ELSI on the L

RIGHT OF CONSCIENCE

2008-12-12T15:01:00.000-08:00

Basking in the glow of having finished my final paper for our bioethics class, I wonder what I will be wondering about this time next week without an assigned dilemma to consider.
For me, the stem cell debate, the genetics debate, the euthanasia debate, etc. all come together very concretely in the issue of health care worker’s ‘conscience clause’. I borrow from the Washington Post article linked below to describe some examples.

“In Chicago, an ambulance driver refused to transport a patient for an abortion. In California, fertility specialists rebuffed a gay woman seeking artificial insemination. In Texas, a pharmacist turned away a rape victim seeking the morning-after pill.”

Is it right for health care workers to refuse to do thing that violate their own moral and religious values? Or do healers have an ethical and professional responsibility to put patients first?

The heck if I know.

But I will be thinking on it. ... sort of like a never-ending Thursday night discussion.

http://www.washingtonpost.com/wp-dyn/content/article/2006/07/15/AR2006071500846.html

PJM

Elective surgery with a side of nan

2008-12-12T14:58:00.000-08:00

You can now get an all-expense paid trip for yourself and a companion to travel to India and get that procedure taken care of.
http://www.nytimes.com/2008/11/21/health/21abroad.html?_r=1

One of the many any issues that occur to me regarding international ‘medical tourism’ is how this impacts informed consent issues. A search for ‘medical tourism’ turned up the two following medical travel agencies. These are not providers or insurers. From what I can see, you sign your consent in the foreign country after consultation with the foreign doctor.

I wonder if this consent would hold up in the United States? After traveling thousands of miles for the purpose of a surgical procedure, isn’t an individual somewhat captive and under some duress and ‘forced’ to sign a consent? Or is traveling thousands of miles to get a elective surgical procedure a form of consent in and of itself? I have always been focused on health care in the United States and would like to know more about how ethical practices are handled in situations like this.

http://www.medicaltourismsolutions.com/procedures/sample_packages.htm
http://www.medpathgroup.com/

Declaration of Helsinki Abandoned

2008-12-11T16:03:00.000-08:00

Earlier this year the FDA made a decision that would replace the Declaration of Helsinki (DOH), a system put in place in the 1970s by the U.S. and several other countries to govern drug trials on humans, with a system called Good Clinical Practice (GCP). http://www.thenation.com/doc/20080602/shah In charge of this new system is the International Conference on Harmonization which consists of drug regulators and pharmaceutical representatives from the U.S., EU and Japan. Instead of the standards set in place by DOH, which outlined principles emphasizing that “extreme care must be taken in making use of a placebo-controlled trial” where proven therapies exist, this new system practically allows pharmaceutical companies to dictate their own ethical rules in conducting experiments.

Though the DOH wasn’t a perfect system either, as it had undergone numerous revisions and had been characterized as being too vague, it was much less biased than the system in place now. The significance of this change is that the FDA will now permit pharmaceutical companies to conduct clinical trials in which the control group could be treated with placebos. Instead of old treatments being tested against new treatments, this change allows new treatments to be tested against placebos. This is a departure from the DOH which restricted the use of placebos ensuring that the patients would not be denied already proven life saving treatments. The argument for using placebo groups in less developed countries rests on the justification that those patients wouldn’t have access to traditional treatments anyway, so the placebo experiments are merely testing the new treatment against the existing “standard of care”—meaning no treatment.

It’s obviously unfair that trials which would never be conducted in the U.S. are being conducted elsewhere, but what worse is that this new system approved by the FDA allows pharmaceutical companies to conduct trials on their own terms. At least the provisions by the DOH provided that patients would obtain access to the study drug after the trials ended and that the communities in which the drugs were tested would likely receive benefits from the research—but the GCP does away with these restrictions.

It’s well known that lack of consent is common in poorer countries, but under this new system, there will be far less oversight on pharmaceutical companies than there was previously. I wouldn’t be surprised if many of these patients were coerced into these experiments due to lack of any alternative treatments. The lack of informed consent combined with coercion leads me to consider that much of what’s going on bears resemblance to the crimes perpetrated by those found guilty in the Nuremburg Trials.

Placebo Effect

2008-12-11T15:32:00.000-08:00

A nationwide survey this year suggested that as many as half of U.S. doctors prescribe a fake treatment — or placebo — at least once a month.

That sounds.. relatively harmless to me. Studies have shown repeatedly that placebos are effective in treating health complaints with a strong psychological component, such as pain, depression, constipation and erectile dysfunction. As long as the pill that I am given is having its desired effect (i.e. reducing the itching on the rash I want to go away, calming my anxiety, etc.), then I have no problems with not knowing that there is actually no real "medicine" in the harmless pill.

However, the survey ALSO found that most doctors who prescribed placebos actually were using real drugs not proven effective in treating patients' complaints. These "impure placebos," such as antibiotics and sedatives, could be doing more harm than good.

And THAT.. is when it becomes frightening. It's one thing if I am being prescribed harmless "sugar pills" which do nothing but alleviate the mental component of my "illness", and thereafter alter some physical effects as well. It's entirely a different stories when I am unknowingly putting actual drugs with actual effects (and possible side effects) into my body without full disclosure by the physician. That to me is a very scary thought, borderlining on malpractice.

Article found at: http://www.usatoday.com/news/health/2008-12-10-placebo_N.htm?loc=interstitialskip

Practical Ethics

2008-12-11T14:50:00.000-08:00

I thought you might be interested in playing a game called 'practical ethics'. Once a month or so, AHA poses a fictitious ethical dilemma to its magazine readers. First, you read the question. Then take a minute to think about what you would do. Then you compare your thinking to two opposing responses from hospital CEOs.

I thought I would share this question on patient privacy - that's a bit different than what we have been discussing, but I thought I would leave you with something a little less profound to grapple with - ethics in the trenches.

QUESTION:
Two members of your staff took photos with cell phone cameras of patients in the emergency room. The photos were later posted on the Internet on social networking sites. Since then, you’ve dismissed the employees who were responsible, and it appears that the patients were unrecognizable in the photos. Still, there is concern in your organization that this could happen again—and potentially lead to HIPAA violations—and some think you should ban staff from having cell phones outside of employee-only areas as a precautionary step. What should you do?

++++++++++++++++++++++++++++++++++++++++++++++
Doug Vinsel, CEO, Duke Raleigh (N.C.) Hospital
The action taken has to be balanced and proportionate to the problem at hand. Certainly the scenario described is one that creates the potential for institutional embarrassment and liability. The dismissal of the employees involved and the presumed apologies to the patients/families is appropriate. While the thought of banning cell phones outside of employee-only areas is an understandable reaction, it is, I believe, an overreaction and an impractical way to address the misconduct of two employees. Employee education around the proper use of cell phones should be a requirement for department managers to ensure staff understanding of appropriate usage. However, the vast majority of staff can be trusted to use cell phones appropriately and understand the consequences of not doing so. We want to build a culture of trust and treating one another and our patients respectfully. Establishing a ban on cell phones is contrary to those principles.

+++++++++++++++++++++++++++++++++++++++++++++++++++++
Anthony Spezia, CEO, Covenant Health, Knoxville, Tenn.
We absolutely support and wholeheartedly agree with the terminations of the two employees. This is a clear violation of our corporate compliance program, code of conduct and our standards of behavior. I would not place the ban on staff. Our values are incorporated into our strategic plan, are utilized in many internal and external communications and are all approved by the board of directors. This is not a matter of compliance; it is a matter of conviction, faith and trust. If our culture is to be strong, we must trust employees to do the right thing in clear cases where a situation is covered by our policies and standards. This is such a case, and we would not support banning cell phones solely for the purpose of enforcing an articulated policy. We would not violate our employees’ trust, nor would we diminish their commitment to act according to our norms by taking away their cell phones. Rather, we would trust them and our strong culture of accountability.

This article 1st appeared in the November 2008 issue of HHN Magazine.
____________________________________________________________________________________PJM

No More Stretchmarks

2008-12-11T14:39:00.000-08:00

http://www.commondreams.org/views02/0117-05.htm

This is article on the advancing medical technology of artificial wombs. Although it was of signifigant value in my final paper, I was unable to find evidence of any more research being done in this area.

Roe v Wade needs to be reevaluated and challenged with this new technology in mind. In 1973, abortion via surgical method was the only option. Since the 1990's we have many many herbal and chemical abortive options readily and cheaply available.

TO Die Early

2008-12-11T13:28:00.001-08:00

To Die Early
Persons that are considered mentally ill tend to die early. The question is why? Depending on the individuals mental illness they are granted surrogate or guardians that play a major role in their finances, property management if owned, and medical decision. So what are the contributing factors? The Association of State Mental Health Program Directors conducted research and determined that people that are severe mentally ill die 25years earlier than the general population. Therefore, the journey began to decide why this occurs. The illnesses that are prevalent are diabetes, obesity, and cigarette smoking. The diseases are all treatable and preventable. The socioeconomic factor does play a role for person without money do not always have access to healthcare and one could only image how hard it is to receive care when it is determined that you are mentally ill. The article pointed out that person who are mentally ill tend to substandard medical because physicians do not take their concerns seriously. Smoking was cited as the leading cause of death and in some psychiatry hospitals patients are used as reinforcement if behaved well the reward was a cigarette and if your actions were deemed deplorable a cigarette was denied. Obesity is contributed to medication and the adverse effects. As well the general public has an issue with obesity. If people are in a controlled area then why is exercise not included in their daily regimen. Not too compare state mental facilities to jail yet, in jail exercise is considered necessary for their quality life So is a person that is mentally disable, does their life lack quality. There are many changes that are occurring in that are require the standard of medical care for patients in a clinical setting. For example, the patient’s weight, fasting blood glucose test, and carefully reviewing the patient’s medical history. The issue I have are the standards that are set because the standards are the normal standard of care that each patient should receive. SO why was the standard so different for mentally ill patients.
KIRK
Article title: Why Do the Mentally Ill Die Younger?
http://www.time.com/time/health/article/0,8599,1863220,00.html

The Logic of HPV

2008-12-11T13:27:00.000-08:00

The Logic of HPV
If I want to peanut butter and jelly I go to the cabinet and get the bread, peanut butter, and go to the refrigerator and get the jelly. Now that brings back so many memories as well how disappointed I was when there was not any jelly. My mom forgot to pick up some jelly or my brother used the last of the jelly and decided not to tell anyone. At the end of the day I will not have my coveted sandwich. The vaccine HPV is currently marketed to young women as a way to prevent cervical cancer….One less as the ad proclaims. That is important as well if there was a vaccine to prevent breast cancer many parents would offer this vaccine to their sons and daughters because it effects us all. The controversy surrounding this vaccine is the ideology of pre-marital sex and particularly young women. If the young lady decides to have sex she is considered “protected” from cervical cancer or at least she has received preventable care. The fact is in order to have sex a partner is needed. True the young lady may become a lesbian so what are her worries…..that is not of issue the premise is that men induce the likely hood of a women developing cervical cancer. So why are boys not vaccinated. If this is a sexually transmitted disease why not offer the vaccine to all of the actors involve. The reality is that some boy may become sexually active while some will not. The reality is some girls may become sexually active and some will not. As well even though the marketing was directed at women I wonder how many people question the motive of the pharmaceutical company. The boys were left out. It is said in 2009 boys will begin receiving this vaccine, the question are parents willing to protect only their daughters and if so how protected are they if their future lover is not vaccinated.
KIRK
Article title: Vaccinating Boys for Girls’ Sake?
http://www.nytimes.com/2008/02/24/fashion/24virus.html?pagewanted=1

Treat me Please

2008-12-11T13:26:00.000-08:00

Treat me please…
Pediatricians see children all of the time and most children keep their pediatrician until they are 18. When children are infants the parents stay in the room the doc. will ask how he is eating, sleeping, playing and etc. Does the formula upset his stomach and what vegetable does he really like? As time goes on the child will grow and the next visit the questions are how is he adjusting to school, does he seem behind to you developmentally if so I will refer you to Dr. Brown. The child gets older and pretty soon it is time for the parent to leave the exam room and give their pre-teen or teenager privacy. This fosters a relationship of trust and most importantly the pediatrician is able to speak privately with their patient. The first statement out of the child’s mouth is you are not going to tell me mom….and the answer is no. Of course the pediatrician is not going to tell the mother or father their conversation for the pediatrician needs a great relationship with their patients. Therefore, many pediatricians not only provide their discipline of care rather psychological care and the child just may need an ear. So what can you tell the parents? If the child is thinking about death is that a warning sign or rather the reality of growing up or just human nature. If the child is being bullied at school is that information to give to the parent or just a part of life. Not to trivialize certain issues rather it is important to assess the context of the conversation and the issues surrounding the situations. If your grandfather or mother passed away we would all question death. As well at some point in our lives we were teased we were not always this cool. I am sure that is still to be determined rather we have learned to accept ourselves. The point is a child truly autonomous when it comes to their care. The child does not decide their doctor, where they live, where they attend school, what car to drive, and etc. This is all determined by the parent. If my child was being bulled I would want to know and if my child was thinking of death I would want to know or would I want to know that if he has any issues he is able to seek counseling from an adult that I trust. I just hope the pediatrician will clue me by immediately suggesting that this is an interesting time in his life. That is a very broad statement but it says so much. Yet, at what time should the parent become informed of the child personal thoughts. The reality is as an adult no one truly knows our deep personal thoughts so what right does a parent have to their child’s.
KIRK
Article: What to Do When the Patient Says, ‘Please Don’t Tell Mom’
http://www.nytimes.com/2008/12/09/health/09klas.html?ref=science

The Right to Die

2008-12-11T13:24:00.000-08:00

The Right to Die
The other night a documentary aired on Britain’s television and it was the actual last moment of Craig Ewert. Mr. Ewert actually died in 2006 at a clinic in Zurich. Craig Ewert traveled to this clinic because it is illegally to assist, counsel, and procure suicide. This places many individuals in a compromising position, Craig Ewert stated: “If I go through with it, I have death. If I don’t go through with it, my choice is essentially to suffer and to inflict suffering on my family, and then die.” That statement is a reflection of the how the individual feels about their right to die. Craig Ewert’s wife was not prosecuted for helping her husband travel to Zurich and recently another family assisted their son in traveling to Diginistas, a clinic located in Switzerland. This family was not charged due to public interest. As well, last month a young woman of the age 13, decided to forgo a heart transplant and die at home with her family. The parents did not object to her decision rather the hospital. The hospital threatens to send the parents to jail for neglect and not acting in the child’s best interest. The hospital also threatens to take legal action to receive a court order to force a transplant. Therefore, the question, is it ever right to end your life? Is my life truly my own or rather is it in the best interest of the government. If I decided to cut my hair no one would question my actions. If I decided to fly to Paris someone might wonder why yet, they may not question my actions. If I decide to forgo medical treatment someone might question my decision but it is predicated upon the end result. The reality is we will all die. No one can argue or question that statement. If I am a religious person I may believe that I am going to heaven or hell yet, I am content with my decision. So what interest does the government have with this decision? The British government has decided to forgo treatment for patients due to the fact that they are going to die based on evidence care. The individuals life is not work the amount of money it would take to prolong the person life if only for six months. The person may only need six months to prepare for death and an individual such as Craig Ewert may not need another day to live their life. So, if the government may decide to stop treating an individual that is dying then why is the individual unable to make that determination.
KIRK
Article titled: TV Broadcast of an Assisted Suicide Intensifies a Contentious Debate in Britain
http://www.nytimes.com/2008/12/11/world/europe/11suicide.html?_r=1&ref=health
Article titled: Britain Debates a Child's Right to Choose Her Own Fate
http://www.washingtonpost.com/wp-dyn/content/article/2008/11/13/AR2008111303879.html?hpid=moreheadlines

Should changing your sex be tax-deductible?

2008-12-11T03:15:00.000-08:00

Last October, the Washington Post reported on a Massachusetts transgender woman's suit filed against the IRS for the right to claim her sex-change operation as a medical deduction on her income taxes.
http://www.washingtonpost.com/wp-dyn/content/article/2007/09/30/AR2007093001194.html

During the trial, Rhiannon O'Donnabhain, 64, described the struggles she faced as a gender conflicted young boy in a staunchly conservative, Catholic family. Growing up she played with boys, worked in construction and even ultimately married a woman and fathered three children.

In 1996, at 53, Rhiannon was diagnosed with gender identity disorder. In the following five years, she underwent intensive counseling and hormone treatments in order to complete her sexual reassignment surgery in 2001. According to the article, this was the first time in her life, that she felt at peace:
"I'm just so glad I did this," stated Rhiannon.

The article explains that Rhiannon spent more than $25,000 on sex-reassignment surgery in 2001, and claimed a $5,000 deduction. After sending Rhiannon the $5,000 check, the IRS denied the deduction, claiming the surgery was cosmetic and thus not a deductible medical condition.

