In a recent Center for Practical Bioethics study published in the Journal of Pain Medicine (September, 2008) it was discovered that in recent years, doctors are rarely criminally prosecuted or sanctioned in connection with the prescribing of narcotic painkillers. The study found that between the years of 1998 and 2006, only 725 doctors, or about 0.1% of practicing physicians, have been prosecuted or sanctioned by state medical boards for charges arising from illegally or improperly prescribing narcotics. The primary reason behind such low levels of prosecution was fear of the "chilling effect", as past studies have suggested that doctors, fearful of drawing legal scrutiny, may not adequately treat patients.
Additionally, the issue has become amplified because of several highly publicized prosecutions of doctors accused of selling narcotics like OxyContin, Percocet and Vicodin, or recklessly prescribing them. Some news accounts about those cases have also contended that they were part of a broader, national crackdown against doctors who treat pain patients.
My take on this whole issue is this: with the huge black market out there for pain prescription medication, wouldn't it make logical sense to issue tougher crackdowns on medical professionals with the ability to prescribe such drugs? Chilling effect or not, the HUGE economic (ahem) incentives out there for doctors to illegally prescribe narcostics would lead one to believe that the number of false prescriptions have and will steadily increase to follow black market demand. After all, medical degree or not, many doctors are still human, and the enticement of the all mighty dollar is very difficult for many people to ignore. Therefore, wouldn't the practical solution be to crack down HARDER on the possibility of such situations, rather than to loosen up prosecution in such events?
I understand the chilling effect... we don't want doctors to prescribe less narcotics to those who legitimately need them for health reasons due to fear of liability. However, wouldn't the oaths taken by such doctors (Hypocrates anyone?) to serve the best interests of their patients, be sufficient to counteract the such an effect? Because in the end, if the physician was doing the best they can in the treatment and prescription of medication for their patients, the fear of liability shouldn't be much of a factor at all, right?
Source: http://www.nytimes.com/2008/09/20/us/20pain.html?scp=3&sq=bioethics&st=nyt
Friday, October 31, 2008
Thursday, October 30, 2008
Million Dollar Baby
The Academy Award winning movie "Million Dollar Baby" is one of my favorite movies. Not only because it has an amazing cast (Hilary Swank, Clint Eastwood) but also because the plot had my friends and I enthralled in debate for hours after. Now that the topic of the "right to die" has been brought up again in class, I'd like to revisit it in connection to the issues raised in the film.
In most cases relating to assisted suicide and the right to die, the focus is on patient autonomy. The main factor in such situations is the wishes of the patient, and in most cases, their coherent requests to accept, refuse or withdraw from treatment must be carried out by the healthcare provider. However, should the emphasis be more heavily placed on the patient's wishes, when they are in such a suicidal state, or should the focus be shifted towards what may be done to change the patient's mind? Medical centers seem to be hesitant in applying such methods, perhaps afraid of being coersive or interfering with the patient's autonomy, but in the end, wouldn't the result (of saving a life) justify the means?
In a survey conducted of those who attempted suicide by jumping off the Golden Gate bridge and survived, almost uniformly, those interviewed have regretted their decision to jump. Ken Baldwin, a 28-year-old man who survived the suicide attempt, recalls, “I instantly realized that everything in my life that I’d thought was unfixable was totally fixable—except for having just jumped.” (http://www.newyorker.com/archive/2003/10/13/031013fa_fact) Therefore, I pose the question of whether healthcare facilities and physicians should take stronger measures, even if it means interfering in a manner with the patient's wishes, to discuss, counsel, and take EVERY measure possible (including physical ones) to force the patient "off the ledge" in a manner of speaking? Are healthcare centers today doing enough towards these measures, or are they too worried about their own risk of liability in violating a patient's constitutional rights?
In the end of Millionaire Dollar Baby (SPOILER ALERT), Frankie (Eastwood) ends up helping a paralyzed Maggie (Swank) commit suicide as she desired to do. I walked out of the movie wondering (and still do today), whether one more day, one more counseling session, one more attempt to persuade Maggie to change her mind, would have made all the difference.
In most cases relating to assisted suicide and the right to die, the focus is on patient autonomy. The main factor in such situations is the wishes of the patient, and in most cases, their coherent requests to accept, refuse or withdraw from treatment must be carried out by the healthcare provider. However, should the emphasis be more heavily placed on the patient's wishes, when they are in such a suicidal state, or should the focus be shifted towards what may be done to change the patient's mind? Medical centers seem to be hesitant in applying such methods, perhaps afraid of being coersive or interfering with the patient's autonomy, but in the end, wouldn't the result (of saving a life) justify the means?
