Up@dawn 2.0

Friday, November 3, 2017

Interview on suicide and euthanasia

Students occasionally request an interview, to fulfill a class assignment. Here are the questions submitted in a recent one:

1. The demographics and privilege of assisted suicide and euthanasia?
2. What is your opinion on assisted suicide and euthanasia?
3. Does assisted suicide and euthanasia affect the poor and elderly in a negative way?
4. Do you know the difference between the two?
5. Should people be forced to stay alive?
6. Should physicians play a roll?

And my initial responses:

1. Not sure what the question is here. I've not studied "the demographics and privilege of assisted suicide and euthanasia," sounds like something to ask a social scientist. But the word privilege suggests a concern that this is a practice not equally accessible to different socio-economic groups because only the relatively well-off can afford the time and expense of identifying and working with a willing medical practitioner. That would indeed be an ethical concern, an issue of inequity and injustice.

2. I strongly discourage suicide, but euthanasia in the case of someone experiencing severe chronic pain with no prospect of recovery is another matter. People of sound mind should not be denied the opportunity to experience a "good death," under such circumstances.

Albert Camus said the ultimate philosophical question is whether life is worth living, despite its challenges and absurdities. I agree, and I also agree with him that life is worth living... until (as in the aforementioned sort of case) it isn't.

I agree as well with Jennifer Michael Hecht:
“None of us can truly know what we mean to other people, and none of us can know what our future self will experience. History and philosophy ask us to remember these mysteries, to look around at friends, family, humanity, at the surprises life brings — the endless possibilities that living offers — and to persevere. There is love and insight to live for, bright moments to cherish, and even the possibility of happiness, and the chance of helping someone else through his or her own troubles. Know that people, through history and today, understand how much courage it takes to stay. Bear witness to the night side of being human and the bravery it entails, and wait for the sun. If we meditate on the record of human wisdom we may find there reason enough to persist and find our way back to happiness. The first step is to consider the arguments and evidence and choose to stay. After that, anything may happen. First, choose to stay.” 
― Jennifer Michael Hecht, Stay: A History of Suicide and the Philosophies Against It

 3. Depends on the circumstances. But since the poor and elderly are generally more likely to suffer ill health and, under our inadequate health care system are also less likely to have adequate access to health care resources and alternative treatment options, they may be more likely to turn to suicide or euthanasia out of desperation - in that case, they would not experience a "good death."

4. Euthanasia is the voluntary ending of a life (not necessarily one's own) in order to end gratuitous pain and suffering, perhaps to minimize "harm" (as in the Hippocratic Oath's injunction to "do no harm"). Suicide is the taking of one's own life, often impulsively and under duress, and thus arguably not entirely "voluntarily"...  Suicide may be precipitated by an emotional crisis, euthanasia is usually a response to physiological and medical illness. The moral difference between the two must always depend on the specific circumstances and context in which suicide/euthanasia are contemplated or enacted.

5. No. They should be encouraged to appreciate the gift of life, even a life surrounded by pain. But in the end, autonomous individuals possessed of their faculties and in a sound state of mind must be permitted their freedom.

6. Physicians should do whatever they must, to fulfill their Hippocratic Oath and alleviate pain and suffering. If they don't play a role, less qualified people - legislators, for instance - will.

Monday, October 30, 2017

What happens when you identify too much with a patient?

The Rules of the Doctor’s Heart

Every medical case, to paraphrase the writer Viet Thanh Nguyen, is lived twice: once in the wards and once in memory. Some of what follows is still intensely vivid, as if it were shot in high-def video. Other parts are blurry — in part because I must have subconsciously deleted or altered the memories. I was 33 then and a senior resident at a hospital in Boston. I had been assigned to the Cardiac Care Unit, a quasi I.C.U. where some of the most acutely ill patients were hospitalized.

In mid-September — it had been a moody, rain-drenched month, as I recall — I admitted a 52-year-old man to the unit. I’ll call him by the first letter of his given name, M. As medical interns, we were forewarned by the senior residents not to identify too closely with patients. “A weeping doctor is a useless doctor,” a senior once told me. Or: “You cannot do an eye exam if your own eyes are clouded.” But M.’s case made it particularly hard. He was a doctor and a scientist — an M.D., a Ph.D., like me. He must have been about 15 years ahead of me in his schooling; I could imagine him returning to my class in med school to teach us “Patient-Doctor,” in which students are taught how to deal with real-life patients. He’d trained as a medical resident and then as a fellow in cardiology at another hospital across town. He was now an assistant professor — it seemed like such a victory to have that title — and ran a small laboratory. I knew a student who once worked with him. Six degrees of separation? There was barely one.

