Many physicians consider sleep medicine a fascinating field because of the tremendous advances in research made in the past decades. These discoveries have been significant not only for their basic scientific value and clinical applications but also for the light they shed on profound philosophical questions such as the definition and meaning of consciousness. As true as these statements are, it could just as truthfully be said that sleep medicine is fascinating because of what is yet to be learned and the scientific studies yet to be undertaken. The current nosology of sleep disorders, for example, is symptom driven, meaning that dysfunctions are classified by patients’ subjectively reported symptoms rather than by anatomical reference or pathophysiology. Because of this subjective component, perceptions of sleep disorders can vary greatly by geographical area, religious and cultural background, and age. Hence, setting guidelines for ethical standards of care in sleep medicine is a complex task.
Three subcategories of ethics are often distinguished: (1) normative ethics—how should we behave? (2) metaethics—when ethical principles conflict, how do we decide which takes precedence? (3) applied ethics—what conduct is proper for certain groups of people or under certain circumstances? Sleep medicine raises questions in all three areas. Beyond the normative ethics of everyday clinical decision making, physicians also confront conflicting ethical standards for practicing evidence-based sleep medicine, and they ponder how to apply clinical ethics to the new discoveries in neuroscience that affect how we think about consciousness and how sleep medicine is practiced.
This issue of Virtual Mentor opens with four case studies analyzed by veteran clinicians who specialize in sleep medicine. Eric Frenette explores the tension between paternalism and respect for patient autonomy in a physician’s response to a patient who wants to use a sleep disorder treatment drug for cognitive enhancement. Clete Kushida discusses a physician’s professional obligation to provide testimony in court for a patient who committed a crime while sleepwalking. In a third case, Dennis Auckley examines a difficult patient-physician relationship—something many of us encounter in our daily practice. The difficulty is further complicated when the patient’s report of insomnia symptoms cannot be objectively measured, and clinical progress is not easy to assess. Finally, Shannon Sullivan weighs the ethical principles of beneficence, nonmaleficence, and respect for autonomy in the case of a patient with REM behavior disorder that might be a precursor to a neurodegenerative disease. Should the physician inform the patient of the possible future illness?
Delays between scientific advances in sleep medicine and their acceptance by the general medical community and the public and influence on policy occasionally manifest as culture clashes and ethical dilemmas in the clinic and beyond—situations we examine in the remainder of the issue.
A problem that underlies many others is the disparity between what is currently known about sleep disorders and what is taught in medical schools. Although many physicians are interested in sleep disorders, they are not trained in methods of detection and treatment and are unable to integrate sleep medicine into their practices. Christopher Miller suggests how this gap might be closed in his medical education article. The policy forum by Kingman Strohl asserts that society has a duty to protect would-be victims of sleepy drivers. He outlines the responsibilities of the driver, physician, and licensing agencies in recognizing and managing disorders and medications that impair driving. One of the most common of those disorders is obstructive sleep apnea, the cause and diagnosis of which Nitun Verma describes in the clinical pearl.
Rob Meadows sheds light on the “rights and duties” of the sleeper in his medicine-and-society essay and introduces the idea of the medicalization of sleep disorders. In the journal discussion, Christian Krautkramer traces the first expression of that trend—looking at how the media have contributed to establishing lack of sleep as a medical disorder. The medicalization of sleep disorders has two distinct forms—labeling deviation from normal sleep as a disease and enhancing what is considered “normal” wakefulness through medical interventions. William Cheshire Jr.’s op-ed piece—“The Pharmacologically Enhanced Physician”—takes the second expression of medicalization to one of its obvious conclusions.
In another perspective on how society views sleep, Steven Kroll-Smith reminds us that, while napping is becoming an acceptable workplace activity, there was a time when sleep was regarded as a necessary evil, and those who needed less of it were more highly valued as employees. Michael Bornemann, the world’s first sleep forensics expert, explains the proper role of ethical directives in guiding criminal case expert medical testimony, which he views primarily as an educational—not an adversarial—role.
Our cultural ideas about sleep and its relationship to our physiological needs, health, and safety are changing rapidly. Those who practice in the field of sleep medicine must establish standards of patient care on the basis of sparse evidence and determine how best to address sleep disorders at the public health and policy levels. I hope this issue of Virtual Mentor awakens some of you to the new and exciting field of sleep medicine, a field that is more than just “interesting,” and an important aspect of our overall health that is often overlooked.
Meredith Broderick, MD
Assistant Professor,
Department of Neurology
University Hospitals of Cleveland Case Medical Center
The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.
Copyright 2008 American Medical Association. All rights reserved.
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