In a survey conducted of those who attempted suicide by jumping off the Golden Gate bridge and survived, almost uniformly, those interviewed have regretted their decision to jump. Ken Baldwin, a 28-year-old man who survived the suicide attempt, recalls, “I instantly realized that everything in my life that I’d thought was unfixable was totally fixable—except for having just jumped.” (http://www.newyorker.com/archive/2003/10/13/031013fa_fact) Therefore, I pose the question of whether healthcare facilities and physicians should take stronger measures, even if it means interfering in a manner with the patient's wishes, to discuss, counsel, and take EVERY measure possible (including physical ones) to force the patient "off the ledge" in a manner of speaking? Are healthcare centers today doing enough towards these measures, or are they too worried about their own risk of liability in violating a patient's constitutional rights?
In the end of Millionaire Dollar Baby (SPOILER ALERT), Frankie (Eastwood) ends up helping a paralyzed Maggie (Swank) commit suicide as she desired to do. I walked out of the movie wondering (and still do today), whether one more day, one more counseling session, one more attempt to persuade Maggie to change her mind, would have made all the difference.
The Possibilities of Memory Modification
What was once confined to the realm of science fiction may just be one step closer to becoming reality. In the movie Eternal Sunshine of the Spotless Mind, the characters seek to recover from a painful break up by embarking on an experiment to erase certain memories. Most recently, scientists have discovered a way to selectively erase the memories of genetically engineered mice, an article in the New Scientist reveals. http://www.newscientist.com/channel/being-human/dn15025-eternal-sunshine-drug-selectively-erases-memories.html?feedId=online-news_rss20
The scientists first increased the levels of a protein called alpha-CaM kinase II, an important component in memory storage and retrieval, while placing the mice in a chamber and exposing the mice to a tone accompanied with a mild shock. After a brief enough time for the mice to have remembered the experience, the scientists placed the same mice (while overexpressing the protein again) in a different chamber but played the same tone without the shock. This time, however, the mice were unresponsive. Yet after the scientists placed the mice back into the original chamber where they had received the shock and played the same tone again, the mice froze and showed the classic fear response. The changed reaction signified that the scientists were able to selectively erase the memory of tone recall.
Once thought to be ingrained in the anatomical structure of the brain, scientists are finding that memories are “the stuff of molecular connections, constantly built and destroyed by specific enzymes,” the article states.
This finding heralds a host of possibilities: anyone desiring to erase unwanted memories could one day pop a pill that manipulates the protein and obliterate the remnants of a traumatic experience. Of course this is years or possibly even decades into the future, but scientists seem to be optimistic that this could one day become possible.
Scientists view this technology as a possible treatment for post-traumatic stress disorder and phobias. Another article even mentioned its usefulness in the Central Intelligence Agency and Department of Homeland Security. (http://digitaldaily.allthingsd.com/category/alpha-cam-kinase-ii/) But imagine the reverse--its use in the hands of terrorists or criminals.
The staff working paper of the President’s Council on Bioethics explains that studies conducted by James McGaugh and Joseph LeDoux and other scientists, suggest that “our memory system has specific capacities, involving the amygdala, that match the intensity of an experience with the intensity of our memory of that experience. “ http://www.bioethics.gov/background/better_memories.html#endnote20 This allows our brain to adapt to our environment by associating negative memories to fearful things.
By modifying the stress hormone that regulates memory scientists are able to control patients’ recollection of traumatic experiences. Scientist Roger K. Pitman administered propranolol hydrochloride (a drug which blocks the activation of stress hormones released during emotionally arousing experiences) on emergency room patients within hours after car accidents. Weeks later, those administered the drug exhibited a lower “psycho-physiological response to ‘internal cues that symbolized or resembled the initial traumatic event” than those in the placebo group, the paper stated.
Many potential questions arise as scientists begin manipulating hormones that regulate memory. The paper asks “how are we to judge an intervention in human memory so soon after an event, before the ultimate significance of the experience has fully revealed itself and before it is even possible to know whether the individuals will suffer from PTSD?” The next question is then, are we tampering with nature or are we fixing a faulty encoding system? What permanent effects do these drugs have on the brain when memories of traumatic experiences are dulled?