Earlier that year, in March or April, M. became short of breath in the middle of his run. (Was his running route the same as mine? Across the Longfellow Bridge at Mass General, looping around the river and then back again by Storrow Drive?) His legs turned cold and blue. He had dizzy spells and lost words in midsentence. He saw a cardiologist — presumably one of his own colleagues — who diagnosed heart failure. A series of scans must have revealed a sluggish heart. In place of the regular, intentional motion — jellyfish pulsing in a tank — there was an eerie wobbliness, just jelly. A biopsy was performed, and the diagnosis was amyloidosis, a mysterious condition in which misfolded proteins begin to be deposited in the organs of the body. Sometimes the proteins come from cancer cells; sometimes from poorly understood sources. The deposits choke the organs: heart, liver, blood vessels, kidneys. “And then, bit by bit by bit, I was all pro-te-in,” he said dryly, paraphrasing the Tin Man in Oz. We laughed.

M. needed a new heart. I’m writing this casually, as if you go to the used-heart salesman on Long Island and pick one up on a three-year lease. Hearts are notoriously hard to find; someone has to die for you to get one. About 3,000 hearts are available in the United States every year. Many come from youngish men and women who’ve had accidents or drowned, leaving them in a peculiar limbo — brain-dead but heart-alive. But there are never enough: At any given moment, about 4,000 patients are waiting for a heart. Many of them will never find one... (continues)

Tuesday, October 24, 2017

Bioethics: the Basics

The text we begin with. NOTE: the new 2d edition (978-0415790314) has just been released.

What is Bioethics?

Is health care just a business like any other, or should health care professionals have a higher standard of ethics? Should we invent a pill that enables people to live for hundreds of years? Have parents the right to use science to design the kind of children they want? Does everyone have an equal right to health care, whatever it costs? 

Monday, October 2, 2017

"Can I Spread the Word About an Unvaccinated Child?"

