Archive for the 'Medicine and Ethics' Category

The wager

“Yes, but you have to wager,” said Blaise Pascal in response to agnosticism. In the end, death intervenes, and not deciding on God’s existence is ultimately tantamount to choosing against Him. Choose for belief, and at best you gain salvation; choose against, and at best you gain nothing at all. Of course, if the probability of God’s existence is precisely zero, then all bets are off, but you’d have to be rather myopic to make that claim, which you cannot prove. No, when all is said and done, you have to wager.

The same goes for the current debate on embryonic stem cell research. A wild jump, you say, to go from discussing Pascal’s wager on belief to public policy? Not so, because at the core of our endless arguments on stem cells is a dilemma which requires a wager and has no definitive materialist answer. Is the human embryo a human life? If we were simply studying the embryo, observing its development, awestruck at the formation of a human being from one cell, then yes, contrary to Pascal’s conclusion about God, you could abstain from a wager. No action has been committed against the embryo; it is allowed to develop naturally.

But, we aren’t merely observing; we are destroying. Once that decisive step has been taken, then we must wager. Either that destruction is blameless, or it is murder. There is no question as to the embryo’s innocence; the best argument for abortion, the violinist argument, falls apart since we’re not destroying an embryo because it’s infringing upon the mother’s rights. The intentional killing of an innocent life is murder; therefore, unless my reasoning is terribly mistaken, the creation of stem cells by disaggregating a human embryo’s cells is one of two things: if a human being, then murder, if not, then no big deal.

But how do you decide between those two options? You cannot turn to science. Any embryology textbook shows what a seamless process embryonic development is from the moment of fertilization until birth. Unless impeded by faults determined by the interplay between its own genetics and the environment provided by its mother’s womb (otherwise known as miscarriage), it will be born 40 weeks or so after it was but a single cell. Markers such as the heart beginning to beat, or the first neuron firing, or development of a recognizably human face, are mere symbols devoid of any real meaning. Since at this moment, it would be terribly difficult to select an embryo that could not develop into a human being and would be intrinsically miscarried, then use its cells, we still must wager.

Science cannot tell you whether a human embryo is a human being at the stage in which it would be dismembered to create stem cells. If anything, the evidence points firmly toward its humanity. But, we deeply want to cure crippling, deadly diseases like Alzheimer’s and Parkinsonism. We would do almost anything if we could make the lame walk. However, if we were told tomorrow that the cure to Alzheimer’s disease was present within the brains of a family with a newly discovered genetic variant, but we would have to kill them to get it, we would all recoil in horror. Why do we not flinch at the production of stem cells? I suppose it’s because a “blob of cells” simply doesn’t look human. In the end, though, looks aren’t everything, and you have to wager. You cannot claim ignorance; what you may be supporting has the possibility of being murder. Is it worth the lebensraum?


The real reason not to make animal-human hybrids

The Caveman has discovered why we should not mix human and animal DNA to create a hybrid. Don’t say I didn’t warn you before clicking.

Another wonder drug fails

First it was Vioxx and Celebrex, which really helped arthritis but unfortunately, due to their mode of action, also increased the risk of heart disease. Now, a major new drug used to treat type II diabetes, Avandia (rosiglitazone), may be in trouble. Preliminary studies (which must be confirmed with a larger sample size) indicate an over 40% greater risk of heart attacks for patients on Avandia than in control groups receiving other standards of care.

Avandia works by activating a receptor in the cell, PPAR-gamma, which then modifies the transcription of various genes having to do with lipid metabolism, and other things. It is useful in diabetes because it sensitizes cells to insulin, supposedly helping to reduce hyperglycemia and other side effects of insulin resistance. But, it appears that there is either a non-specific effect leading to increased heart attacks, or PPAR-gamma has some other role yet to be discovered. We’ll see–the results publicized in the news are just preliminary, but it proves the adage that my old clinical medicine instructor drilled into us: “The only drugs without side effects are new drugs.”

Athletic scholarships vs. unborn children

Take a guess as to which won.

I don’t know which makes me more upset: that those Clemson athletes valued their scholarships over their children, or that administrators would make pregnancy a condition to lose the scholarship.

UPDATE: More complete story here.

Catholic hospitals and “emergency” contraception

I suppose I shouldn’t be surprised, but it turns out that some bishops allow their Catholic hospitals to provide emergency contraception in cases of rape, provided there is no evidence of ovulation (therefore making it unlikely that the woman involved could be pregnant). The USCCB’s ethical directives do appear to support this, but there is a huge problem. To my knowledge, there is no way to definitively, without a shadow of a doubt, show that ovulation and fertilization have not occurred. As Dr. John Shea explains:

A serious problem with this approach is that the LH [luteinizing hormone, the presence of which correlates with ovulation] assay may fail to indicate the presence of a pregnancy and plasma levels of progesterone may fail to distinguish whether a woman is in the phase before or after ovulation. The fact that there is no elevation of the progesterone level does not necessarily mean that ovulation has not
taken place. It takes a few hours before that increase shows up in the blood.

