Ethics: The Philosophical Science of Morality


I was pleased when I was asked to provide a blog on ethics, as this topic has personally intrigued me throughout my career. “Ethics” per se, is the division of philosophy that deals with issues that pertain to morality, which has such a tremendous significance in everything we do as doctors: caring for patients, conducting research, and teaching trainees. Ethical or moral behavior of course is a very important topic for any profession, but is perhaps most discussed in the field of medicine.

Ethics, the philosophical science of morality, has been a central interest to thinkers, philosophers, and doctors since the ancient Greek times. Socrates, Aristotle, Aristippus, Epictetus, and later Jeremy Bentham, John Stuart Mill, and also Immanuel Kant all addressed ethics. As much as we can enjoy reading the works of these great thinkers, in our everyday life and in medicine, it is probably pragmatic ethics (e.g. John Dewey) or postmodern ethics (e.g. David Couzens Hoy) that would be most applicable. In his writings, Hoy particularly addressed the powerless, which of course patients belong to, in this sense.

Ethics and conflicts of interest (COI) have long been associated with medicine. The general view is perhaps one where the good doctor navigates COIs well and resolves conflicts without compromising integrity and morals. Yet, COIs and morality aren’t entirely synonymous. Morality should deal with behavior and a code of ethics that has nothing to do with enforceable laws. In other words you could be a perfectly law-abiding citizen and still be immoral. Morality, according to its scientific definition, addresses behavior that is within legal limits.

In our practice, in our teaching activities, and in our research, we do so many things where moral behavior and ethics come into play. In fact there probably is very little that we do where ethics are not applicable! A colleague once said that everything we do every day is infiltrated by conflict of interest (COI) and that you cannot ever eliminate COIs. Of course we hear plenty about COIs such as undue industry influence in continuing medical education (CME) programs, and in research studies, as well as practitioners receiving “freebies” and other favors (creating the urge to reciprocate, perhaps in their prescribing behaviors). However, those are only a small fraction of COIs in medical profession. Most COIs we are not even aware of and most don’t necessarily pose a moral dilemma.

When you take out milk from the refrigerator, there are competing interests (i.e. whether you should satisfy your urge to drink now or wait until later, when you may need it more; whether somebody else in your household might need it more; if this will trigger a need to go to the grocery store today, which you really don’t want to do, as opposed to tomorrow when you were going anyway, etc.).

Likewise, in academic medicine, it is critical that while working with students and residents (and making sure they get the education they need), at the same time also focusing on research achievements (which lead to promotion), we do not compromise the quality of medical care provided to our patients.

Some instances of poor conduct in the recent past have triggered a backlash prompting new legislation. Once, thus there is state legislation or an apparatus that enforces moral order, the related ethics issue ceases to exist. For example, should animal experimentation become illegal in a society, it would no longer pose an ethical dilemma (it will become a legal issue).

On the other hand, as remarked by another colleague, Dr. Joe Jankovic, one cannot achieve 100% ethical behavior through enforcing rules and laws. No matter how many rules and laws there are, there always will be loopholes, and if willing, individuals who can go around them. So what can we do?

1. Transparency. Well, since we already established COIs cannot be eliminated, our only option is to find a way to live with them and manage them the best way we can. How do we do that? The very first critical ingredient is transparency. Appropriate access to vital information bz concerned parties is half the battle. Also, when I speak of transparency, I mean true actual transparency, access to pertinent data in a way that makes sense to an average patient.

Of course we cannot open up our research folders and patient medical charts to the public. HIPAA and other regulations as well as research contracts restrict what can be accessed. However, “de-identified” data should be made accessible to all concerned parties. Transparency would enable patients to determine how many patients their doctor sees, what their office practices are, what research and teaching obligations she or he may have, including their financial relationships.

