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Videos and medicine.

Videos and Medicine

With the presence of video recorders becoming nearly ubiquitous in U.S. homes and businesses, it is not surprising that video technology has begun to creep into the practice of medicine as well. Unlike most consumers, however, for whom videotapes and tapig are value neutral, some of the recent medical usage is ethically problematic, raising many traditional questions of bioethics: allocations of resources, the doctor/patient relationship, confidentiality, and informed consent.

For example, amidst all the controversy surrounding the issue of AIDS education, such as how graphically to depict the dangers, or what preventive measures--condoms and/or abstinence--to advocate, etc., two types of AIDS videotapes are somewhat troubling. The first involves the issue of marketing versus informing. A videocassette describing the use of Retrovir (AZT), the only anti-AIDS drug approved by the FDA, was sent unsolicited to thousands of physicians across the nation. One Chicago physician, Dr. Abigail Zuger, complained that "to launch Retrovir with the usual costly marketing glitz seems to me to be a particularly unfortunate gesture" (Washington Post, Health, November 3, 1987, 5). Although a representative of the pharmaceutical firm selling the drug, Burroughs Wellcome Co., defended the videocassette as a "state of the art educational tool," bioethicists might rightly ask if this is the best use of scarce resources.

The second type of educational tapes involves TV-screen counseling for AIDS. In a two-hour interactive video, counseling is provided for individuals who have taken the AIDS antibody test. The viewer sees a doctor on the screen who asks if the test was positive or negative. The viewer then touches the screen beside the words, positive or negative, and the TV physician responds with either "I am sure you are very interested in what this positive blood test means ...." or "I am sure you are very relieved!" The tape goes on to discuss various implications and strategies. This video appraoch is being researched by Dr. Samuel W. Perry III, a professor of clinical psychiatry at Cornell Medical Center. As an educational tool the tape may be quite useful. However, it puts even more distance between doctor and patient, eliminates the possibility of meaningful exchange, and reduces the individual patient to a generic category. In an area as urgent and sensitive as AIDS counseling, the results could be disastrous (American Health, September 1987, 62).

Another potential challenge to the doctor-patient relationship is the practice of videotaping physical examinations for the protection of the physician against lawsuits. A Dallas plastic surgeon, Bart Mazeika, has been recording "every last slice of the knife and every patient consultation" since November 1986. Dr. Mazeika established this audio-video system after he was sued eight times in six years, once successfully. He is now marketing these video systems to other physicians.

The idea has both its ardent advocates and vehement opponents, not necessarily from the most predictable sources. Among those in favor are some patients' rights groups, including the People's Medical Society in Emmaus, Pennsylania. Says its president, Charles Inlander, "It's a terrific idea. It would be like the black box in an airplane; we'd see where the mistakes happen" (Wall Street Journal, November 25, 1987, 17).

Other patients, however, will undoubtedly find the videotaping an invasion of privacy, a threat to confidentiality, or a further erosion of the once more personal doctor/patient relationship.

From the physician's perspective, there are those who believe such tapes would provide "foolproof" evidence for use in the courtroom to defend doctors' work and decisions. Others think that is unrealistic, that there is no "ultimate truth" to present to a jury, only different perspectives on the same incident.

Recently, however, one New York hospital sought specific permission to videotape the physical exam of a patient to be used in its defense. The patient was suing the hospital and several physicians for negligence, alleging that he was allowed to fall out of bed several times while hospitalized, causing him to be semi-comatose. The hospital requested a physical exam of the patient.

If the attorney for the patient were the only one present and a disagreement arose over the way the examination was handled, the attorney might be put in a position of conflict of interest, having to testify about the conduct of the examining physician. The court ruled that the videotaping would not inhibit the examining physician from performing any legitimate test on the patient (American Medical News, October 9, 1987, 55).

Lastly, there is the issue of video surveillance. In several recent cases, hidden video cameras were used to document parental child abuse in the hospital. According to the British Medical Journal, on two separate occasions mothers of infants brought their children to the hospitals, complaining of cyanotic episodes (skin discoloration due to lack of oxygen to the blood). After repeated testing and observation no cause could be determined. Because all of the episodes occurred when only the mothers were present, medical, nursing, and social service staff had strong suspicions that the women were smothering their children. Unfortunately, the staff felt the mothers would likely deny it if directly confronted or the hospital would be in an awkward position if untrue. In order to validate or reject the "smothering" hypothesis, they decided that covert video surveillance was the only practical solution.

In both cases the camera was able to record the mother placing a soft garment over the face of the infant and when confronted with the video record, both mothers admitted they had been inducing the cyanotic episodes. A similar method was used at Yale-New Haven Hospital in Connecticut to confirm suspicions that the mother of an eighteen-month-old infant was inducing the child's recurrent diarrhea by giving the child laxatives (Pediatrics, 80:2 [1987], 220-24; American Association of Pediatrics News, September 1987, 6).

Although in all three cases cited the outcomes were fairly positive, there are certain ethical questions to be entertained before the practice of covert video surveillance is widely adopted. Clearly, some would argue that the mothers ought to have been informed of the videotaping or at least confronted with the suspicions. Some opponents of the practice "have called it everything from unconstitutional to immortal to unethical." They maintain that "unlike other types of private institutions that have the legal right to monitor their premises without regard to privacy, a hospital must recognize its responsibility to preserve the privacy of patients and, in the case of children, of the parents as well."

Proponents, however, insist that the patients (in these cases, children) would have consented to the video-taping in order to find the cause of their suffering and that parental rights cannot be insisted upon by a parent who has abused these rights.

Thus the video revolution has brought to the field of medicine an array of technological advancements from product information to physician counseling to malpractice evidence to child abuse surveillance. Yet each video advance has multiplied the work of medical ethicists wrestling with the knotty questions of right and wrong.
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Author:Stack, Margaret Fletcher
Publication:The Hastings Center Report
Date:Feb 1, 1988
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