not doing anything. There ARE so many people out there who don't do anything, ever, when they see another person they suspect is in distress.( I've worked with children and domestic violence victims who were never ever asked what was happening to them).
The writer doesn't deserve a sarcastic lecture, especially after taking the trouble to seek counsel -and is as deserving of respect as the woman. I've dealt with intrusive, overbearing types - the ones who know what's best for everyone and never hesitate to give directions. That doesn't seem to be the case here.
As for it NEVER being appropriate to comment on appearance: Not by me. I've occasions had someone say something nice to me about my appearance, and I have done the same: even to strangers. It's I-thou. You do of course pay attention to the other's receptiveness, and never criticize.
37
@cheryl Thank you for your compassion
9
Was it medically ethical for the pain clinic in NC to deprive me of hydrocodone that I need for back pain in order to sleep because my urine came back positive for cannabis (also used for pain relief)?
FYI: NC does not have medical marijuana. All cannabis illegal.
I think it is medical malpractice.
30
Agree completely. I am in NC, & I personally know a man in Stage 4 bone cancer who was deprived of his opiates because the VA found THC in his urine. So it's better to throw someone into opiate withdrawal than allow them cannabis, which helps him sleep?
Its unconscionable in addition. to cruel & unusual punishment.
45
@jessie
Opioids are not appropriate treatment for non-cancer related chronic back pain. Cannibis would be absolutely reasonable in this setting, however.
7
@jessie Is the situation you describe medically ethical? Probably not.
However, there are strict legal implications for a physician to continue to prescribe narcotics to a patient using illegal substances (at least as classified by the DEA).
A physician might not object to the use of marijuana, but still fear the loss of his or her DEA license and ability to earn a living.
16
Re: Cannabis & doctor
I didn't mention my cannabis use because I was afraid that my insurance company would deny my coverage beyond the initial 2 years of my treatment, seeing as how they denied my coverage for the first 2 years claiming a pre-existing condition.
I didn't die from overdosing on opioids because I was able to manage the pain with cannabis.
I'd like to tell that doctor who's against pot where to shove it, and how far.
60
@Sarasota Blues
My elderly father sees a pain specialist monthly and is prescribed narcotic pain medication for chronic, intractable pain. He signed a contract stating he would not use any other pain medications or illegal drugs while under that doctors care. He is given random urine drug screens both to prove he is not taking other drugs and to prove that he is taking his prescribed meds because some patients sell their meds. A physician may personally believe that cannabis is beneficial. However, they have a license to protect and must work within the confines of state and federal licensure. His pain specialist has fired patients for breaking the rules, which is his right to do so.
9
I had a similar situation once in a gym, where a painfully thin woman also had scars suggesting that she had been cutting herself. I thought about saying something but decided - I still think rightly - that she knew she was doing this and it was obvious to any friend or relative who regularly saw her, so that my intervention as a stranger was neither needed nor appropriate.
78
Marijuana - What the physician owed his patient was an explanation. He may be guided by insurance regulations, county or state regulations or personal beliefs. The patient deserves to know why the decision was made.
LW3- The student moved across the country for a job, so we can assume that it is in the student's chosen field of endeavor. Unless the grad school situation makes it impossible, our student should seek accommodation from the school to take some courses on weekends or at night. The employer should see it as being in its own interest to accommodate the student as well, since the better-prepared student makes a better-prepared employee. Possibly the student/employee can participate in training a part-time employeee to fill in on days when the grad school cannot make a change in schedule. Depends on the field of endeavor.
All this is very difficult, I know, and sometimes there are jerks in positions from which one needs help. Still, before resigning, the student needs to explore all possibilities. A really good job and grad school are opportunities that are not just lying around. Do the best to preserve both.
25
"Given his insurance coverage, my friend does not have the option of changing physicians."
Do there really exist insurance plans where there is only *one* choice of specialist?
15
@polymath, I have multiple myeloma. It's a pretty rare cancer, and there aren't a lot of specialists.
34
@Diane
Yes, there are not that many myeloma specialists (perhaps 200-300 top specialists in the U.S.). I am wondering a couple of things. One is whether the doctor in the article really is a myeloma specialist. If not, the patient ought to be seeing one. I would do some more research on whether an insurance plan covers such a specialist and would do my best to change plans if not.
18
My grandfather had myeloma and suffered most horrendously. Denying a patient access to something legal that may alleviate such suffering seems inhumane to me.
71
LW #1 - my cynicism kicks in whenever there is a choice between a pharm industry product and anything else. The follow-the-money theme pops up. There are probably not too many doctors or pharmacists out there (yet) who get kickbacks from marijuana producers Gifts to docs was oen reason opioids became so prevalent. It makes one wonder what's in it for the doc.
LW #3 - gal at the gym - she may look painfully thin to the LW, but she just might be one of those people born that way. The fact that she's still at the gym after at least a year says something about her trying to be physically fit. She could be eating three times what most big men eat, but simply have a very high metabolism rate that burns it off just by breathing every day.