According to leading medical experts, Gender Identity Disorder is a recognized medical condition that results in an estimated 1,000 to 2,000 sex-change operations a year in the U.S. alone.

Marshall Forstein, an associate professor of psychiatry at Harvard Medical School, asks: "When did the IRS suddenly become physicians?" Forstein reiterated that transgender identity is a condition expressly discussed in diagnostic manuals. Forstein continued:
“It seems the IRS is now in the business of practicing medicine without a license."

According, to Rhiannon's lawyers from the Gay and Lesbian Advocates and Defenders (GLAD), the case will likely set a precedent as to whether such procedures will be considered tax deductible.

Independent of whether Gender Identity Disorder is a medical condition, sexual reassignment surgery may have substantial legal repercussions. Firstly, in 31 states, documented proof of sexual reassignment surgery is necessary in order to change your legal sex status on your driver's license.

Secondly, in a 1997 unreported case of Vecchione v. Vecchione, a California Superior court held that a postoperative transsexual acquires his postoperative sex for purposes of marriage. In the middle of a custody battle dispute over her three year old daughter, Christie Vecchione, claimed her marriage to Joshua Vecchione should be annulled. After revealing to the court that her husband had been recognized as a female at birth, she pointed to the state's ban on same-sex marriages to argue that the marriage had never been valid. Superior Court Judge Gary Ryan held that the annulment and not the marriage was invalid. In ruling that Christie was legally a female, the court placed great weight on a state statue that expressly permits a post operative transgender individual the right to change the sexual designation on their birth certificate.

I would like to see the IRS explain to Mr. Vecchione that sexual reassignment surgery-- a procedure that directly prevented the annulment of his marriage and protected his custody rights over his 3 year old daughter--is merely a cosmetic operation.

The producers of Jurassic Park IV have announced that it is unlikely that they will go forward with the project .

2008-12-11T03:00:00.000-08:00

Although our class devoted a sufficient amount of time on the issues on the frontier of genetics -- e.g. synthetic biology, hybrids, and chimeras-- for some inexplicable reason, Professor Herder failed to touch upon a subject incredibly relevant to our day to day world: the potential cloning of mammoths.

Okay, granted this topic is mostly only relevant in the worlds created by Michael Crichton (rest in peace). Nevertheless, what is a bioethics blog without a piece on mammoths?

According to a November New York Times piece, scientists believe that the extinct woolly mammoth could be scientifically regenerated for a mere $10 million.

http://www.nytimes.com/2008/11/20/science/20mammoth.html

However, in this month's Time magazine, Stephan Schuster, a prominent scientist with the project, warns us not to get too excited: "What I'm trying to say is that there is a workable route to do that, but it is at this time technically, and cost-wise and time-wise, not feasible." http://www.time.com/time/health/article/0,8599,1861136,00.html

Nevertheless, the scientific and legal community have been moderately excited about this for a while. Back in 2000, A Stanford Technological Law Review analyzed the legal implications of the matter and concluded there to be no national or international hurdles to pass.

Primarily, the brief is most excited about the project's “potential application to the conservation of the endangered and near-extinct species of our own time.”

The Law Review counter ecological and evolutionary arguments opposed to the project, by asserting that any such problems would be averted by keeping them in captivity.

To the Stanford Law Review's defense, I should add that Jurassic Park III had not yet been released.

Other common points/counterpoints on this issue include:

Con: These animals are extinct. Are we playing God by trying to resurrect them?

Pro: Humans had a role in killing off mammoths.

(Although studies point to climate change being the primary cause, it would be difficult to claim that humans didn't have at least a partial role in that as well. )

http://www.democraticunderground.com/discuss/duboard.phpaz=view_all&address=115x53524

Con: Cloning will create monsters that will destroy life as we know it.

Pro: Mammoths would actually be incredibly similar to an elephant, although hairier.

Consequently, the mammoth clone would be reared by an elephant mother.

Con: There are no modern environments suitable for these creatures.

Pro: Environmental conditions for mammoths can be replicated.

Con: It would be inhumane.

Pro: Mammoth clones would not be laboratory specimens.

Con: Such an endeavor would release a plague of unknown diseases on Earth.

Pro: There is no evidence of transmissible disease from defrosted specimens.

http://www.actionbioscience.org/biotech/agenbroad.html

Sadly, as Schuster points out, all this discussion is more or less moot at this point. Unfortunately, the world has considerably more important issues to face and then post about on bioethics blogs.

The "Three's Company" episode where they discuss bioethics

2008-12-10T21:15:00.000-08:00

Last February the UK Telegraph announced that British scientists had created an embryo with three parents. Researchers at the University of Newcastle took the nucleus of an embryo produced during assisted reproduction and placed it inside an egg from which the original DNA was removed, leaving behind the donor's mitochondria. Thus, the resulting embryo contained genetic contributions from three people.
The researcher's goal is to create a procedure to prevent mitochondria-related diseases.
Although, these diseases are rare, the results can be devastating. By using the Newcastle method, a traditionally-formed embryo with a defective mitochondria could then be replaced with functional mitochondria.

The Telegraph explained that “in effect, the new technique would be like changing a battery in a computer without affecting the hard disk, the nuclear DNA that influences our appearance and other characteristics, so that an affected woman does not pass them on to her children.”

http://www.telegraph.co.uk/scienceandtechnology/science/sciencenews/3324321/Transplant-creates-embryos-with-three-parents.html

At this time, the legality of the operation in England is still in question.

Although the Telegraph piece focused on the pathological implications. The internet instantly buzzed about the cultural possibilities. A Wired.com article explained that the Newcastle procedure might be useful for people in a trinogamous relationship or “a long-term union of three people rather than two.” (The article notes that linguistically binogamous would be proper, however, the class of individual for which the term applies have apparently already taken the aforementioned term).
The article explains that “like anyone else, people in trinogamous relationships may want to have children with DNA from all the parents. Enter the Newcastle method. The same holds for same-sex couples for whom an embryo conceived through traditional assisted reproduction contains DNA from only one partner.”
http://blog.wired.com/wiredscience/2008/02/calling-jerry-s.html

Although I tend to believe that a human family is best structured around a monogamistic center (be of it any combination of gender and sex), I am not opposed to a trinogamous child. Indeed for individuals opposed to monogamy, such a unique child would certainly be an incredible way to reinforce their non-monogamistic union. As I type this, I'm finding more and more that I have strong conservative feelings as to monogamy; still, as I do not know any trinogamous individuals I can't get myself to judge such domestic situations as wrong per se.
On the other hand, in the event such a trinogamistic societies are structured around one male and multiple females I might be concerned with the implications of encouraging such domestic situations. Although, HBO's Big Love does make a relatively strong case for polygamy.
(incidentally the DNA used in the Newcastle method happened to be 2 women and 1 male).

Watching a Suicide

2008-12-10T17:05:00.000-08:00

http://news.aol.com/health/article/british-tv-will-show-assisted-suicide/272690

An assisted suicide is being aired on television tonite. I do not have the stomach to watch it.

This man was dying of ALS, a very severe disease that inspires even additional sympathy in all healthcare workers caring for their patients. I am hoping that if this film is done in an appropriate manner, it will also generate sympathy and understanding from the general public.

The amount of pain and expense for dying patients is immense. Assisted suicide, if carefully controlled by healthcare is a viable option. Going forward we need to explore all options in controlling costs. This certainly would include educating the general public of the benefits of hospice and educating them realistically about their prognosis.

Patients have a right to choose their medical treatments under the law.

Jennifer Burns RN

Brain Candy--Part 3

2008-12-10T16:40:00.000-08:00

To my dismay, as I checked my email before posting my blog, I realized that several other students had blogged about the exact same issue. So, in addition to posting my blog below I’ll first comment on a few of my classmates’ thoughts--in order for my entry to appear less redundant.

I also believe there is a distinct difference between OTC remedies like caffeine and drugs like Adderall. These differences stem not only from the fact that one is more precise and therefore more effective than the other. In an excellent article by Erik Parens, “Is Better Always Good?” several bioethicists get together to discuss the ramifications of cognitive enhancements. They state that the difference lies in treating different means as morally the same. Not to get into a philosophical debate, but there are concerns that resorting to drugs to enhance ourselves, we are blinding ourselves to underlying problems in our society. For example, they compare administering Ritalin to hyperactive kids as opposed to decreasing class size. In some ways, forcing pills on kids who don’t learn in a typical classroom setting is ignoring the fact that there is something wrong with our education system.

In regards to the use of enhancements in sports, there is a similar line of thinking in banning its use in sports as well as in academics. The reason why we ban steroids is somewhat related to the value we place on winning. In an article in the Atlantic Monthly entitled, “The Case Against Perfection” by Michael Sandel, he states that the use of enhancements cheapens the game. If we win or get A’s simply because of the edge we get through steroids or Adderall, would we really feel as fulfilled and satisfied with the achievement? We as a society value achievement not only because of the hard work involved, but also because of the unique talents that allow get us to that level of achievement. If we are all placed on a level playing field through an array of enhancements, winning wouldn’t mean as much.

(Beginning of original blog entry) Now that we’re nearing the end of the semester, with the pressure of finals and research papers looming over us, many of us probably use energy drinks or extra cups of coffee to stay awake—or as a growing number of students prefer, take Ritalin or Adderall.

A study by the National Center on Addiction and Substance Abuse at Columbia found that almost twenty percent of college students have used Ritalin or Adderall to increase concentration and pull all-nighters. http://www.nytimes.com/2005/07/31/education/edlife/jacobs31.html

Ritalin or Adderall is easily obtainable through friends who are written prescriptions after claiming to have ADHD. These stimulants are now commonplace among college campuses. "Things have really gotten out of hand in the last four to five years," says Dr. Robert A. Winfield, director of University Health Service at the University of Michigan. "Students have become convinced that this will help them achieve academic success." "The culture here actually encourages people to use stimulants," remarked a student at Columbia.

Though relatively safe, and non-addictive, the Adderall could pose risks if combined with other drugs. However, those with heart problems should be cautious as the drug increases heart rate and disorientation, which can lead to sudden death. In fact, due to reports of twenty international deaths due to Adderrall, the Canadian government temporarily suspended sales of Adderall in 2005, as reported by the NYT.

Despite the health issue, off-label use of prescription stimulants in schools poses other serious problems involving fairness. Is it fair for some students to obtain an edge in concentration and perhaps even increase memory capacity and not others? If the effects are nominal than what explains the increasing prevalence among college students? As enhancements are banned in sports, should cognitive enhancements like Ritalin or Adderall be banned in universities? Like the sports enhancement debate, discussions around cognitive enhancement raise concerns of larger ethical questions regarding not only fairness and cheating but concerns of a competitive society that drives us to take drugs in order to get an edge over the next person.

Ellie

Brain Candy Pt. 2

2008-12-10T14:04:00.000-08:00

Just now walking from my locker up to library I passed an incomprehensible scene, a pair of book-carrying law students engaged in a heartfelt laugh during finals week. I wanted to stop and shake some sense into both of them. Then it hit me. They must have been on drugs.

Although, a cheerfully composed student during exam week may be the product of a semester of preparation (or even a semester of ignorant bliss), it's also possible that their studies have been supported by such academic steroids as Adderal or a number of AdHd drugs.

It appears CTF has beat me to the punch on this issue, but here are some additional matters to consider. Firstly, I believe the study that CTF's article is alluding to is a 2005 study by Addiction Journal. After surveying students at 119 American colleges, a 2005 study by Addiction Journal, found that up to 25% of students at competitive schools had misused an ADHD medication within the year.

http://www2.jsonline.com/story/index.aspx?id=410902

I personally do not know any law students that partake in such practices, but I would not be surprised if such practices were common on campus.

The academic trend was tracked in “Brain Enhancement Is Wrong, Right?”, a New York Times piece from last March. http://www.nytimes.com/2008/03/09/weekinreview/09carey.html?_r=1&pagewanted=1

The article lightheartedly compares academic enhancement to our recent doping era of sports. The article also, however, brings up some serious questions as to the repercussions of such academic enhancement habits. “What happens if you’re in a fast-paced surgical situation and they’re not available?” asks one graduate student. “Will you be able to function at the same level?”

Dr. Anjan Chatterjee, an associate professor of neurology at the University of Pennsylvania, envisions a world where such performance enhancement usage is not only a common professional practice, but one that is required. “You can imagine a scenario in the future” posits Dr. Chatterjee, “when you’re applying for a job, and the employer says, ‘Sure, you’ve got the talent for this, but we require you to take Adderall.’ Now, maybe you do start to care about the ethical implications.”

Indeed, there are signs that Adderall usage may be coming more widespread as noted by CTF's piece and as evidenced in other countries. For example in 2006, Canadian medical regulators decided to allow Adderall XR back on pharmacy shelves. http://pn.psychiatryonline.org/cgi/content/full/40/19/2

In spite of this trend, my number one qualm with both CTF's AP link and my NY Times' article, is that the negative repercussions are not emphasized. While CTF's piece claims a “drug to improve brain function is functionally no different than getting a good night’s sleep or eating healthy,” chronic well-restedness or a chronic healthy diet, will never lead to psychosis; the chronic use of Adderall might:

“Chronic abuse of amphetamines can result in the manifestation of amphetamine psychosis”

Pliszka, et al., A Double-Blind, Placebo-Controlled Study of Adderall and Methylphenidate in the Treatment of Attention-Deficit/Hyperactivity Disorder, Journal of the American Academy of Child & Adolescent Psychiatry. 39(5):619-626, May 2000.

Interestingly, while academia remains relatively mute on the ethics of the matter, some sports are taking a hardline position against such brain enhancement. For example, the Nevada State Athletic Commission recently banned athletes in the state from using Adderall. Tim Credeur was removed from a UFC fight on the finale of The Ultimate Fighter 7 because of a positive drug test due to his use of it.

http://sportsillustrated.cnn.com/2008/mma/06/23/credeur.cancelled/index.html?eref=si_latest

If wrestlers are ready to go to the mat against Adderall's unfair advantage, perhaps academia should at least further consider the matter as well.

Over the Counter Prozac Continued: Should we Consider Over the Counter Adderall too?

2008-12-10T13:13:00.000-08:00

When I read the post about Prozac potentially being sold over the counter, I immediately commented about what seems to me a pretty interesting problem: the overuse and over-prescription of attention deficit hyperactivity disorder (ADHD) medicine, such as Adderall and Ritalin. I found myself struggling to decide whether I thought these kinds of medications should be made available over the counter, and I’m still not sure what side of the fence I fall on. I spent a few minutes looking online for related articles, and I came across a fairly persuasive article entitled “Scientists Back Brain Drugs for Healthy People.” The article can be found here: http://hosted.ap.org/dynamic/stories/M/MED_BRAIN_PILLS?SITE=NCKIN&SECTION=HOME&TEMPLATE=DEFAULT.

The article explains that there are a growing number of professionals, including authors, ethics experts, and doctors, that are publicly arguing that “brain drugs,” like Ritalin, should be made available to the public. There are a number of arguments made in the article, a few of which I’ll mention here. For example, one argument suggests that taking a drug to improve brain function is functionally no different than getting a good night’s sleep or eating healthily. And the benefit is tangible: these drugs would allow people to multitask better and boost memory. Most importantly: the side effects are minimal. Another argument is that because these drugs do not have significant side effects, they function really as an improved version of caffeine, and there’s no ban on caffeine.

I’m not sure I buy this last argument. I think the devil is in the details and I think comparing prescription “brain” drugs to caffeine found in coffee or soft drinks is a little disingenuous. The way and amount that these drugs alter the brain is so significantly more than we see with caffeine that I think the comparison is a little moot. I may be making assumptions, but I personally feel this comparison is trying to equate apples and oranges. Adderall and caffeine may overlap in some ways or even fall into the same category, but there is a distinct difference.

I think the most interesting ethical argument is whether we should make these drugs ore widely available simply because a lot of people are already taking advantage of them and using them. The article cites that at some colleges, students who have used these drugs are as high as 25%. I know from my own experience as an undergrad and here in law school, that MANY students have been taking advantage of Adderall and Ritalin despite not having ADD or ADHD. I’ve asked some of my friends whom I know do not suffer from ADD how they managed to get a prescription, and the response is usually very similar: they simply tell the doctor they have a hard time focusing, or that they can’t manage multiple things at one time, and poof! Prescription. And I wonder if this is like this everywhere, because I know people from different parts of the country who all have basically the same story. More concerning, is the fact that once diagnosed, people seem to be able to get more meds with relative ease, which I believe is why people are now buying and selling Adderall and the other meds “illegally.”

So is the fact that this is has become almost a common practice reason enough to make these drugs available to everyone? I do not think so. While it is a completely different issue, I think the way sports (struggle) to handle steroids sheds some light on this problem as well. Even though many people use banned substances, the NFL isn’t about to let steroids and other banned enhancements become sanctioned. The idea is to keep the field as natural and fair as possible. And when people violate the rules, it is an unfortunate consequence. But penalties seek to deter infractions, and at least by keeping substances illegal, it makes access to them more difficult. While it is ENTIRELY unrealistic to assess “penalties” for this kind of drug use, I think imposing some restraints on their access is prudent and at least keeps the problem from expanding at an exponential rate. Shouldn’t we seek to keep our brains as “natural” as possible and not encourage stimulate use/abuse?