Disclosure of financial relationships is mandatory now for all CME work. However, patients may also want to know whether their physician, who recommends a certain treatment, is actually on the payroll for the company that stands to financially benefit if more patients are receiving that treatment. Similarly, a simple, easy to understand list of all professional activities and relationships reflecting potential COIs (financial or otherwise) of each health care provider should be prepared and made available to patients upon request.

Such disclosure would likely preserve, or in some cases, restore the trust between patients and their health care providers, eliminating most concerns about COIs and the potential for immoral conduct that could affect patient care. Of course disclosure in itself may not guarantee that everyone will all of a sudden become ethical, but disclosure of these data would help advise patients to make choices about their health care providers.

2. Healthcare metrics. Another important way to keep people honest is by tracking their performance. If a physician is navigating multiple, complex COIs, yet is providing highest quality healthcare to his/her patients, then we may be less concerned about COIs because ultimately what really matters is their level of care and professionalism. Of course we would need to have accurate and relevant healthcare metrics in place that are also practical and feasible. There is an entire branch of science dedicated to this, but patient advocacy groups definitely could push for and help support such efforts.

3. Selection. No matter what measures we take or regulations we put in place, our best guarantee that future medical professionals will practice medicine in an ethical manner is to select candidates of the highest moral caliber. Also, as medical educators we have to place a greater emphasis on medical ethics in the training process.

Medicine and morality are intertwined in so many ways. The Hippocratic Oath illustrates this relationship. In modern healthcare with so many potential COIs, no matter what regulation and measures we undertake to ensure moral conduct, it probably still is the rigorous process of selection and training that most helps to ensure that our healthcare providers are truly and genuinely driven entirely by their internal sense of right and wrong, as opposed to all the rules and regulations. Ethics in research and health care will remain an intriguing and important topic for generations to come, and the principles will remain the same as when the Hippocratic Oath was written in Ionic Greek in the late 5th Century BCE: “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.”

The problem of Republicans run into when it comes to God, religion, and the public eye


I found this article particularly helpful and relevant. It talks about Perry and his prominent denial of landmark laws separating state and church, in the context of his recent joining the race for presidency, but I think the points made in the article are actually farther reaching than anyone's presidential bid.

I think the main point, well and often (but perhaps not visibly enough) made and discussed before by others, is about the contrast between the hypocritical, double-standard embracing "religious" evangelical right-wing America's faith (God this, God that, church going, etc) and what they actually fight for (deprive the poor, basically).

Jesus taught of tolerance, not intolerance. What seems to emerge from evangelical subtext supported by the religious right aligns much better with intolerance.

I know religious people, who believe in God, and feel that whatever humans have used the name of God for (and abused) is despicable. To love God, you don't need church, political affiliation, none of that. All you need is a personal relationship with God and whatever you believe in. That is your business. What you believe in does not make you better or worse than your fellow human beings who happen to believe in something else, or happen not to believe in something supernormal at all. Most importantly, you are not supposed to announce and show off your religion to score political points with a certain group of phony and hypocritical individuals.

Android, Motorola, and the Patent Wars


Ever since the arrival of the Motorola Droid, hailed as the first serious Android contender to the iPhone, changing the smartphone (or rather app phone) landscape forever (and arguably not to the advantage of Apple), I have been a Motorola Droid user. I had 2 units of the original Droid, then at my 3rd Droid 2 Global.

Overall, I should say I am generally happy with both the platform and the hardware. There are of course glitches and frustrations, which I think is unavoidable to some extent with such gizmos (at least knowing me they are), but in general there are no major reasons for me to move away from this combo that I have relied on for almost 2 years.