15
@L.E. My state pretty much banned pharma reps from giving gifts to doctors, yet marijuana dispensaries set up shop at medial conferences all the time.
The idea that canabis use in Colorado is legal ignores federal laws. It may not be illegal under state laws, but federal laws are what matter. Go to a pharmacy, or ask your insurance provider about medical use of marijuana. Neither will have anything to do with the drug. Federal laws and regulations put the drug in a category with cocaine, heroin, LSD, you get the picture. Banks won’t take deposits, or loan money to growers and sellers. Until congress acts, don’t expect federally licensed businesses, to support distribution. State licensed physicians don’t need the hassle. What’s in in for them, other than heightened federal scrutiny of their prescribing of narcotics?
15
@Jay -- Science and widespread experience have shown marijuana has no significant harms.
If doctors had any principles, they would at least join their patients - and 68 percent of all Americans - to help bring a quick end to the fraudulently enacted, monstrously destructive marijuana prohibition.
23
@John Thomas
Family doc here. I work over 50 hours per week trying to keep old people alive. Getting enough sleep is an issue. I think I'll let someone else fight the cannabis fight.
Odd how people often have no idea how doctors spend their time.
6
Letter #3. Employers have no right to demand a commitment of a specific amount of time without a contract. Your employer may and will terminate you at any time for any reason. (Except blatant discrimination). Give notice when the time comes to leave. Thank them. No need to apologize.
72
@Masha
Bingo. If the employer's "plans changed," you would be out the door in forty seconds. You, too, can leave any time you want if you aren't violating a contract. You should give two weeks' notice … done.
36
@DW
"If the employer's "plans changed," you would be out the door in forty seconds."
That long?
17
hey slow down, considering and applying to grad school doesn't happen overnight. LW has time to consider when to announce. by the time school is scheduled to start the 2-3 years may have already been spent.
11
Wow, the question regarding the doctor's behavior was disturbing enough, but seeing comments talking about doctor's subjecting their suffering patients to mandatory drug testing really floored me. What happened to "do no harm?" I don't understand why people tolerate this - any doctor who does that to cover their own selfish worries about insurance should lose their license. Why do people hate lawyers? They should hate their doctors; at least lawyers don't kill sometimes their own clients and willingly impose suffering on them. The entire system is backward and is set up for the benefit of the doctor and not the patient.
24
@Bsheresq
The system is set up for the benefit of the insurance companies. PERIOD.
23
@Bsheresq Clearly you don't live in an area with an out of control opiod epidemic. Many states have laws that require physicians to perform mandatory drug testing.
7
@Bsheresq The testing is mandated by the FDA and any pain specialist who fails to follow this rigid structure is in danger of losing his licence. Most "paid specialists" are anesthesiologists who get minimal extra training. It's not really a money maker for them, but rather an add-on business. Many are getting out of the business because they find dealing with the FDA's compliance demands to be excessive time wasters.
5
As a doctor, I have another thought. Does the patient have a primary care doctor? Can he/she have a conversation with the oncologist or patient about this issue? I find this works better than filing a complaint especially when your primary care doctor has a relationship with you that predates the diagnosis of cancer.
75
Letters 2 & 3 illustrate a seemingly constant refrain of late - we have become a nation of busybodies who think it's our business to tell others how to live their lives, even total strangers. From political matters where WE determine that someone else is "voting against their own self-interest" to health matters where WE just "know" what another should do about their own bodies and lives, there needs to be push back against this intrusive attitude.
Bottom line - mind your own business!
67
@George S
I agree with you to a large degree, especially concerning L2 and L3. But I’m also troubled by the extent to which we’ve become a nation where Good Samaritans are seemingly a dying breed, where we’ve taken the “Mind your own business!” dictum to extremes. How many times have we heard of scenarios where someone in dire need received no intervention, no assistance, no helping hand from anyone? At times of course it’s difficult to know whether one should intercede, as so many letters to Professor Appiah illustrate. But surely we can agree that we all can and should do a better job of being Good Samaritans.
21
@George S Hear! Hear! I am so annoyed at judgmental nosiness that seems so pervasive. I once practiced neurology, a specialty where one often can make diagnoses by looking at, or listening to, a patient. When I go out in public, I see people with Parkinson's, hemiparesis, paraparesis (both legs weak), foot drops, facial droops, tremors, ptosis, eye movement disorders and hear various speech disorders (aphasias, tremor), etc. The only times I asked to examine people were (1) if they were my patient, and very rarely, (2) if they accompanied the patient and had a condition that in my medical judgment they might not be aware of and might want to know. That was rare, and I once asked one of my senior partners what I should do. He told me to ask the individual if I could examine them. I took his advice and never regretted it.
