SURPRISE, IMMUNE SYSTEM! You want this kidney!

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

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?

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"

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

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?

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

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.