The Ethicist (nyt)
I’m pregnant with my first child, and concern for my unborn baby has prompted me to ask my friends if their children are vaccinated. One close friend, Y, has two young (vaccinated) children, and lives near another friend, X. Both Y and I have suspected for some time that X chose not to vaccinate her child, and we have been trying to work up the courage to ask her. With the new pregnancy as an excuse, the task fell to me.
It turns out that X has indeed chosen not to vaccinate. When telling me this, she also asked me to keep her answer private. While her choice is not one I would make, I am perhaps even more upset by her request that I conceal the information.
Y and X’s children play together, and we have regular gatherings with many young children present. I feel that parents have a right to know whether they are exposing their children to unvaccinated children, especially with anti-vaxxers on the rise and herd immunity declining. My frustration is compounded by the fact that X’s child attends a public school and as far as I know has no valid grounds (for instance, an immuno-compromised child) for exemption.
I respect the privacy of others; however I don’t like being asked to be complicit in placing others at risk. I feel a responsibility to other parents of young children, especially parents of new babies who are not yet vaccinated. Do I respect X’s request to keep the information secret? Name Withheld
Having children can be scary. Parental love, like all love, makes you vulnerable, because you can be profoundly threatened by harm to someone else. Unlike most other loves, however, parental love also involves overwhelming responsibility. Your young children are enormously dependent on you. In light of these intersecting conditions, it’s not surprising that parents can be panicked by the possibility that they will fail as caretakers. Such panic has been promoted by activists who spread untruths about the dangers of vaccines, especially the vaccine that protects against measles. (The anti-vaccination movement was fueled by a discredited study from 1998 that linked the measles vaccine to autism.) I refer to untruths and not lies, because the anti-vaccination movement is no doubt largely sincere. Sincerity, though, doesn’t make them true.
As you make clear, two benefits come from vaccination. First, a vaccinated child is less likely to suffer serious harm from exposure to the relevant pathogen. Second, if enough children are inoculated, everyone’s risk is reduced by the “herd immunity” you mention. That means that you can help protect all the kids in your community, including those who (because they are immune-compromised or allergic to the vaccine) can’t be vaccinated.
When vaccination rates are high enough, the disease disappears from the population until it’s reintroduced from outside. The level where this happens is called the “herd-immunity threshold”; and it varies depending on the efficacy of the vaccine and the contagiousness of the pathogen. Unfortunately the immunity threshold for measles is very high, around 92 to 94 percent. Fortunately, in most of the United States, we’re at that level. In 2000, the disease had effectively been eliminated here. But there are 10 million cases a year outside the United States, and travelers (especially unvaccinated ones) bring it back. The anti-vaccination movement, meanwhile, appears to have depressed vaccination rates in certain communities, as happened recently in Minnesota. So the virus reappears, and outbreaks can happen.
Given the combination of vulnerability and responsibility I mentioned, one reason parents avoid vaccinations is some version of this thought: “If I decide to vaccinate my child and something bad happens, my child will have suffered at my hands.” But if that’s a sensible thought, so should this one be: “If I decide not to vaccinate my child and something bad happens, my child will have suffered at my hands.” What’s important is whether the likely results of vaccination are better than the alternative. And the answer, once exposure to measles is a possibility, is yes. Even if that weren’t true, there would be a second reason for being vaccinated: If we all did it, we would get herd immunity.
At that point, someone who thought that there were even small risks associated with vaccination might say, “Hey, I’m going to avoid the risks of vaccination for my kids, because the disease is very unlikely to reach them.” But that’s true only because other people are vaccinating. So someone who thinks this way is a free rider, like the person who figures she doesn’t need to pay the bus fare because everybody else does. One of the anti-vaxxers’ offenses is refusing to undertake their fair share of the burdens for something from which they benefit.
And just to be clear about how great those benefits are: In a typical year before the measles vaccine was available in the United States, the virus infected millions, sent tens of thousands to the hospital, gave encephalitis to at least a thousand and killed hundreds. Given that measles is a highly contagious disease that can be fatal and that the risks of vaccination are minuscule, not vaccinating your children is wrong. X has done wrong, too, if she’s lying to her kid’s school — public schools require vaccination unless there’s a recognized medical reason not to or the parents have a sincere religious objection. (Can’t imagine a religious objection? Many Christian Scientists believe that health problems should be dealt with by prayer, not medicine, and so some reject vaccination, even though the founder, Mary Baker Eddy, said that a Christian Scientist should be vaccinated “if the law demand” and then “appeal to gospel to save him from bad physical results.”)
To be sure, the direct risk of infection remains very small, and the main harm done by avoiding vaccination would occur only if more people did it. But it isn’t crazy to worry about the danger of contact with unvaccinated children; parents are entitled to know the status of the kids that their kids play with. Something like 3 percent of vaccinated people can still get measles (though it’s very likely to be less serious than in the unvaccinated). And children aren’t normally vaccinated until they are 1, so older children with infant siblings need to be kept away from the virus, too.
What about respecting X’s request that you keep her answer private? There’s an important norm here, but it doesn’t necessarily apply to information that other people are entitled to know. Besides, you and Y have conferred in your effort to find out the truth; how are you supposed to respond when Y asks you what you learned?
Tell X that she ought to inform Y about the situation and also tell the school the truth. Letting her do it shows that you acknowledge her request not to pass the information on yourself. Give her a few days. If she continues to leave Y in the dark, though, you can tell Y what you’ve learned. As far as the school goes, there may be no easy alternative to informing its officials directly. Why not tell X that you’ll be checking on her? Because that would turn a request to tell the truth into a threat.
But some vigilance is warranted, especially now that anti-vaccination “science” has a proponent in the White House. A recent study found that even a small increase in what’s diplomatically called vaccine hesitancy would have large public-health consequences. Talk about scary.
I volunteer at a used-book store whose proceeds benefit the local public library. Our books are donations and library discards, which we sell at very low prices. Occasionally an old or rare book comes in. We then check the internet to see who else is selling that book and price it at the lower end of what others ask. Recently I came across a book that was priced by another volunteer at a normal low price. However, the book seemed to be an old and rare book that should have been checked. I bought the book at the low price. Do I have an obligation to check the going internet price myself, and if it is high, pay the difference or return the book? Name Withheld
You can tell yourself that you just did what anyone interested in the book would have done. After all, your store is no worse off than if a random customer had bought it. But people who work for charitable businesses have an obligation to look after their interests. If you thought the book was underpriced, you should probably have brought it up with the other staff members and, if you still wanted it, paid the price that was set once its value was known.