6
I believe this is not the whole clinical situation. I have empathy for patient who is going through tough time. But Dr. also has certain obligations. Just knowing one part that patient want to use MJ for pain is not enough. There is always a concern about using multiple psycho active drugs -- a leading cause of accidental death. I believe there should be more discussion at this request. I will like to start a taper of opiates and then give permission to use MJ. I believe its irresponsible to fire patient but I also believe that it will be irresponsible to allow patient to use multiple narcotics and where there is no control over how much MJ is being used. To me the safest way is discussion and taper of opiates and starting of MJ.
5
@Jasbir This MD would not be my choice if I had a serious unrelenting disease that could worsen and probably will given the diagnosis. Allowing a patient to suffer with pain when they are diagnosed with a serious cancer which can quickly deadly and painful presents a poor quality of life at the end of life. Get a new MD. Not relieving a seriously ill pt's pain is malpractice especially when its an MD specializing in cancer. Unheard of and dangerous. This is a person's quality of life at stake.
2
Several of this week's inquiries (2,3 & 4) truly belong in Social Q's rather than The Ethicist. And I am deeply concerned by Appiah's lack of expertise to answer #1 - several commenters have shared valuable and important insights around insurance concerns at a national level, the realities of just want a physician's obligation is with regard to continuity of care and others. If an important inquiry such as this one is beyond the scope of the columnist's expertise, he should be a good reporter and incorporate the insights of those better equipped to address them in his response.
26
@NewYorkLady
There's a split between the ethics of the situation,and the nuts and bolts of dealing with it.
6
I'm happy to once again see an advice column in the Times written with wisdom and compassion. In the last several months the fare on offer from another writer seemed more like trolling. I hope you are able to continue and I look forward to your future columns. Thank you for stepping up.
3
I wish the Ethicist had addressed whether the doctor was violating a little something callled the Hippocratic Oath.
Just a few weeks ago I was "fired" by my primary care physician because I had the nerve to seek medical attention after an auto accident. (It wasn't an ER situation.) Except that it was a mere office worker who told me, "We don't accept auto accident cases. Find another doctor." It didn't matter that I was fully insured -- they didn't want to deal with auto insurance claims. The actual physician returned a follow-up call many hours later and appeared to be shocked by the situation... but did nothing about it and never called again. It took me another month and multiple visits and nagging of an urgent-care clinic just to find out I had a broken rib.
This is the state of medical care in the United States today. We patients are merely pawns in the relationship between doctors' offices and their insurance company overlords.
82
@Robert Triptow
You need - many people need - something like an ombudsman who can deal with unethical and possibly illegal refusals of care like the one you went through.
12
@Robert Triptow Nothing unethical here. It was not an emergency. And what you were asking for was the doctor bill the auto carrier and be compelled to respond to any number of requests for information about your case and possible court appearance. If you were willing to pay for your care out of pocket and not embroil your doctor is non-treatment focused administrative matters you might have reason to complain. Health carriers won’t pay for work or auto accident claims. Some doctors want to treat patients, and not be forced to deal with unruly carriers.
2
This is very common. The clinic I work for will not accept any new patient coming in for an auto accident or worker's comp. Established patients are okay. It's the insurance companies that are the problem here, not the doctors. I suggest voting for a presidential candidate who will work to bring us single payer healthcare.
21
The writer concerned about the woman’s weight should definitely mind their own business. I lost weight due to a drug reaction years ago and it affected my metabolism. I also had to shop in “teen” stores for jeans that would fit. It was devastating. (89 lbs). It took me 6 years to gain back half of the weight I lost. It has been agonizing and it is not anyone else’s business.
Look on the internet for ways to lose weight and there are millions of posts. Now look for ways to gain weight - protein powder (and milk which supplies most of the calories) and high fat foods such as avocados. Thanks, medicine.
Please stop thinking that strangers need your intervention about their weight, either too much or too little. Weight is one of the last areas acceptable for discrimination and nasty remarks. This is not ok. I know what size my clothes are, thank you very much.
79
Not to make light of your situation, but what medicine caused you to lose weight and made it difficult to gain it back? Asking for a friend...
2
@Gabby B.
I obviously don't know what medication Sally took, but I take Topamax, which causes anorexia as a side effect. I lost about 30 pounds, then leveled off. I never gain weight on this medication.
2
@Gabby B.--Multiple drugs for seizures can cause anorexia, which can be serious, especially in children.
1
In reading this column for sometime now, it appears to me that there's way to much sticking one's nose into other's business under the guise of "concern" for their welfare.
"Let everyone sweep in front of his own door, and the whole world will be clean." Goethe
84
First multiple myeloma has no cure, just extremely expensive treatments for symptoms. The medical establishment and oncology can’t offer you anything but years of agony, at least not yet. Our country is immoral, we are withholding opiates from patients who really need them because the said establishment created this opiate crisis themselves. If I had MM I would speak palliative therapy from a compassionate practitioner and forget about treatment from some jerk oncologist.