Why, some of you might ask, do I all of a sudden seem like brand loyal diehard, when I have made the point so many times before that it is always the actual facts, functions, and needs that determine for me what I buy, no matter who makes it. My motto was "zero brand loyalty". Also, you might ask, why on earth would anyone stick with Motorola, when fancier and flashier Android competitors are abound with better and brighter alternatives? Take, for example, Samsung. Don't they have the "super AMOLED", a screen that is praised as ~30% brighter than any other company's best display option and the only touchscreen technology choice today, which can produce a visible interface on a smartphone in direct sunlight? Or take HTC! There does not seem to be a month go by when they don't come out with something jaw dropping. Specs are following some dizzying exponential accelerating hardware curve, set out by HTC for themselves (and for the rest of the market to follow). It is incredible what they can put together, technologically, in a phone. Google itself is turning to these (Samsung, HTC) for manufacturing its own "Google" phones, the Nexus series, not Motorola.

If you look at the article, however, I think you might get a sense as to (in part) why this newly embraced "brand loyalty" towards Motorola. I mean I do like them in general: I had several Motorola phones way before the smartphone era, and I do believe they do an outstanding, truly highest quality job when it comes to manufacturing. Reliable, business grade, sturdy, dependable are just some words that occur to me thinking of their manufacturing.

However, that is irrelevant here. Manufacturing is expected to be pretty perfect today anyway, technological perfection is a minimum from any of the main Android manufacturers. Patent portfolios aren't equally perfect across the board, though. As pretty much every one of the main Android device makers are tangled in a patent lawsuit (or usually multiple suits) with Apple, who has launched on an ultimate mission to exterminate all its competitors with patent-based weaponry; actually the strength of patent portfolios will weigh in tremendously and determine how exactly the apps phone world will look the day after tomorrow.

At a minimum, Motorola (and maybe only Motorola) can fend for itself, when it comes to legal challenges in the patent arena. In that regard, if you look at all the various Android makers, Motorola stands out by a mile. Pundits have been evaluating Apple's patent assault strategy. HTC was obvious. Small patent portfolio, easy target. Samsung was another must-have target, especially considering the danger it poses with its super AMOLED display and the resulting phenomenal performance on the market. Certainly these fights are showing results, just look at Vodafone's decision to suspend sales of the Samsung Galaxy tab in Europe. It was generally assumed that Apple will not go after Google itself any time soon, as that "clash of the titans" may be a bigger piece than what even Apple can swallow and, albeit that conflict clearly building up, has the dubious prospect of total annihilation of one or the other giant.

Instead, switching gears from small targets to larger beasts, perhaps testing the waters for the ultimate clash, now it seems Apple decided to go after Motorola (Xoom, in Europe), which will definitely be a major test of my assumption (in which I generally concur with the writer of the linked article that Motorola is patent-invincible). Motorola is most certainly a formidable opponent in any patent fight when it comes to phones. Just as explained in the linked article, it can well be the last bastion, even after Google (!), in the Android wars.

In any case, I remain assured, for now anyway, that nobody will announce tomorrow that the sales of Motorola Android based phones are halted until further court order. As to HTC, Samsung, etc devices, well, I am not so sure...

Another Hungarian Luncheon to Consider

August 14, 2010 Luncheon Will be delicious and we'll be waiting for you.

Come Join Us on the Second Sunday, August 14th from 2:00 – 4:00 pm for a delicious Hungarian Luncheon

We meet at the Kensington Baptist Church’s Fellowship room.
10100 Connecticut Avenue (cross street is Dresden)
Kensington, MD 20895-3897
(301) 942-4400

Cost of Luncheon:
Seniors and children $10.00
Adults $15.00

Buy some to take home – Bring Carry Out containers
Call SUSIE Lengyel to confirm 571 594 1961 or susielengyel
Best wishes and see you there,

Cinnamon El-Mulla

AT&T: Confusion at All Levels About LTE-4G


Oh Boy. The "4G" arena has become a complete zoo. Not only do we have a problem on the consumer side to navigate this mess, but things have gotten out of hands so much, that sometimes it is just too complicated for the employees of wireless providers as well. Right, Ashley (at the AT&T shop in Arundel Mills Mall)?