Importantly, even the pro-drug corner believes that more research needs to be done before such a drastic step is taken. The supporters want more research to be done into the use, benefits, and risks of the drugs. I think we need to know more before we make a significant judgment call like allowing these to be sold over the counter. Supporters also believe that doctors need to develop policies for the use of such drugs, and legislatures need to rethink the issues. All of these suggestions I do agree with. Opening up the drugs to more scrutiny would be a better way to assess their potential pros and cons.

However, I do not think that this would eliminate the most critical concern with drugs like these: that people would either feel coerced into taking them, or that the drugs would get abused. It is easy to imagine the scenario where “everyone’s doing it,” and therefore, to compete in (very competitive) workplaces or schools, people almost have to resort to such enhancements simply to keep the playing field level. Opening access to these drugs, even if they don’t have serious side effects, to the public would cause an explosion in the use of such drugs, and I think that many people who would not have sought or needed these drugs in the past would be forced to take them or would at least heavily consider it.

Over the Counter Prozac

2008-12-09T21:31:00.000-08:00

In an interview with Josephine Johnston, associate for law and bioethics at the Hastings Center, a nonpartisan research institute, TIME magazine posed the question of whether antidepressants such as Prozac should be readily available over the counter like many other drugs. As the most frequently prescribed class of drugs in the United States, antidepressants make up about 5% of all prescription medication recorded in outpatient files, according to 2005 figures from the U.S. Centers for Disease Control and Prevention. The question raised is then, if the demand for antidepressants is so high and the pills are so readily dispensed (with the side effects now reasonably well known), would life be easier for many Americans if antidepressants were just available at the drug store?

On one side of the fence, proponents of dispensing antidepressants over the counter argue that people should be free to treat their own problems. Antidepressants are not that dangerous. And even if they are, in America, an argument about autonomy and people making their own choices can end up trumping anything else.

On the other side, opponents of free dispensal argue that antidepressants work best when they're used in conjunction with other kinds of treatment. If you use antidepressants under the supervision of a physician, you can also talk to the physician about how to address some of the underlying problems which have led you to the depressed state. By providing such medication over the counter is to decouple them from an important part of the treatment, and to risk undermining or taking valuable resources away from more intensive treatment that involves therapy or communication.

I can honestly see both sides of the argument in this debate. However, as I think about it, I appear to leaning more towards the side of allowing antidepressants to be provided over the counter in drug stores. Americans have the freedom to choose how they wish to interact with many other forms of "dangerous" items, including alcohol, guns, and even vehicles. To limit their interaction with such things due to the danger possibility would be to take away a fundamental American right of autonomy. There are many similarities between antidepressants and liquor, both of which are used by many Americans to deal with issues of unhappiness and distress in their lives. If Americans have the freedom to obtain liquor without a prescription, shouldn't they have the same freedom of access to antidepressants as well?

Article at: http://www.time.com/time/health/article/0,8599,1809504,00.html

Getting high on HIV drugs in South Africa

2008-12-09T08:09:00.000-08:00

According to this BBC News article, anti-retroviral drugs used to treat HIV/Aids are being bought and smoked by teenagers in South Africa to get high. Reports suggest that the drugs are being sold by patients and even healthcare staff for money. Schoolchildren have been spotted smoking the drugs, which are ground into powder and sometimes mixed with painkillers or marijuana. Aids patients themselves have been found smoking the drugs instead of taking them as prescribed. Apparently this has now become a national problem in South Africa.

Documentary-maker Tooli Nhlapo told the BBC World Service's Outlook programme that the young users that she spoke to get access to these drugs from HIV patients or healthcare workers, and that they know when the individual patients go to collect the drugs and buy them, or if they do not have any money, they steal them. She also said that when she was doing the story, many HIV patients were complaining that they don't get the drugs and that queues are long and it was taking a long time to access them. "It is well organised, no matter how high they are, they do not tell you who is giving them the drugs," said Ms Nhlapo.

The potential health implications of this are huge, on top of the access to care issue. When health care workers themselves are selling ARVs to be used as recreational drugs, what else will happen? These users are exposing themselves to side effects, and the HIV patients are putting themselves at huge risk by not taking these medications as they should be taken. I can only imagine what kind of black market this is going to create, especially in that part of the world. If this spreads to war-torn regions of Africa, how many more human rights violations will occur?

I've little idea how to begin to wrap my head around this one. Just mind-blowing. Wait until word gets round here in the US that apparently ARVs can be used for this. We'll have to watch to see if/when this comes out in the history of the next patient who rolls in to the ER with a CD4 count of, say, 4.

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Cleveland Clinic Discloses Doctors Financial Ties

2008-12-07T21:25:00.000-08:00

http://www.nytimes.com/2008/12/03/business/03clinic.html?pagewanted=1&em

The Cleveland Clinic, one of the nation’s most prominent medical research centers, is making a complete disclosure of doctors’ and researchers’ financial ties available on its Web site, www.clevelandclinic.org. It will now publicly report the business relationships that any of its 1,800 staff doctors and scientists have with drug and device makers.

This comes as the nation’s doctors and hospitals are under mounting pressure to address potential financial conflicts of interest that can occur when they work closely with companies to develop and research new drugs and devices.
In American medicine, doctors’ links to industry are often hidden from public view, and critics argue that such relationships can taint the integrity of medical research and patient care. In one of the most recent controversies, a highly regarded and influential psychiatrist at Emory University, Dr. Charles B. Nemeroff, drew criticism in October for failing to disclose at least $1 million in consulting fees from drug makers.

Senator Charles E. Grassley, Republican of Iowa, has brought Congressional scrutiny to the issue and introduced legislation that would require drug and device makers to divulge the payments they make to doctors. Some drug companies, including Merck and Eli Lilly, say they plan to starting publicly disclosing their payments to doctors next year.

Dr. Cosgrove, chief executive of the Cleveland Clinic, said that potential conflicts of interest need to be managed, not automatically eliminated, because working with industry encourages innovation by the clinic and its doctors.

Some experts wonder how useful the industry disclosures actually are to patients when they are told of a doctor’s industry ties before agreeing to take part in a research trial. A patient, they argue, may not know what to make of such information.

To me, this is quite analogous to attempts to curb political lobbying in D.C. by making earmark requests and the source of fundraising dollars more transparent to voters. Transparency is hyped as the fix to political corruption, but its still unclear whether it really stops "bad" behavior. Voters overwhelmingly disapporove of Congress in general (a dismal 32% as of Dec. 2008 http://mediamatters.org/items/200712130008), but often express approval of their own member of Congress. Many people simply don't care enough to look up the donor lists, and who can blame them? It's hardly enjoyable bedtime reading.

I wonder if patients will pay attention to this type of disclosure. And if they notice, will they care?

Proposition 8

2008-12-05T06:56:00.000-08:00

Go to www.funnyordie.com and click on the Prop 8 skit

http://en.wikipedia.org/wiki/California_Proposition_8_(2008)

I have never seen a larger wikipedia entry than this on California's Proposition 8, a ballot proposition that changed the state Constitution to restrict the definition of marriage to to that being between a man and a woman.

My marriage cost about $15,000 and my divorce costs are still escalating at over $100,000, (yes think about this boys!. I have always thought at the very least, bible thumpers could understand the fudicial benefits of same sex marriages.

Jennifer B.

Stem Cell-ebration

2008-12-05T06:40:00.000-08:00

http://www.cbsnews.com/stories/2008/11/19/health/main4615769.shtml?source=RSSattr=SciTech_4615769

This is an article to found in Time magazine in which European physicians announced the success of a breakthrough procedure in which a woman's windpipe was rebuilt using her own stem cells. The operation, seeded a stripped-down segment of a donor's trachea with stem cells from her own bone marrow ensuring a perfect tissue match and reducing transplant rejection. This is a milestone that could pave the way for radical improvements in organ transplantation and treatment of serious illnesses.

This is very promising for regrowing organs such as soft tissue, lungs, bladder, uterus, pancreas. Also note that although a pioneered operation like this was done at Mt Sanai in New York in 2005, this successful operation was a result of the COMBINED efforts of Milan and England.

I do not know what the attitudes and understanding of Europeans in regard to this research is, any comments?

Jennifer B.

Separation of Church and Health?

2008-12-04T13:13:00.000-08:00

After blogging about the CDC restriction on homosexual males donating organs, I started thinking about how Jehovah's Witnesses refuse blood transfusions during organ transplant surgeries, which is a vitally important part of the surgery and recovery process. A good friend of mine is a cardiologist, and when I asked him about this, he responded that many such surgeries are unsuccessful. My initial reaction was that this just wasn't fair - that there are thousands of people on transplant lists who would have much higher chances at success. It seemed to me that religion, which in my opinion should not have a place in science, is a solid part of society in the United States.

An article entitled, "Are Scientists Playing God? It Depends on Your Religion", reported that American and European researchers have made most of the progress so far in biotechnology. Yet they still face one very large obstacle — God, as defined by some Western religions. Some scientists who are frustrated with the governmental debate over the morality of stem-cell research and genetic engineering have in fact moved to Asia, which offers researchers new labs, fewer restrictions and a different view of divinity and the afterlife. “Asian religions worry less than Western religions that biotechnology is about ‘playing God,’” says Cynthia Fox, the author of “Cell of Cells,” a book about the global race among stem-cell researchers. “Therapeutic cloning in particular jibes well with the Buddhist and Hindu ideas of reincarnation.” Most of southern and eastern Asia displays relatively little opposition to either cloned embryonic stem-cell research or genetically modified crops. China, India, Singapore and other countries have enacted laws supporting embryo cloning for medical research (sometimes called therapeutic cloning, as opposed to reproductive cloning intended to recreate an entire human being).

In another article entitled, "Children's health can't be left to faith alone," the author argues that when parents won't seek medical care, they must be punished by law. This was in response to a case where a 15 month old baby died from bronchial pneumonia and a blood infection, problems easily treated with antibiotics; however, she received no antibiotics because her parents belong to a small fundamentalist sect, The Followers of Christ Church, and do not believe in antibiotics. The Followers believe that faith will heal all and that death, if it comes, it is God’s will. While their baby struggled for days to breathe, her parents prayed, never calling a doctor, an ambulance or 911. I agree with the author that any adult has and should have the right to refuse medical care. I also agree with him that society must make the protection of children a core value, and the way to do that is to make it clear that child neglect is still neglect, even when performed under the cover of religious faith.

I am very interested to see how the separation between church and state evolves under the Obama presidency, and where this takes stem cell research. America is on the verge of scientific breakthrough, and I think it should heed the message when some of its most important researchers are moving across the world in the name of science. Religious freedom is revered in the United States, but health should be given as much deference.

GISAID - Flu Trackers

2008-12-04T12:46:00.001-08:00

http://gisaid.org/

I came across GISAID while researching the World Health Organization's (WHO) Pandemic Influenza Preparedness Plan (see http://wikileaks.org/leak/avian-flu-chair-text-2008.pdf).

GISAID stands for "Global Initiative on Sharing Avian Influenza Data." It is a non-profit that was started in August of 2006 by a group of leading scientists and researchers, headed up by Dr. Nancy Cox, head of the Influenza Division at the US Centers for Disease Control and Prevention (CDC), and Ilaria Capua, an Italian veterinary virologist who is a leading advocate of greater sharing of H5N1 genetic data.

GISAID "is the world's largest and most comprehensive influenza database." (See http://www.flutrackers.com/forum/showthread.php?t=81678). GISAID aims to facilitate access to avian influenza research and vaccines through a publicly accessible online database that offers basic intellectual property rights to those who submit genetic information. The website says, "We have all pledged to share the data, to analyze the findings jointly, and to publish the results collaboratively, on the basis of open sharing of data respecting the rights and interests of all involved parties." As a result, GISAID has encouraged many countries including Indonesia, China, Russia, and others to start sharing information about their viruses again.

GISAID is currently frustrated with the WHO, claiming that the WHO is going to extreme lengths to withhold money from GISAID ($450,000 that the United States' CDC intended to go to GISAID). Furthermore, WHO is apparently asking for $10 million to start its own online database, which GISAID already has established free of charge. GISAID scientists do not understand the WHO secretariat's unwillingness to embrace them, after they have put much effort and time into the development of an effective and efficient avian influenza technology transfer database.

It will be interesting to see whether WHO embraces or at least acknowledges GISAID as it moves forward with the Pandemic Influenza Preparedness plan, as GISAID is not currently mentioned anywhere in the text.

Paying Doctors to Ignore Patients

2008-12-04T12:04:00.000-08:00

The United States have higher health care costs than any other advanced country, whether measured on a per capita basis, as a percentage of the economy, or in total dollars spent. The high cost of health care in America has been largely affected by the current financial crisis, and public insurance programs are also being hit. State and federal governments are straining to meet the rising costs of Medicaid and Medicare. Many states are having to decrease funding in other areas, such as education, to meet elevated Medicare costs. For physicians, especially, Medicare has become a burden more than a blessing. It is a source of frustration that at times prohibits physicians from doing the jobs they set out to do, in the name of regulation and money. Currently one in seven Americans are covered by Medicare. For the physicians who treat these people, Medicare may become a barrier to proper treatment.

Under Medicare Part B, physicians are only reimbursed for procedures that are considered to be reasonable and necessary. Physicians are not compensated for talking to patients, but rather for the procedures they complete and for the number of patients they see. Physicians are often criticized for not spending enough time with their patients and for not providing informed medical care with empathy and effectiveness. However, it is Medicare that dictates how many patients that physicians must see in order to meet the reimbursement quota, and therefore how much time they can spend with each patient. Overhead practice expenses, including rent, nurses’ salaries, and malpractice insurance, have become so high that physicians must see more patients in order to be able to pay for all of the other costs associated with practicing. The physicians who do not own expensive equipment, such as MRI machines, which are much more lucrative as far as Medicare reimbursements than office visits, are forced to see fewer patients in more time in order to keep up with their overhead. Dr. Michael Stewart, chairman of the department of otorhinolaryngology at New York-Presbyterian Weill Cornell Medical Center, said that the challenge today is that “everything is going up except reimbursement. The tendency is to see more patients in a given amount of time, and so less time is spent with each patient.”

Although each fee paid by Medicare to physicians is meant to reimburse them for the time and skill they put into each service to each patient, the reality of the system seems to have become almost the opposite. Many physicians believe they cannot fully perform their jobs and desire to have more face-to-face time with their patients. They are frustrated that they are unable to do so because regulations deny them the ability to do something that automatically should be done.

The future of medicine will depend on how the Medicare system adapts and evolves with the realities of health care today. Dr. Byron M. Thomashow, medical director of the Center for Chest Diseases at New York-Presbyterian Columbia Medical Center, said, “We need to go forward with something that keeps the humanity in medicine.” I agree.

http://www.nytimes.com/2008/07/24/opinion/24bach.html

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The Vatican’s bioethics opinion: what does it mean?

2008-12-01T20:32:00.000-08:00

http://www.catholicnews.com/data/stories/cns/0805983.htm

Later this month, the Vatican is planning on issuing a bioethics opinion on human cloning and stem-cell research. This opinion is being created by a Vatican department known as the Congregation for the Doctrine of the Faith and is meant to examine biological research and health care as it relates to Catholic ethics. These issues have not specifically been by the Vatican in previous opinions such as "Donum Vitae" ("The Gift of Life") and "Evangelium Vitae" ("The Gospel of Life") which were written in 1987 and 1995 respectively. Specific topics that are going to be discussed include the freezing of human embryos, the selective, pre-implantation genetic diagnosis (PGD), research on embryonic stem cells, and attempts at human cloning.The pope said the starting point for the church's opinion is: "The two fundamental criteria for moral discernment in this field are unconditional respect for the human being as a person from the moment of conception to natural death, (and) respect for the originality of the transmission of human life through the acts proper to spouses."
This area of bioethics seems very interesting because it seems as though the Catholic Church is going to take a very different stance on many issues than many nations. For instance, abortion is legal in the U.S., it is illegal in many countries and this policy falls in line with Catholicism. However, from what I am reading about for my paper concerning the use of PGD, most nations are allowing PGD even though the Church will presumably say that PGD is unethical.
The question arises of how important the opinion of the Catholic is and how will people respond to a nation allowing for a medical procedure that a religious entity says is illegal. Surely this is not the first instance of this happening, but a though I had was that this was becoming more common with these newer topics of biological research and health care with new procedures.

What is wrong with choosing the sex of your baby?

2008-12-01T18:14:00.000-08:00

(CNN) -- A new type of embryo testing is being offered by a growing number of fertility clinics as a way of improving the chances of a successful pregnancy.