This science carries much potential by offering relief from painful experiences, but a larger ethical question remains: to what extent do memories, good or bad, shape our identity and would the numbing of certain memories eventually be a detriment when applied to the larger framework of our existence? In other words, if at the end of our lives we can only remember the good, would we really have lived?
Ellie
Wednesday, October 29, 2008
Half of Doctors Routinely Prescribe Placebos
An article published on October 23, 2008 in the New York Times (summarized below) reveals that half of all American doctors responding to a nationwide survey say they regularly prescribe placebos to patients. Skip to next paragraphSurveys in Denmark, Israel, Britain, Sweden and New Zealand have found similar results.
While the most common placebos the American doctors reported using were headache pills and vitamins, a significant number also reported prescribing antibiotics and sedatives. Although these drugs, contrary to the usual definition of placebos, are not inert, doctors reported using them for their effect on patients’ psyches, not their bodies.
One of the authors of the study, Franklin G. Miller, director of the research ethics program in the department of bioethics at the National Institutes of Health, was among the medical ethicists who said they were troubled by the results, citing such reasons as informed consent and erosion of the doctor-patient relationship.
At least one doctor defended the practice when used to "treat" diseases like fibromyalgia that many doctors suspect are largely psychosomatic.
The American Medical Association discourages the use of placebos by doctors when represented as helpful. “In the clinical setting, the use of a placebo without the patient’s knowledge may undermine trust, compromise the patient-physician relationship and result in medical harm to the patient,” the group’s policy states.
However, controlled clinical trials have hinted that placebos may have powerful effects. Some 30 percent to 40 percent of depressed patients who are given placebos get better, a treatment effect that antidepressants barely top. Placebos have also proved effective against hypertension and pain. But despite much attention given to the power of placebos, basic questions about them remain unanswered: Are they any better than no treatment at all? Must people be deceived into believing that a treatment is active for a placebo to work?
Dr. Howard Brody, director of the Institute for the Medical Humanities at the University of Texas Medical Branch, in Galveston said that placebo use reinforces the deleterious notion that “when something is the matter with you, you will not get better unless you swallow pills.”
Dr. Ezekiel J. Emanuel, one of the study’s authors, thought doctors should not prescribe antibiotics or sedatives as placebos, given those drugs’ risks, but felt the use of less active placebos is understandable since risks are low. “Everyone comes out happy: the doctor is happy, the patient is happy,” said Dr. Emanuel, chairman of the bioethics department at the health institutes. “But ethical challenges remain.”
http://www.nytimes.com/2008/10/24/health/24placebo.html?_r=1&th&emc=th&oref=slogin)
I have to admit, I found this article more amusing than troubling. In the case of headache pills/ vitamins, as long as the doctor isn't foregoing a more useful treatment in favor of placebo (which this article does NOT suggest is going on) or conducting research on unwitting patients without consent (which, again, the article does NOT suggest is happening), I don't see the real harm.
I suppose the harm is lack of information, but when a doctor prescribes a non-placebo treatment, is the information any more extensive? Typically, the information that accompanies medication is a list of side-effects, other medications/foods to avoid, and directions for when to take it. It's not as if the doctor spells out in detail what exactly the medication will do once it's in the body. Presuming the doctor is informing the patient about side effect, etc. I think the harm is negligible. Sedatives and anti-depressants may be another story, however, given the risk of dependency and other more severe side effects.
I do wholeheartedly agree with the doctor from UT that placebo prescriptions foster an "only-a-pill-can-make-me-better" mentality, which I think is harmful. Still, at the end of the day, the doctor is doing what little he can do (in the case of a psychosomatic patient) to make them feel better.
Erin
While the most common placebos the American doctors reported using were headache pills and vitamins, a significant number also reported prescribing antibiotics and sedatives. Although these drugs, contrary to the usual definition of placebos, are not inert, doctors reported using them for their effect on patients’ psyches, not their bodies.
One of the authors of the study, Franklin G. Miller, director of the research ethics program in the department of bioethics at the National Institutes of Health, was among the medical ethicists who said they were troubled by the results, citing such reasons as informed consent and erosion of the doctor-patient relationship.
At least one doctor defended the practice when used to "treat" diseases like fibromyalgia that many doctors suspect are largely psychosomatic.
The American Medical Association discourages the use of placebos by doctors when represented as helpful. “In the clinical setting, the use of a placebo without the patient’s knowledge may undermine trust, compromise the patient-physician relationship and result in medical harm to the patient,” the group’s policy states.