16
@Hb, I have multiple myeloma, and while there is no cure yet, there has been tremendous improvement in treatment. I was diagnosed in 2016, and have lived most of the time since then with no pain and no symptoms, though my bloodwork shows myeloma proteins. At this point, some myeloma patients have lived for ten years or more with no signs of the disease at all. A myeloma board I'm on has patients who were diagnosed twenty years ago. If you're diagnosed with multiple myeloma, please see an oncologist. They can do a lot now.
38
This authoritarian thing that is sweeping the world is truly out of hand. This doctor needs to reign in his or her ego and serve the needs of the cancer patient.
19
One of the many horrific damages of the insane war on marijuana consumers is how it trashes doctor-patient relationships. - Who knows how many deaths this has caused?
How sad that millions of people have to lie to their doctor. Future historians will call this era the American Inquisition!
18
"Cannabis is routinely recommended for cancer patients to improve appetite, decrease nausea and alleviate pain. The medical literature is fairly consistent on the efficacy and minimal side effects of cannabis ..."
Outrightly False !
Most people cannot differentiate between THC ( the psycho active ingredient of Marijuana/ Cannabis) and Cannabidiol or CBD - which has some medicinal value but is not psychoactive and does not give a high.
People conflate these terms and perpetuate this myth that Cannabis is harmless. Cannabis is not CBD. The Cannabis smoked nowday's has 10 times THC concentration ( 0f 1970's and very little CBD).
In 2017, the National Academy of Medicine report" The Health Effects of Cannabis and Cannabinoids " found strong evidence "Cannabis use is likely to increase the risk of developing schizophrenia and other psychoses; higher the use, the greater the risk"the scientists concluded.
Increased Marijuana usage often leads to increased Opiate and other substance abuse.Canada and USA the two biggest western countries that have by far the biggest worst Opiate epidemic , also have by far the highest rates of cannabis use. That often quoted dumb study about Cannabis helping Opiate addiction is a myth.
Legalizing Cannabis instead of decriminalizing it is a new disaster in the making.The data coming from legalized states is disturbing and downright discouraging.
Ref : "Tell Your Children" The Truth About Marijuana, Mental Illness and Violence- Alex Berenson
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Berensons book has been debunked in the pages oy this newspaper.
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Opioid use in states with legal medical marijuana drops by 30%.
Cannabis use only contributes to schizophrenia in those who are already prone to schizophrenia.
You need to be better educated on cannabis as you clearly are radically uninformed.
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You are incorrect on all points. The best cannabis for cancer pain is a combination of thc and cbd. While some cannabis has thc of 20-30%, that is used recreationally. There are many high cbd/low thc strains of cannabis grown specifically for pain control. It is available in dry flower form, oil to vaporize, edibles, capsules and topical creams.
We’re no longer living in the age of reefer madness. Cannabis is well known to help with pain and nausea. Please educate yourself before you post on this subject
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I find it fascinating that three of the four queries are cut from the same cloth - essentially, “I want to tell somebody how to live their life, and I’m looking for justification to do so.” Seriously, most of the time the appropriate response to these questions is a gentle MYOB. Cushy job for Mr. Appiah, though. . .
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Not one but two comments today involving people minding other people’s business. Different but alike. First how can anyone be arrogant enough to presume to tell a sister much less a friend it is time to dump your longtime boyfriend before your biological clock runs out, unbelievable. The second is harder because you are concerned about someone you believe maybe sick. But she may just be naturally very thin or she may be anorexic as you obviously fear. But that is serious disorder and I don’t know what a casual observer is going do to help. Ultimately people need to mind their own business more when dealing with adults. Clearly if we were dealing with issues involving potential abuses of children, battered women, elderly or ever pets I would feel differently.
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All because we've criminalized our shoddy so called health care system and NO doctor is qualified these days to say no to cannabis
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It is clear from the context, that the cannabis patient is cared for at a VA or other US Government run health care facility.
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Tell the doctor that you've stopped using pot and then continue to use it without telling him. He won't find out and lying about it is no worse than his threatening to dump you as a patient.
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I would very much want to know what the oncologist's relationship to the pharmacutical industry is. Incentives in any industry causes a great deal of willful ignorance.
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LW#1 I have to wonder if this doctor "fires" his smoking patients. They are the ones using carcinogens. If he doesn't, this would seem like discrimination to me
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LW#2: Don't bring up fertility. The friend either is already aware of her declining window, or else has a very different perception of when her window does decline and doesn't want to hear your opinions about it (which, btw, might not be right. You don't mention her age, and some people think that fertility declines far sooner than it does; tho others think it declines far later than it does).
However, a good friend will occasionally broach the subject of relationships. Ask her how she's feeling about the guy, how she sees her future with him, etc. If she shut downs, then shut up. If she's open to talking about it, then by all means do so. I know so many women who have stayed in bad relationships only b/c they think they can't do better. Eventually they realize the relationship isn't worth it, and then grieve they wasted so many years with that person rather than starting over and investing in a new one. It can help to have a friend encourage you to see a different perspective: why continue to invest in a failing relationship when you can cut your losses and start investing in a new one?