It involves genetic testing of chromosomes in embryos created by in vitro fertilization, or IVF, and implanting only those embryos with normal chromosomes into the mother. (cnn.com by Kahn, 2002)

As a nurse who has investigated the IVF process personally, I would like to offer some insider info. The IVF process has actually come a long way. In my opinion this is not a dangerous procedure at all. Hormone intramuscular shots are given to the female for one month stimulating hyper ovulation. Ultrasound is used to determine the exact day/hour when normal ovulation should occur. Female is prepped for surgery with a Valium sedative and lidocaine injections internally at the site. Scope is passed through the vaginal wall and obtains the eggs via suction. Patient recovers shortly and is able to walk out and go home to rest.

The eggs (approx 15-25) are inspected under microscope for abnormalities. IVF occurs after the sperms are also cleaned and inspected. The gamete is inspected all along the way. Only the most viable and healthy gamete is implanted.

As a woman from a family of girls, I was only blessed with two boys myself. I wanted a girl badly. The physician offered to centrifuge the sperm prior to IVF and draw off only female sperms. This can be done because female sperms are heavier and sink to the bottom. This is a very common request and method in America. I was paying out of pocket $17,000.00, I wanted that daughter. Isn't this America? Do we just let the wind blow? Do we leave it to chance? No. We pay to "have it your way"!

Jennifer B.

Snake oil Anyone?

2008-11-29T15:23:00.000-08:00

A company in Boulder, CO is offering a genetic test to determine what kind of sport your child is most genetically suited for. For $149, with the swab of a cheek your child will know if he or she would be best at speed and power sports like sprinting or football, or endurance sports like distance running, or a combination of the two.

These seems like a terrible idea to me. First of all you are possibly pigeon-holing your child into a specific sport when he or she could excel at any number of activities. Secondly, this is frighteningly a reminder of our eugenics past. Where will this drive for genetic advanage stop?

Also as many of the Dr.'s in this article point out. Everything we know about genetics is pointing less and less to the isolation of certain genes causing certain traits and more towards a combination of genetic and environment causes.

Seems like a new snake oil salesman if you ask me.

2008-11-27T09:39:00.000-08:00

http://news.aol.com/article/poll-rates-most-and-least-ethical-jobs/259161?icid=100214839x1214058528x1200860973

Why is it that every year nurses are voted the most ethical of professions? I will be very proud and pleased to explain it to you.
The philosophy and understand standing of ethics in healthcare is taught directly from the first day of nursing school. While we are learning the biology and science of medicine we are constantly reminded of the ramifications of what could go wrong given a situation. This concept is driven into our head at every turn and the answers on every multiple-choice question. In addition, the instructors also boost our pride at every opportunity by glorifying the profession and reminding us that we are the patient advocate. Our primary purpose in life is to protect the patient from harm and to educate them because we have better bedside manners.
This is not the case in every culture I have found however. Specifically in some east Indian cultures I have come to learn that nurse is our one of the bottom respected professions. As a matter of fact lower than a housekeeper, janitor, maid. For whatever reason having to care for the old and sick is not respected. I have run into this discrimination many times in my career and now do not take offense by this. I view it as an opportunity to engage more fiercely with that family member or patient that usually is not getting the appropriate emotional care they deserve as a human being.
I plan to use my law degree in the area of advocacy within the court systems. Although I do this every day through communication and facilitation, I know there are some patients who get caught up in the legal system with no appropriate representation. I have been complemented many times on this natural ability. A recent manager of mine once stated on my review, “I always want you on my side and God help me if I am up against you on a patient issue.”.

2008-11-27T09:38:00.000-08:00

http://news.yahoo.com/s/ap/20081119/ap_on_he_me/med_artificial_heart

Please see the above article in which a young girl was kept alive on a heart machine for over 100 days while waiting for heart transplant. The machine is approximately the size of a photocopier and pumps the blood through the body.
In light of our discussions recently in regards to the donation prosthetic process and lack of available organs, I am thrilled to see this successful piece of medical technology. I feel it is only a short matter of time when we are able to produce medically sufficient man-made organs. I believe that going further with stem cell research and DNA transfer will only expedite the process.

Jennifer B.

Save the Cord - Non-Controversial Source of Stem Cells

2008-11-24T09:56:00.000-08:00

Cord blood is blood left in the umbilical cord or placenta after childbirth that is said to be a non controversial source of stem cells. Cord blood banking seems like a promising way to ensure that stem cells will be available for future medical use, partly because the procedure is easy and non-invasive, and it does not interfere with the childbirth process in any way. Women who choose to preserve cord blood have the option of donating their cord blood to a public bank, or paying to store it in a private bank for later use exclusively within their own family.

In the case of private banks, when a donor or immediate family member has a disease that requires a stem cell transplant, cord blood from a newborn bay in the family may be the best treatment option, as it will be a perfect match for the donor and has a 1 in 4 chance of being a perfect match for a siblings.

Unlike bone marrow transplants, which require a perfect match, cord blood transplants only require 3/6 Human Leukocyte Antigens (HLAs) to match. Cord blood is unique in this respect because it is the “youngest” source of stem cells and, thus, readily accepted in to a recipient’s system.

Save the Cord Foundation (www.savethecordfoundation.org) is a non-profit organization that was started by co-founders Charis Ober and Anne Sarabia. Both women graduated from the University of Arizona, and worked in the biotech and pharmaceutical industries before starting the foundation. They were motivated to start the foundation after visiting a public cord blood bank in Tucson, AZ, and meeting children with leukemia and sickle cell anemia whose lives had been saved with cord blood donations. Save the cord aims to make the collection of cord blood the standard of care in hospitals across the nation, and to make public cord blood banks a national priority.

Cord blood seems like a promising solution for stem cells. Are there any mothers contributing to this blog who have donated or preserved their cord blood? If not, did you know about the option at the time of giving birth? Thanks for any input!

Why Discussing Limiting Medicare Benefits for the Elderly Is Worthwhile

2008-11-23T20:01:00.000-08:00

While browsing the opinion section of the New York Times, I came across an interesting editorial about limiting benefits for senior citizens in order to make health care more effective. The article, by Daniel Callahan, can be found here: http://newoldage.blogs.nytimes.com/2008/11/13/heart-surgery-how-old-is-too-old. Callahan, in essence, argues that we should limit expensive treatment given to the elderly in order to cut costs upon the Medicare system and avoid otherwise necessary increases in taxes.
Callahan succinctly explains the burdens levied upon the Medicare system by expensive treatments for the elderly. While I believe some will find that assessing life-saving treatments as “burdensome” or perhaps “wasteful,” as Callahan certainly implies, the cold numbers are extremely persuasive. And they should at the very least not be overlooked. So let’s examine the numbers. The Medicare program cost $429 billion in 2007, and has a 7% annual cost increase. Thus, by 2017, it should cost $884 billion. Most importantly, by 2017, the Medicare program will be bankrupt.
Now, how do expensive treatments for the elderly factor in? While Old age itself is certainly not a barrier to coverage. In fact, the average age of those undergoing heart surgery, organ transplantation, kidney dialysis, and cancer treatment is continually rising, Callahan explains. Essentially, science is finding ways of keeping the sick or weak alive longer. It is important not to forget that just a few decades ago, the methods used to keep people alive were not even dreamed of. Significantly, not only are people staying alive longer, but many elderly people are opting for expensive, aggressive treatments, even when the likelihood of success is dismal. I personally do not blame anyone for this decision; if your life is on the line, wouldn’t you opt to try to extend it? But the fact remains: people aren’t likely to simply roll over and die. If treatment is available, they’ll want it.
Thus, the effect on the system is significant. Callahan writes that the average Medicare recipient has to spend between $5,000 and $10,000 for treatment not covered by the program. Doctors are becoming reluctant to take on elderly patients because they are often poorly reimbursed. Out of pocket costs for drugs and co-payments are expected to jump anywhere from 31 to 60 percent in 2009 alone. Therefore, if I interpret the numbers correctly, it seems that not only is the system going bankrupt, but recipients are facing significant price increases or will have to pay out-of-pocket because the system itself cannot afford to treat them.
In light of these numbers, Callahan argues that limiting benefits based on age should be done, because it is not likely that the other possible fix (raising taxes) will be seriously considered in the near future. I thought the most important part of Callahan’s argument was the simple fact that he acknowledges that age-based rationing will not be accepted. Thus, I think he effectively removes that contention from the argument. However, his point is that we can’t completely factor out cost and age from the equation. Congress has refused to allow Medicare to take costs into account in its coverage decisions. But should it play some role? Should age? Callahan’s answer is emphatically yes. I agree with Callahan’s sentiment that our society “can not, and should not, promise open-ended, progress-driven medical care that is indifferent to costs.” Because in the real world, age does matter. It matters in that there are more and more elderly people undergoing expensive care, putting increasing burdens on a system that is already on the brink of collapse. This is a practical way to save money. This is not a proposal to eliminate access to benefits for the elderly altogether. It's a proposal that cuts extremely expensive treatments that likely either won't work or won't work for long. And freeing up cash helps the system. And, although now I am editorializing, I wonder: at the end of the day, what is better? A functioning system that, admittedly has its flaws and is imperfect? Or no system whatsoever? I say an imperfect system.
Keep in mind, age isn’t the only factor. Likelihood of success, cost, and patient wishes should all weigh in. Perhaps a government-regulated healthcare system would solve ALL of these problems? But we’re not there yet, and I think it is important to try to make our system work until we get there. I think Callahan’s point is that we need to consider solutions that may not be popular or pleasant, not because they will ultimately be implemented, but because they are often realistic and therefore, a reasonable starting point to formulate serious solutions.

America Shrugs at Being Fat

2008-11-21T14:47:00.000-08:00

The fattest city in America has just been named, and apparently it "shrugs" at that moniker. This makes me think long and hard about how a city in America, a country so weight-obsessed, can be as nonchalant about being called The Fattest. Professor Pasquale's lecture about image-obsession reminded me of how beauty throughout history has been paralleled with wealth. Huntington, West Virginia, the aforementioned unhealthiest city in America, also has a poverty level worse than the national average. With the economy in the state it is, will the future of America's health suffer as dramatically as the stock market? And if so, how will the health care system adapt? The economy is sickening the hospitals in the U.S. Decline in elective procedures and admissions, and patients who cannot pay for care have left hospitals in an economic slump. Poor times call for cheap measures, for sure. Kentucky Fried Chicken's $10 Challenge is no help. A KFC commercial challenged a family in a grocery store to put together a dinner for $10 or less that was comparable to the KFC $9.99 7-piece value meal. Access to health seems to be as big of an issue as access to health care.

Huntington leads the nation in a half dozen other ailments too, including diabetes, heart disease, and tooth loss. I wonder how a city that is so evidently health-poor can just not seem to care? When did being healthy become associated with being rich? When did health become a luxury? Americans pine after having the newest thing, and despite the economic situation, people will keep shopping. KMart reinstated layaway just in time for the holidays. But people don't seem to want to spend that money on healthier foods -- the apathy is there, and it doesn't seem to be going anywhere. Not even the mayor of the fattest town in America seems to want to do anything about it.

In Mauritania, fatter women are considered beautiful. Young girls in rural areas are forcefed until they vomit in order to attain this goal. This, on a continent with with 50% of the population living below the poverty line, seems reflective of the trend that wealth equals beauty. In India, even in the most rural areas, the poorest of women wear a piece of jewelry because that represents her beauty. However, even with America's economy plummeting as it has, that desire for beauty in the U.S. seems to fade. Priorities change, and rightly so, but the desire to preserve one's health, the most basic human instinct, has seemed to vanish from the American psyche. One would think being called the fattest city in the entire country would be a wakeup call, but when the reaction is no more than a shrug, I worry.

Please Make Me Look White?

2008-11-20T15:13:00.000-08:00

An issue was raised in class a couple weeks ago regarding the trend that in an effort to appear more white, Asians were demanding plastic surgery. I’ve often questioned this idea and wondered if it wasn’t instead a misperception perpetrated by the media.

Consider for example the argument which posits that the reason Asians flock to plastic surgeons for double eyelid blepharoplasty is to achieve larger, rounder, Caucasian eyes. It seems like a post hoc argument to me (hearkening back to the LSAT, it’s a necessary but not sufficient condition). Associating the rise in blepharoplasty procedures with the rise in Western media influence is certainly plausible, but it’s not an entirely sound argument.

I’m not discounting the fact that the media plays an enormous role in shaping perceptions of beauty, but I think that it’s just as important to look to the underlying evolutionary basis (that crosses cultural lines) behind plastic surgery trends. Obviously there’s much interplay between these two, but when it comes to this debate I often see the focus on the aforementioned cultural imperialist notion rather than on evolutionary reasons.

It seems almost universal that humans are drawn to big eyes—notice our penchant for babies, puppies, and kittens. Big eyes are associated with youthfulness, as evidenced by the popularity of brow lift procedures in older American woman seeking to “open up” their eyes. And seeing that there are almost four billions Asians in the world there are obviously those with varying eye sizes.

After college, I lived in Taiwan for a couple years and traveled extensively throughout Asia. I met a few people with plastic surgery, but none would say that getting their eyes done made them look more Caucasian. In fact, the surgery allowed them to look more like other Asians who had relatively larger eyes. Naturally occurring double eyelids are prevalent in those from the southern part of China and Southeast Asia, and to a lesser extent (but not uncommon) in Northern Chinese, Koreans, and Japanese.

Another issue that is often discussed is the fixation with skin lightening. Again, I’m wary of the media’s conclusions that it’s just another example of Asians desiring to look more Caucasian. Throughout the centuries in Asia, dark skin has been frowned upon because of its association with toiling under the sun and menial labor—thus, the reason fair skin is generally desirable.

I just had to throw it out there, but there are plenty of other reasons Asians prefer bigger eyes or lighter skin and it may be due to reasons other than trying to look like their Western counterpart. It’s more likely that their reasons for doing so are more similar to the reason Westerners prefer bigger eyes.

When two cultures collide there’s bound to be misperceptions. As someone who embodies both Asian and American cultures and has lived on both sides of the world, I think it’s important to take what you read with a grain of salt-- there are obvious reasons which needn’t be mentioned here why the Western media’s portrayal of the East is skewed (as with the East’s portrayal of the West).

Ellie

Misleading Research From Industry?

2008-11-18T20:20:00.000-08:00

By John Tierney
http://tierneylab.blogs.nytimes.com/2008/10/30/misleading-research-from-industry/
In 2005, The Journal of the American Medical Association cited “concerns about misleading reporting of industry-sponsored research” to justify its stricter standards for any such research to be considered for publication. The new policy, requiring researchers with no financial connections to the sponsor to vouch for the data and perform statistical work, was promptly criticized in an editorial in The British Medical Journal as “manifestly unfair” because it created a “a hierarchy of purity among authors.”
Now some researchers have looked to see what kind of hierarchy actually exists. After analyzing weight-loss research conducted over four decades, they’ve found that the quality of data reporting in industry-sponsored research does seem to be different from that in other research: It’s better.
The researchers found that the quality of data was significantly better in industry-supported research than in nonindustry-supported research, particularly in studies involving drug treatments. The researchers conclude:
This suggests that, while continued efforts to improve reporting quality are warranted, such efforts should be directed at nonindustry-funded research at least as much as at industry-funded research. A benefit of the greater funding offered by industry, the greater scrutiny of industry, or perhaps greater concern or training of industry personnel for rigorous reporting may be an enhancement of the overall reporting quality in the literature, at least for long-term weight-loss studies.
The author’s colleague Gina Kolata recently reported that some prominent medical researchers are starting to shun any financial support from industry — not because they think it leads to bad research but because they’re tired of having their integrity impugned. These ad hominem attacks have become routine against anyone or any group receiving industry money. In light of the new study, the author worries what will happen if the best scientists become afraid to work with the sponsors that can afford to pay for the most thorough studies. What happens to the quality of future research? And should this new study give pause to JAMA’s editors? By stigmatizing industry-sponsored research, is their “hierarchy of purity” doing more harm than good?
This article only mentioned obesity studies, but it seems to suggest that other industry funded studies are superior to their non-industry funded counterparts. It shouldn’t come as a surprise that well funded research provides better results regardless of who’s footing the bill - even organizations with an agenda value solid research. Maybe articles like this will help lessen the stigma of working for “the man.”
EEM

Woman who got HIV from kidney transplant sues University of Chicago Hospital

2008-11-17T16:26:00.000-08:00

A woman who contracted HIV and hepatitis C from a kidney transplant sued the University of Chicago Medical Center and one of its doctors on Monday, saying they should have told her the organ donor was gay. In November, she was asked to come back to the hospital because 3 other people who had received organs from the same donor had tested positive for HIV. She said she was not told at the time of the transplant that the donor who was killed in an automobile accident had engaged in male-to-male activity, but that had she been told of this, she would not have gone ahead with the operation.