We cannot completely rule out fertilization, therefore we cannot completely rule out that treating a rape victim with “emergency contraception” is not actually causing an abortion. The USCCB’s directives are terribly vague and liable to being interpreted wrongly–as they have been by bishops in Connecticut, Wisconsin, and elsewhere.

This is a terrible tragedy, and I pray that the Vatican, which has been requested to rule on this matter, moves quickly to stop it.

As it is, I fear that there are quite a few more bishops who, as St. Athanasius said, will have their skulls paving the floor of you-know-where.

(HT: the Caveman)

Doctors and drug companies

One of the big news flashes this morning was the results of a study looking into the contact doctors have with the pharmaceutical industry. Nearly 95% of physicians accept some sort of gifts. That didn’t surprise me one bit–in fact, I thought it would be closer to 98% or 99%. Free lunches and other perks from drug reps are omnipresent in medicine.

The big question, which this study did not address, is whether receiving these perks influences the way doctors practice medicine. Common sense dictates that it would: you hear enough about the latest and greatest drug, and despite all attempts at objectivity, I’m sure you’ll prescribe it at least a little bit more. It is indubitable that such marketing affects prescribing habits: take Vioxx, for instance, which was still widely given for a long, long time after stories about heart trouble started coming out.

The other side of the coin is even more insidious: direct marketing of drugs to the public. Spending time shadowing a family practice doc a few years ago, I saw many occasions where a patient would come in asking whether a certain drug might be good for his condition, based upon what he saw on TV or in a magazine. Again, it is inevitable that such questions influence prescriptions, if only to appease a demanding patient. I am firmly convinced that the biggest factor affecting prescribing habits today is not drug company appeals to physicians, which are at least couched in the language of scientific study and real results, but ads that promote new drugs as panaceas to the generally ignorant general public.

So in an ideal world, medicine would be completely objective: doctors would have the best data at their fingertips for prescribing the right drug or therapy at the right time. And patients would accept the knowledge gap between themselves and their physicians, and follow their recommendations, not the promises made on television. But, the world will never be ideal. Even if we were to outlaw drug company marketing entirely, there would still be subtle influences. Perhaps it would be your doctor’s best friend, the research scientist at a big drug company who’s told him all about their latest product. Maybe it would just be the biases he has acquired through years of practice, sticking with drugs he knows best even when, if he looked at the data, there would be something better.

In the end, it seems like curbing drug company influence would be better for everyone involved, but we should not be foolish enough to think that the practice of medicine will ever be objective. Conflicts of interests and human nature will always be there. The best thing we can do is accept those facts, and work with them. Understand your biases, and those of your patients. Only then can we even approach rational, albeit not objective, medicine.

Cuckoos out of the nest

Over the past week, the consistently best op-eds on the VT shooting have come out of the Wall Street Journal, which is no surprise as it’s one of the few center-right editorial pages out there. Today, there is a beautiful essay by Dr. Jonathan Kellerman, clinical psychologist and bestselling crime fiction writer, on how the focus on the individual rights of the mentally ill led at least indirectly to what happened last week. Some tidbits:

Were the state hospitals wretched nightmare-palaces straight out of “One Flew Over the Cuckoo’s Nest”?

A few were. But many were well-run institutions for patients in wretched circumstances, providing optimal care within the limitations of what constituted psychiatric treatment at that time: a handful of poorly understood psychotropic drugs and supportive talk-therapy. Perhaps more important, they offered clean beds and three squares a day, which led to them being belittled as warehouses. But the protective environment of the best state hospitals has yet to be improved upon, or even matched.

No matter, this was baby-and-bathwater time.

By the time I received my doctorate in 1974, the doors to many of the locked wards had been flung open and the much vaunted community mental health centers were being built–predominately in low-rent neighborhoods. A few years later, government funding for these allegedly humane treatment outposts had been cut, as yet more fiscal belt-tightening was inspired by findings that they didn’t work.

Because crazy people rarely showed up for treatment voluntarily, and when they did, the treatment milieu consisted of queuing up interminably at Thorazine Kiosks.

And now we had a Homeless Problem.

And everyone was astonished.

Estimates vary but there’s no doubt that a significant percentage of people living on heating vents, pushing their belongings in shopping carts, squatting in city parks and immersed in the squalor of tent cities suffer from severe mental disease. And their psychosis is often exacerbated by drug and alcohol abuse–what is, essentially, a regimen of self-medication that should make a Szaszian proud.

Many of these unfortunates end up as victims of violent crimes. A few become victimizers and when they do, watch out. For though it is true that schizophrenics are responsible for a proportionally lower rate of violent offenses than the general population (because many forms of the disease engender passivity and physical inactivity), when crazy people do act out the results are often horrific: bloody spree killings ignited by paranoid thinking and the angry urgings of internal voices.

Read it all.