However, controlled clinical trials have hinted that placebos may have powerful effects. Some 30 percent to 40 percent of depressed patients who are given placebos get better, a treatment effect that antidepressants barely top. Placebos have also proved effective against hypertension and pain. But despite much attention given to the power of placebos, basic questions about them remain unanswered: Are they any better than no treatment at all? Must people be deceived into believing that a treatment is active for a placebo to work?
Dr. Howard Brody, director of the Institute for the Medical Humanities at the University of Texas Medical Branch, in Galveston said that placebo use reinforces the deleterious notion that “when something is the matter with you, you will not get better unless you swallow pills.”
Dr. Ezekiel J. Emanuel, one of the study’s authors, thought doctors should not prescribe antibiotics or sedatives as placebos, given those drugs’ risks, but felt the use of less active placebos is understandable since risks are low. “Everyone comes out happy: the doctor is happy, the patient is happy,” said Dr. Emanuel, chairman of the bioethics department at the health institutes. “But ethical challenges remain.”
http://www.nytimes.com/2008/10/24/health/24placebo.html?_r=1&th&emc=th&oref=slogin)
I have to admit, I found this article more amusing than troubling. In the case of headache pills/ vitamins, as long as the doctor isn't foregoing a more useful treatment in favor of placebo (which this article does NOT suggest is going on) or conducting research on unwitting patients without consent (which, again, the article does NOT suggest is happening), I don't see the real harm.
I suppose the harm is lack of information, but when a doctor prescribes a non-placebo treatment, is the information any more extensive? Typically, the information that accompanies medication is a list of side-effects, other medications/foods to avoid, and directions for when to take it. It's not as if the doctor spells out in detail what exactly the medication will do once it's in the body. Presuming the doctor is informing the patient about side effect, etc. I think the harm is negligible. Sedatives and anti-depressants may be another story, however, given the risk of dependency and other more severe side effects.
I do wholeheartedly agree with the doctor from UT that placebo prescriptions foster an "only-a-pill-can-make-me-better" mentality, which I think is harmful. Still, at the end of the day, the doctor is doing what little he can do (in the case of a psychosomatic patient) to make them feel better.
Erin
Tuesday, October 28, 2008
Everything You Wanted to Know About Genetic Speed Dating BUT Were Afraid to Ask Ernst Ruedin
Had Emile Zola and Ernst Ruedin been invited to last month's Genotype "Spit" Party, hosted by 23andMe in New York last month, the air of vindication would have gotten us all high. One can almost hear Emile, all ascot and jodsphurs...right arm rested on the crisp, epauletted shoulder of Herr Ruedin..."Finally! A way to see just how good a lass' stock really is!" With other things (like whether one's political inclination reveals itself genetically) on his mind, Ruedin gasps a teutonic ja, replying, "Endlich! Du bist absolut korrekt mein Freund..."
But alas, they were edged out on the guest list by the likes of Rupert Murdoch, Chevy Chase and of course, Harvey Weinstein, all of whom attended the shindig to hack in a little glass vial in the lobby of the opulent IAC Building. The party was hosted by Linda Avey and Anne Wojcicki, the two ladies behind the company 23andMe...as in chromosome pairs...clever no?
It appears the company https://www.23andme.com/ will take $399 and a vial of spit from the customer, ship the sample off to a lab where the DNA is placed on a chip that can analyze around six hundred thousand sections of the customer's genome. Then, three to four weeks later, the customer simply logs on and receives bio-technology's equivalent of a fortune cookie. In other words, the company is putting the STOCK back in stock portfolio...and how about their timing?!?
The company's homepage purports to "democratize personal genetics" (Ruedin beware) by providing its customers with information about one's health traits, ancestry and specific similar DNA patterns shared by family members and the community at large. Obviously, the concept of knowing the cards one has been dealt has serious implications for the field of personalized medicine, as it allows us to adjust accordingly to the threats we're at increased risk for. For example, it might be extremely useful for frequent flyers to know whether they suffer from deep-vein thrombosis as it would clue them off to stretch out and move around the cabin area a bit...maybe NOT have the fourth vodka gimlet. In relating a personal anecdote along those same lines, my parent units might have chose a different topping for my brother's 5th birthday cake had they known he was allergic to coconut, thereby saving the entire family a trip to St. Joseph's and tearing yours truly away from the Bears-Dolphins game. Some of you out there might remember our beloved Bears lost that game...the only loss on their way to shuffling to a Super Bowl celebration.