The U.S. Centers for Disease Control and Prevention guidelines say that gay men who are sexually active should not be organ donors unless the patient is in imminent danger of death. The guidelines also say patients should be informed if a donor had engaged in homosexual activity. I wonder how fair this policy is. I understand that high-risk activity is not to be taken lightly, but what about gay men in monogamous relationships with people who are not HIV-positive?

I know of the patient who received the heart from this same donor. He was on the verge of death prior to the transplant. His quality of life after the transplant was far better than it was prior to receiving the heart, and he believed he would not have had the opportunity to feel better again and to live longer without the operation. He did not have sex with his wife between having the operation and finding out he was HIV positive. He did not blame the hospital or the physicians and he did not intend to sue them.

HIV tests require one week to get the results back, and organs would be dead by that time, and therefore useless to the recipients. What if a hospital has no way of knowing if a donor has engaged in high risk activity? I know many physicians who find this scenario horrifying -- the potential of being sued for yet another situation that they may not be responsible for.

This situation is unprecedented for hospitals and physicians alike. Nothing like this has ever happened before, there are no studies or lawsuits regarding this scenario, and its results are potentially devastating, both for the hospitals as well as for the patients and their families. There is a question of what the patients' quality of life will be, since many of the medications that donor transplant recipients will be on stimulate white blood cells, which HIV medications do as well. HIV drugs have become quite effective, and the lifespans of infected persons are longer now than ever before. The patients potentially could feel well and live another ten to twenty years because of the medications, which they may not have had the potential for prior to receiving their organs. For the heart recipient, the infected heart gave him more time to live.

I am curious to see how many millions of dollars this woman will make...

Implications of BRCA1 gene mutation as it relates to In The Family and otherwise...

2008-11-17T09:37:00.000-08:00

In preparation for our screening of Joanna Rudnick's documentary, In The Family, I wanted to pass along some information and links to recent articles written on the subject. Although the film is centered around a female of jewish descent, it bears mentioning that surprising new studies have shown the BRCA mutations to have revelance to a wide range of ethnicities, and affects men with prostate and breast cancer as well. On an even larger scale, the documentary points to the dilemmas associated with gene patenting, disclosure, and genetic mutations in general-whether it be a BRCA mutation, or otherwise. The following list of links are by no means all-inclusive, and I invite any and all to add and expand upon those attached below as we try to better understand the gene mutation before Thursday. Thanks.

WHAT YOU NEED TO KNOW ABOUT BRCA1:

BRCA1 stands for "breast cancer 1, early onset," and belongs to a class of genes known as tumor suppressors. Like most tumor suppressors, the protein produced by the BRCA1 gene helps prevent cells from dividing too rapidly or erratically. Specifically, the BRCA1 gene is essential for providing instructions for producing proteins involved in repairing damaged DNA. To date, researchers have identified more than 1,000 mutations of the BRCA1 gene, most of which are associated with an increased risk of breast cancer.

IN THE FAMILY INDEED:

http://news.yahoo.com/s/ap/20081117/ap_on_he_me/med_breast_cancer

As the article linked above asserts, a family's medical history may be a more accurate indicator than genetic screening for breast cancer. Although BRCA1 and BRCA2 are considered aggressive hereditary mutations, the problem emerges when female relatives test free of the mutation in the belief they are not still at risk. Dr. Steven Narod stresses, "family history is a much stronger predictor regardless of what gene tests show." Of 1,500 women tested from 365 cancer-prone families who had nonetheless tested negative for both mutations, the group still had a four-fold higher risk thatn average women of developing breast cancer. The report goes on to remind that the $3,000 BRCA tests are still generally well accepted but newer tests will be available soon that will be more available, less expensive, and hopefully, more accurate.

In the meantime, I would argue that the importance of sitting down with one's family and hashing out the good, the bad and the ugly of shared medical history cannot be over- emphasized.

WHO SHOULD GET TESTED:

Traditionally, the BRCA1 mutation has been to known to be more prevalent for Ashkenazi Jews, and recent studies have shown that Ashkenzi women with breast cancer had the highest BRCA1 mutation of the ethnic groups studies, at around 8.3%. However, the same study (cited below) also showed the mutation is widespread among Hispanics and young black women as well. A research scientist at the Northern California Cancer Center in Fremont and assoc. professor of health research/policy at Stanford, Ester John reported that Hispanic women had a higher chance of carrying the BRCA1 mutation than caucasian women, but that young black women carried the most alarming rate. For all black women the rate of the BRCA1 mutation was 1.3%, however of that subsection under 35 who had breast cancer, the rate skyrocketed to 16.7%.

John's research appears to be backed up by Dr. Christine Pellegrino (NYC) who said that the findings mirror what she's seen in her clinical practice. Pellegrino supports a widespread program of genetic counseling for young patients and genetic screening for all women and female relatives who develop breast cancer at an early age.

http://health.usnews.com/usnews/health/healthday/071226/brca1-mutation-prevalent-among-hispanic-younger-black-women.htm

Given that the 2007 findings were surprising to even the specialists, it might not be overly presumptive to encourage screening for women with known, higher than usual rates of risk for breast cancer. In realizing that option is more or less taking the easy answer, I still would rather error on the side of caution and too much data, rather than not enough.

AND THIS FROM MYRIAD:

http://www.myriadtests.com/provider/brca-mutation-prevalence.htm

BRCA NEWS FOR MEN:

Men with a strong family history of prostate or breast cancer also experience BRCA related dangers. As cited by the attached link below, prostate cancer caused by a BRCA2 gene mutation are more than twice as likely to die from the genetic disease than those carrying the fault BRCA1 gene mutation. The study found that carriers of the BRCA2 gene were found to live for an average of four years compared to an average of eight years for BRCA1 carriers. While the information is unsettling, it does help to tailor future therapies and treatments, especially in treating the lethal BRCA2 mutation.

http://www.news-medical.net/?id=39490

Again, the above articles and information is a slim fraction of what is available on the BRCA mutations and I invite anyone to supplement this thin offering. Thanks, JWD.

Specialty Hospitals

2008-11-14T19:34:00.000-08:00

After class the other evening, I was wondering about the specialty hospitals we spoke of briefly and had some questions about their existence. From what I have read, the only types of specialized hospitals that exist are ones that specialize in cardiac, orthopedic, and general surgery. There are very few of these hospitals and are typically geographically located in a small area (Kansas, Oklahoma, South Dakota, and Texas). The major issue surrounding these hospitals is the fact that many claim they are taking away the most profitable and generally easier cases from community hospitals. This argument relies on the fact that patients at these hospitals are generally insured on other policies than Medicare and are not in highly emergent situations. While I definitely understand that community hospitals rely on insured patients for much of their funding to cover uninsured patients and patients with Medicare that does not pay as much, specialized hospitals really do not seem to have anything to do with this problem other than they are taking some of the insured patients away. Therefore, it seems that the overall complaint with specialty hospitals is not going to be addressed by not allowing them, but by correcting the payment problems at community hospitals.

I think that patients should have a choice in where they receive their care and not be forced to make up for losses that are incurred elsewhere. As I was reading this article, I could not help but think of nationalized healthcare. A nationalized healthcare system would correct the problem of uninsured patients and also presumably help Medicare type insurance pay more money. However, a nationalized healthcare system is bound to have a privatized option that will take the same form as a specialty hospital.

A further issue that is raised in the article is the one of conflict of interest of a doctor’s who own hospitals. However, with this point, the article cites statistics that state the doctors individually only own very small parts of these hospitals, 1% per physician. Also, with cardiac specialty hospitals, physicians only own 34% of the hospital on average. These seem like small numbers to be creating conflicts of interest. A further point is that it seems like a far stretch to be saying that physicians are performing surgeries that they otherwise would not be because they own a small part of the hospital. This argument would make much more sense in a different field like dermatology (which by the way is a specialized practice usually that is owned by physicians). To me, it makes more sense that a dermatologist might prescribe is different medication that they profit more off of rather than a different option that is cheaper well before a cardiac surgeon performs a procedure on someone’s heart that is unnecessary. While the cardiac surgeon might also prescribe a different medication, that is a different point and will exists no matter where the physician is working.

In the end, I definitely do not know much about specialty hospitals, but these were just a few thoughts I had. The last thing that I thought was interesting was a website for a specialty hospital that claims:
"Some day all hospitals wil be like this."

Girls Wins Right to Refuse Heart Treatment

2008-11-14T11:34:00.000-08:00

On Tuesday, November 11, in the U.K., thirteen year old Hannah Jones persuaded her hospital to abandon the legal proceedings that could have potentially forced her to have a heart transplant against her will.

Hannah was diagnosed with leukaemia at the age of five and was given a high-strength drug to kill off the infection that also caused a hole to develop in her heart. She was left with severe heart damage that requires treatment with a combination of drugs and a special pacemaker. After being told the only solution was a transplant, Hannah decided against it because there was a strong chance she would not survive the procedure and, if she did, the leukaemia could return. The new heart would also last only 10 years at best and she would need constant drug treatment. In the end she decided to return home to Marden near Hereford under the expert care of her mother, a specialist nurse.

But in the complex right-to-die case, her local hospital began High Court proceedings to temporarily remove her from her parents' custody to allow the transplant to go ahead. Hannah was required to plead her case to a child protection officer. Hannah told doctors and the officer that she believed the treatment was too risky and that she would prefer to enjoy her remaining days in the company of family and friends. Hannah's plea was ultimately compelling enough to convince the child protection officer to take her side, and persuade the hospital to back down.

Hannah's story poses another layer to the right to die question that makes it even more complex. The primary factor that makes this decision is difficult is the fact that Hannah is not an older adult individual who has suffered from a painful terminal disease their entire life. Rather, Hannah is a young girl, with potentially her entire life ahead of her. Her choice in this matter is one of quality of life, and I do agree that she (and her family) should have the right to make that final decision. However, I can also see the hospital's conflict in that they want to do everything they can to save the life of this girl. The family may not have the entire medical know-how of the experts at the hospital to fully evaluate the risks possibilities they are facing. Additionally, the hospital may be able to evaluate the situation from a purely medical standpoint of whether the procedure is too risky or not, while the family may be too emotionally drained from all the years of distress they've faced throughout the course of Hannah's medical treatment. Ultimately, I feel that the resolution taken is the correct one, to follow the wishes of the patient and her family. However, I definitely understand how difficult it must be for hospital staff to stand back and do nothing while this young girl with her entire life ahead of her chooses to die, especially when there are existing viable medical alternatives out there that may possibly save her life.

Story at: http://www.independent.co.uk/life-style/health-and-wellbeing/health-news/girl-13-wins-right-to-refuse-heart-transplant-1009569.html

With Friends Like These, It's Best To Get It All Down in Ink, Or How Sobchak and Kaufman Killed Surrogate Decision Making

2008-11-13T16:12:00.000-08:00

In recent classes we've debated the topics surrounding surrogate decision making from acting on advanced directives to substituted judgment standards in the context of end-of-life determinations. We haven't yet tackled the same decision making questions that arise for surrogates when a loved one dies before stating precisely how and what the ceremony of remembrance might be. However, to keep it light, I'll offer as exhibits, scenes from popular culture that might shed light on why the state might not be crazy about granting family and friends the final say. Specifically, I would like to look at the untimely passings of Donny Karabotsos and Gram Parsons.

In the penultimate scene of the Coen Brothers' cult classic, The Big Lebowski, Walter and The Dude perform the last rites of their dear friend, Donny. Despite his generosity, loyalty, and other personality traits that would have made him the perfect Thurbian, hen-pecked husband or ever prudent older brother, poor Donny has apparently died without family members through blood or marriage. Therefore, the Falstaffish Walter Sobchak serves as master of ceremony on a stage made of beach dunes to an audience of one, The Dude, thus:

"Donny was a good bowler, and a good man. He was one of us. He was a man who loved the outdoors... and bowling, and as a surfer he explored the beaches of Southern California, from La Jolla to Leo Carrillo and... up to... Pismo. He died, like so many young men of his generation, he died before his time. In your wisdom, Lord, you took him, as you took so many bright flowering young men at Khe Sanh, at Langdok, at Hill 364. These young men gave their lives. And so would Donny. Donny, who loved bowling. And so, Theodore Donald Karabotsos, in accordance with what we think your dying wishes might well have been, we commit your final mortal remains to the bosom of the Pacific Ocean, which you loved so well. Good night, sweet prince."

And after butchering Hamlet, Walter empties the coffee canister serving as an urn against the wind covering both The Dude and himself with Donny's remains. Now, while Walter claims to be acting in accordance with what he thought Donny's dying wishes might have been, suffice it to say such wishes probably didn't include being dusted over his friends' faces after an evocation of Nam flashbacks. In the Dude's own words, "With friends like these...."

Rock'n'Roll has had its fair share of morbid death scenes, but the passing and subsequent events surrounding the death of Gram Parsons has to be the most bizarre. After founding the Burrito Bros., composing the Byrds' best album and writing songs for the Rolling Stones, Gram Parsons came back to California to get clean. That's right...came to California to get clean. By the late 1960s, Parsons would routinely disappear in the desert near Joshua Tree while under the influence of psilocybin or LSD. On the last occasion he was accompanied by Margaret Fisher and the infamous rock'n'roll roadie, Phil Kaufman. Tragically, Parsons died at the age of 26 from a lethal combination of morphine and alcohol. At this point things get strange.
Prior to his passing, Parsons was reported to have said that he wanted his body cremated at Joshua Tree and his ashes spread over the prominent Cap Rock. Parson's stepfather however arranged for a private ceremony in New Orleans and neglected to invite any of his friends from the music industry.
Acting on his alleged promise, Kaufman borrowed a hearse and managed to purloin Parsons' corpse from the airport security and drove out to Joshua Tree to commence cremation ceremonies. Needless to say the nincompoop Kaufman was not trained in cremation and instead thought pouring five gallons of gasoline into an open coffin and lighting a match would do the trick.
It didn't. The half burned remains were eventually returned to Parsons' step-family, who claimed that Gram's body was only 60% mutilated. Other reports emerged that Kaufman left 35 pounds of Gram's charred body in the desert. Kaufman was arrested not long afterwards, however since there was no law on the books against stealing a dead body at the time, he was only fined for stealing a coffin.
The lesson to be learned from both accounts is to purchase a Moleskine and a Sharpie and write it all down. Do not leave any important decisions regarding your health or body left to the idiocy of family and friends. Have fun with it...imagine every Edward Goreyian tragedy that could befall you, and the likely and not so likely damages you might suffer...and provide instruction.

http://comunidad.ciudad.com.ar/argentina/capital_federal/visualmix/vonzai/gorey.html

W is for Wyatt who was guillotined by the Deans.
Instruction One: If my head can still listen to music, keep me alive and start shopping my resume.
Instruction Two: If music is no longer an option for me, get me a gig in a John Carpenter film and then off to organ donation or plastination.
Instruction Three: Please do not gasoline and alight me. Please do not powder your faces with me.
Instructions Four: Songs to be played at the wake: "Sweep Out the Ashes in the Morning," "Don't Let the Sunshine Fool You," and "Hey, That's No Way to Say Goodbye."

Begging you to write it all down,
JWD

Keep your Friends Close and Your Surrogates Closer

2008-11-13T14:04:00.000-08:00

Slate Magazine has an article about couples using one of their mother's as a surrogate if the wife is unable to carry the child herself. In this most recent case a woman marries, has two children,and a hysterectomy and a divorce and then re-marries. Her new husband wants to have children and all they are missing is the womb. So the wife's mother volunteers to have her daughter and son-in-law's embryo implanted in her.

At the age of 56 grandma gave birth to triplets. It makes sense that if you would entrust someone with your embryo, it should be someone very close to you, and a familial relationship is obviously even better. However the author raises potential sticky situations:

"Motherhood is splintering. You can have a genetic mother, a gestational mother, an adoptive mother, and God knows what else. When one of your moms is Grandma, it's even more confusing."

I think as long as the surrogate is healthy and the doctor approves there is nothing wrong if they are OK with it. While the author thinks it's just plain creepy, it's about as creepy as any surrogate mother relationship, however it's not with a stranger.

FILE UNDER: THIS COULD BE BIG

2008-11-12T18:17:00.000-08:00

http://news.aol.com/health/article/marrow-transplant-may-have-cured-aids/246178

Unfortunately (or fortunately as the case may be), I cannot comment on this as of yet...just wanted to pass it along as soon as I could.