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@Itsy
Good lord. Seriously? This person has NO business to, as the Scots say,"Poke her nose where there's no smell." She should MYOB.
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Some day (soon) we will look back at this absurd Reefer Madness with incredulity. One wonders if this "doctor" would also refuse to treat a smoker? boozer? soda drinker?…
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Is Dr. (not so) Kinderlehrer living in another world? "You say that your friend has access to only this one oncologist. That’s disturbing, if true. In a decent medical system, the ability to switch doctors is a central element in respecting patient autonomy." Doc, have you heard of "out of network", "don't accept Medicare, Medicaid, don't accept certain insurance companies insurance"???!!!! Clearly the US does NOT have a decent medical system. Please, let us have single payer, universal healthcare. This doc must be smoking something. In a real medical system that places patient care above doctor and insurance company profit, the question of care would not be an issue. Sign me a MM patient.
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What you quote is what Appiah said, not the LW. The LW may very well Agree with you.
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Let this be a warning to ALL Patients, even in States with Legal Marijuana.
Keep your lips zipped. Due to possible " insurance " problems OR just being a prig, some Physicians are better left in the dark, about YOUR use of Cannabis. It's YOUR body, YOUR pain, Your life. YOUR Business.
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I would never have hidden any drug use from my oncologist. His judgment was my lodestar. That being the case, I was blessed with one who always explained everything very well, so I understood that even something as seemingly benign as multivitamins might affect his treatment. And I definitely wanted his treatment to work.
Noncompliance is a huge medical problem.
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Doctor sounds like another amoral pusher of opiates that are destroying America.
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@Stephen "Opioid deaths" includes everything from suicides to accidentally mixing opioids and alcohol (which killed Tom Petty) to heroin overdoses to people who die with 3, 4, or more drugs in their system (if one of those drugs in an opioid, it counts as an opioid death). The vast majority of opiate users are not heroin addicts.
Ethics requires the doctor know the context of the patient. If patient has no choice, then the doctor is essentially laying out a death sentence as ultimatum. Name and shame this damned doctor.
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For LW 1, the patient should get a consult with a trained physician who can speak to the possible drug interactions between cannabis and the treatment regimen that the patient is undergoing. If there is no drug interaction concern, the patient should feel free to use cannabis without telling the oncologist.
For LW4, it seems that there is an expectation that you will go to graduate school eventually. Has your employer guaranteed that you will be employed there until you have gotten into the graduate program of your choice? My expectation is that you can be fired at any time.
If you were taking a fellowship, you would be obligated to complete the fellowship especially if there were other fellows in the program expecting that the workload would be shared for the duration of the program.
Consider what leaving shortly after taking the job would do to your career. I took a job related to my graduate work for two years after I completed my undergraduate degree (and was told during the interview that it was expected that I would go to graduate school, but that they strongly encouraged people to stay for at least two years in the position). What I learned working probably cut a year off of my PhD program. It was good to have both knowledge and some money in my pocket when I started graduate school-- and the letters of recommendation.
Do not stay because of something that you said during an interview, but consider if an how the job may help you overall.
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An oncologist who wants to practice on no one but cannabis-free patients while passing out opioids without a glimmer of the same objections is not being consistently ethical. If they are the only oncologist reasonably available to the patient, it might be legal to turn them away without suggesting an alternative arrangement, but it is not ethical.
If cannabis is perceived as dangerous, the fatality rate nonetheless is 0%. We all know the statistics associated with use of opioids. It is logically inaccurate to make any claim about the "dangers" of cannabis that isn't far more applicable to opioids.
BTW, while ridiculously overpriced compared to MMJ, dronabinol (AKA Marinol, an artificial THC) is available for prescription and should be offered to a patient by any doctor citing objections to MMJ in any case.
As for doctor's insurance prohibiting such patients, that simply raises a vast new set of ethical lapses in such relationships, however legal it might be. It is very important to address the questionable ethics of seemingly legal maneuvers like that - at least in an ethics column. Insurance companies are among the most ethically challenged of our institutions, Don't let them off the hook.
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Stigmas are not going away in the USA any time soon. But visit our neighbor to the North and there are no stigmas. Cannabis is embraced not shunned.
How about this scenario. Cigarette smoker is denied medical care. Alcoholic is denied medical care. Would you care? Probably. But cannabis?
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@Warren Bobrow: What about opioid users, the vast majority of whom are *not* addicts, being denied medial care because the sate board of medicine or the local Walgreen's decides they are using too much?
Big Pharma doesn’t want people to find out how effective marijuana is in relieving pain. I had cancer. Marijuana helped me when pain meds didn’t.
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Re: LW #4, you write “unless you promised your new employers not to apply to graduate school ...”, but do not discuss that it would be ethically very problematic for the employer to ask a prospective employee to make such a promise. We are talking about a job, not indentured servitude. In my opinion even if the letter writer had made such a promise, it would be null and void.