Carriers have been often criticized for frivolous use of the term 4G, which is meant to loosely indicate "fourth generation" in wireless data protocols, obviously to describe that is better (faster, more reliable, etc) than the data protocols grouped under the also very loose category of "3G". You can find the ITU requirements for 4G as well as other useful technical data on 4G here:

According to this, this should not be that complicated... Only 2 protocols among today's available technologies measure up to the 4G requirement, LTE and WiMAX. All other wannabes, HSPA+, HSPDA, etc, offer amazing rates and other wonderful things under laboratory/artificial test conditions, but in real life they stay far below 4G, i.e. LTE or WiMAX, in performance (see the "notes" column in the table under the above referenced Wikipedia page's "Comparison of Mobile Internet Access methods" table for "real life" speeds). In other words, all the marketing for anything but LTE or WiMAX as "4G" is flawed and purposefully misleading.

I did not intend to address that flat-out lying or even the comparison between the 2 currently available true 4G protocols, in which Verizon's LTE humiliated Sprint's WiMAX (see, even though those points are relevant in their own right.

Here I just wanted to share a highly interesting, even shocking, experience I had at the above AT&T store, to underlie the 4G confusion at even customer service level. I walked in teh Arundel Mill Mall AT&T shop, with my GF, who has AT&T cellular service, but without a high-speed data plan, and wanted to explore her data options with her preference of doing business with AT&T (as opposed to opening a 4G/LTE account with Verizon, that I have). She wished to keep all her mobile needs serviced by the same provider, as opposed to spreading different wireless subscription across multiple carriers. I went with her, even though I personally no longer have any relationship with AT&T. Considering the hype and multiple news announcements on AT&T's new plan to roll out their 4G/LTE on some markets by the summer (starting with Chicago) and then 15 markets by the end of the year (|wireless), we were interested in learning more about this.

I have Verizon LTE with a USB data card and I let my GF test it on Amtrak between DC & Balto. It tested very well (good speeds, stable connection). That is the reason I argued that she should get Verizon LTE now, which is available and working well today (at least where she would be mostly using it), as opposed to AT&T, which may have it available by December in our market and we don't know how well it will work (I had a AT&T 3G data card a couple of years ago and the service really sucked with extremely low speed and unreliable connection, for why I switched to Verizon LTE when it became available, and I have been very pleased so far with that, although my experience is still somewhat limited).

In any case, it was logical to check with AT&T, regarding their LTE; i.e., when will it be available in the DC-Balto market, what pricing and data usage numbers are we looking at, etc. And here comes the shocker. Ashley at AT&T flat out declared that LTE was ALREADY available in our market and she offered LTE phones! I was surprised. I was pretty certain of my news intelligence about AT&T's announcement about their plans rolling out LTE starting in the summer (meaning it is not available ANYWHERE at this moment) so I asked her to confirm.

She confirmed with absolute authority and attitude. She repeated many times that LTE is only available in select markets, but that it WAS already available, today. Her confidence was gigantic, hard to process for us. She even appeared a bit annoyed at my double checking giving me the meta-communication (between the lines) of "did you not hear me, what's wrong with you?" kind of message. I was baffled. I have not seen anything like this before. She was obviously dead wrong and was sticking with it. In her describing the total BS, she kept falling back on using 4G term, as opposed to LTE, which kind of hinted that she was not as dead set on her claim about LTE, but when I specifically addressed that point, although she did declare that 4G and LTE were the "same".

I agreed (that LTE was 4G), but reminded her that the other protocols, currently available on AT&T and marketed as "4G", are not strictly speaking meeting the requirements for "4G" and pointed out that what she probably meant was not LTE, but likely HSDPA or HSUPA, which AT&T "generously" calls 4G, when it is not (see above), and that LTE, to my knowledge, was NOT yet available on the AT&T network. She grew more and more annoyed by my stubbornness. At this time I pointed to one of their USB data devices hanging on the wall right next to us and the box announced in orange color that it was "LTE ready". I asked why it would use such announcement, being "ready", if LTE was already available, as she claimed. The way it was announced as "ready" to me suggests that it will be compatible with LTE when such technology will be available. Well, she did not have a very good explanation to that, other than clearly communicating with even more attitude and body language the same message, i.e. that she already told me many times LTE WAS available on AT&T now, period.