JWD

UIC Medical Center Pays $2 Million to United States and State of Illinois to Settle Liver Transplant Fraud Suit

2008-11-09T09:59:00.000-08:00

In November 2003, the University of Illinois paid the United States and the State of Illinois $2 million to settle a "whistleblower" lawsuit brought by Dr. Raymond Polak, a liver transplant surgeon and professor at the University of Illinois College of Medicine, that alleged that the University's Medical Center at Chicago improperly diagnosed and hospitalized certain patients and exaggerated the seriousness of their medical conditions to liver Status 1 - confined to intensive care and likely to die within 7 days, and liver Status 2A - chronic liver disease with sudden deterioration, in intensive care, and likely to die within 7 days, to allow them to become eligible sooner for liver transplants. The suit was brought under the False Claims Act and the Whistleblower Reward and Protection Act. Similar allegations were settled around the same time with the University of Chicago and Northwestern Memorial Hospitals. Dr. Pollack received 25%, the maximum allowed by the law, of the total settlement proceeds, which added up to be over $500,000. UIC also payed $300,000 for Dr. Pollak's attorney fees, expenses, and costs.

The suit alleges that the improper hospitalization and diagnoses enabled UIC to transplant enough patients to meet the minimum number of liver transplants necessary to be certified under the Medicare and Medicaid programs, thus enabling it to receive federal and state reimbursement for the procedures. Illinois Attorney General Lisa Madigan said, "A hospital's desire to receive additional state and federal health care dollars should play no role in whether or not a patient is eligible for an organ transplant...Not only did the defendant defraud the state and federal governments, it endangered individuals. These actions are legally and morally wrong."

This case reminds me that, although hospitals should be examples of high integrity, places where people are born and lives are saved, they are just like any other place of business, motivated by money. Are these hospitals any better than the organ black market? Aren't they both run by a thirst for monetary reward rather than by a regard for life? Neither in this case have respect for federal laws and systems in place, such as the Organ Procurement and Transplant Network and the United Network for Organ Sharing, which are designed promote the most ethically fair and logical processes of organ donation. What separates other rogue operations from those that on the surface appear to be on the patients' side, but which choose not to abide by rules that promote life?

Although the settlement contained certain "integrity requirements" in addition to payment, I wonder how much integrity a hospital can regain after such gross indiscretion. How long will it take to regain the public's respect and trust, when the place in whose hands a person puts his or her life turns out to have such disregard for them? A hospital's walls are filled with people who have taken an oath to promote and protect human life, and it saddens me tremendously that those lives were manipulated just to make the cut and to make a buck.

The case is United States of America and State of Illinois ex re. Raymond Pollak, M.D., v. Board of Trustees of the University of Illinois and the University of Chicago, 99 C 710 (N.D. Il.).

http://www.usdoj.gov/usao/iln/pr/chicago/2003/pr111703_01.pdf

Septuagenarian Gives Birth to Twins Via IVF!

2008-11-05T14:32:00.000-08:00

While browsing websites this afternoon, I stumbled across an article from this summer (July 24, 2008) that actually went as far as to shock my conscience. Thus, I decided to throw it out here, because I’d love to see what kind of reactions this piece evokes from everyone else.

In July, Omkari Panwar gave birth to twins, a boy and a girl, at a hospital in India via in vitro fertilization. What is newsworthy about this? What shocked my conscience? Mrs. Panwar is 70 years old, and her husband is in his mid-seventies. The article, which can be found at: http://www.msnbc.msn.com/id/25837220, goes on to discuss the origins of in vitro fertilization (IVF), but for the purposes of this blog, if your curiosity is piqued, you can read about the origins in the original article, for I am not going to address that here. What the article deftly highlights, however, is how the fears associated with IVF have changed since its inception. Initially, there were worries that IVF would produce deformed babies and that it was unsafe. Today, the fears are an entirely different monster, as highlighted by Omkari Panwar’s story. When is IVF okay? Who decides? Should the child’s rights be factored into the decision? Should the parent’s motives?

Admittedly, the Panwars’ case has another layer to it. The Panwars sought to have additional children as septuagenarians due to the cultural bias in India that sons are better than daughters. It is not that the Panwars have had boys in the past; they have female daughters and even female grandchildren. But now they wanted a boy. While I try to view this in a light most favorable to Mrs. Panwar’s plight, and while I struggle to realize that the cultural value judgment placed on her shoulders must indeed be significant if she was ready to go through childbirth again at the old age of 70, I cannot feel anything but remorse for her newborn twins. Her children are likely to lose their parents anytime in the near future. And even if the Panwars are lucky enough to live extremely, extremely long lives, will they really truly be able to care for their children in 10 years? Maybe even in 5 years? Raising children is something that is exhausting for parents forty years younger than the Panwars. Can these stark facts really be outweighed by the fact that Mrs. Panwar’s culture emphasizes the value of male children? Resoundingly, I say it cannot. I am appalled at the selfishness of their decision.

So this gets back to my initial questions. Who should decide when IVF can be used? Is it entirely the right of the parents to decide? Should the doctors be in a position to refuse treatment to potential parents? And if so, under what circumstances? Can they look to the parents’ motives? This would place an immense burden on doctors to make value judgments about people and families. Is this fair? I think not. But I do think there needs to be some sort of check on the parents’ access to IVF, if only for very special cases like this one. Perhaps legislation is the best route (I think it’s the only feasible one) to restrict IVF from being used in certain cases. Defining the law would be incredibly difficult and would not doubt meet significant challenges (I can foresee the due process claims being filed already…), but does this situation not demand some sort of scrutiny? I think it does. This entire scenario just reinforced to me, the casual reader, how issues with new treatment, technology, and so on, evolve, and frankly, can become more troublesome than at the outset.

The Diving Bell and the Butterfly

2008-11-05T08:38:00.000-08:00

Reading the case McKay v. Bergstedt reminded me of the movie The Diving Bell and the Butterfly, or Le Scaphandre et le papillon. It is the heartwrenching true story of French Elle editor-in-chief Jean-Dominique Bauby who, in 1995 at the age of 43, suffered a stroke from a cerebro-vascular accident that left him in a state of total paralysis, incapable of any verbal communication, in what is known in the medical community as "locked-in syndrome." Only his left eye wasn't paralyzed. His mental faculties totally intact as he lay motionless in his hospital bed, Bauby learned to communicate with the outside world using his left eyelid, the only part of his body over which he still had any control. During the next fourteen months, using a communication code developed by his therapist and his publisher's assistant, who transcribed this code, Bauby was able to compose, letter by letter, a memoir of his life struggle eloquently describing the aspects of his interior world, including the psychological torment of being trapped inside his body. Bauby died in 1997, two days after its publication. The movie, which is based off of Bauby's autobiography, was nominated for 4 Oscars, and won the Golden Globe for Best Foreign Language Picture and Best Director.

Immediately after watching this movie, all I could think about was the rights of mentally-competent quadriplegics. Throughout the movie, you grow to understand and feel Jean-Do's frustration, anger, and sadness as he lays in bed, unable to tell the nurse when he did and did not want to watch tv, unable to tell his children he loved them, constantly remembering his old life. He wanted to die. He repeatedly gave this sentiment, but everyone around him refused to let him give up his life. He eventually spent his days recounting his life story, but many people in his situation do not have this opportunity. It made me weigh the balance between desperately wanting to die because life has nothing more to offer, and using your days to be productive in whatever capacity you can. The world is a better place because of Bauby's memoir. The Diving Bell and the Butterfly is truly a piece of art. I believe a person has the right to choose when he or she can die, especially in such a solemn situation. However, general society usually begs to differ. It makes me wonder if the quadriplegic community should enlist help from the medical and legal communities to establish their rights in a formal manner.

Don't Sue the Medicine Man

2008-10-31T12:08:00.000-07:00

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

Million Dollar Baby

2008-10-30T22:16:00.000-07:00

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.

The Possibilities of Memory Modification

2008-10-30T13:51:00.000-07:00

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

Half of Doctors Routinely Prescribe Placebos

2008-10-29T18:48:00.000-07:00

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

Everything You Wanted to Know About Genetic Speed Dating BUT Were Afraid to Ask Ernst Ruedin

2008-10-28T12:54:00.000-07:00

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

2008-10-27T22:38:00.000-07:00

Do Ask – Do Tell

After steadfastly opposing a 1992 state ballot measure and multiple bills that would have permitted physician-assisted suicide, the California Medical Association (CMA) fully supported the Terminal Patients’ Right to Know End-of-Life Options Act which was signed into law in May, 2008. Under the law, terminally ill patients in California have the legal right to information from their doctors about end-of-life options. Doctors are required to provide information about hospice care, palliative care and sedation, refusing or withdrawing life-prolonging treatments, and making the choice to refuse food and hydration – but only if the patient specifically requests the information.

CMA explained their insistence on the provision that patients must ask for the information with the reasoning that a physician who volunteers end-of-life information - or even raises the subject unbidden - could be exerting undue influence on patient choice. Doctor’s who want to avoid influencing patient choice? Something about that sounds a little hokey to me.

Isn’t it my physician’s job to be my advocate and partner? Am I naïve to expect full and complete information about treatment options if I develop some condition or disease? And that includes a bad prognosis and the possibility of addressing end-of-life choices. Quite frankly, I prefer my physician to volunteer all relevant information and try to influence the heck out of me. If I don’t like what I hear - or it’s actually something significant - I would get a second option. And maybe a third if I need a tie-breaker. Ultimately, I make my own decisions.

I can only speculate on why CMA felt it imperative to require patients to ask before they tell. There is also a provision in the law that if doctors are uncomfortable complying with a patient’s wishes (say to refuse a ventilator, to abandon chemotherapy or antibiotics, or to stop eating and drinking); they can recuse themselves and assign the patient to a doctor who will comply. This provision could suggest that a significant portion of physicians in California are opposed to end-of-life care. It could suggest that they believe aggressive medical intervention is always the best answer. On the other hand, requiring patients to bring up the subject of the futility of continued aggressive treatment could suggest a fear of litigation over end-of-life decisions and this law is meant to immunize physicians.

In my opinion, it is a sad statement that this law was necessary for terminally ill patients in California to get complete information about their end-of-life choices.

PJM

2008-10-27T18:27:00.000-07:00

Withdrawal of Feeding Tube, Current Event

Most nurses and doctors can tell the difference between stopping feeding and intentionally starving a patient. Last week I was asked to take a "special case" in which a 50yr old patient's wife chose to stop feedings. Patient was in a vegetative state due to electrocution 25 yrs ago and hasw lived in the nursing home since. Patient aspirated on his feeding 10 days ago and wife made this decision.

Patient has abilities of an 8month old infant and does respond to me, reaches out to me, throws me his stuffed animal, screams in pain, curses, makes eye contact, recognizes me. This is an extremely uncomfortable case and I keep reminding myself that this is legal. He is starving to death, which will take about a month.

Jennifer B

2008-10-22T17:37:00.000-07:00

Please view this info on the Glascow Coma Scale as we discuss end of life issues for next class and readings.

http://en.wikipedia.org/wiki/Glasgow_Coma_Scale

I find that persons who are not in healthcare have a very very difficult time grasping the reality of what a person's body looks like when they are in a vegetative state. In addition, with the yearly stupidity of the National Enquirer headlines a "Man awakens from 20 year coma! States "I am really hungry"!

I will be happy to share my first hand knowledge of the dying process, coma, in class this week.

Jennifer Burns RN, Hospice Nurse

2008-10-22T17:36:00.001-07:00

Sorry I did not put this blog in the correct link, herre it is:

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Supreme Court Case Upcoming
Sunday, October 19, 2008

Gonzales v. Planned Parenthood Federation of America, Inc.Planned Parenthood sued the Attorney General of the United States for an injunction against the enforcement of the Partial-Birth Abortion Ban Act of 2003, 18 U.S.C. § 1531. The district court granted the injunction, holding that the Act was facially unconstitutional because it was impermissibly vague, imposed an undue burden on a woman's constitutionally protected right to have an abortion, and had no exception to the ban for the health of the woman.The Attorney General appealed to the United States Court of Appeals for the Ninth Circuit, which affirmed the injunction for each of the three reasons stated by the district court. The Act was unconstitutionally vague because it used non-medical terms like "partial-birth abortion," which makes it too difficult for doctors to know what the statute covers. The Act also effectively outlawed second trimester abortions, causing an undue burden on a woman's right to have an abortion, which the United States Supreme Court ruled was unconstitutional in Stenberg v. Carhart. Finally, the Act does not contain an exception for abortions performed for the health of the woman, which Stenberg also requires.Question Presented: Whether, notwithstanding Congress's determination that a health exception was unnecessary to preserve the health of the mother, the Partial-Birth Abortion Ban Act of 2003 is invalid because it lacks a health exception or is otherwise unconstitutional on its face.Decision under ReviewWhat is a partial birth abortion?See this link. Warning it is graphic...http://www.nrlc.org/ABORTION/pba/diagram.htmlI think what I have discovered so far is that viability of fetus is still considered at 6months gestation. This is a fetus approximately 2-4 pounds. Many of you have known premature infants and can readily identify with this tiny person. I do not know personally of any physician that would perform this.I did have a friend who was born in 1950's as a result of a botched abortion attempt. He told me that the nurse took pity on him and put him in an iron lung machine and cared and raised him. He was very healthy, became a police office, then a lawyer, then went on to public office. He told me that he always felt he didn't want to waste his life's chance.He certainly did not.Jennifer Burns RN
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Foreign Policy and Bird Flu Vaccine Concerns

2008-10-22T01:17:00.000-07:00

Seeing the headline, “U.S. controls bird flu vaccines over bioweapon fears,” http://news.yahoo.com/s/ap/20081011/ap_on_re_as/as_bird_flu_biological_warfare , piqued my curiosity, as I had recently posted a question after 9/26 class about how pluripotent stem cells could become “dangerous.” Further reading revealed that the keyword in the headline was “fears.” There is only a potential threat of biological weaponry with the HSN1 or Avian influenza virus.

In the article, the idea of a bird flu bioweapon was called “the nuttiest thing I ever heard” by U.S. defense secretary Robert Gates and other unnamed experts called the idea “far fetched.” We allegedly do not possess the technology to produce such a bioweapon. Experts believe that they cannot create a bioweapon from the bird flu vaccine, because the vaccine is created with an inactivated virus that cannot be genetically altered and cannot be resuscitated back to its virulent form.

Despite this lack of technology, the fear of biological warfare is apparently the motive behind the supplement to the U.S. export regulation. The Act, the International Emergency Economic Powers Act (Title 50 1701-1707), makes it convenient for the U.S. President to order embargoes to countries that are designated “state sponsors of terrorism.” Examples are North Korea, Iran, and Sudan; areas with strained diplomatic relations, human rights violations or nuclear weapon potential. Some countries are able to apply for export licenses to the U.S. Other countries, such as Iran, Cuba and Sudan have longstanding embargoes that prohibit trade with the U.S. Using language such as not letting the vaccines get into the wrong hands,” and “legitimate (italics mine)public health and scientific research is not adversely affected,” does sound as though bioterrorism through vaccines is a real national security concern.

Unfortunately, this ban is perceived negatively by some countries. Notice how the same article that I am citing is posted by the web site, Plan for Pandemic: HSN1 Avian Influenza What you need to Know and what you need to do about it: “Indonesia refuses to send bird flu virus to American lab fearing Bush may use same for bioweapons on non-white countries.” Consider the following headline: “U.S. Hoards Bird Flu Vaccines Over Bioweapon Fears” http://wjz.com/national/bird.flu.vaccine.2.838462.html. Perception truly is reality for some.

Bioethicists would say that limiting vaccines to select countries because of the foreign policy is morally questionable. This is because other countries accused of having biological weapons or weapons of mass destruction (WPD) such as Libya or Iraq do not have such trade restrictions. There should be consistency in the regulation of importation of viruses and the exportation of vaccines, if we are to appear ethical in our trade policy.

2008-10-20T22:21:00.000-07:00

Dangerous Clots
What is a blood clot? Well if you speak patois then it is something not too nice to say. Well, when it comes to our bodies it is something not to be desired. Deep vein thrombosis (DVT) and Pulmonary embolism (PE) affect people every year yet are undiagnosed at the early stage, this silent killer was introduced more publicly when David Bloom a NBC journalist covering the war died suddenly from DVT and PE. The symptoms and or warning signs of DVT are sometimes swollen arms and legs, skin redness, and a warm red spot, typically on the leg. The symptoms of PE are shortness of breath. The issues are physician’s mistake these signs as skin infections and a person considered out of shape. The Agency for Healthcare Research and Quality have stated some causes for blood clots are obesity, being over the age of 65, having had a bad bump or bruise, being confined to chair or bed for a long time, taking hormones (e.g. birth control) and there are plenty more. Once a person is diagnosed they are typically prescribed a blood thinner, the most common warfarin. The National, Heart, Lung, and Blood Institute (NHLBI) has begun funding research on genotype guided dosing of warfarin. The two genes being tested are CYP2C9 and VKORC1. These two genes would help clinicians find the best treatment for their patients. The question may not be is this necessary testing of genetics or sound reason to determine the best medication needed. The facts are if the dosage is administered wrong a person may experience excess bleeding while taking the medication. If the genetic testing is administered the side effects could be avoided as well the patient receives truly effective treatment. Is genetic testing for persons taking medicine for heart issues, diabetes, cancer, flu, common cold, and etc? Now some might suggest that is not the same yet, the purpose is to receive effective healthcare and have great outcomes. If genetic testing is applied to the common illness is this not preventative healthcare? Is not better to know the best medicine to take for a cold rather than purchasing the medicine that is not for your body? The issue of warfarin does not only address genetic testing rather it determines out future of medicine. We all know that no one person is the same and genetic testing supports this theory in some respect. Yet, as a society would we perceive genetic testing only imperative in the matters of life and death or a necessity to live a full healthy life.