Moreover, even just asking a job candidate if they plan to apply to graduate school is problematic. If nothing else, all it ends up achieving is that people end up conveniently “changing their minds” a few months after they start the job when they “had no plan” to apply to grad school during the job interview. Basically a system that creates incentives for people to lie (to themselves and/or to their prospective employers) is ethically fraught. I wish the Ethicist would have addressed that aspect of the question.
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I would refuse to have a doctor who, at this point in time, is so ignorant to reject patients who use cannabis.
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Letter Writers 2 and 3, the ethical thing is to mind your own business . LW2 your friend is in no jeopardy. Give her credit for managing her own life. LW3 you know nothing about this person other than their physique.
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Is this an example of an "asking for a friend" article?
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Wow, are you ignorant about the ins and outs of most health insurance. it is entirely possible that this doctor is the patient's only option, especially if the patient resides in a rural, remote community. Health networks are often extremely narrow, with only one provider for certain specialities.
The point seems to be that a frank conversation is in order between doctor and patient. Especially as the prescription of the opioids to mange pain will likely be addicting, or to help these not become so, limited to the point where the patient must endure horrible pain.
The patient is resposnbile for advocating for himself, as long as he is able, and also designate (in writing) a health advocate to do so when/if he can not. The docotr must be committed to providing the best possible care.
Hopefully they can find common ground.
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@elise
Why are health networks narrow? It was a response to the dictates of oblamacare, which required all plans to cover all sorts of lifestyle "treatments". In order to be able to compete on price, virtually all plans drastically narrowed their networks.
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@red sox 9
I have had the same very limited network since well before Obamacare.
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@Diane And my in-network doctors all appeared to be the same before and after the ACA.
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Should a doc refuse to treat an alcoholic who refuses to change his/her ways? Yes.
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And what does that have to do with the topic?
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@PegnVA Do alcoholics deserve no medical treatment because you say so?
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@PegnVA I've very rarely turn down a patient and if I do, it's because something they said or did threatens me, my staff, or other patients. In the scenario you describe, the doctor really needs to clearly examine their feeling why they would turn down a patient. If it's anger, frustration, etc. on their own part they need to sit down, own that, and realize that doesn't help the patient. It's more about them and their feelings than the patient. I've had one instance in my career where a patient never followed what I suggested and whose health deteriorated. I sat here down and explained I was trying my best and maybe she would try another MD with different ideas. I would help her find a new MD. This was done calmly and warmly with the attitude of helping her. After the talk, this patient chose to stay with me. I learned sometimes, it's not about the patient being compliant with your suggestions but rather you -- the provider --ARE the medicine. She felt comfortable talking and visiting with me, despite not following what I suggested medically. It's possible her health might have even been worse without me being a placebo.
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I have had to deal with trigeminal neuralgia for seventeen years. It is a savage, intolerable pain not touched by opioids. At first, my excellent doc tried Tegretol with ever diminishing results. We switched to a lab-made THC that is normally used for cancer patients. Over night I went from 500mgs Tegretol with side effects to the liver, to 2.5mgs of THC, which masks the pain 99.99% 24/7. It is legal, prescribed, and insurance pays. There are no side effects other than a trivial, rarely experienced sense of being stoned which quickly clears up. I carry a copy of my script with my driver's license just in case. My use of THC is not ever apparent to anyone.
Some docs are timid, and rigidly follow established protocols. The truth is that they are not empathically serving suffering people who can benefit from cannabis when they try to prohibit, on the face of it a bad idea.
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@Wally Weet
what an incredible turnaround! I hope that soon we can get rid of the federal road blocks to treatment and research with cannabis. Nerve pain is horrendous - and has many INEFFECTIVE treatment approaches which often leave people incapacitated to some degree.
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Us physicians now use "non-adherence" instead of "non-compliance.". The change in terminology better reflects the patent's role in the relationship.
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My husbands had a doctor that was head cancer doctor and well know hospital. She told him to use Marijuana if it helps.
Its all changed now. They tried to convince us that marijuana was the bad drug and opioids were the good drugs. Now we know that the opposite is true.
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Your answer to the writer wondering about obligations to an employer when considering (considering is all the writer doing at this stage) a change in employment to attend graduate school, is completely off the mark. An employee has no obligation to disclose (let alone to predict the future) to anyone of future plans at this point in the process.
Informing the employer now might well end in termination of the employment.
If and when the writer decides to leave employment to attend graduate school (or for any reason, for that matter), the the usual 2-4 week notification to the employer is all that should be expected.
If the employer was planning any kind of disruption at the workplace that might effect the writer's position, how much notice do you think the employer would give the employee.
There is no ethical or moral reason to disclose planning ahead. This is a job, not a marriage.
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If the effects of cannabis had not been known to man until just the past 10 years, it would today be hailed as one of the most important medical discoveries of modern times.