Tuesday, September 19, 2017

The Best Health Care System in the World

Friday, July 28, 2017

Dying: A Memoir

Years ago, a palliative care doctor told me that what he knew of a patient’s personality often had little to do with how he or she coped with dying. Generous people could become ungenerous, and brave people could become frightened. Angry people could become gentle, and controlling people could become Zen. Dying, in other words — like combat, like becoming a parent, like any transformative life event — doesn’t always reveal or intensify aspects of our character. It sometimes coaxes out new ones.

For a long time, the writer Cory Taylor took, by her own admission, “a fairly leisurely approach to life.” That changed in 2005, just before her 50th birthday, when doctors removed a mole on the back of her leg. Melanoma, Stage 4. She wrote the novel she’d always meant to write, then another. Then she wrote “Dying: A Memoir.”

The book rings louder in my imagination the more time I spend apart from it, a kind of reverse Doppler effect. “Dying” is bracing and beautiful, possessed of an extraordinary intellectual and moral rigor. Every medical student should read it. Every human should read it. My own copy is so aggressively underlined it looks like a composition notebook.

“Dying” is short, but as dense as dark matter. There is an electrifying matter-of-factness to it, one that normalizes death, which is part of Taylor’s goal. She deplores the “monstrous silence” surrounding the subject of mortality. “If cancer teaches you one thing,” she writes, “it is that we are dying in our droves, all the time. Just go into the oncology department of any major hospital and sit in the packed waiting room...” (nyt, continues)

Cory Taylor, a fine Australian writer, has died within weeks of the rush-publication of her last book, Dying: A Memoir.
Taylor, who had just turned 61, died peacefully on Tuesday in a Queensland hospice with her family at her side... Sydney Morning Herald

Debunking "What the Health"

There’s a sensational new documentary out on Netflix that seems to have a lot of people talking about going vegan.

In the spirit of so many food documentaries and diet books that have come before, What the Health promises us there is one healthy way to eat. And it involves cutting all animal products from our diet.

Meat, fish, poultry, and dairy are fattening us up, giving us cancer and diabetes, and poisoning us with toxins, Kip Andersen, the film’s co-director and star, tells us.

Reflecting on a youth spent inhaling hot dogs and cold cuts, he asks, “Was this like I had essentially been smoking my whole childhood?”

No, Kip, not really... (continues)
Q. It seems that many people who are not elite athletes are now hyper-focused on protein consumption. How much protein does the average adult need to consume daily?

A. The recommended intake for a healthy adult is 46 grams of protein a day for women and 56 grams for men. And while protein malnutrition is a problem for millions of people around the globe, for the average adult in developed countries, we are eating far more protein than we actually need.

Most American adults eat about 100 grams of protein per day, or roughly twice the recommended amount. Even on a vegan diet people can easily get 60 to 80 grams of protein throughout the day from foods like beans, legumes, nuts, broccoli and whole grains.

The Hartman Group, a consumer research firm that has been conducting a study of American food culture over the past 25 years and counting, has found that nearly 60 percent of Americans are now actively trying to increase their protein intake. Many are avoiding sugar and simple carbohydrates and turning to protein-rich foods, snacks and supplements. The firm calls protein “the new low-fat” or “the new low-carb,” even “the new everything when it comes to diet and energy.”

“Soccer moms feel they can’t be anywhere without protein,” says Melissa Abbott, the firm’s vice president for culinary insights. “Really it’s that we’ve been eating so many highly processed carbs for so long. Now it’s like you try nuts, or you try an egg again, or fat even” to feel full and help you “get through the day.”

In her research, Ms. Abbott said she always seems to be finding beef jerky in gym bags and purses, and protein bars in laptop bags or glove compartments. Many consumers, she notes, say they are afraid that without enough protein they will “crash,” similar to the fear of crashing, or “bonking,” among those who are elite athletes.

But most of us are getting more than enough protein. And few seem to be aware that there may be long-term risks of consuming too much protein, including a potential increased risk of kidney damage. To learn more, read “Can You Get Too Much Protein?”