KIRK

For further information please visit these websites http://www.ahrq.gov/consumer/bloodclots.pdf
http://www.ama-assn.org/amednews/2008/10/06/hlsb1006.htm
http://www.ama-assn.org/ama1/pub/upload/mm/464/warfarin_brochure.pdf
http://www.warfarindosing.org/Source/Home.aspx

Genetic Exposure v. Privacy Concerns

2008-10-20T11:12:00.000-07:00

Great story in today's NYTs about ten people who agreed to have their DNA mapped and posted online for the international community to see. The idea is that dispensing with privacy concerns will speed along genetic research. The more genetic information made publicly available, the faster research will progress. The project hopes to have 10,000 participants.

In exchange for the decoding of their DNA, participants agree to make it available to all — along with photographs, their disease histories, allergies, medications, ethnic backgrounds and a trove of other traits, called phenotypes, from food preferences to television viewing habits.

It will be interesting to see the social consequences of making public all of this personal information. GINA prohibits health insurers and employers from discriminating against individuals on the basis of their genetic profile. But participants could be denied life insurance, long-term care insurance or disability insurance, with no legal penalty. I was not aware that GINA did not cover those things. What if a person predispositioned to diabetes makes public her preference for a chocolate bar a day? Does she risk being denied long-term care insurance because she could be said to be bringing on the disease through her actions?

Because of risks like this the first ten participants were required to have the equivalent of a Masters degree in genetics. However, a person can have their entire genetic code sequenced for as little as $5,000, so these issues are going to become more of a concern as more people seek to acquire this information (this cost over $1 million two years ago)

I can just imagine a new Facebook application "MYgENOME" where you can compare your genetic code to others in order to find out who your are most compatible with. Americans simply do not value privacy. If you aren't willing to have a public persona, the first question asked is "What are you trying to hide?" While we are not sure what the consequences of publicly posted genetic code will be, maybe we should proceed slowly in order to properly assess the risks.

On the other hand, since genetic technology has been creeping along so slowly, maybe the risk is worth it. As one Doctor involved in a similar project said, “To truly understand humans we need a huge data set of 10,000 complete genomes, and the data needs to be open to everyone for interpretation.”

Why not create these "public" genetic databases, but require that in order to access the information you have to be a member of the International Geneticists Association. (I'm not even sure that that exists but, something like that.) I mean, does every Joe Schmoe really need to know about all of your family history and habits? I think not.

Concepts of Medical Triage in the US Pandemic Response Plan

2008-10-17T08:50:00.000-07:00

I am currently editing a journal article discussing flu pandemic response plans in the United States. If a flu pandemic were to break out in the US, there would be nowhere near enough vaccines available to treat everyone, so there has to be some kind of priority distribution system. The US’s Pandemic Response Plan relies on principles of medical triage (French term meaning: sorting, picking, or grading according to quality; today defined as the medical screening of patients to determine their priority for treatment). The priority system consists of 4 Tiers:

Tier 1:
-People who are essential for vaccine production
-Medical and public health care workers

Tier 2:
-People 6 months-64 years who are most susceptible to influenza excluding those over 65 and those with compromised immune systems based on the idea that treatment would be futile
-Other emergency responders and public safety workers

Tier 3:
-Government decision makers
-Funeral directors and embalmers

Tier 4:
-Healthy people 2-64 years of age not otherwise included in other categories (the reasoning being that this group is least likely to actually catch influenza in the first place)

The US’s Flu Pandemic Response Plan is based on distributing vaccines in a manner to maximize the common aggregate benefit. In other words, sacrificing individual interests to obtain the greatest good for the greatest number of people. Is this a fair system?

I could not help but notice that similar ideas of medical triage seem to be pervasive in our organ donation allocation system. It appears from my minimal research that organ priority is currently based on “need.” However, if the US is going to apply consequentialist ideas of obtaining the greatest “aggregate good” in its Pandemic Response Plan, why not apply the same logic in organ transplantation? Wouldn’t this mean factoring in the ability of the persons on the wait list to contribute to society? Wouldn’t it be more beneficial to give organ priority to young, otherwise healthy people with more years ahead of them to contribute to society? Although certain elderly persons may be unfairly denied organs with such a system, the whole idea should be the aggregate good, shouldn’t it?

Although I do not necessarily agree with the ideas of triage over a lottery or need based system for organ allocation, it is an interesting argument from a consequentialist point of view.

SURPRISE, IMMUNE SYSTEM! You want this kidney!

2008-10-16T16:17:00.000-07:00

Surprise, immune system

While I was browsing Red Orbit (www.redorbit.com) today, I came across a pretty interesting article detailing recent developments regarding the process of kidney donation (article linked below). The article explains that a third of patients needing kidney donations either will not receive one or will not receive a successful one because their bodies are hypersensitive to receiving a donated organ. In order to assist these patients, doctors are now trying to trick the immune system, the article explains, and one successful method has been a combination of blood cleansing and cancer drugs.

The article also chronicles the major changes that the kidney distribution system is undergoing in the United States. Patients in need of a new kidney are often forced to wait for years for a match. The article states that the time on the waiting list can last from for to five years, and 4,000 patients pass away annually while waiting. Thus, if the new “tactics” that scientists are developing to aid that considerable third of patients with sensitive immune systems are increasingly successful, it would seem at first glance that the time on waiting lists should drop.

Or should they? It is not clear in the article, or perhaps I just missed it, how the national waiting list would be affected if suddenly a third of those patients in need of kidneys could viably accept a donation. Is the fact that they (currently) would likely reject a kidney already factored into their position on the list? As I am a mere law student and a medical laymen, if anyone has any insight I would love to be educated.

What the article does explain, however, is that the system for kidney distribution in the United States is undergoing a major overhaul. The United Network for Organ Sharing is considering proposed changes to the system, one of which being determining waiting periods by kidney deterioration as opposed to how early someone is put on the transplant list. Another suggestion is to consider the patient’s age and medical condition. These proposed changes strike me as a very utilitarian approach to the donation system, and seem to prioritize donation based on need. Intuitively, this seems like sound logic, but I think it does raise some ethical issues. Is it really relevant how old someone that needs a kidney is? How does age factor into who deserves to get a kidney first? Is a middle aged woman’s life less valuable than a teenager’s, simply because she has lived longer? Would her children think so? Or is a patient in need of a kidney that also has another medical issue less deserving than one that simply needs a kidney?

While these proposed changes make sense at first glance, I think they run a slippery slope. I take no issue with prioritizing donation by need (by looking at deterioration of the kidney, for example), but if you start considering age and other medical conditions, in my opinion it must be done with reservation. I believe the intent is good, but evaluating the value of people’s lives comparatively must be done with extreme caution.

The article can be found here: http://www.redorbit.com/news/health/1587820/kidney_transplant_list_undergoing_renovations/index.html

Indian abortion of females is still on ongoing epidemic

2008-10-10T22:50:00.000-07:00

Different opportunities are available for sex selection in the world including selective abortion, pre-fertilization sperm separation, or post-fertilization but pre-implantation diagnosis of sex thereby choosing the sex. In certain cultures, these options are viewed as very important and have led to great disparity in the overall sex ratio. Specifically, the Indian culture has shown a rural as well as urban preference for male children. Suburban sexism generally relates to the family business/lifestyle being much more profitable if a son is involved. Also, sons can care for their parents much more easily in old age than daughters. Urban sexism can easily arise when daughters are viewed as burdens because dowries must be paid. Because of these views, many female fetuses have been aborted in India forcing the Prime Minister to call the epidemic a “national shame” that needs to be regulated in order to save these unwanted daughters.

The Prime Minister, Manmohan Singh, made these comments while addressing the statistic that in 1981, there were 962 women to every 1000 men and in 2001, the number had decreased to 927. An estimate shows that as many as 10 million female fetuses have been aborted in the 20 year period from 1981 to 2001. Because of this change, India has made it illegal for pregnant women to be given the sex of their fetus because of the fear of selective abortions. This means that the availability of ultrasounds, since they are so affordable and available, should be declining in the future to help India’s overall sex ratio. Specifically, in order to be able to have an ultrasound, a pregnant woman must agree to not seek the seek the sex of the fetus while the ultrasound is occurring. Also, doctors that still disclose the sex of the fetus are liable for up to five years in prison. However, these law are not strictly enforced, leading many doctors and patients to blatantly ignore the law and the possible penalties.

While this epidemic still occurs, it is difficult to come to an overall solution while the current regulations are not being enforced. After their enforcement takes place, the entire scenario will have a dramatic change. However, as many have noted, this sex selection problem is most obvious in the upper-class part of the Indian culture. Therefore, even if India enforces its current regulations, these upper-class citizens may seek refuge in order countries with much looser regulations like the U.S. So in the end, what is the solution? The overall solution may be to have a global policy against selective abortions. However, sex-selection abortions are only part of the problem and that means that the overall question is much larger than simply regulating sex selection in the U.S. Selective abortions also deal with genetic defects and chromosomal defects. Weighing these extra issues into the equation means that the problem is that much more unclear. However, sex selection may be regulated beyond these other issues. Hopefully India can enforce a regulation that fixes their current sex-ratio problem, but this solution may involve other countries backing India in order for the regulation to be enforced.

Pre-implantation genetic diagnosis (PGD): Should it be used on older mothers?

2008-10-10T17:36:00.000-07:00

PGD is a procedure that occurs on an embryo that analyzes the embryos genetic contents. The goal of this analysis as used with in vitro fertilization is to determine which embryos have defects and which are “healthy.” However, as this expensive procedure (~$3,000) rapidly expands, many questions exist as to how accurate it results really are in detecting chromosomal abnormalities. An article in the Los Angeles Times recently addressed this issue with the specific question of how effective the procedure is with older women undergoing in vitro fertilization. The article states that many in the field are not very confident in the procedure when it is used “on the embryos of otherwise healthy mothers whose only problem is the decline in fertility that inevitably comes with advancing age.”

Surveys have shown that 2/3 of PGD users are using the procedure to detect abnormal chromosomal counts as opposed to detecting genetic diseases. Abnormal chromosomal counts are far more common in older mothers and can lead to miscarriage or birth defects. The problem in this use of PGD is that with older mothers, PGD may not be helpful to finding a healthy embryo because there are no healthy embryos due to fertility issues related to age. A Belgian study found no improvement in full-term pregnancy rates for 150 women 37 and older who had PGD done compared to an equal number of women who did not have the procedure done. In a similar study performed by Scott, a group of women in the age group of 32 to 38 produced similar results.

These results are due to the fact that while PGD may limit the number of miscarriages, the procedure does not increase the number of viable embryos. Also, women having PGD performed will have embryos discarded that “may” be healthy. This means that the procedure may in fact be lowering the number of viable embryos that only appeared to be abnormal. Scott said that 1/3 of abnormal embryos self-correct later in development.

So what does all this mean? It does not mean that PGD should not be used because PGD is a very good option for women seeking to avoid specific genetic abnormalities. However, older women with possible fertility issues should be informed about what is exactly happening with the procedure and how the results may affect an abnormal embryo that only has a 66% of actually being abnormal.

Get It While Its Hot: The Ethical Dilemma of Premature "Donation"

2008-10-05T16:38:00.000-07:00

In 1844, Edgar Allen Poe's "The Premature Burial," enthralled readers with instances relating perhaps the most terrifying of human fears, that of being buried alive. Poe's narrator describes the phenomenon of catalepsy, a singular disorder that effects a death-like trance upon its sufferers, some who are mistakenly believed to have died and then buried. In some cases, the mistake was discovered upon re-opening the tomb to find the presumed corpse in the final death throes, trying to claw out. Other more forunate undead, were able to call attention to themselves from the depths in time for exhumation. The fear of being buried alive was common in Poe's time and public captivation culminated still in the Victorian era's organization of The Society for the Prevention of People Being Buried Alive and an obsession with vampires. Now, however, such nonsense is left for the likes of Tim Burton and Stephen King, or so I thought...

In the latest issue of The New England Journal of Medicine, several children's doctors confess to having removed hearts from infants just over a minute after they've stopped. The infant "donors" were declared dead of heart failure despite the fact that their hearts, once transplanted to lucky recipients, resumed beating like clockwork. The unenviable, ethical dilemma faced by doctors is the mission to do whatever possible to save the life of an infant measured against the risk of failing to use viable organs that could save the life of another infant. From either side a doctor could face accusations of lethal negligence.

Compounding the problem in the medical arena is the fact that nowadays anything is possible and miracles are becoming commonplace. That is, without the aid of advanced life support systems and high-tech medical treatment, the time of death was fairly definable. Now, however, the precise moment of death is becoming more difficult to pin down as medical advances easily counter the courses of nature. The NEJM piece reports that there isn't even a uniformly accepted lapse of time used by surgeons to measure when an infant goes from patient to donor. Some surgeons wait five minutes from the last heartbeat, others only two. The Children's Hospital in Denver, which the article focuses on, waits between 60 and 75 seconds. Note to infants: if you're going to get life-threateningly ill, stear clear of the Mile High City. Seriously, what's the real rush...have we impatiently foregone the ancient doctrines of "respect for the dead" in our haste to roll the dice with a donee? If we're going to play Gawd, doesn't that mean going both sides of the ball, offense and defense?

The truth is that every second counts dearly, and with organs already scarce, doctors are being forced to redefine, or at least reinterpret, the definition of death. Not long ago, doctors used the rule of "brain death," which permitted ganking organs from patients on ventilators. Now doctors are self-governed by the "donation after cardiac death" principle which permits donating based on heart stoppage rather than brain stoppage. In short, the time of death, the period of resuscitation, and the window of donation are three very distinct moments that overlap, but not necessarily as much as we'd want them to...for the sake of simplicity.

Bioethically, ought we consider standard forms that allow family members/power of attorneys to decide not only when doctors should continue resuscitation, life-support treatments but also clearly outlined periods of organ donation? If there is still such a thing as non-medical miracles, shouldn't we at least give them a chance to occur? Personally, I could imagine making the decision to suspend life-support systems for a loved one with the reservation that doctors provide a four minute window for a miracle to happen. It may be selfish and may even deny another patient the chance at a successful transplant, but depending upon the loved one in question I am willing to live with that regret. Kidding...erm...kind of.

For the record, I am sticking with my plan to be the plastinated drummer in von Hagen's rock band, however, should the band break-up before my audition, I hereby declare my organs available at the two-minute mark. Don't even bother with the liver...and the heart was never worth a damn to begin with...still got both kidneys though and I've never smoked a cigarette so the lungs are alright...good luck, and please no jumping the gun...I want all 120 seconds. JWD

Support for Embryonic Research Grows

2008-10-02T13:48:00.000-07:00

A 2007 survey of more than 1,000 infertility patients found that 60 percent were willing to donate their frozen embryos to stem-cell research. This article in Newsweek. Couples were found to be three times more likely to donate embryos to science than for adoption. While this is inline with the percentage of Americans in favor of stem cell research, it was never before confirmed directly from potential donors.

I wonder what percentage of these donors who were willing to donate actually did. The artile interviews co-author of the study Ruth Faden. This data is so significant because it is the closest thing the US has to actual data about how many embryos are donated. Now we know that not only is the American public supportive of stem cell research, but the people who have moral and legal authority over their own embryos are mostly supportive of destroying human life for the possible benefit of man-kind.

68% of Americans now support stem cell research. Clearly the country's current policy ban on funding for embryo research is out of touch with the American people. Bush has led the charge on embryo adoption, which does not seem realistic to me.

Another Cause of Obesity?

2008-10-02T06:45:00.000-07:00

As I scanned the home page of my internet service provider one morning, I see the ‘hook,’ “Kids of Stressed, Low Income Moms Prone to Weight Problems.” As a stressed, former low income mom, I took a mental survey of myself, family and peers from the time frame studied. I soon discovered that not only is the headline misleading, but I contend that this country’s epidemic weight problem is due to more factors than income and parental stress level.

The news brief, written by Alan Mozes, reports children between the ages of 2 and 11 years old have a higher risk of being overweight if their female parent is stressed and low income. The brief is based on a study published in Pediatrics magazine September 2008 http://pediatrics.aappublications.org/cgi/citemap?id=pediatrics;122/3/e529. The report states that thirty-seven percent of the 841 children surveyed were overweight. The written survey was given to heads of households with income of 200 percent below the poverty line. The respondents reported a combination of external stress and financial difficulties. The researchers found a correlation between obesity and food security in the household. “Food security” is defined as the ability to feed all its family members three meals a day for an entire month. There was no correlation between food insecurity (the inability to feed all family members three meals a day each month), and obesity (go figure). The report then concludes that since 37% is greater than the 25% national average (they did not give this statistic, I found it in www.CDC.gov/nccdphp/dnpa/obesity/index.htm), the difference is related to maternal stress. The hook worked. I had to read the study.