The basic case against cannabis is the Calvinist belief that anything that might cause pleasure is sinful. Not exactly the most scientifically rigorous evidence for prohibition.
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@Glen Where did you get your information on Calvinist views? Because what you state is completely untrue. Pleasure does not equal sin.
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@Glen I'm of the opinion that a big part of the Reefer Madness thing is racism.
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"You might consider sticking around for a year, though, so that you could give them a good chunk of what they’d been hoping for. That you’re not obliged to do so doesn’t mean that it wouldn’t be a decent thing to do."
OK, but ask yourself first if you think that loyalty would be reciprocated.
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LW#2. Your friend's fertility window... Answer: Mind your own business.
LW #3. Skinny woman at the gym... Answer: Mind your own business.
LW #4. Graduate school. You answered truthfully at the interview. Your goals/aspirations have since changed. Nothing wrong with that. Do what's best for you. The company would drop you in a heartbeat if it was what's best for them. Maybe give them adequate notice to cushion the blow to them, if they've treated you well. But don't feel bad about doing what you think is best for you.
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It is important that this person continue to receive care for their very serious illness.
One solution to this problem is to bring anonymous public pressure upon this doctor to stop this inappropriate behavior.
This can be achieved by sending an anonymous letter to the local newspaper in the editorial section. The letter should essentially state that the patient has sought life saving medical care and the use of legal marijuana is not a reason to refuse that medical care. A similar and more powerful letter can also be sent to the state board of medical examiners requesting an inquiry into abusive behavior by the physician.
Even if the letters and inquiries do not have a direct result on the behavior of this one position they may affect the behaviors of the medical community as a whole.
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@Joe Would these letters be truly anonymous or would the the physician be easily able to identify the writer and then drop the writer as a patient ?
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@Joe
There is no "life saving medical care" when it comes to multiple myeloma. Death is inevitable in a relatively short period of time.
@carnap, this is completely incorrect. I have multiple myeloma (diagnosed in 2016), and though there is no cure, there is excellent treatment now. The myeloma board I participate in has patients who have lived with this disease for more than twenty years. My doctor told me at diagnosis that average life expectancy is ten years - and life expectancy data are by definition out of date.
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The first problem of cannabis clearly highlights the transition society is in with regards to medicine. With more information at their fingertips, the patient may in fact be better informed than the doctor. If they were to explain the why to the doctor, I am sure any reasonable doctor might be persuaded. In the event the patient chooses to blindly take the drug in the belief it helps them, he places the onus of burden of the doctor, rather unfairly, in which case the latter should drop them as a patient.
In the second case, I believe the friend should certainly remind her friend about her window of opportunity. What's the point in being good friends if you are as politically correct as a stranger passing you by? If she chooses to have a kid by someone she has had the confidence to live with for a long time, by jove it would be the right decision by the kid surely. I don't see a fabulous affair with a dreamboat going very far. And if this relationship does not work out, so what, she will have her dream child no?
In the third case, I am torn in my feelings. One has but one life to live. What if everyone the girl knows keeps avoiding addressing the elephant in the room? Perhaps deliberately, working out next to her and trying to strike up a conversation will lead to a better understanding of how one should proceed. She has survived as is for year, a bit more strategic patience may be in order :-)).
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@Meena
No, no, and no. Particularly the girl-in-the-gym invasion of privacy.
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@SUNDEVILPEG, this is going to depend on the vibe of the gym. Big city Sports Club vibe? No way should you start a random conversation. Everyone smiles and greets each other smaller gym? Totally legit to ask how someone learned a certain move, or if they recommend an audiobook or podcast for working out. It generally takes years of friendship or a crisis to reach the level of intimacy to effectively discuss eating disorders, though, so doubt it would be helpful the way the writer thinks it might.
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The first question is a familiar patient complaint. When I took over clinic, I found that the previous physician's controlled substance prescribing was too lax and could potentially attract negative attention. I started to taper or discontinue controlled substances as much as I could. Urine toxicology screens were regularly obtained.
Alternative treatments were offered.
I had patients complain about me refusing to treat them. That phrasing is wrong. Never did I refuse to offer treatment- just treatment with controlled substances!
My local standard of care for discharging patients is to give referrals and provide bridge care until they see the new doctor. We do not have to find the patient a new doctor.
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The first questioner omits a critical detail by not explaining why the doctor takes that position on cannabis -- is it medical or personal?
If not medical, it's unbelievable that when dealing with cancer any doctor would not want all possible options available for treatment.
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@Pat
did you not fully read the question? he clearly states his friend wants MEDICAL Marijuana to manage his extreme cancer pain.
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@Lu
You misunderstood both the initial question and my response. Go back and read more carefully to figure out where you went wrong.
