Ethical discussions in medicine often take place at the fragile margins of life and death. Hospital ethics committees predominantly deal with end-of-life cases; bioethicists ponder when life begins vis-à-vis the stem cell or cloning debates. Certainly, the temporality of the human condition has fascinated men and women for thousands of years. Yet, as we focus our attention on examples such as the Terri Schiavo case, I cannot help but feel we are neglecting the more mundane medical conditions that affect a much broader group of individuals. This quest to recognize the ethical significance of everyday illness on overall health led me to devote November's Virtual Mentor to endocrinology, a medical subspecialty that frequently manages chronic illnesses and whose expertise resides in controlling that which often seems to control us—our hormones. But this issue of VM isn’t just for a relatively small group of subspecialists—we all know someone who struggles with diabetes or obesity. Indeed, this is an issue we can all relate to.
Through your reading of this month’s VM, I hope you will come to the same surprising conclusion as I: the everyday ethical dilemmas faced by endocrinologists and of concern to most of us are, in truth, anything but mundane. They range from the theoretical (whether or not obesity is a “disease”) to the practical (a patient’s nonadherence to a diabetes management plan). As the authors lead us to discover, these questions and concerns should not be categorized so simply. The "diseasification" of obesity (and one could replace obesity with other endocrine conditions like menopause or premenstrual dysphoric disorder) has substantial practical implications for Medicare, insurance, and prescription drug coverage decisions. On the flip side, there remains a significant theoretical semantic divide between patient "compliance" and patient "adherence," the implications thereof delineating the obligations of the physician in the patient-physician relationship.
Endocrinologists also find themselves on the front lines of certain "sexier" issues that have found play in the bioethics literature of late (and, for that matter, on episodes of "Oprah"). In clinical case 3, the authors contemplate a case of intersexuality in a newborn about which no clear consensus exists regarding assignment of sex. This case illustrates the important differences between sex and gender, theoretical questions about gender identity and patient autonomy, and pragmatic concerns regarding the timing and necessity of surgical interventions. The op-ed discusses a "hot topic" resonating in the medical literature, on ESPN, and on Capitol Hill: use of performance-enhancing hormones by athletes. Do physicians have specific obligations beyond those ascribed by law? Finally, clinical case 2 provides enough fodder for debate that The New York Times Magazine scooped us in mid-October. Thus, I will not describe it in detail here, but will say only that, whether you are of short stature like me, or fairly tall like most US Presidents, you will find it of interest.
I hope that this month’s VM provides you with insight into the complex ethical quandaries facing endocrinologists today. The field of endocrinology encompasses such a broad array of conditions that it was impossible to address them all here; notably absent are problems confronting reproductive endocrinologists, in part because the ethics of assisted reproductive technologies have been the topic of debate in prior issues of VM. It strikes me that while endocrinology stands as a subspecialty in medicine, its practitioners treat a large and diverse group of patients, many with well-known "general" conditions. As this month’s authors indicate, endocrinologists often serve their patients as part of a team of health care professionals; I would argue that they are uniquely well-suited and well-trained to do so, considering their vast expertise in the management of chronic illnesses. Moreover, these articles demonstrate both that chronic conditions are by no means static and often not routine (for the patients or the physicians). Clinical ethicists know well that some of the most interesting ethical issues arise in daily practice, not just in what we see as acute decision points at the fringes of life; but it is difficult to gain first-hand insight into these instances which rarely warrant a consult. I am grateful to the authors for providing valuable insight into the difficult ethical matters they encounter across their patients’ lifespans, which are pertinent to more than endocrinologists, and are anything but ordinary.