The results did show a statistically significant difference in the probability of obesity- 43.7% in food secure households. Here’s the problem I had with the study:

1) I didn’t see other factors that may cause weight problems: maternal obesity, inherited disease factors, sedentary lifestyle, parental education level or number of children in each household.
2) If we concede that most parents in poverty are likely to report high levels of stress, I cannot see the correlation to obesity. Except perhaps that this age group is highly dependent on parental food choices for their nutrition.
3) There is no discussion of the increase in eating disorders in America, along with a societal need for comfort measures during stressful times- especially overeating. I’d like to see the prevalence of obesity in middle class or above the poverty level households as well.

How does this relate to bioethics? The taxpayers of the United States elect the officials who make the decisions about how the healthcare dollars for the impoverished are spent. A policy of not giving paid maternity leave, the 47 million citizens without health insurance in this country, and their dependence on Emergency Centers as their health care, are all examples of a reactive, rather than proactive approach to health maintenance in this country. Eventually, billions of Medicare and Medicaid dollars will be spent on the many complications of obesity: heart disease, hypertension, diabetes, bariatric and orthopedic surgeries to name a few. All of these costs will be the result of not combating obesity with education, and if the study is correct, assistance with stress management in parents with young children.

BODY WORLDS

2008-10-01T14:23:00.000-07:00

I attended BODY WORLDS at the Arizona Science Center a couple years ago. I absolutely loved the exhibit, and would recommend it to anyone. In my opinion, BODY WORLDS celebrates human dignity by illustrating how complex and amazing the human body is, as well as the many different things it can do.

My experience was not necessarily "educational" per se, because I spent most of my time admiring the artistic elements of the exhibit. However, now that I look back, I think the exhibit did open my eyes/give a worthwhile introduction to anatomy and physiology. Furthermore, the exhibit does a great job at showing how various bodily systems interrelate and interconnect with one another.

I disagree with author Lawrence Burns' comments that the overall "value of the palstination for the general public is minimal because the general public cannot appreciate the complexity of the human body in such detail." As a member of the "general public" I felt that I greatly and completely appreciated the level of detail just as much, if not more, than a specialist, because I, and the "general public," am never exposed to that type of detail so it was all the more incredible.

Also, I disagree with Burns' statement that "to improve its educational impact and to maintain its focus on what makes plastinates uniquely instructive, BODYWORLDS should continue to display the fragments of bodies but reduce the number of whole-body gestalt plastinates." The whole body plastinates were BY FAR the best part of the exhibit! While they might not have shown the bodily systems as clearly, the whole body displays are exciting enough to generate an interest in anatomy to an otherwise uninterested person.

Lastly, I do not find the suggestions persuasive that the names of the donors should remain anonymous, the artistic & creative poses need to be eliminated, or that the artist von Hagen should be required to remove his name from the label. In my eyes, the artistic elements glorify the human body, and von Hagen should be credited for the work, much like any other doctor, scholar, teacher, or artist.

RSVP for the After-Life Party, or What to Do in the "Real" Retirement

2008-09-28T09:35:00.000-07:00

A decade ago, the Kass court asserted strong support for planning well ahead of time with regard to the disposition of embryos by concluding that previous agreements ought to be presumed valid and binding, and what's more, the court found such contracts corral expensive and drawn-out litigation, provide a framework for the effective operation of IVF programs, and minimize misunderstandings between the parties. The forethought and execution of prior agreements fall, for all intents and purposes, in the same family as Consent Forms and other Release Authorizations, that take the guesswork out of an individual(s) intention as to what (s)he would want done with various biological by-product. The only major differences being that the previous contract addressed by the Kass court focused on the agreement of two parties and the by-product had the potential for procreation.
That is all well and good. However, recent developments in scientific techologies are giving new meaning to the Boy Scout motto, "Be Prepared," by pushing the ethical envelope and asking us to gaze a bit longer into the crystal ball before deciding what to do with our leftovers. Since our course on Bioethics and the Law has already touched, and will probably revisit, the many pre- and potential human life issues of stem-cell research, genetic engineering, and IVF programs, I would like to turn our attention to the darker side of donation consentment; not the viable, hopeful, endless potential of procreation and life-sustainment...rather the stiff gift of a dead body. Besides, during a ten-day stetch that has seen the deaths of DFW, Paul Newman, Summer, and the American Economic System, I am finding myself donning a tad more black than usual and think a meeting at the cemetery gates more apropos. So without further ado, let's let the wake begin...allow me to introduce...
Herr Doktor Gunter von Hagens is the real, modern-day Dr. Frankenstein who invented and patented a technique for preserving biological tissue and body specimens known as plastination. Since founding the Institute of Plastination in the medieval university fortress of Heidelberg in 1993, von Hagens has overseen other plastination centers in the most remote research areas of Bishkek, Krgyzstan (google earth that one) and Dalian, China. Herr Doktor has also performed televised autopsies and cadaver dissections while wearing his trademark costume: a black fedora and cape.
In spite of the creepy, Bela Legosi showmanship, von Hagen is most famous for his controversial Koerperwelten ("Body Worlds") exhibitions that show a circus of plastinated cadavers enjoying routine, everyday poses in their skinless, flayed and dissected honesty. Yours truly first witnessed the gruesome cabinet of curiousity in 2002 in London, where mile long lines waited outside an Art Gallery in Bankside to see what most didn't really want to see...what the body looks like while it does what it does everyday. That is, one cadaver is playing chess (...and winning), another equestrian cadaver is mounted atop a hideless horse, there's a cadaverina pirouetting, and still another cadaverunner finishing a marathon in all his veiny glory. The morbid absurdity runneth over however, when attendants come face to face with a cadaver, fist under chin, assuming the position of Rodin's Thinking Man. The subsequent sick smile is quickly wiped off every face with teutonic precision around the next wall as a room full of plastinated pregnant women cadavers at varying trimesters and jarred fetuses showing one week olds, four week olds and so on were displayed. Leave it to the Germans for a real party faux-pas.
Having lasted longer than I would ever had expected, I left shaking my head with the full realization that Body Worlds would never make it across the Atlantic.
I was wrong. It has toured the States, and on limited publicity, haunted the halls of Chicago's Museum of Science & Industry. I went again, this time with my own students at the U of C and couldn't help thinking that it was a toss-up between the exhibition and the U of C campus as to which had more signs of life.

How does any of this relate to consent forms or Bioethics or the legal implications surrounding previous contractual agreements?

Well, for the past four years, our von Hagen has been dogged by a slew of legal proceedings that started as a result of his showmanship getting the better of him; he photographed plastinated corpses late at night all over Hamburg, including the Reeperbahn (the red-light district). Is it still necrophilia when the dead are doing the come-hithering? The charges in Hamburg included the serious offense of disturbing the dead. Additional proceedings against the good doctor were lodged in Siberia regarding a strange shipment of 60 corpses to Heidelberg that had little in the way of paperwork. 2004/2005 brought legal accusations that von Hagen had illegally received and plastinated several hundred corpses from prisons, psychiatric institutions and hospitals from China and Kyrgyzstan, most if not all without the notification of the respective families.

After some ridiculous google searching, during which I actually typed, "plasticate my dead, rotting body," I found the following consent form:

http://www.bodymobil.de/Downloads/Englisch/BD_Consent_ENG_euro_120208.pdf

Surprisingly, I found the consent form inclusive in that it reasonably addressed the inevitable concerns brought by family members, or others who would rather not know their loved one is touring the world as the resident? piano player in von Hagen's traveling band. In fact, it's the most interesting and bizarre consent form I could find that carried at least the pretense of being legally binding. Still, it raises the question that if plastination is going to claim the bodies of fellow humans, do it bear the responsibility not to make a mockery out of their situation by posing them in often ridiculous and laughable poses? Should GvH include a checklist of the types of activities the future dead would care to be engaged in? "No" to mixing guacamole, "Yes" to playing the guitar..."Yes" to Giacometti..."No" to the Statue of Liberty.

There was a better piece published in the Reader but here's a link to the basic premise:

http://www.newyorker.com/archive/2006/10/09/061009ta_talk_friend

Del Close, a fixture of the Chicago theatre-scene, wanted desperately to donate his skeleton, and more importantly, his skull, to the stage. Of course, the greatest gig for a skull would have to be Hamlet's Gravedigger Scene but really, how picky is a skull going to be?

For those of you familiar with the story, you know Close's intentions and wishes were not fulfilled due to legal obstacles and the absence of proper consent and authorization forms. I don't know about you, but I am definitely going to make sure I get my papers in order so my great-grandkids can see my onstage for the Mastodon (Reunion) tour in 2058 as a stage-prop, the best plastinated drummer in rock'n'roll history!

JWD

Gene Patents: Hindering Research or Promoting Genetic Discovery?

2008-09-23T13:08:00.000-07:00

Background:

Over three million gene patents have been filed in the United States alone. A gene patent is a patent on a specific gene sequence, its usage, or its chemical composition. The general rule is that naturally occurring products are not patentable. Therefore, it is only after a DNA product is isolated, purified, or modified that a patent is considered.

Currently, the United States’ patent policy allows for gene patents when an inventor can (1) identify a novel gene sequence, (2) specify the sequence’s product, (3) specify the use for the product, and (4) enable one skilled in the field to use the sequence for its stated purpose. Examples of typical gene patents include genes and gene fragments, single nucleotide polymorphisms (DNA sequence variations that occur when a single nucleotide in the sequence is altered), gene tests developed to screen for disease genes in humans; specific gene binding proteins, and stem cells.

Controversy:

There is a controversy over whether gene patents advance technology by providing scientists with an incentive to create new and medically useful gene sequences, or whether gene patents actually hinder research by making it too costly.

Privately funded researchers generally advocate for gene patents, arguing that they would be unwilling to make the substantial investment in research without the ability to prevent competitors from making or using the invention without a license. Additionally, patents allow private-sector researchers to make inventions public without losing exclusive rights; thus, avoiding secrecy and promoting the dissemination of knowledge regarding genetic discoveries.

On the contrary, many research scientists who work in public institutions strongly oppose gene patents. Public-sector researchers argue that science will advance more rapidly if researchers can enjoy free access to knowledge. Those against gene patents also argue that patents could impede the development of diagnostics and therapeutics by third parties because of the costs associated with using patented research data. Furthermore, patent stacking (allowing a single genomic sequence to be patented in several ways) is a problem because researchers who want to use such a gene have to pay royalties to multiple patent owners for the use of one gene. Moreover, public-sector researchers argue that patent filings are replacing journal articles as places for public disclosure.

Another concern is that any research facility that gets federal grants (such as state universities) should not be able to patent, because they used tax-payer money to fund their research.

Potential solutions:

HUGO intellectual property committee recommends the European statutory model of a mandatory exemption from license fees for researchers, which includes all forms of research for the purpose of improving or developing knowledge. Second, HUGO suggests the establishment of a clearing house to expedite rapid and low cost licensing of patented DNA sequences which have potential applications in clinical diagnosis (such as the BRCA1 breast cancer susceptibility gene).This suggestion would be especially beneficial for companies and researchers who are developing technologies for rapid diagnosis of multiple gene variants who may need to acquire patents for large numbers of patented DNA sequences. (Some genetic testing companies, such as Navigenics, Inc., have already adopted such policies. Navigenics licenses gene patents used for risk assessment on a non-exclusive, non-discriminatory basis.)

The Sex Question

2008-09-17T16:34:00.000-07:00

My wife is a medical student who recently worked in a reproductive endocrinology and infertility (REI) clinic at which many in vitro fertilizations occur. The usual process for these fertilizations is:

1. Extracting eggs from the potential mother
2. Fertilizing the eggs to make a set of embryos
3. Optionally karyotyping the embryos
4. Selecting 2-3 embryos for implantation
5. Implanting the selected embryos into the potential mother

The optional third step of karyotyping the embryos is a process in which many attributes of the embryos can be determined including its sex and possibly any defects. The ethical issue arose in the situation where a couple asked for karyotyping to occur and further asked to know the sex of the embryos. At this point at the clinic, there had been many ethical issues that had been addressed through different policies but this particular issue had not been discussed on whether or not the doctor should tell the patient. This particular doctor made it his personal position to tell patients because he felt that it was not in his power to deny them this information, but another doctor could have easily made the exact opposite decision. This doctor did say that he wished there was a policy stating the correct course to be followed.

The further issue could possibly occur at the selection step. The karyotyping of embryos does give some information about the embryo; however, the overall makeup of most embryos is very similar and one embryo cannot be differentiated from another. Therefore, when choosing what embryo to implant, there really is not an objective test to follow. The selection could easily be influenced by outside knowledge of whether a patient prefers a boy or a girl. Furthermore, the idea that the sex of an embryo can be determined before implantation raises the possibility of a patient choosing if they want a boy or girl. The clinic did not have a policy dealing with this issue either. The overall concern stated by the doctor was that the clinic’s policies were inadequate guidance for doctors in the in vitro fertilization field. Further, there did not seem to be any state or national regulations to these particular questions either. In the end, more law and policies need to exist governing these and other ideas if there is going to be any consistency going from one clinic to another or even one doctor to another.

The Human Genome Mapping Project: Failure?

2008-09-16T14:42:00.000-07:00

The New York Times yesterday published an in-depth article about the projected realization of actual benefits from the human genome project. The goal behind the $3 million project was to isolate and eliminate "variant" genes, which predispose people to disease. The basic hypothesis that the research was predicated on was the common disease/common variant hypothesis.
The idea is that the varient genes are only around because they have not been eliminated by natural selection becasue they only harm people later in live after reproductive years are over. We are just starting to learn how wrong this hypothesis is.

The article quotes David B. Goldstein of Duke University, a leading young population geneticist who says the effort to nail down the genetics of most common diseases is not working. “There is absolutely no question,” he said, “that for the whole hope of personalized medicine, the news has been just about as bleak as it could be.”

All of this has develped a split between researchers who want to continue to do huge, nation-wide studies to find these common variant genes, and those, like Goldstein, who think it is a pointless, needle-in-the-haystack exercise. Goldstein says that the genetic burden of disease lies in rare variants. It takes large, expensive trials with hundreds of patients in different countries to find even common variants behind a disease. Rare variants lie beyond present reach.

Yet, we hear so much about the successes of the project. It seems like we hear in the news all the time about a new gene that has been identified for a disease. Apparently, some of this publicity is well-founded, we are identifying precise genetic differneces in humand that contribute to variation in disease susceptibility. "But while the media trumpet the successes of genome scans, little attention is paid to their failures. The fact remains that despite the hundreds of millions of dollars spent on genome-wide association studies, most of the genetic variance in risk for most common diseases remains undiscovered. Indeed, some common diseases with a strong heritable component, such as bipolar disease, have remained almost completely resistant to GWAS."

Is it just going to take time for the science to use biotechnology to solve problems? Is it a funding problem? Is the US falling further and further behind in the math and science fields. It seems like we are due for a breakthrough, right?

Live or Let Die?

2008-09-15T09:21:00.000-07:00

My friend Tom's father-in-law, Frank, was admitted to a hospital a few years ago after suffering a massive stroke from a cerebral hemorrhage. Frank was elderly and already in poor health before suffering the stroke. The blood clot in his brain was quite large and, no matter what course of treatment was selected - medical or surgical - Frank was not expected to fully recover and his already frail health was likely to deteriorate.

Frank was unconsciousness by the time he arrived at the hospital, so it was up to his wife and family to decide how to proceed. Given his very poor prognosis, the family started thinking about Frank's attitudes about life support. They knew that he unequivocally believed that a life hooked up to machines was not a life worth living - and so began their consideration of foregoing surgical intervention and adding a "do-not-resuscitate" (DNR) order to his chart.

But their deliberation was a short one.

All discussion ended when Frank's surgeon simply announced that the plan was to move ahead with surgery. His stated reason: "I am in the business of saving people's lives, not killing them." Since Frank's vulnerable and conflicted family really didn't think they were in the killing business either, they agreed to a highly aggressive course of treatment. Frank survived the procedure and lived another year - bed-ridden and never fully regaining consciousness.

Ed's family takes full responsibility for making treatment decisions they ater came to regret. Still, they have never been quite comfortable that they made the right choices. They don't blame the doctor for 'forcing' them to do anything, but do wonder what they would have decided had he not been so certain about how to proceed.

Is it a problem when a physician equates a choice not to agressively treat a patient with killing that patient? Did the balance between Ed's values (as understood by his family) and his doctor's judgment tip in favor of the doctor's biases? If patient and families can be willingly coerced in a crisis, is patient "choice" more of an illusion than a reality?

PJM