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The situation with the Oncologist's refusal may be a matter of the Oncologist's insurance rather than his desire or lack thereof to treat the patient wanting to use marijuana. My PCP told me that his insurance company had become increasingly concerned with patients misusing prescribed medications or taking non-prescribed medications. He was "forced" to perform urine screenings of all patients receiving certain types of medications in order to keep his own insurance policy. I can see how this might identify patients who are misusing prescription medication (either taking something they have not been prescribed - i.e. opiates, or trafficking prescribed medications). I think the issue here might be that marijuana is still classified as a controlled substance at the Federal level, which probably ties the hands of many national insurers when it comes to policies that might run counter to FDA mandates for controlled substances.
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@Optirealist
I am not buying it. The Dr. may be responsible for meds he/she prescribes but not for other drugs.
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@Optirealist Why did this physician not check the Virginia Database of controlled prescriptions written for a specific patient? Pharmacists do it all the time. And your prescription drug plan administrator will call you in an instant when you get a script for 100 Oxycotin filled. This is not a med mal issue. Now he could say this to keep his patients in line. But if a physician fabricated something like that to say to me I would fire him and get a new physician. The DEA also looks very closely at prescribing patterns as several Virginia physicians have found out.
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@Optirealist Can you clarify what you mean? Do you mean the health insurance provider for the patient (because doctors may contract with multiple insurance companies) or do you mean the doctor's malpractice/ liability insurance?
My thought when reading the question would be for the patient to call his health insurance company to see what their policies are and perhaps to complain about the doctor. If the health insurance company has no issue with what the patients are using on their own dime, they might send a note to the doctor or - if fortunate -- cover another doctor for the patient. Insurance companies may have to adhere to certain discrimination policies in their business -- not just pre-existing condition policies -- but issues concerning doctors not treating particular conditions, certain people, etc.
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This likely has to do with clinic protocol more than the physician's preferences. Given all the new laws and regulations surrounding opiate prescriptions, many clinic's "controlled substance agreements" stipulate that testing positive for illicit drugs or alcohol/THC would violate the contract. This is mainly because combination of opiates with any other psychoactive substance increases risk of injury and overdose. Some clinics even go as far as ban the use of topical CBD! It's a reactionary move to all the attention being placed on opiate prescriptions, and the patients who truly need these medications are the ones that suffer the most.
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@ Vandelay
We long ago crossed the ethical line, in making the "caring professions" arms of local and federal law enforcement. This should disturb everyone. Just as every public school more and more resembles a minimum security prison, doctors' and therapists' offices have become sentinel nodes of a criminal surveillance state.
You would be ill-advised to, in a sincere quest for help, discuss certain problems with a cognitive behavioral therapist these days. Also, from my experience in the legal system I have seen situations where therapists are called to testify in tort lawsuits, and all but a vestige of confidentiality goes out out the window.
Now your doctor (for example, a woman's obstetrician), feels obliged to administer a statistically unreliable bedside drug abuse test to a woman, incident to delivering a child, and then become an arm of law enforcement when the test indicates suspicious substances. There is no due process. The outrageous abuses of this system have been documented, but it's OK because it's "for the children." It's also for the jackboot of government, to remind citizens who's boss.
First the doctors worked for patients. Then their clientele shifted, to the insurance companies. Now, they are the puppets of the DEA, FBI, CPS, and anyone else who wants to stick it to you. It's pointless to talk about "medical ethics" when the person you're dealing with is a government agent.
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I'm not sure the oncologist has to find the another physician to take over care. The rules are that he should cooperate by transferring a copy of the record to the new physician and to continue treating the patient during the transition period until he has established care with the new physician. Finding a new oncologist is still primarily the responsibility of the patient.
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@Sanjay In Virginia to fire a patient you must send a certified return receipt letter to the patient. They usually spell out plainly why you are being fired. He has 30 days from receipt to find a new physician.
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Medical businesses often have rules that patients cannot be on any drugs other than what is prescribed by the clinic and they will not prescribe cannabis as long as it’s illegal at the federal level. My husband has a serious nerve condition and ended up quitting the pain clinic —and the opioids— to use medical marijuana instead. I thought it was cruel to make him choose one or the other; it’s unconscionable to force a cancer patient to forego effective pain relief from cannabis in order to be addicted to opioids.
Please don’t recommend that the friend just start taking cannabis before you find out what the doctor’s policy is. My husband’s pain clinic tested patients and cut off their prescription medications if they tested positive for cannabis, even though it is legal in Massachusetts. Your friend does not want to be withdrawing from opioids while battling cancer.
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@Lisa. The patient might contact The International Myeloma Foundation. They are a wonderful non-profiit that aids Myeloma patients. They can give the patient options and assistance with finding (or keeping) an oncologist. As the caregiver of a long term MM patient, I have been given encouragement to have my husband use medical marijuana instead of opioids.
One other thought, If the patient is in a trial, the doctor is bound to the protocols, but then he should explain that.
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@Barbara
Multiple myeloma patients have a relatively short life-expectancy, not long-term. Death is inevitable.
@Barbara I understand you issue. MM is an extremely painful disease. And the patients are very competent/aware throughout. Watching a loved one suffer like that is terrible.
7