23andMe also surveys its customers about their hereditary quirks...be it sneezing three times no more no less in an arpeggio scale, feckles or birthmarks, or a left-eye twitch when leaving one's queen vulnerable (yes Wallace, I know...I've known for years!...the Cunningham tip-off!) The company intends to plot such outliers against genetic data to see what they'll find.
The ethical dilemmas extend much farther than the bio-medical or bio-technological fields. Say for instance, the Murphy's all take the chromosome challenge and discover no proneness whatsoever to premature male baldness...all 18 brothers, fathers, nephews and uncles took the spit test and all show a happy future of shampoos and haircuts. All except Little Eddy, who was born after the family had moved to Summerdale Ave., which fell within Cliff, the flirtatious but bald mailman's route. Pray for Mrs. Murphy.
Or, will it instead simply reinforce stereotypes...a Y chromosome very common in Jewish populations shows up on the stock card of a Polish Catholic...will this prompt individuals to return to what might have been their true roots...casting off the Vatican and keeping kosher?
I can already see match.com and eharmony scrambling to be the first to co-opt 23andMe...who am I kidding...I can already see my Official Match23 Date Card:
No: premature baldness, extreme coconut allergy, freckles after sun exposure, alcohol-flush
Yes: caffeine addiction, high risk for heart attack, insomnia, prone to vote for the losing candidate.
Merde (even Ruedin sighs Scheisse). JWD
But alas, they were edged out on the guest list by the likes of Rupert Murdoch, Chevy Chase and of course, Harvey Weinstein, all of whom attended the shindig to hack in a little glass vial in the lobby of the opulent IAC Building. The party was hosted by Linda Avey and Anne Wojcicki, the two ladies behind the company 23andMe...as in chromosome pairs...clever no?
It appears the company https://www.23andme.com/ will take $399 and a vial of spit from the customer, ship the sample off to a lab where the DNA is placed on a chip that can analyze around six hundred thousand sections of the customer's genome. Then, three to four weeks later, the customer simply logs on and receives bio-technology's equivalent of a fortune cookie. In other words, the company is putting the STOCK back in stock portfolio...and how about their timing?!?
The company's homepage purports to "democratize personal genetics" (Ruedin beware) by providing its customers with information about one's health traits, ancestry and specific similar DNA patterns shared by family members and the community at large. Obviously, the concept of knowing the cards one has been dealt has serious implications for the field of personalized medicine, as it allows us to adjust accordingly to the threats we're at increased risk for. For example, it might be extremely useful for frequent flyers to know whether they suffer from deep-vein thrombosis as it would clue them off to stretch out and move around the cabin area a bit...maybe NOT have the fourth vodka gimlet. In relating a personal anecdote along those same lines, my parent units might have chose a different topping for my brother's 5th birthday cake had they known he was allergic to coconut, thereby saving the entire family a trip to St. Joseph's and tearing yours truly away from the Bears-Dolphins game. Some of you out there might remember our beloved Bears lost that game...the only loss on their way to shuffling to a Super Bowl celebration.
23andMe also surveys its customers about their hereditary quirks...be it sneezing three times no more no less in an arpeggio scale, feckles or birthmarks, or a left-eye twitch when leaving one's queen vulnerable (yes Wallace, I know...I've known for years!...the Cunningham tip-off!) The company intends to plot such outliers against genetic data to see what they'll find.
The ethical dilemmas extend much farther than the bio-medical or bio-technological fields. Say for instance, the Murphy's all take the chromosome challenge and discover no proneness whatsoever to premature male baldness...all 18 brothers, fathers, nephews and uncles took the spit test and all show a happy future of shampoos and haircuts. All except Little Eddy, who was born after the family had moved to Summerdale Ave., which fell within Cliff, the flirtatious but bald mailman's route. Pray for Mrs. Murphy.
Or, will it instead simply reinforce stereotypes...a Y chromosome very common in Jewish populations shows up on the stock card of a Polish Catholic...will this prompt individuals to return to what might have been their true roots...casting off the Vatican and keeping kosher?
I can already see match.com and eharmony scrambling to be the first to co-opt 23andMe...who am I kidding...I can already see my Official Match23 Date Card:
No: premature baldness, extreme coconut allergy, freckles after sun exposure, alcohol-flush
Yes: caffeine addiction, high risk for heart attack, insomnia, prone to vote for the losing candidate.
Merde (even Ruedin sighs Scheisse). JWD
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