We walked out, but this highly unusual and unprofessional behavior actually bothered me. How can you be so arrogant, as a paid employee who's job is actually to be informed correctly and inform customers correctly, that not only you are dead wrong, you stick to it, with an arrogant attitude, despite all sorts of information that help pointing it out to you in clear terms that you were off on that one. I looked up a random news link from my phone ( and went back to show it to her. This happened to be a PC World article, but the news sites are all over this (that is how I heard about it in the first place). She looked at the article, scrolled up to the address bar to look where it was from and then announced that this was an unreliable source! She STILL insisted that LTE was actually available, as she told us from the beginning, and that the news on this story I was showing her was entirely incorrect. Not only that, but she "informed" me that she participates extensive, daily company trainings, where she gets information that is up-to-date, highly accurate and superior to what I am claiming, so that I am just making a fool of myself with all this effort trying to convince her that she was wrong on LTE. Wow. I walked out of the shop again and was baffled even more.

At this point this issue was clearly not relevant to my GF's decision regarding what data service to consider, it became my personal quest (which it kind of still is, considering I am writing all this). I pulled the AT&T official news announcement about LTE on my phone (see the main link for this posting or go to here). I went back to the shop, just before they closed for the day, with the above page on my phone, and showed it to her. This time, she read it again, scrolled all the way to the top to look at the source again, where she saw it was the official AT&T announcement. It spells out the markets where LTE is going to be rolled out later this year.

Well, she could no longer stand by her BS story at that time. She was speechless for a couple of seconds. She still displayed the same overarching confidence, "I know everything and I am telling you" attitude, and moderate level of annoyance. She acknowledged the total defeat by saying "OK then". No apology or any acknowledging her behavior up to this point (including the fact she was dead wrong and was standing by it with arrogance and attitude). There were no other customers in the store so she could not shrug me off with the excuse that she needed to attend to something else. There were another 2 colleagues next to her, who overheard the entire conversation, one of them seemed to be a supervisor or something like that. They were all looking elsewhere, conveniently avoiding eye contact or any mention of the fact they not only gave completely incorrect information, but they insisted despite many obvious signs suggesting what they claimed was wrong (i.e. the claim that LTE was already available on AT&T's network).

My GF repeatedly told me I should drop the whole thing and I can totally see the rationale of that approach. She told me (in Ashley's defense) that she (Ashley) probably truly believed in what she was saying (as opposed to decidedly and knowingly trying to mislead). I understand all that. I do believe she didn't know better. But that is not the issue. The issue is the fact she was wrong (which is not acceptable for somebody in her position where she is paid to have at least the basic facts relevant to her company's services). Of course it did not help matters that on top of that she handled herself rather strangely about that, which might just have been a personality issue. Or lack of training on the "customer is always right even when they are wrong" principle. In this case I was right, she was wrong, yet she absolutely handled me as if it was the other way around...

This may have been an isolated incidence (I hope so) with little relevance to the "big picture". However, I have experienced situations before when customer service agents are exceedingly uninformed or misinformed about their own company's future plans and technology news. I had somewhat similar experiences with several other phone companies, where the customer service agent, clearly not using the advanced service options or devices offered by the company she/he works for, but also is suffering from sub-zero technology news intelligence relevant to the company she/he should be informed about. I think it would be strongly recommended that scheduled employee training included a technology news component as well, so that they can advise customers who get their information from the news. The experience yesterday felt as if I was teaching the company employees about their own company, but my students were highly ungrateful for the free education.